A Critical Review Of A Quantitative Study On Skin Glue Application And Regular Care To Prevent PIVC Failure In Emergency Department Patients

A critical review is a systematic way of logically evaluating a study to identify its strengths as well as weaknesses along with its applicability in clinical practice (Boswell, 2017). A quantitative study can be critiqued by using many models as CASP, CONSORT, Polit critiquing-tools and Crombie models (University of South Australia, n. d.). CONSORT (Consolidated standards for randomized-trials) guidelines are explicitly developed for critiquing RCT that includes a checklist (22 items) and flow-chart to track the study-participants from the trial through eligibility-assessment (Polit, 2016).

Annals are an international peer-reviewed emergency journal that was published by the American college’s ED physicians in United States. It is the largest circulating journal with impact- factor: 5.008, five year’s impact factor: 5.041 and Science citation-index journal-rank: 1.942 with over 33,000 subscribers. It publishes articles, facts, reports, and opinions related to emergency medicine that includes pediatric, toxicology, injuries with prevention in other specialties which suggest that Annals are the highly regarded journal (ACEP, 2016). The above informations prove that Annals will definitely help me to provide evidence-based care to ED patients.

The authors Bugden, Scott, Clark and Johnstone are the emergency experts of Caboolture-Hospital; author Mihala from the Applied Health-related Economics’ centre, Griffith University while Bugden, Fraser and Rickard is from the NHMRC’s Centre for Nursing-Research and also the members of Critical-care research group. Author’s current position helps me to utilize the study’s findings undoubtedly in my clinical area and prevent PIVC failure.

They have stated a clear title that stimulates a prompt perception of the study’s fundamental nature and is also consistent with the text (Melnyk, 2014). They have given a clear and acceptable objective as ‘to investigate whether the effect of Skin glue application and regular care can reduce the ED-inserted PIVC failure rate. An abstract should provoke clear insight into the study’s complexity and its applicability into the particular healthcare practice setting (Iverson, 2014). The study’s abstract includes an accurate-objective, focused-hypothesis, appropriate study-methods, results and conclusions. They have cited current, appropriate, relevant as well as comprehensive literatures. Bugden (2016) has discussed what is already known about the topic; identified knowledge inconsistencies, mentioned the study’s significance and has also situated this study within the best-available knowledge, as given by Polit (2016).

Research Design

Bugden (2016) has used RCT which is a true-experimental quantitative design in which the investigator manipulates (Skin-glue application & regular measure), controls the independent variable (regular-care group) and randomly assigns samples to both control and experimental group (LoBiondo-Wood, 2014). RCT is considered as a gold standard for providing reliable evidences in-regard to cause and effect relationship (Polit, 2016). They have clearly stated their research question as ‘Whether the Skin-glue applications to secure the PIVCs can prevent PIVC’s failure than usual securing method?’, that matches the study’s purpose.    

According to Limm (2013), about 80% of the hospital-admitted patients are inserted with PIVCs with more specifically in emergencies. Majority of PIVCs are found to prematurely fail because of site-infections, catheter’s dislodgement or others (Marsh, 2015). Such type of failure appears to occur because of improper device fixations in the patient’s skin. Bugden (2016) suggests that no previous studies have been conducted to identify the best securing measures for PIVCs. Hence, their experiment in using the cyanoacrylate skin-glue with regular securement in improving the device fixations is highly crucial.  

Research Design

Hypothesis is defined as the expected relationship between variables (Polit, 2016). They have given a concise and testable scientific hypothesis as ‘the application of skin-glue can minimize the failure of PIVCs within 48 hrs’, to draw the relationship between independent (Skin-glue application) and dependent variable (PIVC-failure). They conducted single-sited, two-arm, non-blinded, RCT-trial among 360 subjects having 380 catheter insertions. They randomized the subjects with the help of Randomizer’s-software for clinical trial to both the experimental (Skin-glue securing & regular securement as per guidelines of Queensland, 2015) and control subjects (regular care) in 1:1 ratio. The experimental subjects received skin-glue adhesive in the insertion-site as well as PIVC’s hub to enhance its securement.

Sample

Grove (2015) stated that the process of selecting target population and study-participants by using appropriate sampling frame is highly crucial. They are interested to propose their study among the ED-patients with catheter-insertions; admitted in Caboolture Hospital. Their setting of Caboolture Hospital is a community hospital (50km from North of Brisbane) with 52,000 ED-presentations every year. Samples are the aggregate of the entire population. They recruited subjects using random sampling by allotting 174 ED-patients having PIVCs to both groups in which all the members of population will get equal chance of being selected (Iverson, 2014).

Ethical guidelines are the standards that govern the degree to which the experiment follows the moral & legal obligations in-order to protect the individual’s privacy (LoBiondo-Wood, 2014). They obtained written consent from their subjects to protect the patient from harm. They got ethical approval from the ethics committee of Caboolture Hospital and have also got registered in the clinical-trials registry of Australia & New Zealand.  

Data collection

Quantitative data-collection involves collection of information in a numeric form (Gerrish, 2015). They collected demographic and study-cofounder data at the time of patient’s recruitment using self-developed questionnaires including categories of age, gender, medication intake, PIVC details with time from PIVCs insertion to intervention & follow up. They have analyzed their primary outcome of PIVC-failure within 48 hours by directly observing the hospitalized-patients or telephoning the discharged-patients and secondary outcomes of investigating the individual aspects of PIVC-failure (infection, occlusion, vein-phlebitis and dislodgement) through observation (direct), reviewing patient’s chart and questionnaire method. Data was collected by 1 of 3 nurses experienced in EDs for 16 hours/ day in one week by above methods.

According to Grove (2015), the researchers should give rationale with advantages and disadvantages of selecting particular tool as compared with other tool and their literature search should have mentioned about the selection of specific tool. Bugden (2016) has not explained about the advantage of selecting their tool but has commented on their tool reference from Rickard (2012). They have given their measurement variables but their measurement method was missing. The reliability (degree of accuracy) and validity (degree to which the tool measures) has to be determined in pilot study which was not found in this study.   

Bias is an influence that can produce error in the study results (Grove, 2015). No evidence of sample imbalances as they have adopted random-sampling approach to give equal chance to all subjects to be selected for both groups with minimal sample losses (Polit, 2016). Blinding involves preventing the subjects from knowing the details of participants, investigation and researchers to avoid bias (LoBiondo-Wood, 2014). They have not blinded the subjects because of their intervention’s nature having subtitle skin glue color as well as appearance on the patient’s limb. Research nurses were also not-masked as they are the one who allocates subjects to intervention group.

Sample

Data Analysis

They have performed quantitative-analysis by manipulating the numerical-data using statistical methods to evaluate the magnitude of the relationships between variables (Polit, 2016). They determined the sample’s size by assuming a single PIVC/patient and hypothesizing PIVC failure-rates of 11% in control and 4% in treatment groups (80% power). Even-though the subject loss to follow-up was low (2.8%/device, 0.83%/patient) with similar occurrence in both groups, they have excluded the subjects with incomplete data. They performed descriptive analysis to describe and synthesis data through averages and percentages and inferential analysis to draw conclusions at CI95% (confidence intervals) and statistical significance at p<.05. They performed per-patient analysis in multiple PIVC patients.

Results  

The primary outcome of PIVC failure-rate at 48 hrs was noted to be lowered in skin-glue (17%) than regular-care (27%) patients (CI95%:–18% to –2%; p=.02), less than 5% possibility (p<.05) of being caused by chance and hence was statistically significant, thus hypothesis was accepted, similar to Edwards (2014). The secondary outcome of dislodgement was lowered in skin-glue (7.0%) than regular-care (14%) patients (CI95%:–13% to 0%, p=0.04) at p<.05 suggesting statistically-significant, thus hypothesis accepted.

Phlebitis-rate (CI95%:–5% to 3%) and occlusions (CI95%:–8% to 4%) were reduced in skin-glue as compared to regular-care patients but not statistically-significant, thus hypothesis was rejected in-regard to these failure-modes. Infection was absent in both groups. In-case of per-patient analysis of standard Vs skin-glue group, primary failure-rate: 52 Vs 31; secondary failure-rate: dislodgement: 25 Vs 12, infection: 0 Vs 0, phlebitis: 9 Vs 5 & occlusion: 20 Vs 14 indicates that skin-glue usage with regular-care could minimize PIVC’s failure. They haven’t given permission to replicate their study yet they have mentioned of conducting cost-benefit analysis in the future. They have given implications as adding skin-glue adhesives enables PIVC stabilization and serves as simplest and rapid measure to be carried-out in emergencies.

Conclusion

In conclusion, the major findings of the study based on their original objectives should be discussed in-regard to whether the analyzed-data supports/negates the study-hypothesis (Grove, 2015). They have given that the application of a single drop of skin glue in the insertion site and hub of PIVC plus standard PIVC care as suggested by Queensland’s Department of Health (2015) can control the failure of PIVCs in adults being admitted in hospital emergencies. The reduction of the failure of PIVC can help the patients by enhancing comfort and reducing the number of admissions in hospital. According to Budgen (2016), the application of skin-glue (cyanoacrylate) can make the PIVC lines to become harder and so unintentional PIVC removal as well as site-infection is minimized (HospiMedica, 2016). They also suggested that using skin- glue in catheter site can in-directly prevent interruptions to medication therapies, thereby preventing patient’s anxiety and discomfort of reinserting PIVCs.

Nursing professionals should constantly contemplate research articles to develop solutions and/or outcomes for patient care; that forms the highest available evidence to continuously validate and promote nursing-care (Grove, 2015). According to PoIit (2016), evidence based practice is the conscientious use of current- best evidence to make clinical judgment about client care. Nurses who are the basic care providers should provide quality evidence care to all the patients based on the ethical principles (ACSQHC, 2013).

Data Collection

Nursing care rendered to the patients should maximize benefit to the patients and minimize harms based on the principle of beneficence and should not cause any harm and/or discomforts to them (maleficience) that includes physical harms (injuries), psychological harm (anxiety, stress), social (no societal support) as well as economical harm (loss of income). The care should be rendered by respecting their dignity and justice (Polit, 2016). Hence, much emphasis has to be given to practice evidence- based care and to protect patient’s lives.

Douglas (2012) given that a nursing professional should strive to prevent illness, promote health and protect health, which implies protecting patient from harms. Nurses should propose appropriate research studies to develop more evidences to protect our profession. As nurses are the front-line care givers in ED of any hospitals, they should render life- saving measures to the patients in which PIVC catheter insertion is commonly needed to initiate management process and should be expertise in protect it from its premature failure and PIVC dislodgement, infections at the catheter insertion site and PIVC occlusions because of blood clot or phlebitis (Rebelem, 2016).

PIVC’s failure can cause disruption of therapies to patients as hydration, antibiotic and/or analgesic therapies causing deterioration in patient’s heath severely as well as interrupting the treatment modalities and cause systemic sepsis (Stuart, 2013). This indirectly burdens the clients and their families by rising the cost, causing anxiety, stress and discomfort of re-inserting the PIVCs repeatedly (Aymes, 2016). Therefore, nurses should increase expertise to secure PIVC line safely in-order to protect the values of patient.

PIVC also increases the healthcare cost of a Nation by increasing the time of staffs in client’s care, extending length of hospital’s stay and increasing adverse event’s management. According to Wallis (2014), at-least a minor reduction in the IV-device failure can cause greater improvements in client-care, healthcare outcomes and healthcare costs. Hence, nurses should use skin glue adhesives to secure PIVCs with patient’s skin to promote patient’s values, minimize healthcare cost and enhance patient treatment.

Reference

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