Critical Evaluation Report On Quantitative Study

Abstract

Discuss about the Critical Evaluation Report on Quantitative Study.

Critical evaluation involves a balanced appraisal of a study requiring logical and objective identification of the systematic manner of enquiry that underpins a research study (Steen, 2011). Critical appraisal should be undertaken by the nurses to determine the applicability of research into practice (Polit, 2016). The models as Rees model, Critical- Appraisal skilled program, Parahoo and Crombie model, Consolidated-standards of reporting trial, etc are used for critiquing studies (Baker, 2014). This study was published in Annals journal- of Emergency-medicine, which is an international, peer-reviewed journal that is published by the ACEP (American college of Emergency- Physicians). Annals publishes research reports, articles and facts of emergency-medicine including out-of-hospital, paediatric and toxicology emergencies, disaster management, injuries and prevention with other speciality topics.  Annals are published in United States.

Annals’ impact factor-5.008, CiteScore-1.81, 5-Years Impact- Factor-5.041, Source- normalized Impact/Paper (SNIP) -2.287 and SCImago- Journal Rank-1.942 suggests that it is the largest circulating journal in emergency-medicine with over 33,000 subscribers (ACEP, 2016). Almost half of the research articles could be accessed through Science-Direct and were downloadable in several countries. In 2015, Annals received submissions from 65 countries as Canada, Australia, etc with 46% outside US (Callaham, 2017). These informations drive me to use the research finding in my practice with evidence.

The authors of this study Simon Bugden, Mark Scott, Sean Clark and Christopher Johnstone are experts in the emergency department of Caboolture-Hospital at Queensland as well as works in Centre for Health-practice innovations and members of Critical-care research group, Griffith-University. The author Mihala has contributed 29 articles, 101 citations and Fraser with 462 articles, 3,697 citations whereas Rickard with 191 articles, 2,231 citations. This study was carried-out in Caboolture-community hospital at Queensland. The information about author gives me confidence to carry out this research study in my clinical care effectively.

The study’s title is clear, concise and congruent with the text. They have stated a concise and achievable objective, which is to determine whether the skin glue application with standard peripheral intra-venous catheter (PIVC) care could minimize the failure rate of PIVCs. The abstract includes a clearly focused hypothesis and concise research design of single insertion-site, two-arms, non-blinded, randomized with controlled trial with sample descriptions of 380 participants. It explains about the standardized securement and skin glue group and measurement instruments for primary outcomes of PIVC failure at <48 hours and secondary outcomes with detailed findings and conclusions.

Structuring the Study

The authors have clearly demonstrated their motivation in the current study by their structured literature-review. They have given that PIVCs are one of the most common medical-invasive devices that are used in the hospitals. Approximately 80% of the hospitalized patients are inserted with PIVC with majority in emergencies (Limm, 2013). According to Marsh (2015), 33% to 69% of PIVCs fails because of infections, catheter occlusions, phlebitis or dislodgement with majority occurring because of inadequate fixation of PIVC. As there are no clear evidences to practice skin-glue securement, the researchers have proposed this study on the effect of addition of skin-glue securement with standard catheter-care based on guidelines of Queensland (2015). The quoting of study by Marsh et al (2015) was not relevant as it describes about PIVC failure only in wards. The literatures were recent, clear, summarized, well-organized and comprehensive. The literatures were relevant to the study title with correct citations. The literature could have concentrated more on PIVC failure in ED and evidences to compare the effectiveness of skin-glue with comparators. Their evidences to demonstrate effect on skin glue on arterial and epidural catheters are highly informative. They have performed a single-site, 2-arm, randomized with controlled-trail among 360 patients having 380 PIVCs. They have randomized the samples through the software (Randomizers for clinical trials) in 1:1 ratio to the standard group and skin-glue group (not blocked/stratified). The researchers have kept a drop of cyanoacrylate-glue at the catheter insertion-site and PIVC’s hub in skin-glue group and have measured the primary and secondary outcomes. They have stated a clear hypothesis which predicts relationship between variables (Polit, 2016) as the addition of ski-glue at the PIVC insertion-site could reduce PIVC failure rate at 48 hours. They used scientific hypothesis and has expressed interest in testing the relationships between variables.

They have described the samples clearly. The samples were determined by three research nurses in emergency department for 16 hrs per day for one week (7 days). The research nurses have included the samples having peripheral intra-venous catheter insertion in any of the upper limbs (with intact skin) that is inserted by the emergency nurses or doctors and has given informed consent. The researchers have determined the sample-size with 174 patients in each group (standard securement and skin-glue group). They have included the samples only after confirming the patency of PIVC by flushing the line with 10 ml (0.9%) normal saline. They have excluded the patients who are known allergic to skin securements, infections at catheter-site, phlebitis with thrombotic features in the insertion-site, unwilling and agitated patients and persons who doesn’t speak English.  

Sample

They have collected the base-line demographic with possible confounder details from all the patients during the enrollment through a self-structured questionnaire. Its variables include age, sex, medication intake, no. of PIVC insertions, insertion-site, limb of insertion, person of insertion, the gauge size of PIVC and time from insertion of PIVC to intervention as well as follow-up time. They have measured the primary outcomes by one of three research nurses as suggested by Rickard (2012) through directly visualizing the patients for in-patients or by telephoning to the discharged patients and collecting informations about the presence of failure features by 48 or more hours (Webster, 2010). The researchers have collected informations for secondary outcomes by directly observing, reviewing the charts and through structured-patient’s questionnaire. They have described about the method of collecting data but they have not adequately given about the method of measuring data. The researchers have mentioned that they have measured the infection, occlusion, phlebitis and dislodgment but they have not mentioned through which measurement they have graded the features. The researchers have clearly measured primary outcomes data by self-structured questionnaire (direct observation/telephoning) and secondary outcomes through direct-visualization, reviewing medical charts as well as standard- patient’s questionnaire. The researchers have not adequately indicated about the measurement instrument’s origin. But, they have clearly included their use of study instruments given by Rickard in 2012 through their quote. The researchers have not clearly indicated about their study instruments for both outcomes. They have not mentioned about the validation of their study instruments which questions about the reliability of the study instruments. Moreover, they have not indicated the reliability of their study instruments anywhere in the study which suggest that they have not checked their reliability. They have mentioned about any ethical issues they have faced other than their procedural issues.

The follow-up by the researchers was adequate enough to judge the study findings credible. They were able to manage their follow-up loss appropriately as only 0.83% of the samples loosed from both groups. They have tackled this issue by eliminating the follow-up loss patients which is evident in their data description. The researchers haven’t blinded the samples as they were unable to blind due to the presence of similar color as well as appearance of samples during data collection (intervention and following-up time). The data-analysis shows that significant differences are noted in the rate of failure of PIVC between skin-glue group as well as standard- group with 10% increased failure rate in standard group at CI-95% between –18 to –2%, p=.02. The significant difference was also noted in the secondary outcomes of dislodgement at CI-95% from –13 to 0%, p=.04 with 7% reduction in skin-glue group and phlebitis and occlusion was also found to be reduced in skin-glue group yet statistical-significance was not shown. There are no infections in both groups. As given by Newcombe (2012), they used inferential statistics with point estimation-Confidence Interval to demonstrate inferences. The primary statistical-analysis shows that PIVC failure was significantly low in skin glue group than that of standard group indicating a statistical difference between them at p<.05 and hence the given statistical hypothesis is accepted. The secondary-data shows that the differences in dislodgement of both the groups were also statistically-significant indicating statistical difference between both the groups at p<.05 levels, which shows that statistical-hypothesis is accepted. The differences of phlebitis between both the groups are low with CI-95% between –5% to 3% indicating that they are not statistically-significant. Occlusions with CI-95% between –8 to 4% indicate that they are not statistically-significant and there was no infection in both groups. 

Data Collection

The findings were expected and they have presented with complete informations to generalize the results. They have clearly given their findings as per objectives. Their findings indicates that the PIVC failure-rate was significantly (10%) lowered in skin glue group patients (17%) as related to the standard group (27%) with CI-95% from –18% to –2%, p=.02) and secondary outcome because of dislodgement was identified to be (7%) lesser in skin-glue group as compared to the standard group with 14% at CI-95% between –13% to 0%. The findings suggest that the PIVC failure rate because of phlebitis and catheter occlusions was noted to be reduced in skin glue group than that of standard- care group yet has no statistical significance. There are no infections (0%) in skin- glue and standard group. The data analysis in standard care group with 179 patients and skin-glue group with 170 patients indicates that the PIVC failure-rate was 52 & 31 respectively and the secondary PIVC-failure was 51 & 28. Limitations were noted as it was conducted in particular setting with specific cultured people.  Their confounder details should have included with other potential drug use (sclerotics, anti-coagulants) with dwell time, etc (Wallis, 2014). Their evaluation over phones may not give appropriate results yet nowadays the patients know the features clearly. The researchers have mentioned that they will conduct cost-benefit analysis study (if they get adequate funding) in the future. The implications for this study were given as the usage of skin glue is shown to minimize PIVC failure. They are highly and are simple and quick method to be performed even in emergencies. They have not mentioned about permitting others to conduct similar study.

Conclusion

The researchers have concluded by suggesting that the addition of skin glue along with the standard care guidelines as given by Queensland can minimize the failure rate of PIVC specifically in patients in ED. When the PIVC failure rates are reduced, it will promote the patient’s values by avoiding unnecessary expenses of cost, time, resources, staff’s effort, etc. By practicing appropriately, this method will promote patient’s comfort, improve their outcomes as well as reduce the number of admissions in the hospitals because of complications caused by PIVC failure. The study findings indicates that when skin- glue is used to attach PIVC to insertion-site, unnecessary interruptions to therapies will be prevented completely and hence comfort of the patient will be maintained. In his study, Stuart (2013) showed that at-least in 0.1% of the PIVC failure acquire sepsis that endangering the life of the patient adversely yet it could be avoided completely.

Data Analysis

The nurses are the primary care- givers to all the patients of all ages irrespective of caste, creed and in all the settings. Their principal duty is to provide a quality care to all the patients based on their ethical principles. The nursing care should provide some benefit to the patients (beneficence) rather than any harm to them (maleficience) with justice and fair treatment (Polit, 2016). Hence, recently more emphasis has been given to practice evidence based care to protect the life of the patient. According to the International Nurses council (2010), a professional nurse should be able to prevent illnesses, promote health of all the people and protect their health which means protecting from harmful deeds. All the nurses should conduct relevant research studies to gain more evidences to protect our profession (ANA, 2010). The nurses are the front line workers in emergency department of any hospitals to provide life saving measures in which peripheral intra-venous catheter insertion is most needed as it helps to initiate treatment process.

Rebelem (2016) has mentioned that the nurses have to be expertise to protect patients from peripheral intra-venous catheter failure such as phelibitis, infection at the catheter insertion site itself and catheter dislodgement and occlusions. Majority of the patients in ED should have to be started with infusions through peripheral intra-venous catheter and the nurses has to protect the patient from failure of 33% – 69% of peripheral intra-venous catheter leading to discomfort, thus affecting the value of patient severely. The main contributing factor to this premature device failure is due to the improper fixation of the peripheral intra-venous catheter causing dislodgement and affecting micro-motion causing vein irritation (phlebitis and occlusion) resulting in infection. It occurs mostly during first 48 hours after insertion which implies that securement methods have to be improved. Hence, nurses should use skin securement at the catheter insertion site to develop adherence of catheter with the patient’s skin. O’Grady et al (2011) has suggested that many researches have to be conducted to study about the intravenous catheter replacement. PIVC failure causes disruption of therapies as hydration therapy, antibiotic and analgesic therapy resulting in the deterioration of patient’s heath adversely causing burdening of the patients and their family members by increasing the cost, producing anxiety and re-inserting the catheter (Aymes, 2016). Moreover, it increases the costs of the health- care including increased man power requirement and increased length of stay (Stuart, 2013). Hence, by using skin glue for securing patients with PIVC, the nurses will surely enhance the patient’s values as well as prevent disease and death rates of people within their ethical principles.

Reference

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