Routine Care of Peripheral Intravenous Catheters versus Clinically Indicated Replacement: Randomized Controlled Trial
By Joan Webster et al. (2008)
Summary of Method and Findings
The objective of the study is to compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated. The study was conducted at the Tertiary Hospital in Australia and included 755 medical and surgical participants, 379 (intervention group) of which were allocated to catheter replacement only when clinically indicated and 376 (control group) were allocated to routine care of catheter. The researchers employed a randomized controlled trial.
By conducting an experiment involving medical and surgical patients, the researchers recorded a composite measure of catheter failure resulting from phlebitis or infiltration. The result of the experiment yielded no significant difference in catheter failure resulting from phlebitis or infiltration between the control group and the intervention group. 123 of 376 or 33 percent of the patients in the control group needed their catheters to be removed because of phlebitis or infiltration. On the other hand, 143 of 379 or 38 percent of the patients in the intervention group needed their catheters to be removed because of phlebitis or infiltration. When the analysis was based on failure per 1000 device days, no difference could be detected between the groups.
The researchers found that replacing peripheral intravenous catheters when clinically indicated has no effect on the incidence of failure, based on a composite measure of phlebitis or infiltration. The authors also suggested that an in-depth experiment be conducted focusing on phlebitis to arrive to a more significant outcome.
Presentation of the Research
The abstract is very helpful and informative. It gives a brief yet concise information about the research, the subjects and a glimpse at the results. The abstract introduced how different methods were used to conduct and analyze data. Background information and explanations were present throughout the article especially in the introduction. What I found lacking was an in-depth literature review which is important as it lays the foundation for the research.
Execution of the Research
The methodology was listed in several areas of the research paper. The researchers thoroughly discussed the steps including the techniques, strategies, tools that were used. The researcher also discussed who conducted the experiments and who helped in the experiment. The characteristics of the subjects including the selection methods that were used to choose the subjects were also discussed. The results of the study were clearly presented and discussed. Tables and figures were used in order to clearly present the results.
Critical Appraisal
The subjects that were included in the experiment came from a general tertiary referral teaching hospital with several specialties, including medicine, surgery, Orthopaedics, psychiatry, oncology, obstetrics, gynecology, and trauma services. Those who were included in the experiment were patients aging 18 years old and above. The researchers only recruited patients that require multiple or consecutive catheters into the study.
The researchers randomly selected the patients that will be included in the routine care (control group), with catheters scheduled to be replaced every three days according to hospital policy. The researchers employed block randomization. This was done using a computer generated random number list that the researchers prepared. In order to avoid selection bias, the researchers made use of allocation concealment. After the consent and randomization, the research nurse collected baseline personal, clinical, and catheter related data, which included the type of infusate and any additives, drugs injected into the intravenous set and their pH level, type and size of the catheter used, and the site of insertion.
In order to measure the primary outcomes of the experiment, the researchers used a composite measure of catheter failure resulting from phlebitis or infiltration. The researchers also made use of secondary outcomes such as infusion related cost.
Participants
The researchers clearly described the size and major characteristics of the population studied. The researchers also clearly described the method for selecting the sample. There were no suggestion of any limitations or biases in the sample. The sample size meet the suggested guideline for minimum sample size appropriate for quantitative analyses.
Instruments
In measuring the primary outcome, the researchers made use of a composite measure of catheter failure because of phlebitis or infiltration. The researchers also used several secondary outcomes including infusion related cost, which was calculated in two ways – costs associated with catheters inserted for the intermittent administration of intravenous drugs, and cost associated with catheters inserted for continuous infusion.
The researchers made sure that in conducting the experiment, they have the permissions of all the people and organization involved. The instruments used were described including their purpose. The instruments used were appropriate for measuring the intended variables. The researchers also presented evidences in order to validate the appropriateness of the instruments for the intended sample.
Design and Procedures
In order to effectively to compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated, the research nurse collected baseline personal, clinical, and catheter related data which included the type of infusate and any additives, drugs injected into the intravenous set and their pH level, type and size of catheter used, and the site of insertion. Choice of catheter type and gauge was at the discretion of the nurse or doctor inserting the catheter. Catheter insertion sites were inspected daily by a nurse from the intravenous therapy team and by ward nurses when intravenous solutions were changed or when drugs were added. Because research staff were not responsible for recording the reason for catheter removal, a specially designed form was developed for completion by the nurse removing the cannula. This was to optimize the standardization of reporting outcome measures.
The design and procedures used by the researchers were appropriate for examining the research objectives. The researchers described the procedures in sufficient detail in order for them to be applied to further researches on the subject.
The title appropriately indicates the objective as well as the type of research design (intervention/control/randomized clinical trial). The abstract is well structured and per the journal standards and is complete in presenting the key points of each section of the article. The clinical problem and the study objectives are clearly presented in the abstract and the text of the article. The authors were also able to present the limitations of existing research and a gap in scientific knowledge about the study topic are clearly articulated in the introduction to the article and provide an adequate foundation and rational for the study.
The study used a true experimental study in which subjects were randomly assigned to control over experimental group conditions. The independent variable is the exposure status to the intervention, and this is clearly articulated in the text of the article. A pre-test/post-test design with repeated measures was used, in which baseline data were gathered from the patients prior to the implementation of the intervention in the experimental group. The methods that the researchers employed were clearly explained and the statistical techniques were discussed thoroughly.
The sampling design for this study appears to have been well planned. The study setting was well matched to the sample the researchers sought to obtain. The study recruitment rate was very high. A very good level of detail is provided about the data collection procedures and measures used in the study.
The data analysis plan appears generally appropriate. The results were generally consistent. The overall presentation and clarity of the article are excellent. The researchers were able to present their findings in an organized way and the use of tables and other figures were appropriate and they added to the clarity of the results.
The major strengths of the study were the processes used to eliminate selection bias to ensure allocation concealment. One weakness of the study is it failed to incorporate theoretical perspectives from the related literature. There were no clear review of literature. However, the authors managed to use several significant references in the introduction section. The references that the authors used helped in the overall understanding of the subject. The researchers also included a broad range of participants and did not impose any limitations on how or by whom catheters should be inserted.
One of the weaknesses of the research was that the outcomes were not strictly monitored. More reliable results could have been achieved if a standardized approach was used.
Assessment of Value of Article
The purpose of the study is to compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated. The researchers’ conclusions to the study are accurate. The conclusions show that replacing peripheral intravenous catheters only when clinically indicated does not reduce the incidence of catheter failure, on the basis of a composite measure of phlebitis or infiltration. The researchers found out that catheters may be safely left in place form longer than 72 hours if no contraindications are present. When catheters are replaced only when clinically indicated 25% of infusion related costs are saved. The researchers were able to establish a new finding that may help the practitioners and patients. The research reveals that it is more effective to change catheters when clinically indicated rather than the standard procedures where in catheters are removed every three days. The research reveals that there were no significant difference between the occurrence of phlebitis or infiltration between removing catheters every three days and removing catheters when clinically indicated. This is an important finding as it will potentially result to the reduction of infusions related costs.
The researchers pointed that larger trials are needed to test their findings using phlebitis alone as a more clinically meaningful outcome. The conclusions are warranted but do not hold implications for catheterization practice. Instead, the conclusions should be used as a springboard to further investigate the implications for catheterization practice, which the authors indicated in the conclusions and recommendations.
Overall I believe that the study makes an important contribution to advancing knowledge regarding catheterization because there is little current research of the subject. Also, it provides valuable information that demonstrates the effect of replacing peripheral intravenous catheters when clinically indicated on the incidence of failure as compared to the established standard.
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