The Reliability of Using IO Devices - Essay Example

Critique Rationale Various clinical studies and standards have already established that using intraosseous access is a safe and effective alternative in ensuring low levels of complications among patients with difficult IV access (Brenner, et.al., 2008). It is usually recommended for establishing venous access to children, but it has also been proven successful among adult patients. American and European clinical guidelines have stipulated that intraosseous access can be established among paediatric and adult emergency patients, if access cannot be established for peripheral veins during CPRs (Brenner, et.al., 2008). I chose this article because it is one of the first studies to discuss the reliability of using IO devices. This article stimulated my interest because I am a possible user of this device, especially with my work in the anaesthesia department. Moreover, since this study is a randomised controlled trial, it provides a reliable and peer-reviewed glimpse into the use of this device (Smith, 2011). Randomised controlled trials are considered as studies with the highest level of reliability in the hierarchy of evidence and using these studies as bases for clinical practice ensures evidence-based practice (Smith, 2011). The process of critical appraisal provides evidence-based support for clinical practice as it assists in the orderly evaluation of available evidence and in establishing which would best fit the needs of the patient (Young and Solomon, 2009). The goal of this paper is to assess the article and review its integrity, findings, reliability, and its defects using the CASP and the CEBM frameworks. The discussion by Parahoo (2006) shall also be used in this critical appraisal. At the end of this critique, a conclusion shall be established based on the discussion, its ethical elements and applicability to practice. Search Strategy In searching for significant articles to critique, I first carried out an online search in various databases, including Cochrane which yielded two positive hits. I also carried out a search in the Ovid MEDLINE database where there were three hits, and finally I also searched the PubMed database. This yielded four possible materials. I used the search words: “intraosseous”, “resuscitation”, “random”, “trauma” and “emergency”. I further defined the search parameters to human and English language studies. This was able to yield 15 randomised control studies which were relevant to the current study. After reviewing all the possible articles available, this study was finally chosen. Leidel, et.al., (2009). Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery, 3(24), 1-8. The study by Leidel, et.al., (2009) was carried out in order to compare the IO access as a bridging procedure when compared with central venous catheterization for in-hospital adult emergency patients being resuscitated with impossible peripheral IV access. This study compared the success rates and procedure times of the IO access versus the CVC among adult trauma patients under medical resuscitation admitted to the ER with impossible IV catheterizations. The title of the study was very detailed and very clear (Boswell and Cannon, 2011). The abstract was also specific and concise in displaying the study background, methods, results, and conclusion (Polit and Beck, 2008). The introduction presented a strong and precise background for the study, as well as a rationale for the use of the IO access route, and the justification for considering it as an effective alternative in applicable cases. The introduction also included a review of related studies, mostly evaluating peripheral venous access difficulty in emergency care, prehospital IV line placements, success rates of peripheral IV catheter insertion, and ultrasonography-guided peripheral IV access versus traditional approaches among patients with difficult IV access. Most of the studies were current, as they were carried out within five years from the publication of the study, but one study was out-of-date (Polit and Beck, 2008). This reduced the reliability of the literature review. The methodology section of the study ideally has to include details on the processes involved in successfully accomplishing the research, including the data gathering tools, why these tools and methods were used, and the population involved in the study (Kothari, 2008). In evaluating the methodology of this paper, the authors employed a well-organized approach by using subheadings for each relevant portion of the paper (Kothari, 2008). The readers could then easily designate the pattern and the thought processes involved in the research. The authors did not specify when the study was carried out, but the span of the assessment for each patient was from admission to 14 days after discharge from the hospital. It was carried out in a level 1 trauma centre which translated to a major hospital and an appropriate and efficient place for this study to be carried out (Leidel, et.al., 2009). The approval of the ethical committee was sought and gained by the authors. This approval complied with the ethical requirement involving human subjects, where a study cannot proceed without previous approval by an ethical committee (Portney and Watkins, 2009). The inclusion and exclusion criteria was logical and appropriate for this study as it included critically ill patients 18 years old and above who were brought to the resuscitative bay without or with insufficient peripheral IV catheterization and necessary immediate vascular access (Leidel, et.al., 2009). The patients’ informed consent was also gained by the authors (Minnies, et.al., 2008). The authors specified the use of the FDA approved the EZ-IO (Vidacare Corporation) for humeral head, proximal and distal tibial access in adults, as well as for proximal tibial access in paediatric patients (Leidel, et.al., 2009). The procedure was carried out by two independent participants along with a third independent observer with two stopwatches. The researchers however did not explain how the independent observers and participants were recruited. The researchers did mention however that the participants were trained consultants who were experienced in resuscitation. Each participant also received a 60-minute lecture on the use of the IO device and the independent insertion on the IO model (Leidel, et.al., 2009). The researchers followed religiously the process recommended by the manufacturers on the insertions; this helped promote patient safety (Bates, 2009). Results were presented in text form, without any tables. This made the presentation of results less organized (Cottrell and McKenzie, 2008). The authors nevertheless supported their results by referring to their literature studies and previous explanations on IO techniques (Wood and Kerr, 2010). The authors also presented limitations to their study (Nursing Research, 2012). First, they mentioned that their sample size is small, however, there was a notable significant difference in procedure times in enabling vascular access (Nursing Research, 2012). Secondly, there also was a potential bias for investigators in favouring IO access, but this was resolved when they used two independent operators (Nursing Research, 2012). Main findings The study revealed that the success rate at first attempt was 90% for IO access patients as compared to 60% for CVC patients. One IO insertion failed because the operator mishandled the process by not inserting the cannula through the proximal humerus. The IO catheter therefore did not penetrate the bone marrow because of the soft tissue at the incorrect site (Leidel, et.al., 2009). There were four CVC attempts which did not succeed on first insertion, but succeeded on their second attempt. In these unsuccessful attempts, a guidewire was not inserted into the vessel. The mean time for insertion was shorter in IO cannulation which registered at about 2.3 minutes; compared with the CVC cannulation which registered a mean time of 9.9 minutes (Leidel, et.al., 2009). No complications for either study groups were seen following unsuccessful insertion attempts. Moreover, no bleeding, malposition, dislodgment, or arterial punctures were also seen. Comments Implications for practice and some ethical aspects: 1. Securing appropriate skill training and education in the insertion of IO devices is an important part of the clinical practice (Wayne, 2006). They ensure the success of insertions and promote patient safety. These trainings must also be carried out on regular and frequent intervals through patient simulations and video skill training exercises (Wayne, 2006). 2. IO devices and related tools must be within easy reach of doctors and of emergency room clinicians in the emergency unit trauma units (Ngo, 2009). They should also be available in all crash carts within the hospital setting. The study above was able to manifest the efficacy of the IO access technique and this provides sufficient support for use of this technique in emergency trauma units. It is therefore incumbent upon hospital authorities to authorize the purchase of these devices for their use. 3. Since this technique is about to become a well-supported part of the medical, nursing, and clinical practice, it is therefore important for medical and nursing schools to incorporate IP access insertions into their academe (Phillips, et.al., 2010). The training must start as early as possible for these health professionals in order to ensure that new entrants into the practice would be armed with the skills to implement IO insertions as routine practices. 4. The application of IO devices is also beneficial for various other reasons. Aside from providing speedy and efficient IV access, they also allow bone marrows samples to be extracted for laboratory diagnosis in venous blood gases as well as electrolyte levels (Tay and Kulkarni, 2011). IO access also allows the delivery of medications to the different parts of the body. Ensuring its widespread use is therefore imperative for the improvement of the healthcare practice. 5. The widespread use of the IO devices includes precautions which the health practitioners must recognize and implement. One of these precautions is on the battery of the EZ-IO devices (Phillips, et.al., 2010). The checks must be routine and regular in order to prevent any compromises on its use and to ensure patient safety. Moreover, the IO expiry dates must also be checked regularly. 6. Even as the use of IO access seems to present with various benefits, significant considerations on its limitations must also be considered, especially those which are indicated by its manufacturers. For one, it cannot be applied on fractured bones because of risks involving extravasation. Secondly, areas with prosthesis must be avoided as insertion sites (Phillips, et.al., 2010). Thirdly, IO needles must be extracted within 24 hours without any follow-up cannulations on same site after 24 hours from first insertion. Fourth, in instances when infections on the site are apparent, IO insertion must not be used; finally, for patients with bone diseases, IO insertions are not often recommended, and are based on other co-morbid conditions (Phillips, et.al., 2010). 7. The ideal insertion sites for IO access insertions are at the proximal and distal tibia. The Leidel (2009) study mentions that their insertion site was at the humeral head and proximal tibia. 8. During IO access insertions, there are often special circumstances which surround the patient, and most of them involve patients who are unconscious. These patients still have a right to be administered with safe and appropriate care; therefore, health providers must still apply the appropriate methods of care, including aseptic techniques and standards of care in order to ensure compliance with ethical and clinical requirements of care (Phillips, et.al., 2010). 9. There is a need for the healthcare givers to coordinate with each other during IO access insertions. With coordinated team working, errors can be prevented and vigilance on the practitioners can be ensured. Ethical considerations There are three ethical considerations which govern patient decisions. These considerations include patient independence/autonomy, beneficence, and justice. 1. Patient independence/autonomy. This also refers to a patient’s right to self-determination or the right to make the crucial decisions which relate to his care and his personal welfare (Husted and Husted, 2007). Since his welfare and his care is his personal business, it is therefore incumbent upon him to make the decisions in relation to his treatment or lack thereof. However, in instances when his life or the life of other individuals is threatened, this right to self-determination has to give way (Husted and Husted, 2007). Moreover, in instances, when the patient would lose his consciousness, the decision regarding his welfare would be taken over by the healthcare provider and shared with his family members or appointed caregiver (Husted and Husted, 2007). Nevertheless, utmost care must be ensured by the health care giver in ensuring that any last directives from the patient regarding his care would be considered (Husted and Husted, 2007). In instances when IO access insertions would be applied in these situations, the patient’s family must be informed about the benefits, risks, and side-effects of the procedure. 2. Beneficence. This refers to the importance of acting in the ultimate benefit of the patient (Westrick and Dempski, 2008). This benefit is weighed in relation to various considerations including the impact of other options for insertion, such as those seen in CVC insertions. The use of IO access is related to a variety of complications, however when these risks and benefits are evaluated in relation to the risks and benefits of CVC insertions, the use of IO insertions still imply better options for the patients. 3. Justice. Finally, justice refers to distributive justice or the process of giving someone his due (Westrick and Dempski, 2008). For patients who deserve the best possible care at the least possible cost and risk to their life, the application of the IO insertions is a beneficial consideration – one which needs to be openly accepted as part of the health practice. References Bates, D. (2009) Global priorities for patient safety research, BMJ, 338:b1775 Boswell, C. & Cannon, S. (2011), Introduction to Nursing Research: Incorporating Evidence-based Practice, London: Jones & Bartlett Publishers. Brenner T, Bernhard M, Helm M, Doll S, Völkl A, Ganion N, Friedmann C, Sikinger M, Knapp J, Martin E, Gries A (2008), Comparison of two intraosseous infusion systems for adult emergency medical use, Resusc, 78: 314-319. Cottrell, R. & McKenzie, J. (2011), Health Promotion and Education Research Methods: Using the Five-chapter Thesis/dissertation Model, London: Jones & Bartlett Publishers Husted, J. & Husted, G. (2007), Ethical Decision Making in Nursing and Health Care: The Symphonological Approach, London: Springer Publishing Company. Kothari, C. (2008), Research methodology: methods and techniques, New York: New Age International. Leidel, B., et.al., (2009), Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study, Patient Safety in Surgery, 3:24. Minnies, D., Hawkridge, T., Hanekom, W., Ehrlich, R., London, L., & Hussey, G. (2008), Evaluation of the quality of informed consent in a vaccine field trial in a developing country setting [online]. Available at: http://www.biomedcentral.com/1472-6939/9/15 [accessed 19 March 2012]. Nursing Research (2012), Evaluating and Critiquing Nursing Research [online]. Available at: http://nursingplanet.com/Nursing_Research/critiquing_nursing_research.html [accessed 19 March 2012]. Ngo, A., Oh, J., Chen, Y., Yong, D., & Ong, M. (2009), Intraosseous vascular access in adults using the EZ-IO in an emergency department, Int J Emerg Med., 2(3): 155–160. Parahoo, K. (2006), Nursing Research(2nd ed), Hampshire: Palgrave Macmillan. Phillips, L., Brown, L., Campbell, T., & Miller, J. (2010), Recommendations for the Use of Intraosseous Vascular Access for Emergent and Nonemergent Situations in Various Health Care Settings: A Consensus Paper, Crit Care Nurse, 30(6), 6 e1-e7. Polit, D. & Beck, C. (2008), Nursing research: generating and assessing evidence for nursing practice, London: Lippincott Williams & Wilkins. Portney, L.G & Watkins, M.P (2009), Foundations of clinical research: Application to practice (3rd ed.), New Jersey: Pearson Education. Smith, C. (2011), Research design and statistics: Randomized controlled trials, Phlebology, 6:84-85. Tay, E. & Kulkarni, R. (2011), Intraosseous Access, eMedicine [online]. Available at: http://emedicine.medscape.com/article/80431-overview [accessed 20 March 2012]. Wayne, M. (2006), Adult Intraosseous Access: An Idea Whose Time Has Come, Israeli Journal of Emergency Medicine, 6(2), pp. 41-45. Westrick, S. & Dempski, K. (2008), Essentials of nursing law and ethics, London: Jones & Bartlett Learning. Wood, M. & Kerr, J. (2010), Basic steps in planning nursing research: from question to proposal, London: Jones & Bartlett Learning. Young, J. & Solomon, M. (2009), How to critically appraise an article, Nature Clinical Practice Gastroenterology & Hepatology, 6, 82-91 Read More