Mitten Restraints in ICU Patients

Mitten Restraints in ICU Patients

The use of mittens or sleeve restraints as effective as the use of wrist restraints in the prevention of unplanned extubation

Endotracheal tubes are an uncomfortable reality for patients in intensive care units. Often, patients will remove their tubes by themselves, placing them at risk of harm from the inability to breath through mechanical means. The issue of various types of restraints is a topic that has received recent attention from the medical community. The problem unplanned extubation is a serious risk for patients and increases the difficulty of caring for intensive care patients. The problem is important for the medical community and for the patients. The following will explore representative articles regarding the use of various restraints on patients to restrict them from removing their tubes before it is deemed medically appropriate.

Literature Review

Mon, Minnick, & Leipzig et al. (2007) explored the prevalence of the extubation problem in intensive care units. The research objectives of the study were to assist in the development of guidelines to help prevent patient-initiated extubation. The study addressed the prevalence of the issue in order to ascertain the significance of the problem. This study used a large, geographically diverse sample population of 49 adult intensive care units spread across five states. This sample population increased the external validity of the study in such a manner that it could be applied to a wide sample population. This study assessed the total patient days and the number of episodes, expressed in terms of patient days. The study found high extubation rates in ICUs that had fewer resources and lower staffing rates. It also found that patient harm occurred in 23% of the extubation episodes. However, only a small percentage experienced major harm from the episode. Of the patients examined, nearly 44% were restrained in some manner at the time of extubation This study highlighted the significance of the problem and also indicated a need to study the problem further, as restraints did not appear to significantly reduce the incidence of extubation in the sample population.

Chang, LY., Wang, KW., & Chao, YF et al. (2008) explored various forms of physical restraint that have been used to prevent patients from prematurely removing their endotracheal tube in intensive care units. The study surmised that physical restraints represented a physical risk and additional safety hazard to patients. Therefore, their benefits and risks must be weighed. The study involved 300 patients that were divided into a control group and a test group. The test group consisted of 100 patients with unplanned extubation and a demographically matched group of 200 who had no record of unplanned extubation. The study was conducted on a group of Taiwanese patient who had experienced a stay during a selected 21-month period.

The data was collected using medical records and incident reports of unplanned extubation. Several factors were found in this study that may lead to a risk of unplanned extubation. This study found that the use of physical restraints actually increased unplanned extubation by almost three times. An infection, longer stays in the unit and higher scores on the Glasgow coma scale also increased the risk of extubation. This study contributed to a general understanding of the risk factors involved in an increased risk of unplanned extubation. One of the key weaknesses of the study is that it used retrospective data. In this type of study, a chance of research bias in the data collection is increased using this type of study method.

Bryan (2009) conducted a study based on the study by Chang, Wang, & Chao et al. (2008). This study also explored risk factors associated with extubation. When a patient extubates, they must often be reintubated quickly, within the first hour to 48 hours. The risk of harm to the larynx, anoxia or death is increased with unplanned extubation. This has led nurses to resort to increased use of restraints or various levels of sedation to decrease the chances of extubation. The study examined the use of untied mitten restraints vs. sedation to decrease the risk of extubation. The study found that the use of sedation increases the risk of extubation, as it often extends the time needed on a ventilator. However, use of mittens also increased the chances of extubation due to increased risk of nosocomial infection. This study concluded that other methods, such as using family members as sitters was as more effective way to prevent extubation. This study used actual patient data and patient observation to draw its conclusion. However, not enough details about the data collection and interpretation criteria were provided to make an accurate assessment of the reliability of the data used in the study. It is not known how the biases of the rules of the institution affected the data collection and interpretation of the data.

Dunn (2009) also explored the topic of unplanned extubation. The article was also a response to the article by Chang, Wang, & Chao et al. (2008). This author felt that the former article was premature in its conclusions that physical restraint presented its own risk factor for extubation. One of the key flaws found with the original study is that the authors provided little information on the criteria that was used to determine which patients would receive the restraints. This lack of information introduced a potential confounding variable that was not addressed by the original authors. Differences in the two groups could have been due to differences in risk factor among the patient groups. Dunn brings up a valid point about the study by Chang and colleagues. Another factor that Dunn examined in a critique of the study is that the original authors did not indicate the type of restraint used. Dunn found that the most typical type of restraint is a wrist belt tied to the bedside railing, but it is not known if this was the type of restraint used in the original study. Dunn's analysis of the study conducted by Chang and colleagues brings up many valid points that were not addressed in the original study.

Silva, Sergio, & de Carvalho (2010) explored the use of restraints of intubated pediatric patients. This study explored the topic of unplanned extubation in pediatric patients. Its purpose was to develop best practices for this special group of patients. It also focused on strategies to prevent extubation in this special population. This study used metaanalysis of studies obtained through a data base search to derive the results. This study found that unplanned extubations in the pediatric population were closely associated with age, placing younger patients at greater risk. They were also associated with inadequate tube fixation, agitation, copious secretions, the performance of patient procedures and nursing workload. In this metaanalysis, the use of physical restraints produced conflicting results across studies. The study found that there are few studies regarding extubations in pediatric populations. As with any metaanalysis, it is difficult to find perfectly matched studies, which can impact the results of the study.

Krayem, Butler, & Martin (2006) explored the incidence and factors associated with unplanned extubation with the intention of determining its impact on nursing workload. This study assessed five risk factors and nine factors of nursing manpower to determine the connection between nursing staffing factors and the risk of unplanned extubation. Data was collected 24 hours before and 24 hours after an extubation event. The results of the study revealed that factors such as agitation rate of the patients, the amount of benzodiazeprines represented more significant factors than nursing staff factors. This study found not significant impact on extubation associated with nurse workload. One of the key strengths of this study is that it carefully attempted to eliminate many as many confounding variables as possible. There still might have been issues that were not addressed, but that could have affected the outcome of the study. However, because the study found no significant connection between staff workload and unplanned extubation incidents, it is unlikely that these factors would have influenced the results of the study significantly.