Mitten vs. Wrist Restraints for Preventing Unplanned Extubation in ICU

Introduction

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

Literature Review

Mon, Minnick, and 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 results could be applied to a wide population. The study assessed 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 levels. It also found that patient harm occurred in 23% of extubation episodes; however, only a small percentage experienced major harm. 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 indicated a need to study it further, as restraints did not appear to significantly reduce the incidence of extubation in the sample population.

Chang, Wang, and Chao 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, and that their benefits and risks must therefore be weighed. The study involved 300 patients 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 patients who had experienced a stay in the ICU during a selected 21-month period.

Data were collected using medical records and incident reports of unplanned extubation. Several factors were identified that may lead to an increased risk of unplanned extubation. Notably, this study found that the use of physical restraints actually increased unplanned extubation by almost three times. 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 unplanned extubation. One of the key weaknesses of the study is that it relied on retrospective data, which increases the chance of research bias in data collection.

Bryan (2009) conducted a study building on the work of Chang, Wang, and Chao et al. (2008). This study also explored risk factors associated with extubation. When a patient self-extubates, reintubation is often required quickly — within the first hour to 48 hours. The risk of harm to the larynx, anoxia, or death is increased with unplanned extubation. This situation 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 versus sedation to decrease extubation risk. The study found that sedation increases the risk of extubation, as it often extends the time a patient requires ventilator support. However, the use of mittens also increased the chances of extubation due to an elevated risk of nosocomial infection. This study concluded that other methods — such as using family members as sitters — were a more effective way to prevent extubation. The study used actual patient data and observation to draw its conclusions; however, insufficient detail about the data collection and interpretation criteria was provided to allow an accurate assessment of reliability. It is not known how institutional policies may have affected data collection and interpretation.

Dunn (2009) also explored the topic of unplanned extubation, responding to the article by Chang, Wang, and Chao et al. (2008). This author contended that the earlier article was premature in concluding that physical restraint itself represented a risk factor for extubation. One of the key flaws identified in the original study is that the authors provided little information on the criteria used to determine which patients would receive restraints. This lack of information introduced a potential confounding variable that the original authors did not address. Differences between the two groups could have been attributable to differences in baseline risk factors rather than to restraint use. Dunn also noted that the original authors did not specify 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 whether this was the restraint used in the original study. Dunn's critique raises many valid points that were not addressed in the original study.

Silva, Sergio, and de Carvalho (2010) explored the use of restraints in intubated pediatric patients. The purpose of the study was to develop best practices for this special patient population and to outline strategies for preventing extubation. This study used a meta-analysis of studies obtained through a database search. The authors found that unplanned extubations in the pediatric population were closely associated with patient age, placing younger patients at greater risk. Additional associated factors included inadequate tube fixation, agitation, copious secretions, the performance of patient care procedures, and nursing workload. In this meta-analysis, the use of physical restraints produced conflicting results across studies. The authors also found that few studies have specifically examined extubation in pediatric populations. As with any meta-analysis, it is difficult to identify perfectly matched studies, which can affect the validity of the overall findings.

Krayem, Butler, and 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 staffing levels and the risk of unplanned extubation. Data were collected 24 hours before and 24 hours after each extubation event. The results revealed that factors such as patient agitation rate and benzodiazepine use represented more significant predictors than nursing staff factors. The study found no significant impact on extubation associated with nurse workload. One of the key strengths of this study is that it carefully attempted to eliminate as many confounding variables as possible. Some unaddressed variables may still have existed; however, given that no significant connection was found between staff workload and unplanned extubation incidents, it is unlikely that such factors would have substantially influenced the results.