| BackgroundIn neurosurgery intensive care unit(NCU), large amounts of critical andunconscious patients, heavy nursing workload, no accompanying from familymembers, and uncomfortableness due to intubation lead to unplanned extubation,which interfer the treatment and cause damage even death. Physical restraints areusually used to prevent the occurrance of unplanned extubation. However, it wasreported that restraint could also cause physical and psychological injury in patientseven misunderstandings and contradictions between nurses, patients and their families.There was also not enough evidence for the physical restraint in preventing unplannedextubation. No literatures were found associated with unplanned extubation onpatients in NCU in recent years, thus the clinical situation in NCU is unknown to us.In the meantime, there were few reports about whether restraint could reduceunplanned extubation or not. Therefore, it is necessary to investigate the status quo ofunplanned extubation in NCU and identify the effectiveness of physical restraintpreventing unplanned extubation, so as to make guidelines to enhance the validity andreduce the injury of restraint.Objectives1. To investigate the status quo of unplanned extubation in NCU and analyze itscharacteristics and risk factors; to find out the impact of the physical restraint onpreventing unplanned extubation.2. Systematically review the physical restraint in preventing unplannedextubation and provide references for the physical restraint’s standardized practices ofneurosurgery conducted in later stages. Methods1. A self-designed record sheet for intubation and unplanned extubationconditions and a UEX registration form were used to observe the intubation andunplanned extubation conditions and analyze the clinical characteristics of UEX andthe physical restraint application of the patients in NCU from a Grade III-Class Ahospital. Same cases of planned extubations patients were matched to the cases whohad unplanned extubations based on age(±5yeas), gender,diagnosis,the type of theintubation etc, and the difference of the2groups in the work shift were compared induration of intubation, use of physical restraint and etc.2. PubMed, Ovid, EMbase, EBSCO, Cochrane Library, CBMdisc, CNKI, VIPwith a computer were searched. Relevant Chinese nursing journals were manuallysearched and references from determined literatures were traced. Only English andChinese literatures were searched with no limitations in publication time. The RCTs,non-RCTs and observational literatures for the physical restraint effect on preventingunplanned extubation were aquired. Study quality was assessed according to themethodological quality evaluation standard. A qualitative evaluation was used in theanalysis of observational literatures while meta-analysis, test for heterogeneity,sensitivity analysis were used when2groups were compared between restraint groupand unrestraint group, or between nursing intervention for restraint group(hereinafterreferred to as the intervention group) and simple restraint group.Results1.337cases of intubation in119subjectives were observed. The total duration ofintubation were1872.5days. There were18cases of UEX of which88.9%(16/18)were nasogastric tubes and urinary catheters and72.2%(13/18) were self-extubation.10cases of self-extubation were with physical restraint. After paired, there was asignificant difference on factors of extubation time(=11.688, P=0.001) and theintubation days(t=2.143, P=0.045), while there was no significant difference betweenthe two groups of physical restraint(=0.000, P=1.000). A total of68patients were restrained, of which43patients (63.2%) had anaverage duration of more than20hours a day for restraint, and50patients (73.5%)with a restraint duration accounted for more than half of their length of stay in NCU.When paired as above,36cases were divided into2groups according to whether theyhad been restrained or not. In the physical restraint group11were UEX patients----accounting for50%, and in the unrestraint group7were UEX----accounting for50%. The difference between the two groups had no statistical significance (=0.000,P=1.000).2. There were15literatures incorporated with2502cases of patients meeting theinclusion criteria, among which11were written in English and4were written inChinese. The15literatures contained1RCT,1q-RCT,4case-control studies and therest for cohort study. Out of15literatures7were generally descriptive and the rest8were provided with control groups and their results were subjected to statisticalanalysis. Cochrane Handbook’s bias risk assessment tool was used to evaluate1literature for RCT and another for q-RCT and graded the former as Level B, thelatter as Level C. NOS was used to evaluate the rest of the15literatures.5literaturesobtained more than5points and were provided with appropriate statistical analysisfor results and8obtained less than or equal to5points and no statistical analysis forresults. The data analyses showed:(1) The unplanned extubation rate of the physicalrestraint group was higher than that of the unrestraint group, and the result was ofstatistical difference(OR:2.84,95%CI:1.91-4.24);(2) The unplanned extubation rateof the intervention group was lower than that of the control group, and the result wasof statistical difference(OR:0.2,95%CI:0.11-0.36). And the occurrence ofcomplications in the intervention group was lower than that of the control group andthe result was of statistical difference(OR:0.19,95%CI:0.1-0.38): as for skin damage,its occurrence of the intervention group was lower than that of the control group(OR:0.03,95%CI:0.00-0.24), but as for the blood circulation disorder, there was nostatistical difference between the two groups(OR:0.09,95%CI:0.00-1.59). Conclusions1. Unplanned extubation still happened from time to time, and to some extent, itwas impacted in extubation time and physical restraint, etc. while the status quo andvalidity of physical restraint application was not optimistic.2. Systematic review discovered that the physical restraint was not effect onprevention of unplanned extubation, sometimes it even increased the occurrence onthe contrary, while after intervening the physical restraint patients by using scientificrestraint tools, personalized restraint and strengthening observing and nursing, etc.,the effect was better than that of only using restraint. More well-designed clinicaltrials are needed to identify the influence of physical restraint in preventingunplanned extubation. |
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