Unplanned Extubation Study Leaves Questions Unanswered

Abstract

Listen

Translate article

With respect to the article by Chang and colleagues1 in the September 2008 issue, I applaud the authors for attempting to address the difficult issue of preventing unplanned extubations in the intensive care unit (ICU). However, I believe that additional information was required to support the authors’ conclusion that the application of physical restraint is on its own a risk factor for self-extubation.The authors provide little information about the decision-making process for application of restraint in the study ICU. They do state that an “evaluation of the risk of unplanned extubation and/or fall”1(p410) was performed, but they provide no details of the content of this evaluation or of the potential differences in risk category among the patient groups that it might reveal. Did the patients who were included in the unplanned extubation group score at higher risk than those who did not or higher than the control group? Why weren’t the members of the control group restrained? What factors were involved in the decision-making process that might also be related to unplanned extubation?Also, the authors state that “[a]mong the 191 patients who were physically restrained, 82 had an unplanned extubation.”1(p411) What about the 109 patients who were restrained but did not have an unplanned extubation? What differences exist among that group, the unplanned extubation group, and the control group? Were they monitored more frequently? Were different forms of physical restraint used?The authors claim, “Currently, use of a wrist belt tied to the bedside railing is the most common method of restraining patients.”1(p413) Were all of the patients in the study restrained this way? Given that the assessment described seems to be both for unplanned extubation and/or for fall, it seems reasonable to ask whether other methods that would be unsuccessful in preventing unplanned extubation (such as use of a vest restraint) were the kind actually used on some proportion of patients in the study.Preventing unplanned extubation in the ICU is a very important topic that deserves further study to promote the most effective and informed practice. In my judgment, though, additional information about the method used to decide to restrain patients, the specific monitoring that was performed, and the type of restraint that was used would have made this study more informative and more valuable.