Mion Lorraine C, Minnick Ann F, Leipzig Rosanne, Catrambone Catherine D, Johnson Mary E
Nursing Research and Geriatric Nursing, MetroHealth Medical Center, Cleveland, OH, USA.
Crit Care Med. 2007 Dec;35(12):2714-20; quiz 2725. doi: 10.1097/01.ccm.0000291651.12767.52.
Information is needed about patient-initiated device removal to guide quality initiatives addressing regulations aimed at minimizing physical restraint use. Research objectives were to determine the prevalence of device removal, describe patient contexts, examine unit-level adjusted risk factors, and describe consequences.
Prospective prevalence.
Total of 49 adult intensive care units (ICUs) from a random sample of 39 hospitals in five states.
Data were collected daily for 49,482 patient-days by trained nurses and included unit census, ventilator days, restraint days, and days accounted for by men and by elderly. For each device removal episode, data were collected on demographic and clinical variables.
Patients removed 1,623 devices on 1,097 occasions: overall rate, 22.1 episodes/1000 patient-days; range, 0-102.4. Surgical ICUs had lower rates (16.1 episodes) than general (23.6 episodes) and medical (23.4 episodes) ICUs. ICUs with fewer resources had fewer all-type device removal relative to ICUs with greater resources (relative risk, 0.76; 95% confidence interval, 0.66-0.87) but higher self-extubation rates (relative risk, 1.27; 95% confidence interval, 1.07-1.52). Men accounted for 57% of the episodes, 44% were restrained at the time, and 30% had not received any sedation, narcotic, or psychotropic drug in the previous 24 hrs. There was no association between rates of device removal with restraint rates, proportion of men, or elderly. Self-extubation rates were inversely associated with ventilator days (rs = -0.31, p = .03). Patient harm occurred in 250 (23%) episodes; ten incurred major harm. No deaths occurred. Reinsertion rates varied by device: 23.5% of surgical drains to 88.9% of monitor leads. Additional resources (e.g., radiography) were used in 58% of the episodes.
Device removal by ICU patients is common, resulting in harm in one fourth of patients and significant resource expenditure. Further examination of patient-, unit-, and practitioner-level variables may help explain variation in rates and provide direction for further targeted interventions.
需要有关患者主动移除设备的信息，以指导旨在尽量减少身体约束使用的法规相关质量改进措施。研究目的是确定设备移除的发生率，描述患者情况，检查单位层面调整后的风险因素，并描述后果。
前瞻性发生率研究。
从五个州的39家医院随机抽取的49个成人重症监护病房（ICU）。
经过培训的护士每天收集49482个患者日的数据，包括单位普查、呼吸机使用天数、约束天数以及男性和老年人的天数。对于每次设备移除事件，收集人口统计学和临床变量数据。
患者在1097次事件中移除了1623件设备：总体发生率为22.1次/1000患者日；范围为0 - 102.4。外科ICU的发生率（16.1次）低于综合ICU（23.6次）和内科ICU（23.4次）。资源较少的ICU相对于资源较多的ICU，各类设备移除事件较少（相对风险为0.76；95%置信区间为0.66 - 0.87），但自行拔管率较高（相对风险为1.27；95%置信区间为1.07 - 1.52）。男性占事件的57%，其中44%在移除时处于约束状态，30%在过去24小时内未接受任何镇静剂、麻醉剂或精神药物治疗。设备移除率与约束率、男性比例或老年人比例之间无关联。自行拔管率与呼吸机使用天数呈负相关（rs = -0.31，p = 0.03）。250次（23%）事件中发生了患者伤害；10次造成了严重伤害。无死亡病例。重新插入率因设备而异：手术引流管为23.5%，监测导联为88.9%。58%的事件使用了额外资源（如影像学检查）。
ICU患者移除设备的情况很常见，导致四分之一的患者受到伤害并产生大量资源消耗。对患者、单位和从业者层面变量的进一步研究可能有助于解释发生率的差异，并为进一步的针对性干预提供方向。
