Falls in Long-Term Care - www.fallslinltc.ca

PHYSICAL RESTRAINTS AND SIDERAILS : Siderails

Guidelines

Bed rails (or side rails) are the most commonly used physical restraints. Thus, in partnership with the U.S. Food and Drug Administration, the Hospital Bed Safety Workgroup released the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings. The goal of this group is to improve the safety of hospital beds for patients/residents in all health care settings. Their guidance outlined in this report is intended to assist caregivers in making decisions about the care of their patients and not intended as clinical standards. This group is also against use of bed rails, and argues that they may pose increased risk to patient safety.

 Guiding Principles/ Policy Considerations

The Workgroup recommends that when planning resident care:

• the use of bed rails should never be automatically considered as they may pose as hazards to patient safety
• nurses should evaluate the risk of using bed rails compared to not using it
• decisions to use or to discontinue use of bed rail should be made according to the individualized patient/resident assessment along with interdisciplinary team and input from resident and family
• if bed rail(s) must be used:
• include in the resident’s chart a risk-benefit assessment that identifies why other care interventions are not appropriate or effective
• include documentation that describe attempts to use less restrictive care interventions and their failure to meet patient’s assessed needs
• educate resident and family on bed rail risks and benefits
• reassess resident’s needs and re-evaluate equipment if an episode of entrapment occurs

Bed Rail Safety Guidelines

As well, if bed rails are required, then staff should pay close attention to the design of the rails and its relationship with other parts of the bed:

• the bars between the bed rails should be closely spaced to prevent entrapment
• space between bed rails and mattress and space between headboard and mattress should be filled to prevent patients from falling in between
• latches securing bed rails should be stable
• maintenance and monitoring of bed, mattress, and accessories should be ongoing

Scenarios and Use of Alternatives

The Hospital Bed Safety Workgroup also listed some scenarios on how to deal with the use of bed rails and provided alternatives.

Scenario 1 : A resident is assessed to be unsafe in bed with an inability to transfer safely to and from bed to wheelchair. The resident also has a previous entrapment or near-entrapment episode.

Solution: Instead of using bed rails, consider placing the patient in an adjustable-height bed or a concave mattress, and use a high-impact mat next to bed.

Scenario 2 : A resident is assessed to need a low bed, but an assessment determines that the resident is in danger of hurting him/herself while exiting from the low bed or is in danger of an unstable transfer after standing up by grabbing onto a bedside table.

Solution: Consider using a bed alarm to alert nursing staff when the resident is leaving the bed.

For the full report by the Hospital Bed Safety Group, click the following link: http://www.ute.kendal.org/learning/documents/clinicalguidance_SideRails.pdf

The following are additional informative documents on the use of bed rails which can be downloaded from the Hospital Bed Work Safety Group website:

• HBSW/FDA Frequently Asked Questions (FAQ) on Entrapment Issues (Issued September 26, 2006): http://www.fda.gov/cdrh/beds/guidance/FAQ52406.pdf

• Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Guidance for Industry and FDA Staff (Issued March 10, 2006): http://www.fda.gov/cdrh/beds/guidance/1537.pdf

• A Guide for Modifying Bed Systems and Using Accessories to Reduce the Risk of Entrapment (Issued June 21, 2006): http://www.fda.gov/cdrh/beds/modguide.pdf

• Press Release: FDA Issues Guidance on Hospital Bed Design to Reduce Patient Entrapment (Issued March 9, 2006): http://www.fda.gov/bbs/topics/NEWS/2006/NEW01331.html

• HBSW Bed Safety Entrapment Kit Ordering Instructions (Issued March 9, 2006): http://www.fda.gov/cdrh/beds/entrapmentkit.html

• Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities and Home Care Settings: http://www.ute.kendal.org/learning/documents/clinicalguidance_SideRails.pdf

• Brochure: A Guide to Bed Safety; Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts: http://www.fda.gov/cdrh/beds/bedrail.pdf

• Bed Rail - Related Entrapment Deaths, Sentinel Event Alert, Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Sentinel Event Alert, September 6, 2002: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_27.htm

• Entrapment Hazards with Hospital Bed Side Rails, Food and Drug Administration Safety Alert, 1995: http://www.fda.gov/cdrh/bedrails.html

• CMS/FDA Letter regarding Physical Restraint Definition: http://www.fda.gov/cdrh/beds/fdahcfa1.pdf

Assessment

Individualized Assessment and Intervention in Bilateral Siderail Use
Elizabeth Capezuti, Karen A. Talerico, Neville Strumpf, Lois Evans (1998)

This article presents an individualized assessment for evaluating side rail use to guide nurses in managing high risk patients who fall out of bed.

Individualized Assessment

In this article, Capezuti and colleagues (1998) recommend that a plan of care should be developed from an individualized assessment of the resident. The assessment should cover the following areas:

• Review of resident history, staff reasons for using side rails, health care records, and incident reports
• Physical examination
• Environmental characteristics of resident's bedroom and bathroom
• Identification of resident-specific problems

The assessment form is Table 1 in the article ( PDF file of article). The authors also provide descriptions for using the individualized assessment to facilitate data collection and plans in minimizing or eliminating side rail use. The following is a detailed list of items required on each section of the individualized assessment:

History: Resident/Staff

• determine resident’s and family’s views of side-rails
• note whether side rails promote patient’s independence in bed or create problems
• educate resident on the benefits and risks of side rails and after demonstration of an understanding, he or she should sign a consent form to confirm preference of side rails
• nursing homes should not be compelled to use side rails based on the interests of the family
• identify staff’s reasons for side rails

 
Resident/Staff Interview

• Assess patient’s mental status
• Determine if there are sleep problems and if yes why they occur
• Describe patient’s mobility at night, check for situations that increase injury risk such as trying to climb over bed rails
• Determine the number of times the resident goes to the bathroom at night and whether the frequency of urination has changed due to bed rails
• Determine reports of pain

 
Record Review

• Look at the patient’s medical diagnoses as falls may be due to acute illnesses
• Look at the patient’s medications as some drugs are strongly correlated with fall risk and should therefore be reviewed
• Determine the circumstances of all falls

 
Physical Examination

• Determine patient’s Body Mass Index or stature: small stature increases likelihood of slipping through or between side rails and increased BMI may prevent fall-related injury because of the shock-absorbing capacity of muscle and fat
• Measure patient’s lower leg length and whether they are equal
• Take patient’s blood pressure and radial pulse
• Examine skin turgor, an indicator of dehydration, by lifting a skin fold and observing the speed with which it returns to place
• Check resident’s vision and perception of light
• Check resident’s range of motion of major joints
• Evaluate resident’s feet, balance and gait, and muscle strength
• Describe site and intensity of pain

Environmental Characteristics

• Bedroom assessment: assess firmness of the mattress, assess bed height compared to patient’s lower leg length, evaluate furniture in patient’s room (whether it acts as barrier), and determine distance from bed to bathroom
• Observe lighting conditions at night and make sure patient is able to turn on lights
• Evaluate safety of bathroom, make sure it is marked with a recognizable signal and that handrails are in place

Data from the above individualized assessment for evaluation of side rail use can be used to identify specific problems that contribute to fall risk at night. The use of side rails, similar to physical restraints, can be safely reduced by a comprehensive assessment process.

Capezuti, E., Talerico, K., Strumpf, N., and Evans, L. (1998). Individualized assessment and intervention in bilateral siderail use. Geriatric Nursing, 19: 322-30. Abstract available at PubMed.

The following article describes the process of using individualized interventions to reduced bed-related falls. It is very similar to previous article and can be useful as well. A summary of this article can be found under the section Individualized care approach to falls management.

Capezuti, E., Talerico, K.A., Cochran, I., Becker, H., Strumpf, N., Evans, L. (1999). Individualized interventions to prevent bed-related falls and reduced siderail use. Journal of Gerontological Nursing, 25: 26-34. Abstract available at PubMed.

Decision-Tree

[For full-size printable pdf version of this tree, please click here or on the image below]

Source: Talerico, K.A., Capezuti, E. (2001). Myths and facts about side rails. Am J Nurs, 101:43-48. Abstract available at PubMed.