Bedrail Use Research Articles

193 A review of the bed rail use and use of a bed rail risk assessment tool in a rehabilitation unit

Abstract Background Bed rails are used frequently throughout acute, community and home care environments to reduce the risk of bed occupants falling out of bed and causing injury. The use of risk assessment, along with patient preference, has been advised by HSE. Methods A chart review in a rehabilitation ward was undertaken to determine consideration and compliance of a Bed Rail Risk Assessment Tool (BRRAT) by nursing staff during inpatient stay. Results 44 patients were assessed. 31(70%) used a bed rail, with documented hourly observation noted in 97% of these charts. Of the 31, 30 patients (71%) voiced preference for a bed rail, specifying safety (n = 5) or fear of falling (n = 3) as a reason. Patient preference for no bed rail was documented in the majority (n = 7/9). Where bed rails were used, no patients were deemed at high risk of injury or entrapment. 4 patients at medium risk elected not to use a bed rail with the remaining 3 patients at medium risk choosing to have a bed rail despite the risk, due to fear of falling. All patients at low risk chose to have a bed rail (n = 25). Four patients had no BRRAT documented. 82% of decisions were documented to have been discussed with the patient. 18% were not assessed by the BRRAT as patient preference was taken solely into account. Conclusion A high proportion of patients were involved in decision-making, and the majority chose to use bed rails in a rehabilitation setting. Most had documented hourly observation of rails. The use of a BRRAT tool allows one to assess the risk of bed rails also on an individual basis, to ensure a well-rounded decision can be made. A full assessment should be carried out however, to inform the patient of their risk before taking their final decision into account.

177 REDUCTION OF RESTRICTIVE PRACTICES IN AN OLDER PERSON RESIDENTIAL CARE FACILITY; THE IMPACT ON HUMAN RIGHTS AND RESIDENT SAFETY

Abstract Background We are a 140 bed long term care residential care facility for older people. We strive to achieve a ‘Restraint Free Environment’ in accordance with Article 40.4 of the Irish Constitution and Articles 14 (liberty and security) and 15 (freedom from torture or cruel, inhuman or degrading treatment) of the UN Convention on Rights of Persons with Disabilities(1). Health Act 2007, Regulations 2013 defines restrictive practice as ‘the intentional restriction of a person’s voluntary movement or behaviour’. Use of restrictive practices is warranted when there is a real and substantial risk to a person and this risk cannot be addressed by non-restrictive means’ (HIQA, 2019) (2). Methods An extensive review of non pharmacological restrictive practices in the Organisation was undertaken. This included One to One supervision, use of bedrails, Exit Alarm mats and Electronic Monitoring bracelets. Bedrails were replaced for some residents with Safety Wedges and Ultra Low beds. Results Review of restraint interventions showed no clear link to prevention of falls or injuries as a result of restraint. Contrary there was evidence of breach of dignity and privacy for the residents. Based on the review, bedrail use was reduced radically between 2016 and 2021 by 79% (42–9). Falls rate remained consistent approximately 3.6–3.2 per 1,000 Occupied Bed Days. Exit Alarm mats, Electronic Monitoring bracelets and One to One supervision was discontinued. These were replaced with direct observation and two hourly anticipation of needs. Cost saving on One to One estimated to have been €25,000 in 2016 alone. Clear care planning of the resident’s needs are core. Conclusion We have demonstrated that we could successfully reduce restrictive practices, thus respecting Human Rights, with no compromise to resident safety.

Patient safety and bedrail use as a global phenomenon: A prevalence study

Background: Although bedrail use may increase the risk of accidents among patients, bedrails are still extensively used in healthcare facilities. Therefore, the field calls for a review of bedrail use in practice. Objective: This report examined the prevalence and implications of bedrail use in rehabilitation facilities in Hong Kong. The findings are compared with the current state of bedrail use worldwide. Design and methods: This work is a cross-sectional, observational study. A secondary analysis was conducted on the database of a prospective trial. Bilateral bedrail use was observed in two Hong Kong rehabilitation hospitals. Logistic regression was performed to examine the factors associated with bedrail use. Results: A total of 3,384 restraint observations were made. The bedrail rate was 31.34%, which revealed that bedrail use was the second most commonly used physical restraint. The fall history (OR: 2.84), cognitive impairment (OR: 0.91) and functional dependency (OR: 0.79) of patients were significant predictors of bedrail use, p < .05. Conclusion: This study examines bedrail prevalence through direct observation, which is the preferred method for examining bedrail use in practice. We found that actual bedrail use is higher than the numbers reported in previous studies in Hong Kong. In addition, our research reveals that bedrails are commonly used for vulnerable patients. This finding highlights the need to change nurses’ beliefs on bedrail use through education. The management of these health facilities should also aim to create an institutional environment that promotes the reduction of bedrail use. Implementation strategies on restraint reduction should also fit the culture of the organisation and local nursing practices, as well as the staff’s values. Impact Statement: This study provides preliminary information about the widespread use of bedrails in Hong Kong and other countries. The research also introduces effective ways to achieve the reduction of bedrail use.

Bedrails and Falls in Nursing Homes: A Systematic Review.

Bedrail use for fall prevention in elderly clients (>65 years) is controversial. Some healthcare providers believe bedrails prevent falls, while others think they are ineffective and dangerous. A systematic review was conducted to address: "For older adults living in nursing homes, does more or less bedrail use reduce the incidence of falls?" We searched HealthStar, MEDLINE, CINAHL, Academic Search complete ProQuest and Canadian Health Research Collection using "elder*," "bedrail*," "fall*," and "assisted-living*." After filtering for primary data, English records, older adult population, relationship between bedrails and falls, fourteen studies remained. Results suggest using alternative fall prevention measures, and bedrails are either beneficial, harmful, or do not influence falls. Bedrail reduction with fall prevention interventions led to no changes in fall frequency. Ambiguity persists regarding fall frequencies and bedrail use without using other fall prevention strategies. Educating health care providers on fall prevention is key to patient safety.

Design, delivery and evaluation of a simulation-based workshop for health professional students on falls prevention in acute care settings.

Aims and objectivesTo describe the design, delivery and evaluation outcomes of a simulation‐based educational workshop to teach a patient‐centred falls prevention strategy to health professional students tasked with implementing the strategy during clinical placement.BackgroundFalls are among the most common and costly threat to patient safety. The Safe Recovery Programme (SRP) is an evidence‐based, one‐to‐one communication approach with demonstrated efficacy at preventing falls in the postgraduate context. Simulation‐based education (SBE) is commonly used to address issues of patient safety but has not been widely incorporated into falls prevention.MethodsThis study was a Pre–Post‐test intervention design. Health professional students were taught how to deliver the SRP in an SBE workshop. The workshop incorporated content delivery, role‐play simulations and interactions with a simulated patient. Students completed surveys immediately before and after the workshop and after clinical placement. Linear and logistic regression analysis was undertaken to identify differences within each pairwise comparison at the three time points. Qualitative free text responses underwent content analysis.ResultsThere were 178 students trained. The educational design of the programme described in this paper was highly valued by students. Following the workshop, students' falls knowledge increased and they correctly identified evidence‐based strategies except bedrail use and patient sitters. Following clinical placement, fewer SBE students correctly identified evidence surrounding bed alarm use. Students became more confident about falls communication post‐SBE; however, this confidence decreased postclinical placement. Motivation to implement the SRP decreased between postworkshop and postclinical placement time points.ConclusionsFalls research often includes educational components but previous studies have failed to adequately describe educational methods. Students learnt about best evidence falls prevention strategies using interactive educational methodologies with a workshop viewed by students as being well‐designed and assisting their learning from theory to practice.While students valued the delivery of the SRP using SBE, confidence and motivation to implement falls strategies were not sustained following clinical placement. A programme of education including SBE can be used to support the delivery of falls‐based education, but further research is needed to identify what factors may influence student's motivation and confidence to implement falls prevention strategies during clinical placement.

Prevalence and predictors of bedrail use in an acute hospital.

to determine the prevalence and predictors of bedrail use in an acute hospital. overnight survey in a University teaching hospital. Three-hundred and twenty-seven beds and patients in 14 wards. data were collected on bedrail use and on the bed system, ward and patient characteristics. Medical, nursing and physical therapy notes were examined and the night and day nurses and, if necessary, the doctors and therapists caring for the patient interviewed to determine patients' diagnoses, functional and cognitive status. there were 133 (40.7%) beds with one or more raised rails. Independent predictors of bedrail use were use of electric profiling beds, confusion, reduced alertness and any difficulty with transferring from bed. The most common reported indication for bedrail use was 'to prevent rolling out of bed' (59%); 'to prevent getting out of bed' was recorded in 11% of cases. Use of bedrails was judged inappropriate in 27/133 (20.3%) patients and in 14/43 (32.6%) patients with abnormal mental status; misuse was particularly common in those with confusion or agitation [13/34 (38.2%)]. Failure to use bedrails was potentially inappropriate in 32/194 (16.5%) of those without bedrails. this study using individual patient data shows that the use of electric profiling beds, abnormal mental states and difficulty transferring from bed are the main predictors of bedrail use in acute hospitals. Inappropriate use of bedrails is common in those with cognitive impairment or with agitation.

Which bed designs and patient characteristics increase bed rail use?

the design and use of bed rails has been contentious since the 1950s with benefits including safety, mobility support and access to bed controls and disadvantages associated with entrapment and restraint. to explore which bed designs and patient characteristics (mobility, cognitive status and age) influence the likelihood of rails being used on UK medical wards. the use of rails was surveyed overnight at 18 hospitals between July 2010 and February 2011. data were collected on 2,219 beds with 1,799 included (occupied). Eighty-six percent had rails attached; 52% had raised rails (42% had all raised). Adjusted logistic regression results suggest a significantly increased likelihood of rail use for (i) electric profiling beds and ultra low beds; (ii) >80 years; (iii) described as having any level of confusion or mobility impairment. These variables together explained 55% of the variance in rail use. The most frequently mentioned reason for raising rails was 'to prevent falls from the bed' (61%) especially for patients described as confused (75%). there were indications that rails were being used inappropriately (as a restraint) for both confused patients and those needing assistance to mobilise.

Bedrail Use in English and Welsh Hospitals

To explore rates of bedrail use, nurses' rationale, and factors related to bedrail use. An overnight observational study of patient and equipment characteristics related to bedrail use, analyzed using a logistic regression model. A stratified random sample of seven organizations, drawn from 167 organizations providing acute general hospital care in England and Wales during 2006. One thousand ninety-two inpatients on adult inpatient wards observed at night. Categorical data on bedrail use related to bed type, mattress type, patient age, nurses' description of patients' mobility and confusion, and nurses' rationale for bedrail use or nonuse. Approximately one-quarter of patients had full bedrails raised at night; prevention of falls was the nurses' main rationale. Full bedrail use was much more likely to occur in patients who nurses described as immobile and very or slightly confused. Older patients appeared no more likely to be given bedrails than younger patients after adjusting for individual patient and equipment factors. Bedrail use varied significantly between organizations and could not be explained by differences in nurses' description of patients' mobility and confusion levels, equipment, or policy.

An audit of bedrail use and implications for practice

Bedrails are used extensively in both the hospital and community care settings to protect vulnerable people from falling out of bed. However, there is evidence of indiscriminate bedrail use and some inadvertent use of bedrails as a form of restraint, which in turn may compromise patient safety, dignity and autonomy. This article describes a night-time bedrail audit undertaken in one integrated NHS trust to determine the numbers and types of bedrails in use, the patient demographic, locations where bedrails were used and, importantly, why staff decided to use them. The information collected was used to inform local policy development and improve practice. The implications of the audit findings for practice are discussed, and a new decision aid for the use of bedrails is presented.

The effect of bedrails on falls and injury: a systematic review of clinical studies

around one-fourth of all falls in healthcare settings are falls from bed. The role of bedrails in falls prevention is controversial, with a prevailing orthodoxy that bedrails are harmful and ineffective. to summarise and critically evaluate evidence on the effect of bedrails on falls and injury systematic literature review using the principles of QuoRoM guidance. adult healthcare settings using the keyword, bedrail, and synonyms, databases were searched from 1980 to June 2007 for direct injury from bedrails or where falls, injury from falls, or any other effects were related to bedrail use. 472 papers were located; 24 met the criteria. Three bedrail reduction studies identified significant increases in falls or multiple falls, and one found that despite a significant decrease in falls in the discontinue-bedrails group, this group remained significantly more likely to fall than the continue-bedrails group; one case-control study found patients who had their bedrails raised significantly less likely to fall; one retrospective survey identified a significantly lower rate of injury and head injury in falls with bedrails up. Twelve papers described direct injury from bedrails. it is difficult to perform conventional clinical trials of an intervention already embedded in practice, and all included studies had methodological limitations. However, this review concludes that serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather than being inherent, and bedrails do not appear to increase the risk of falls or injury from falls.

Patient Choice: An Influencing Factor on Policy‐Related Research to Decrease Bedrail Use as Physical Restraint

This paper shows patients' enactment of choice in mixed methods, multidisciplinary study on the use of bedrails as restraints. Under the pressure of the implementation of impending legislation, patients from a Canadian elderly care rehabilitation unit were recruited to be part of this study and assigned to either a study or control group. Study group patients were exposed to a new facility policy on restraints in which bedrails were not to be used on a patient's bed except under specified conditions. Patients in the control group continued to have bedrails on a routine basis according to the facility's old policy. Following group assignments, patients could choose to crossover to either the control or study group based on their opinions about bedrails. After patients crossed over into either the study or control group, findings for the new groups differed significantly. Participants in the rails-up group had lower admission Functional Independence Measure scores (p = .001) and higher admission Cumulative Illness Rating scores (p = .000) compared to those in the rails-down group. Patients have specific concerns related to the use of bedrails that might affect implementing bedrail minimization policies. Additionally, the authors conclude that patients' input into research design may increase patients' support of the protocol and help maintain study integrity.

Poster 47: Does use of bedrails in a subacute rehabilitation facility benefit the patient?

Objective: To analyze the number and severity of falls in a subacute rehabilitation facility before and after the implementation of the “no-restraint policy” of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Design: Retrospective study. Setting: Subacute rehabilitation facility. Participants: All residents at the facility between January 1, 1996, and July 1, 1999. Interventions: Not applicable. Main Outcome Measure: The number of falls were quantified. Severity of injuries was qualified: level 0 is no injury, level 1 is a minor injury, level 2 is a major injury, and level 3 is death. Results: There was a significant increase in falls (207 before, 227 after) when the no-restraint policy started ( P=.0005), with a relative risk (RR) of 1.4 (restraints were defined as bedrails). There was no significant difference in the severity of injuries between the groups. In the bedrail group, significantly more injuries were found in those who were confused ( P=.0595). In oriented patients, a significant decrease in the number of falls ( P=.0624) and risk of injuries were found with bedrail use (RR=.54). Conclusions: After the implementation of the JCAHO no-restraint policy, a significant increase in the number of falls was found in our long-term care facility. There was an observable tendency of a subgroup of patients to benefit from bedrails (oriented patients).

Use of restraints and bedrails in a British hospital.

To determine the prevalence of restraint and bedrail use in a British hospital. Cross-sectional observational study. Six hundred sixty-eight patients in the acute medical, surgical, and geriatric beds of a large British teaching hospital on a single night. Observed use of restraints and bedrails. Reasons for restraint use were determined by interviews with nursing staff and examination of the case notes. Fifty-six (8.4%) patients had bedrails raised. No other restraints were in use. Reported indications for bedrail use were: prevention of falls (52 patients), prevention of wandering (1), and patient request (3). In stepwise logistic regression analysis, bedrail use was associated significantly with agitated confusion, age 70 years or more, and stroke, while patients on the acute geriatric wards were significantly less likely to have bedrails raised. Restraint use is relatively uncommon in Britain. Nevertheless, inappropriate use of bedrails is a reason for concern.

Standards of medical care based on consensus rather than evidence: the case of routine bedrail use for the elderly.

“An 88-year-old male patient was found on his hands and knees on the floor beside his bed. The bedrails were up.”—From an indent report filed by a nurse at the Stillman Infirmary, University Health Services, Harvard University, in May 1980.Finding elderly patients lying on the floor beside their beds despite the presence of elevated bedrails seems paradoxical: how can a patient fall out of bed when the bedrails are up? Surprisingly, this paradox constitutes one of the leading incidents plaguing hospitals in the United States today. It exemplifies a much larger problem created, we believe, by the uncritical adoption of measures designed to enhance patient welfare, but which may in fact undermine it. This article documents our experience with bedrails, reviews the literature, and comments on the rationale for routine adoption of bedrails for the hospitalized elderly. It concludes by advocating that a randomized, controlled study be conducted to determine whether bedrails constitute protection or a hazard to the average elderly patient.