What are the three points to consider during a risk assessment for bed rails?

According to the U.S. Food and Drug Administration (FDA), bed rail entrapment incidents have resulted in hundreds of deaths over recent decades, demonstrating their serious risks. Therefore, a comprehensive risk assessment is crucial for patient safety, identifying what are the three points to consider during a risk assessment for bed rails to mitigate potential harm.

Quick Summary

A proper bed rail risk assessment involves evaluating the patient's condition, inspecting the bed and rail equipment for compatibility and maintenance issues, and reviewing the overall care environment and alternative strategies.

Key Points

• Assess the Patient: Consider individual factors like cognitive status, mobility, body size, and psychological state, as these can drastically alter the risk profile when using bed rails.

• Inspect the Bed System: Verify the compatibility of the bed frame, mattress, and rails, ensuring there are no dangerous gaps or faulty components that could cause entrapment.

• Evaluate the Environment: Explore safer alternatives, ensure staff are trained, and establish regular monitoring protocols before defaulting to bed rails.

• Avoid Misuse as a Restraint: Understand that using bed rails as a physical restraint is dangerous and can increase agitation and panic, leading to higher risk of injury.

• Conduct Ongoing Reviews: Patient conditions change over time, so risk assessments are not a one-time event; they must be revisited regularly to ensure the safety measures remain appropriate.

• Prioritize Alternatives: Always consider less restrictive and potentially safer options, such as low beds or bed alarms, before deciding that bed rails are necessary.

The use of bed rails in healthcare settings is a complex safety issue that balances the potential benefit of fall prevention against serious risks like entrapment, strangulation, and fall injuries. Healthcare and home care providers must conduct a thorough risk assessment to ensure bed rails are used appropriately and safely. This assessment should be holistic, considering the patient, the equipment, and the care environment. Failing to address all aspects can lead to preventable incidents and severe harm.

The Patient's Individual Condition

One of the most critical components of a bed rail risk assessment is a detailed evaluation of the individual's physical and mental state. A person's unique health needs and behaviors significantly influence the risks associated with bed rails. What is safe for one patient may be dangerous for another.

Cognitive and Psychological Factors

• Confusion and Cognitive Impairment: Patients with conditions like dementia, delirium, or general confusion are at a higher risk of injury. They may not understand the purpose of the rails and could attempt to climb over or through them, resulting in a fall from an increased height. The rails may also increase agitation, causing the patient to struggle against the perceived confinement.
• Agitation and Restlessness: Agitated or restless individuals may move erratically in bed, increasing the likelihood of a limb getting caught in gaps. This behavior, combined with compromised cognitive awareness, poses a significant entrapment hazard.
• Communication Difficulties: A patient with communication problems may be unable to call for help if they become entrapped or are in distress. This necessitates more frequent monitoring and alternative solutions.

Physical and Physiological Factors

• Mobility and Strength: Assess the patient's level of mobility both in and out of bed. Those with impaired mobility may not be strong enough to free themselves if they become trapped, while those with sufficient strength may be more likely to attempt climbing over the rails.
• Body Size and Weight: A patient's stature, weight, and build can influence entrapment risk. Individuals who are small in stature or have a low body mass may be more likely to slip through gaps that a larger person would not.
• Repetitive or Involuntary Movements: Conditions causing uncontrolled body movements, such as Parkinson's disease, can increase the risk of a body part striking the rail or becoming entangled within it.
• Medication Effects: Sedatives or other medications can alter a patient's level of consciousness or awareness, increasing their vulnerability to entrapment.

The Bed System and Equipment

The physical components of the bed and rails must be rigorously assessed for compatibility and safety. An ill-fitting system is a major cause of injury and death.

Compatibility and Sizing

• Mattress and Rail Fit: The mattress, bed frame, and rails must be specifically designed to work together. An incompatibility can create dangerous gaps, particularly between the rail and the mattress, which is considered one of the highest-risk entrapment zones. The FDA identifies seven potential zones for entrapment.
• Mattress Compression: Even with a compatible system, mattress compression caused by a patient's weight or movement can create temporary gaps. This risk is heightened with softer mattresses or specialty overlays used for pressure injury prevention.
• Rail Design and Standards: Bed rails should meet current safety standards, such as those published by the FDA, to ensure proper gap measurements and structural integrity. Older, non-compliant designs with large openings or ill-fitting parts should not be used.

Condition and Maintenance

• Regular Inspection: Routine preventive maintenance is crucial to identify wear and tear, loose components, or damage that could compromise safety. Examples include checking for rust, cracks, bent components, and secure fittings.
• Correct Installation: Proper installation according to manufacturer's instructions is non-negotiable. If the rail includes a retention system with straps, they must be attached securely to the bed frame.

The Care Environment and Alternatives

The third point of consideration involves the broader care setting and management practices, emphasizing that bed rails should be a last resort after exploring alternatives.

Use of Alternatives

Before implementing bed rails, alternatives must be considered and exhausted. Examples include:

• Low-Height Beds: These reduce the distance of a potential fall, minimizing injury severity.
• Floor Mats: Placed beside the bed, these cushion a patient who falls.
• Alarm Systems: Bed or chair alarms can alert staff when a patient attempts to exit the bed, prompting timely intervention.
• Repositioning and Monitoring: Increasing the frequency of staff checks and providing assistance with toileting or pain relief can address the root causes of restlessness and eliminate the perceived need for rails.
• Positional Aids: Body pillows or wedges can be used to help position the patient and prevent rolling.

Policy and Training

• Staff Education: All staff must be trained on the risks of bed rails, proper installation procedures, and alternative safety measures. Awareness of bed system compatibility and monitoring protocols is essential.
• Informed Consent: Involving the patient, family, or representative in the decision-making process is a critical ethical step. The risks and benefits must be discussed, and consent obtained before installation.
• Ongoing Reassessment: The patient's condition is dynamic, and the risk assessment is not a one-time event. It must be reviewed regularly and after any significant change in the patient's health or changes to the bed system.

Comparison of Bed Rails vs. Alternatives

Feature	Bed Rails	Alternatives (e.g., Low Beds, Mats, Alarms)
Primary Goal	Physical barrier to prevent falls out of bed	Reduce fall impact and alert staff to a patient's movement
Risk of Entrapment	High, especially with incompatible equipment	Very low to none
Risk of Fall Injury	Can increase severity of injury if patient attempts to climb over	Minimized by reducing fall distance and providing a softer landing
Risk of Restraint	Can be perceived as a physical restraint, causing agitation	Generally non-restrictive and respects patient's freedom of movement
Dependence on Equipment	Requires precise bed-rail-mattress compatibility and maintenance	Relies on different equipment types that may need less complex integration
Need for Monitoring	Requires monitoring to ensure proper use and to detect entrapment	Requires monitoring to respond to alarms or address needs

Conclusion

Conducting a thorough risk assessment for bed rails is an essential, multi-faceted process that goes far beyond simply raising the rails. It requires a deep understanding of the patient's individual vulnerabilities, an inspection of the bed system's integrity and compatibility, and a comprehensive review of the care environment and available alternatives. Only by carefully considering these three points—the patient, the equipment, and the environment—can caregivers make an informed decision that prioritizes safety and ethical care. Regular reassessment ensures that the solution remains appropriate as the patient's condition changes over time. A focus on less restrictive options and proper staff training ultimately creates a safer environment for those under care.

Health and Safety Executive: Safe use of bed rails

Frequently Asked Questions

What is the primary risk associated with bed rails?

The primary risks associated with bed rails include entrapment, where a person's body part gets caught between the rails or the rail and mattress, leading to suffocation or serious injury. Additionally, patients can sustain more serious injuries from falls if they attempt to climb over the rails.

Who is at the highest risk for bed rail entrapment?

Elderly or frail individuals, those with cognitive impairments like dementia or delirium, people with involuntary movements, and those with a smaller body size are at the highest risk for bed rail entrapment. Lack of mobility and impaired communication can also increase risk.

What are some alternatives to using bed rails?

Safer alternatives to bed rails include using ultra-low beds to reduce fall height, placing fall mats next to the bed, using bed or chair alarms to alert staff, and addressing a patient's underlying needs like pain, thirst, or toileting.

How often should a bed rail risk assessment be reviewed?

A bed rail risk assessment should be reviewed regularly and whenever there is a significant change in the patient's condition, weight, mobility, or any change to the bed system (e.g., a new mattress).

What should be checked during a bed rail and mattress compatibility assessment?

During a compatibility assessment, check for any gaps between the bed frame, rails, and mattress. Pay close attention to the gap between the rail and the mattress, as this is a high-risk entrapment zone. Ensure the mattress is the correct size and density for the bed and rails.

Can bed rails be used as a physical restraint?

No, bed rails should not be used as a physical restraint. They can increase a patient's agitation and anxiety, potentially leading them to attempt unsafe ways of exiting the bed. Alternatives should be explored before any restrictive measures are considered.

Who should be involved in the decision to use bed rails?

The decision to use bed rails should involve an interdisciplinary team, including medical professionals, caregivers, and, most importantly, the patient themselves or their legal representative. Informed consent must be obtained before installation.