Safe Use of Bedrails

Bed rails are designed and used in hospital and community settings. They must be used with care as incorrect use of bed rails can constitute a hazard.

Bed rails are:

• intended to reduce the risk of people falling from bed and injuring themselves
• not intended to be used as a means of preventing a person intentionally leaving their bed - which could be considered a form of restraint
• only play a small part of preventing falls; bed rails are not appropriate for all patients at risk of falling from bed.

Patients can be at risk of falling from bed for many reasons.  These include poor mobility, dementia, delirium, visual impairment and effects of medication.  While the majority of falls from beds may only result in negligible or minor harm, it must be remembered that in some cases, the outcome is major or extreme for example a fractured neck of femur, serious head injury or death.  

It is not appropriate to use bed rails for all patients at risk of falling from bed as bed rails can:

• impede rehabilitation by preventing independence
• prove a hazard for patients who are confused or have dementia, or have any presentation where there is a risk of the patient attempting to climb over the bed rail or squeeze through the gap between the bed-rail and the foot of the bed
• cause injury to the patient who is restless e.g. scrapes and bruises to limbs
• lead to entrapment of the head or limbs due to restlessness
• cause unnecessary distress to patients who may feel ‘trapped’ or claustrophobic
• act as a ligature point

If a patient is at risk, it is not permissible to use a single bed rail under any circumstances. Bed rails must be used as a pair or not at all.

Weighing up the risks and benefits of using bed rails requires a combination of risk assessment and professional judgement.  Consideration must be given to the patient’s physical and mental health needs, personality, lifestyle and the environment while taking account of the patient’s right to make decisions regarding their care.  Also all steps should be taken to ensure patient safety while maintaining the patient’s independence.

Evidence indicates that falls from beds where bed rails have not been in place are more likely to result in a greater number of injuries. Where there have been moves to greatly reduce bed rail use this can result in an increase in falls. Best practice is to always carry out an assessment of the risks and benefits for the individual and then agree a decision about the use or not of bed rails with the patient/patient’s family or carers.

Appropriate falls risk assessment tool for your clinical board must be completed, prior to any decision being made regarding use of bed rails.

Patient consent to the use of bed rails will be sought; where the patient is deemed to have reduced mental capacity to make this specific decision and unable to give informed consent, the patient will be given the opportunity to decide whether or not to have bed rails in situ. Written consent is not required for use of bed rails.  On occasion a patient might request bed rails in order to feel safer and more secure.  While this may not accord with professional opinion, the patient’s choice should be taken into consideration when completing a risk assessment. The patient’s decision regarding the use of bed rails will be documented in their health record.

Relatives and carers may be consulted but unless they have been granted the legal responsibility to make decisions on the adult patient’s behalf will not be able to decide whether or not bed rails should be used. A record of the discussion with a relative or carer, and the outcome of the discussion must be documented in the patient’s health record.

Where a patient lacks capacity and there is not someone legally appointed to make decisions on their behalf, the decision regarding whether or not bed rails are used will be made by staff using the guidance provided and recorded on the Section 47 Adults with Incapacity Act (AWIA) treatment plan.

Decision making in respect of bed rail use will as far as possible and practicable be multidisciplinary.

Any decision made in respect of bed rail use and the rationale for this must be documented in the patient’s health record and on the Person Centred Falls Bundle.

All healthcare professionals are responsible for ensuring all patients are assessed in relation to safety, including falls from bed.

On admission or transfer to a ward a risk assessment appropriate to the area of   admission will be undertaken in relation to the individual patient to ensure that they can be cared for safely within that environment. The patient will be reassessed either weekly or daily according to their needs and whenever there are changes in their clinical presentation.

When assessing to ensure that the patient can be cared for safely within any environment, factors for consideration include:

• size of patient
• previous history of falls
• evidence of confusion/disorientation
• impaired judgement
• age
• sensory loss
• mobility
• nocturia
• use of a pressure relieving mattress
• type of bed
• ability to use the call bell
• bed-space visibility for staff

Bed rails are only a small part of falls prevention.  Staff must ensure all other falls prevention measures are employed as appropriate.  All patients must have a falls assessment documented.

In the course of making an assessment regarding the use of bed rails, assessors will weigh up risks posed by the use of bed rails against potential benefits to the patient using the algorithm - Appendix 2

Bed rail use will be a balance between competing risks and needs of the patient.  Account must be taken of the patient’s physical and mental health needs.  Consideration must be given to the risk of harm to the patient, if bed rails are used, and if they are not used.

Bed rails will be routinely used:

• when a patient is being transported on a bed or trolley
• in areas where patients are recovering from anaesthetic or sedation and are under constant clinical observation (except for those receiving care from mental health services)

Bed rails would not normally be used if:

• the patient is likely to attempt to climb over the bed rail
• the patient is likely to attempt to climb through the gap between the bed rail and the foot of the bed
• the bed rail prevents the patient being independent
• the bedrail may or does cause the patient distress

The likelihood of the patient using the bed rail as a ligature point must also be fully risk assessed and take account of NHS Borders Ligature Policy.

Bed rails must only be used when the benefits outweigh the risks.

Decisions regarding the use of bed rails will be under constant review.  Decisions will be based on the patient’s needs, the associated risks and any evaluation of the direct impact the use of bed-rails is having on a patient. For example, psychological distress or increased confusion.

The decision whether or not to use bed-rails will be reviewed a minimum of once per week or if the patient’s medical/clinical condition changes.

The initial risk assessment and every review and outcome will be recorded in the patient’s healthcare record.

All equipment, this includes bed rails, requires to be risk assessed under Health and Safety legislation.

A risk assessment form will be completed in accordance with the Occupational Health and Safety Policy, Heath and Safety Risk Assessment Guidance⁷ and the Risk Management Strategy and Policy.

A generic assessment can be applied where there are integral bed rails, but a specific assessment is required for third party bed rails.

In order to reduce the risk of musculo-skeletal injury, two members of staff should always undertake the fitting and removal of third party bed rails.

If the patient is of unusual body size (e.g. very emaciated, hydrocephalic, microcephalic, growth restricted, obese, etc.), all bed rail gaps must be checked to assess risk of entrapment.  Refer to The Medicines and Healthcare Products Regulatory Agency (MHRA) Guidance Bed Rails: management and safe use

Bed rails used for domestic and divan beds are nearly always third party bed rails and therefore are not tailored to one specific bed or mattress length, width or density.  It is therefore essential that a full assessment is undertaken, taking account of the patient’s needs, the type of bed, all risks identified for both using and not using bed rails and risks weighed up prior to arriving at a decision.

Bed rails will be checked prior to use, and regularly during use to ensure patient safety.

Checking of the patient with bed rails should not necessarily be treated as a separate issue but rather as an important part of general observation.

If a patient is found in a position where they are at risk of entrapment, e.g. halfway off the mattress or a limb through a gap in split bed rails, this will be taken as an indication of risk of serious injury to the patient and a need to make changes to the patient’s care plan and documented in the patient’s health record.

Where a patient is assessed to be at risk of getting a limb trapped in a bed rail a further assessment will be undertaken to decide if it is appropriate to use bed rail bumpers, prior to these being attached.

If a patient is found to be attempting to climb over the bed rails, or out of the end of the bed, this must be taken as an indication that they are at risk of serious injury from falling from a greater height, and that the use of bed rails requires to be reviewed, as the risk of continued use is likely to outweigh the benefits. Floor mats (Crash mats) should be considered as an alternative safety measure. NB bed rails not to be used at the same time.

Staff must ensure that any bed rails that are to be used can be fitted properly to the bed and used safely.

Where bed rails are found not to comply with recommendations as per 4.8, they will not be used.

Bed rails will only be used in accordance with the manufacturer’s instructions for use.

Careful consideration must be given to the use of bed rails where a pressure redistribution mattress is placed on top of the existing bed mattress as this may reduce the effective height of the bed rails, and the patient may be able to roll over the top of the bed rail.

In areas such as the Emergency Department (ED) where patients may be on trolleys, the integral bed rails on the trolley will be used.

Bariatric beds allow the mattress base to be widened, however, when the bed is widened the correct mattress for the bed size must be used.  Using the incorrect mattress could increase the risk of entrapment.

Bed rail bumpers, padded accessories or enveloping covers are primarily used to prevent impact injuries, but they can also reduce the potential for limb entrapment when securely affixed to the bed or rail according to the instructions for use. However, bumpers that can move or compress may themselves introduce entrapment risks. Care should be taken that the patient cannot remove these accessories. For example, a young child may not be able to undo attachments, but as the child grows, they may learn to detach them and this increases entrapment risks from the resulting gaps.

Bed rails are not moving and handling aids.

A risk assessment will always be carried out on the suitability of a bed rail for the individual child. Most bed rails are designed for use with adults and adolescents.                                            

Spacing and other gaps must be risked assessed on an individual patient basis taking account of the patient’s size. There are no published standards on bed rails for children, other standards addressing entrapment risk in relation to other equipment, suggest element spacing should fall between 45mm and 78mm.

This section addresses issues to relating to bed rail use in the patient’s home environment and should be applied in conjunction with the rest of this policy.

Healthcare staff requesting the fitting of bed rails for use in the patient’s home will be responsible for undertaking a risk assessment which should be saved in the patients clinical records. Staff should provide any instruction to the patient and/or carers in relation to the specific needs of the patient and the use of bed rails.

Assessors will prescribe bed rails only if the benefits outweigh the risks. The risk assessment must record the reasons for non issue of bed rails and the assessor must ensure that a further risk assessment is carried out to ensure appropriate controls are implemented for the residual risk.

If the patient’s needs and mattress specification changes the bed rails must be reassessed to ensure they are compatible

When bed rails are required to be fitted in a patient’s home Borders Ability Equipment Store delivery driver will:

• ensure the bed rails are fitted safely in accordance with the manufacturer’s instructions
• provide the patient and /or carers with operating instruction/demonstration of the equipment as per the manufacturer’s instruction but not in respect of the interaction of patient and equipment i.e. the delivery driver will not undertake any assessment or provide instruction specific to the unique needs of the individual patient.

Healthcare staff having assessed the need for and requested fitting of bed rails in a patient’s home, must ensure that the patient and/or carers are aware that the bed rails must not continue being used if they are damaged in anyway or a crack appears or a fault develops in them.  

The member of healthcare staff who has requested the fitting of the bed rails will be responsible for ensuring the need for continued use of the bed rails is regularly reviewed.

Staff will not be involved in making decisions about bed rails or advise patients on bed rail use without having the appropriate knowledge to do so.

All staff responsible for supplying, maintaining or fitting bed rails will have received training and will have the appropriate knowledge to do this.

Bed rails are supplied by the ability store

Maintenance is undertaken by the estates department, unless the bedrails on the bed belong to a hired bed, then the hire company is responsible for the maintenance.

The training of clinical staff in the use of bed rails will be covered in the moving and handling training for NHS Borders will have the appropriate knowledge to do this.

All staff (including students), who have contact with patients in areas where bed rails are used, will during induction to the ward/unit, have been instructed:

Pre use checks do the rails lock in place fully. Do not have any excessive gaps

• on how to raise and lower the bed rails safely
• to alert the nurse in charge if the patient is:
• distressed by the bed rails being in place
• in an unsafe position
• is attempting to climb over the bed rails
• all staff are required to regularly check bed rails for signs of damage, faults and cracks and alert the nurse in charge if any evident.

Bed rails will be maintained in line with the manufacturer’s instructions.

All staff caring for the patient has a responsibility to check bed rails for signs of damage, faults or cracks.

Bed rails that are found to be damaged, or have faults or cracks must not be used, be clearly labelled as faulty, and removed for repair or disposal.

Bed rails when in use on a patient’s bed must be regularly cleaned with detergent and warm water.

Fuse is to be used to clean bed rails that are contaminated with blood/body fluids.

Detachable bed rails must be cleaned using Fuse solution each time they are used for another patient.

Integral bed rails should be cleaned using Fuse solution prior to a patient occupying the bed.

All adverse events and near misses linked to a patient fall (including falling from a height) and/or the use of bed rails e.g. entrapment, patient climbing over the bed rail, bed rails not being used when the patient is transported on a bed or trolley must be reported on NHS Borders Electronic Adverse Event Recording System

An adverse event will become RIDDOR (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) reportable when:

• a patient sustains an injury as a result of a fall from bed and requires hospital care. The assessment identifies the need for bed rails but they, or other preventive measures, had not been provided
• bed rail entrapment results in a patient sustaining a fracture

Development Group 2008

David Henderson           Charge Nurse, DME, BGH

Derrek Hedderly            Charge Nurse, ITU, BGH

Lynne Huckerby             Unscheduled Care Network Manager

David Hume                   Moving and Handling Trainer

Fiona Jackson                Ward Manager, Kelso Community Hospital

Ann Laird                      Clinical Services Manager, Surgical, BGH

Sheila McColm               Risk and Safety Manager

Sheila McLellan             Occupational Therapist, BGH

Frances Mason              Patient Safety Programme Manager

June Nelson                  Charge Nurse, Accident and Emergency, BGH

Anne Palmer                 Clinical Governance Facilitator

Suzanne Phaup             Senior Physiotherapist, BGH

Ann Purvis                    Public Representative

Review Groups

Review Group 2010

David Henderson           Charge Nurse, DME, BGH

Derrek Hedderly            Charge Nurse, ITU, BGH

David Hume                  Moving and Handling Trainer

Sheila MacDougall         Risk and Safety Manager

Sheila McLellan             Occupational Therapist, BGH

June Nelson                  Charge Nurse, Accident and Emergency, BGH

Anne Palmer                 Clinical Governance Facilitator

Suzanne Phaup             Senior Physiotherapist, BGH

Review Group 2013 (update/amendment December 2014)

Elaine Auld                   Falls Lead

David Henderson           Senior Charge Nurse, Department of Medicine   for the Elderly,

David Hume                  Moving and Handling Trainer

Anne Palmer                 Clinical Governance & Quality Facilitator – Clinical Effectiveness

Review Group 2017

Mags Baird                    Project Manager

Janet Bennison              Clinical Lead/Consultant DME

Angie Lloyd-Jones          Strategic Lead for OT and Reablement

Miriam Norris                Charge Nurse

Anne Palmer                 Clinical Governance & Quality Facilitator – Clinical Effectiveness

Val Redpath                  Clinical Lead Physiotherapist

Alison Wilson                Director of Pharmacy

Sam Whiting                 Infection Control Manager

Caroline Wylie               Clinical Risk Facilitator

Review Group 2019

Caroline Wylie               Quality Improvement Facilitator: Patient Safety

Elaine Cockburn             Interim Head of Clinical Governance & Quality

Dr Jenny Ingles              Clinical Lead/Consultant DME

Karen Williamson           ANP: Paediatric/Children’s Services

Mags Baird                    Project Manager

Natalie MacDonald         General Services Manager

Sam Whiting                  Infection Control Manager

Ali Forster                     Hospital to Home Manager

Caroline Burgess            Clinical Service Manager

Kathy Steward               Community Nurse Manager

Peter Lerpiniere             Associate Director of Nursing for Mental Health, Learning Disability & Older People

Lisa Clark                      Operational Manager

Christine Proudfoot        Alzheimer Scotland Dementia Nurse Consultant

Laura Jones                   Head of Clinical Governance & Quality

Review Group 2024     References updated, HIIA performed

Laura Jones                   Head of Clinical Governance & Quality

Diane Laing                   Clinical Effectiveness Administrator

Dr E Dearden                 Consultant Physician, DME    

Robin Brydon                 Interim – Head of Health & Safety

Zoë Spence                   Quality Improvement Facilitator – Patient Safety

Appendix 1 Bedrails Policy

Appendix 2 Bedrails Policy

The matrix below is taken from the National Patient Safety Agency’s safer practice notice: ‘Using bed rails safely and effectively’

The matrix must be used in conjunction with the full Bed rail Policy as well as a combination of nursing judgement and awareness that:

• patients with capacity can make their own decisions about bed rail use.
• patients with visual impairment may be more vulnerable to falling from bed.
• patients with involuntary movements (eg spasms) may be more vulnerable to falling from bed and if bed rails are used, may need padded covers.