Policy for the safe and effective use of bedrails within community hospitals
Document History
Version Date: / February 2010Version Number: / 2
Status: / Approved
Next Revision Due: / February 2012
Developed by: / Professional Development Lead (Community Hospitals) in consultation with relevant PCT staff
Policy Sponsor: / Assistant Director(Integrated Community Based Services)
EQIA completed: / Approved 5th November 2007. CLINQ/07E27 Reviewed October 2009
Approved by: / Provider Services Clinical Governance Committee
Date approved: / 8th March 2010
Revision History
Version / Revision date / Summary of Changes2 / February 2010 / Policy updated with reference to current service provision and includes the latest MHRA guidance
Policy Information Leaflet (delete if not applicable)
Reference Number / Title / Available fromAppendix / Safe Use of
Bedrails /
Table of Contents
1.FULL DETAIL OF POLICY
1.1individual patient assessment
1.2responsibility for decision making
1.3bedrails and falls
1.4documentation
1.5using BEDRAILS
1.6reducing risks
1.7education and training
1.8supply, cleaning, purchase, and maintenance
1.9reporting incidents
1.10DISCHARGE
2.references and associated documentation
3.appendices
appendix 1current mhra instruction for provision and safe use of bedrails
4.aim
5.Background
6.Area for Implementation
7.Organisational Accountability /Responsibilities i.e. CEO, Directors, Managers, Staff
8.Intended Users
9.Definition
10.Indications for Use
11.Contra-indications
12.Equality Impact Statement
13.Monitoring and Performance Management of the policy
14.Support and Additional Contacts
Equality & Diversity Impact Assessment: Level I Screening
Policy for the safe and effective use of bedrails in community hospitals
Policy for the safe and effective use of bedrails in community hospitals
1.FULL DETAIL OF POLICY
Patients in hospital may be at risk of falling from bed for many reasons including poor mobility, dementia or delirium, visual impairment, and the effects of their treatment or medication. In England and Wales over a single year there were approximately 44,000 reports of patients falling from bed. This includes eleven deaths and around 90 fractured neck of femurs, although most falls from beds resulted in no harm or minor injuries like scrapes and bruises. Patients who fall from beds without bedrails were significantly more likely to be injured and to suffer head injuries (usually minor). A systematic review by the NPSA in 2007 of published bedrail studies suggests falls from beds with bedrails are usually associated with lower rates of injury and initiatives aimed at substantially reducing bedrail use can increase falls.
Bedrails are not appropriate for all patients and using bedrails also involves risks. National data suggests around 1,250 patients injure themselves on bedrails each year, usually scrapes and bruises to their lower legs.
Based on reports to the Medicines and Healthcare products Regulatory agency (MHRA) the Health and Safety Executive (HSE) and the National Patient Safety Agency (NPSA) deaths from bedrail entrapment in hospital settings in England and Wales occur less often than one in every two years, and could probably have been avoided if MHRA advice had been followed. Staff should continue to take great care to avoid bedrail entrapment but need to be aware that in hospital settings there is a greater risk of harm to patients by them falling from beds.
1.1individual patient assessment
Bedrails are only provided following a risk assessment of the individual needs of the patient ensuring compatibility with the mattress and bed. The Bed Rails Risk Assessment for In-Patients should be completed within four hours of admission.
To access the document click here .UseofBedRailsRiskAssessment-0041-ASS-
a.Bedrails should usually be used:
- if the patient is being transported on their bed; or
- in areas where patients are recovering from anaesthetic or sedation and are under constant observation, e.g. in Minor Injuries units (MIU) and Diagnostic and Treatment Centres (DTC)
If bedrails are used, how likely is it that the patient will come to harm? Ask the following questions:
- Will bedrails stop the patient from being independent?
- Could the patient climb over the bedrails?
- Could the patient injure themselves on the bedrails?
- Could using the bedrails cause the patient distress?
Most decisions about bedrails are a balance between competing risks. The risks for individual patients can be complex and relate to their physical and mental health needs, the environment, their treatment, their personality and their lifestyle. Staff should use their professional judgement to consider the risks and benefits for individual patients. Consideration should also be given to the use of a “high-low” bed if available.
b.Bedrails should not usually be used:
- if the patient is agile enough, and confused enough, to climb over them;
- if the patient would be independent if the bedrails were not in place.
c.If bedrails are not used how likely is it that the patient will come to harm?
Ask the following questions:
- How likely is it that the patient will fall out of bed?
- How likely is it that the patient would be injured in a fall from bed?
- Will the patient feel anxious if the bedrails are not in place?
Use bedrails if the benefits outweigh the risks.
The behaviour of individual patients can never be completely predicted and the Trust will be supportive when decisions are made by frontline staff in accordance with this policy.
Decisions about bedrails may need to be frequently reviewed and changed. Even stable patients in rehabilitation or mental health settings can have rapidly changing needs when physical illness intervenes. Therefore, decisions about bedrails should be reviewed whenever a patient’s condition or wishes change but as a minimum reviewed every seven days.
1.2responsibility for decision making
Decisions about bedrails need to be made in the same way as decisions about other aspects of treatment and care as outlined in the Trust’s Consent Policy. This means:
- The patient should decide whether or not to have bedrails if they have capacity. Capacity is the ability to understand and weigh up the risks and benefits of bedrails once these have been explained to them.
- Staff can learn about the patient’s likes, dislikes and normal behaviour from relatives and carers. The benefits and risks of bedrails should also be discussed with relatives and carers. Relatives or carers cannot make decisions for adult patients (except in certain circumstances where they hold a Lasting Power of Attorney extending to healthcare decisions under the Mental Capacity act 2005).
- If the patient lacks capacity, staff have a duty of care and must decide if bedrails are in the patient’s best interests.
DCHS will provide a leaflet for patients, relatives and carers giving information on bedrails and preventing falls. This can be accessed via:
The Trust does not require written consent for bedrail use but discussions and decisions must be documented by staff (see section 1.4 below).
1.3bedrails and falls
Decisions about bedrails are only one small part of preventing falls and should be seen in the wider context of falls prevention
1.4documentation
The decision to use or not use bedrails should be recorded as a standard part of DCHS patient documentation, except in Minor Injuries Units and Diagnostic and Treatment Centres where bedrail use is standard practice.
1.5using BEDRAILS
- All unsafe bedrails (e.g. two-bar bedrails, bedrails with internal spaces exceeding 120mm, bedrails not in matched pairs, and bedrails in poor condition or with missing parts – see MHRA advice) have been removed and destroyed.
- Trombone bed rails should no longer be used and the patient should be transferred to a bed with integral rails on.
- All bedrails or beds with integral rails have an asset identification number and are regularly maintained by the Estates Department.
- Types of bedrails, beds and mattresses used on each site within the organisation are of compatible size and design, and do not create entrapment gaps for adults within the range of normal body sizes except for mattress overlays which should only be used with three inch mattresses
- For bariatric patients, ensure that the bed, mattress and rails are suitable for the weight and shape of the patient. If rails are required they must be integral to the bed. If a specialist bariatric bed is required (e.g. an extra wide, greater safe working load), any bed rented or leased must satisfy MHRA guidance. For Further advice contact the Trust Back Care Coordinators
Whenever frontline staff use bedrails they must carry out the following checks:
a.For all bedrails: See Appendix 1
- The gap between the top end of the bedrail and the head of the bed should be less than 60mm or more than 250mm.
- The gap between the bottom end of the bedrail and the foot of the bed should be
less than 60mm or more than 250mm.
1.6reducing risks
For patients who are assessed as requiring bedrails but who are at risk of striking their limbs on the bedrails, or getting their legs or arms trapped between bedrails, then covers must be used unless the patient declines their use. Document any discussions re the use of covers in the Multidisciplinary Records.
If a patient is found in positions, which could lead to bedrail entrapment, e.g. feet or arms through rails, halfway off the side of their mattress, or with legs through gaps between split rails, this should be taken as a clear indication that they are at risk of serious injury from entrapment. Urgent changes must be made to the plan of care. These could include changing to an alternative type of bedrail or deciding that the risk of using bedrails now outweighs the benefits.
If a patient is found attempting to climb over their bedrail, or does climb over their bedrail, this should be taken as a clear indication that they are at risk of serious injury from falling from a greater height. The risks of using bedrails are likely to outweigh the benefits, unless their condition changes.
The safety of patients with bedrails may be enhanced by frequently checking that they are still in a safe and comfortable position in bed and that they have everything they need. However, the safety needs of patients without bedrails who are vulnerable to falls are very similar. All patients in hospital settings will need different aspects of their condition checked, e.g. breathlessness, anxiety and pain. Consequently, observing patients with bedrails should not be treated as a separate issue but as an important part of general observation within each ward/department and should be considered as part of the Falls Assessment.
Beds should usually be kept at the lowest possible height to reduce the likelihood of injury in the event of a fall, whether or not bedrails are used. The exception to this is independently mobile patients who are likely to be safest if the bed is adjusted to the correct height for their feet to be flat on the floor whilst they are sitting on the side of the bed.
Beds will need to be raised when direct care is being provided. Patients receiving frequent interventions may be more comfortable if their bed is left raised rather than it being constantly raised and lowered.
New beds, bedrails or mattresses can introduce new risks if they are not fully compatible with existing stock. To reduce this risk, in future all new bedrails should be integral to beds purchased by DCHS. When special mattresses are hired, the company renting the mattress will be asked to confirm that the mattress is compatible with the bed and bedrail that it will be used with.
1.7education and training
DCHS will ensure that all staff who:
- make decisions about bedrail use, or advise patients on bedrail use, will have the appropriate training in the use of the Bedrails and Falls Risk Assessment tools;
- supply, maintain or fit bedrails have the appropriate knowledge to do so as safely as possible, tailored to the equipment used within the Trust;
- have contact with patients, including students and temporary staff, understand how to safely lower and raise bedrails and know they should alert the nurse in charge if the patient is distressed by the bedrails, appears in an unsafe position, or is trying to climb over bedrails.
These points are achieved through DCHS staff accessing in-house training on bedrails via the information booking line: Training Information - Derbyshire County PCT Intranet
1.8supply, cleaning, purchase, and maintenance
DCHS aims to ensure bedrails, bedrail covers and special bedrails, can be made available for all patients assessed as needing them.
The nurse in charge/departmental manager should be told of any shortfall. He/she will endeavour to release bedrails from patients who no longer need them. If bedrails cannot be obtained, staff should explore all possible alternatives to reduce the risk to the patient and report the lack of equipment on an incident reporting form.
Method of Cleaning
For general cleaningthe bedrailsand covers (if used) should be cleaned as per Stages 1,2,4 and 5 below where there is an infection control issue step 3 should also be followed
Stage 1:Cleaning
The first stage or infection control cleaning involves the use of warm water and detergent to remove organic matter and microorganisms from surfaces and patient equipment. Cleaning with detergent and warm water lubricates and suspends the microorganisms, dirt and dust in the solution enabling them to be removed effectively from the surface. However this will not necessarily kill micro – organisms.
Cleaning with detergent and water is an essential aspect of cleaning that must be undertaken before disinfection. Cleaning with a general purpose detergent must be used.
Stage 2:Rinsing
Detergent can leave a residue, which affects the activity of disinfectants, therefore all areas need to be rinsed or wiped down with warm water following cleaning with detergent and water
Stage 3:Disinfection
Disinfection is a process, which involves the use of a chemical agent such as chlorine to inactivate and destroy microorganisms. Disinfectant will only kill on contact and will not remove any organic matter or dust.
The use of disinfectants is an essential 3rd stage of infection control cleaning and is ineffective if it has not been undertaken following the use of detergent and water and rinsing first.
Within DCHS the chlorine based product to be used is Actichlor 1,000 parts per million. N.B. This must be prepared as per manufacturer’s instruction using the bottles provided to ensure that correct concentrations are prepared and health and safety is maintained.
Stage 4:Rinsing
Rinsing or wiping with warm water must be undertaken to ensure that any residual chlorine is removed from the surfaces.
Stage 5:Drying
Drying is the final stage of the process and must be undertaken thoroughly as some microorganisms will thrive in wet and moist environments.
N.B: Hotel Services staff only will be using a combined detergent and chlorine-based product. The procedure for the use of this product sits within Hotel Services Policy & Procedures files.
1.9reporting incidents
All incidents or near misses that occur in relation to falls, including those related to use or lack of use of bedrails, must be reported following DCHS Incident Reporting Policy.
1.10DISCHARGE
Inpatients within DCHS Community Hospitals through the ongoing bedrail risk assessment and review should aim for the use of bedrails to be withdrawn prior to discharge. However where there is a clear identified need for bed rails to continue to be used in the community staff should complete the Joint Social Services and NHS Stage 1 Assessment form within the Joint Derby and Derbyshire Health and Social care Policy for the safe use of Bed rails in the Community Link to Clinical Polices Page
The name of the person who will be picking up the referral in the Comunminity should be documented in the Multidisciplinary notes and any verbal communications should also be documented A copy of the referral assessment form should be retained within the multidisciplinary notes with a copy to the referrer
2.references and associated documentation
Joint Derby and Derbyshire Health and Social Care Policy for the safe use of Bed Rails in the Community July 2009
DCHS Infection Control, Cleaning Policy for Barrier Precaution areas and During Outbreaks November 2007
DCHS Consent Policy 2008
DCHS Mental Capacity Act policy 2007
NPSA 2007 Safer practice notice 2007, Using bedrails safely and effectively
NPSA 2007 Resources to support implementation of safer practice notice, Using bedrails safely and effectively
NSPA 2007 Slips, trips and falls in hospitals.
MHRA Device Bulletin DB2006 (06) the safe use of bedrails and MHRA Device Alert 2007/09 Bed Rails and Grab Handles.
MHRA Device Bulletin DB 2006(05) Managing Medical Devices.
Healey, F, Oliver, D. Preventing falls and injury in hospitals: where are efforts best directed? Healthcare Risk Report. 2006: June: 15-71.
Mental Capacity Act 2005. The Stationery Office Limited: London.
Queensland Health (2003) Falls prevention best practice guidelines for public hospitals. Queensland Government 2003. p37.
Vassallo M, Stockdalle, R, Wilkinson, C. et al. Acceptability of falls prevention measures for hospital inpatients Age and Ageing 2004 33;4;400.
3.appendices
Appendix 1 MHRA Instruction for Provision and Safe Use of Bedrails.
appendix 1current mhra instruction for provision and safe use of bedrails
Code / British Standard 2001A / Gap between rails
Should be a maximum of 120mm
B / Mattress depth including pressure mattress, if fitted
C / Measurement from top of mattress (NOT COMPRESSED) to top of rails
Should be a minimum of 220mm
D / Gap from end of rail to top of headboard
Can be up to 60mm or more than 250mm
E / Gap from end of rail to foot board
Can be up to 60mm or more than 250mm
F / From top of mattress platform to bottom of rails
If D is 250mm or more then F must be a maximum of 60mm
If D is 60mm or less then F must be a maximum of 120mm
G / Length of rails
Should be at least 2/3 of the bed
H / No requirements for bed length