Bed rails/cot sides for adult/paediatric inpatients - Safe and effective use of

Publication: 27/02/2013  --
Last review: 26/04/2019  
Next review: 04/04/2022  
Clinical Guideline
CURRENT 
ID: 3258 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Safe & Effective use of bed rails/Cot sides for adult/paediatric inpatients

Summary

Bed rails are equipment that should only be used to reduce the risk of a patient accidentally or involuntarily falling, slipping or rolling out of bed. Bed Rails should be the least restrictive alternative to reduce the likelihood and seriousness of harm. Bed rails are a form of restraint and staff must follow the standards set out in the LTHT Restraint Policy.

Restraint is defined as: Use or threat of the use of force to make someone do something they are resisting or anything that restricts a person’s freedom of movement, whether they are resisting or not (Mental Capacity Act 2005). Bed rails will not prevent a patient leaving their bed should they wish. Bed rails are also not intended as a moving and handling aid and care should be taken if patients are using them for support whilst rolling in bed.

Potential risks of using bed rails which should be considered include; will bed rails stop the patient from being independent? Could the patient climb over the bed rails, or mobilise to the end of the bed to get out? Or could the patient injure themselves on the bed rails or become entrapped?

Rigid bed rails used at LTHT are the Integral type which are incorporated into the bed design and supplied with it or offered as an optional accessory by the bed manufacturer, to be fitted later. Third party bed rails that can be attached and detached are not permitted within LTHT.

In terms of this guideline, and in line with mental capacity and common law, an infant is defined as being 0 - 1 years of age, a child is 1 - 15 years of age, and an adult 16 years and over.

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Background

This guideline was developed to comply with NPSA SPN17 and to standardise practice across the Trust.

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Patient assessment

Adult Inpatients
For adult patients a baseline assessment of the patient’s ability to maintain a safe environment should be made and documented on admission on the Nursing Specialist Assessment eform .

Child Inpatients
For children any discussions with parents/carers on the use of bedrails/cot sides should be documented on the Child and Family Assessment (WQN1507).

On admission the nurse should establish with the parent/carer the infant/child’s usual sleeping preference ie cot or bed. Children under the age of 2 years should generally be nursed in a cot, children over 3 years should be nursed in a bed. A risk assessment should be carried out for any exceptions to the guidance above.

For example: If a child is aged between 2 and 3 years of age and usually sleeps in a cot with integral sides, the practitioner should undertake a risk assessment and document the risk of the child climbing out of the cot and causing harm to themselves.

All Inpatients
Following this initial assessment, and in conjunction with a professional judgement, a decision about whether or not to use bed rails should be made. The Bed Rails Risk Assessment and Care plan (WUN638) or Bed Rails eform should be completed (Appendix 1) for all adult and child inpatients who have been identified as at risk of falls.

On completion of the assessment, if bed rails are indicated, the result of the assessment  should  be  discussed  with  the  patient  and,  where  appropriate,  their relatives/carers.  

Integral bed rails should only be used when a risk assessment has identified that they might prevent harm to the patient. Integral bed rails should not usually be used if the patient is agile enough but confused enough to climb over the bed rails or if the patient would be independent if the bedrails were not in place. They 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.

Staff should use their professional judgement to consider the risks and benefits for individual patients. It is also important to take into account the views of the main carer who knows the patient best. Potential risks of using bed rails which should be considered include; will bed rails stop the patient from being independent? Could the patient climb over the bed rails, or mobilise to the end of the bed to get out? Or could the patient injure themselves on the bed rails or become entrapped?

Integral bed rails should only be used when the benefit of using them is assessed as outweighing potential risk to the patient.  Use of bed rails should be time-limited and for the shortest time possible.

The behaviour of individual patients can never be completely predictable and the Trust  will  be  supportive  of  staff  when  decisions  are  made  by  frontline  staff  in accordance with this guidance.

This decision should be made jointly between parents and nursing staff and the decision recorded in the Child and Family Assessment document and the Bed Rails Risk Assessment and Care Plan or Bed Rails eform. If a family request sleeping arrangements which fall outside this risk assessment it should be clearly written in the Child and Family Assessment documentation and the situation escalated to a Senior Nurse/Matron.

Infants must never be left unattended when the cot sides are semi down or completely down. Parents/carer’s of the infant need to be made aware of the dangers of leaving the cot sides down and the conversation should be written in the Child and Family documentation.

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Decision making and consent

From the age of 16 years, informed consent of the patient who has mental capacity should be obtained prior to the use of bed rails. Mental capacity is the ability to understand, retain and weigh up the risks and benefits of bed rails once these have been explained to the patient. The Trust does not require written consent regarding bed rails, but discussions and decisions should be documented in the nursing notes by the person obtaining that consent. When a patient is unable to give their consent, the use of the bed rails should be, wherever possible, discussed and explained to relative or carer. If the patient lacks capacity staff have a duty of care and must decide if bed rails are in the patients best interest.

If bed rails are indicated but a patient with mental capacity declines to have them in situ this should be documented in the medical/nursing notes and an alternative measure to prevent harm to the patient explored with them. If a patient or relative/carer requests the use of bedrails full nursing and risk assessments should be made, as above, prior to the decision being made to use bed rails. If bed rails are identified as not being required for the patient, this decision should be explained to the patient and/or relative and an alternative to bed rails should be sought and used. This should be documented in the medical/nursing notes.

For patients under the age of 16 years, consent can be gained from the person with parental responsibility.

All adult inpatients identified as at risk of falling on the Nursing Specialist Assessment, and who have a Falls Prevention Care Plan (WUN1019) completed, should have a Bed Rails Risk Assessment and Care Plan or Bed Rails eform completed.

All child inpatients identified as at risk of falling on the Child and Family Assessment should have a Bed Rails Risk Assessment and Care Plan or Bed Rails eform completed.

Alternatives to Bed Rails
Some alternative to bed rails should be explored if the patient declines bed rails or if bed rails cause distress these are; low care beds, bed alert system, specialing (additional staff), positioning the patient in constant view of nursing staff.

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Documentation and ongoing assessment

Patients who require bed rails should have a completed Bed Rails Risk Assessment and Care Plan or Bed Rails eform. Patients who are considered not to be at risk must be re-assessed on a weekly basis or on change of condition/ability to maintain a safe environment. The Bed Rails Risk Assessment and Care Plan or Bed Rails eform should include the rationale for the use of bed rails and should be completed once for an early, late and night shift for the first 72 hours.  Risk assessments should then be reviewed after each significant change in the patient’s condition or any incident relating to safety in bed or as a minimum of every week for inpatients.
 
The rationale for the removal of bed rails should be documented and explained to the patient/relative/carer.

If a patient is found trying to climb over the bed rail or from the bottom of the bed this is a clear indication that they are at risk of serious injury from falling from a greater height. The risk of using bed rails are likely to outweigh the benefits, unless their condition changes. This then needs to be documented in the patient’s notes.

If a patient is found in positions which could lead to entrapment e.g. feet or arms through rails this is a clear indication that they are at risk of serious risk injury and urgent changes must be made in their care and documented within the nursing documentation.

Beds should remain at the lowest position during the use of integral bed rails; unless this is not practicable then the reason should be documented within the patients nursing record. Note: The Enterprise 5000 found in many clinical areas has a function which allows them to be lowered a further 6-8 inches.  The Enterprise 8000 will lower to approximately 320mm from the ground.

Integral bed rails should be used according to the manufacturer’s instructions. Staff should refer to the MRHA advice for guidance. Integral bedrails should be inspected prior to and during use for any signs of damage, faults or cracks and, any identified as defective must be quarantined and either reported for repair or condemned (as appropriate).  Defective integral bed rails must NOT be used, and disposed of immediately. Staff must also take care to ensure that the bed handset coiled cables and other items such as the bed sheets do not become entwined around the bed rail plunger mechanism.

Integral bed rails that are Split should always be used with both parts of the bed rail in an upright position.

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The safe use of therapeutic beds and air mattresses with bed rails

Additional vigilance should be used with profiling beds to ensure that there is no possibility of entrapment once the bed is adjusted to a differing profile from horizontal as potential entrapment hazards can be created in different configurations.  All instructions regarding the use of hired beds should be handed over to the member of Trust staff receiving the bed in the clinical area. As this information can be limited instructions for use can be found in clinical areas within the Pressure Area Care Equipment Selection Guide and on the Trust intranet site:

Staff should consider the overall height of the mattress plus overlay as the reduction in the effective height of the bed rail relative to the top of the mattress may allow the patient to roll over the top of the bed rail. Extended height bed rails are available and should be used in this situation.

The  hazard  of  entrapment  between  the  mattress  and  the  bed  rails  may  be exacerbated due  to the soft, easily compressed nature of the mattress therefore a risk assessment of the mattress/bed rail should be carried out to ensure entrapment cannot occur.

If using a Bariatric bed with a pressure relieving mattress and it creates a gap then foam wedges must be used to provide a continuous mattress platform.

Bed rail bumpers
Should the patient require bumpers to cover the bed rails to prevent impact injury or entrapment, only bed rail bumpers or equivalent should be used. Under no circumstances should duvets, blankets, pillows or cushions be placed over or against bed rails to prevent injuries.

Cleaning and maintenance
Bed rails should be cleaned with detergent wipes in between use or if contaminated with blood and body fluids as per the Standard Infection Prevention and Control Precautions Policy.

Maintenance issues with integral bed rails are referred back to the supplier of the bed. Integral bed rails are asset identified as part of the bed.  All beds and cots within the Trust are serviced yearly through a service agreement.  As part of this bed rails are inspected.  If staff find any faults with bed rails they must report this to medical physics.

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Reporting of injuries sustained due to the use of bed rails

Any injury caused either to a patient or a member of staff, due to use of integral bed rails should be reported as a clinical incident, documented in the nursing notes and a datix web form completed.  Any serious untoward incident due to the use of bed rails should be reported to the Medical Devices Agency. Defective equipment should be removed from service immediately but be identifiable for possible photograph and examination following an incident.

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Appendix 1
Description: WUN638 PAGE 1.jpg

NB; For the purpose of this policy the word child will be used but will relate to infant/child/young person.

Provenance

Record: 3258
Objective:

Aims
The aim of this guideline is to define clear standards for the assessment and decision making for the safe and effective use of bed rails for adults and children. It will provide a standardised document for record keeping.  

Objectives

The aim of this guideline is to define clear standards for the assessment and decision making for the safe and effective use of bed rails for adults and children. It will provide a standardised document for record keeping.  

Clinical condition:

N/A

Target patient group: LTHT Adult/Paediatric Inpatients who require the use of bed rails.
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
All Secondary Healthcare Professionals
Adapted from:

Evidence base

Department of Health - Medicines and Healthcare products Regulatory Agency(MHRA) : Device Bulletin Safe Use of Bed Rails MDA DB2006

(06) December  2006

http://www.mhra.gov.uk

Mental Capacity Act 2005 Deprivation of Liberty Safeguards

Mental Capacity Act 2005 Code of Practice

 

NPSA 2007 (NPSA/2007/17) Safer Practice Notice 17 Using, MHRA 2007/009 Bed rails and grab handles, Health & Safety Executive.

A. Systematic reviews of RCTs

B. Robust experimental or observational studies

C. Expert consensus.

D. Leeds consensus.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

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