Bedrails: Do They Have a Benefit?

The provision of safe and effective care for frail older persons in hospitals and nursing homes continues to raise questions about how such care can be provided. Established and accepted practice has often been based on an assumption of benefit even when there is no evidence to support such an assumption. This has come about, in part, as a result of a practice being introduced and accepted as an appropriate standard of care before there are any real data showing that benefits from the practice outweigh any subsequent harm. New therapeutic medications are now rigorously tested to ensure that their benefit is indeed greater than any harm, but therapeutic physical interventions are much less likely to be evaluated carefully before becoming established in clinical practice; in fact, evaluation occurs only after the practice is implemented. These care practices are now being looked at with increasing rigor as clinical practice becomes increasingly evidence-based and based less on untested assumptions. One such well established care practice, the use of physical restraints, has been scrutinized rigorously only in recent years. The early physical restraint use studies did not consider the use of bedrails to be a form of physical restraint and did not, therefore, develop evidence for or against bedrails having a beneficial effect.1–4 The regulation of provision of care has been expanded increasingly by numerous agencies. The Omnibus Budget Reconciliation Act (OBRA) of 1987, which addressed the use of physical restraints in nursing homes, considered logically that bedrails may be a form of physical restraint. Since enactment of the OBRA regulations, from 1990 onward there has been a continuing reduction in the use of physical restraints in nursing homes.5 More recently the focus has been directed increasingly toward bedrails as potential physical restraints. In turn, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has paid increased attention to the use of physical restraints in hospitals, resulting in recommendations for many hospitals to improve the care of physically restrained patients in order to meet the standards of the Joint Commission. The JCAHO also includes bedrails within the definition of a form of physical restraint. The regulatory attention now being paid to bedrails has been engendered by recent demonstration that seemingly benign bedrails have the capacity to kill patients and residents.6 A serious accident arising from the use of bedrails is considered to be a “sentinel event” by the JCAHO and requires a prescribed review and actions on the part of the accredited organization. The US Food and Drug Administration also requires that significant harm arising from a physical restraint, including bedrails, must be reported to that agency. Even with this regulatory attention and the recognized potentially lethal attributes of some bedrails, there are very few studies designed to produce evidence of either the beneficial or the harmful results of their use. In the US, beneficial effects seem to be assumed to be true in that hospital beds have bedrails as an integral feature of the bed and cannot be removed. Furthermore, established normative clinical practice by caregivers has been to raise the bedrails when direct clinical care is no longer being provided to a patient in bed in order to prevent a fall from the bed. The assumption underlying this action was that the safety of the patient was ensured. That assumption has been in question for more than 15 years.7 Although a well designed trial to find evidence to support the use of bedrails as a beneficial practice was suggested in 1983, it was pointed out that such a study could well run into difficulties both legally and ethically.8 Since then, many of the legal concerns surrounding the use of physical restraints have become clearer, and these apply equally to bedrails. Furthermore, the current regulatory climate suggests that carefully designed studies to provide the evidence for the use or non-use of bedrails are likely to be approved. See also p 529 It is not surprising that there have been very few formal studies designed to evaluate the assumed benefits that arise from the use of bedrails. The paper by Dr. Hanger and colleagues may well be the first of many such papers that begin to create clear evidence that bedrails do or do not have a place in the provision of clinical care, especially the care of frail older people.9 Their study concludes that bedrails did not have the beneficial effect of preventing serious injury from falls and, further, that the removal of bedrails led to a reduction in the number of serious injuries. This finding of a reduction in serious injury following removal of bedrails is in keeping with similar findings when physical restraints were removed.10 Bedrails have been given increased importance beyond that of a safety feature as hospital beds have become more sophisticated and more mechanically complicated. Numerous electrical controls are incorporated into the bedrails so that the need to raise bedrails is almost imperative for the position of the bed to be adjusted by either the patient in the bed or by the caregivers. Bedrails, however, are not designed to be lowered by the person in the bed and, thus, can fall within the definition of a restraint. In contrast to bedrails, other forms of physical restraint must be attached to the bed frame by caregivers, and, therefore, their use is more readily questioned. In places where bedrails are not an integrated feature of the bed, their use may be more judicious and not a normative practice.11 Attaching bedrails to a bed is not accomplished as easily as tying or strapping a physical restraint to a bed frame. The incorporation of bedrails into the bed design itself, therefore, encourages their use. Bedrail use, moreover, is such a familiar aspect of hospital and nursing home care that a change in practice to keep bedrails lowered will require significant educational efforts directed toward staff, patients, and family members. The successful removal of other physical restraints required a great deal of education and the support of clinical staff and also of families.12 The removal of bedrails or keeping them in a lowered position will require an even greater effort in education of families and clinical staff and the support and encouragement of the administrative staff as well.13 As with other physical restraints, legal concerns will be raised. It has been pointed out that hospitals and nursing facilities have a duty to prevent harm but not a duty to restrain.13 All of this points to a real need for an imaginative redesign of hospital beds. This radical redesign must result in bedrails no longer being an essential feature of the bed. An ideal bed will be of adjustable height, with a range of height for the bed frame from floor level to a comfortable height for caregivers to provide direct care and for lateral transfer to a stretcher. A challenge for manufactures is to come up with a robust design that achieves this end. A bed frame that can be lowered to floor level removes the need for bedrails. In 1978 it was pointed out that bedrails “treat the bed not the patient, because if the bed is at the right height, cotsides (bedrails) are unnecessary.”14 Such a design has been developed in Australia, but it is not yet in widespread use, nor is the robustness of the design assured. In addition to possibly being a safety feature, bedrails may be valuable because they enable patients to turn themselves while in bed using the rail as a hand grip.15 This is especially true for hemiplegic patients. A complete redesign for a hospital bed should incorporate that useful aspect of bedrails. A trapeze bar at the head of the bed can also enable patients to move more easily in bed. In a new design, the bed controls should be readily accessible to both the patient and the caregiving staff; the needs of both are equally important. Finally, the image of a patient in bed surrounded by bedrails must be given some consideration. The raised bedrails may make the person in the bed feel encaged or, perhaps worse, behind bars, thereby adding to already present agitation, or delirium, or despair.13 The effect on the caregivers may be to view the patient behind the bedrails as having diminished physical or mental capacity, thereby demeaning the patient. The physical appearance of a patient inevitably creates biased thoughts in family members and staff in favor of or against the patient's best interests.16 As occurred with the reduction of physical restraints and with the replacement of nasogastric tubes with gastrostomy tubes, the removal of bedrails may well enhance the image of a patient in a hospital bed. In this way, ill or frail patients will be treated with more dignity and receive greater respect. It seems evident that a particular challenge for those who care for frail and ill older people is to encourage a comprehensive redesign of a modern hospital bed to incorporate its virtues and eliminate its harmful features.