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Rates of Death Associated with Use of Bedrails



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Am Fam Physician. 1998 Jan 15;57(2):348-350.

Bedrails are used extensively in hospitals and nursing homes for restraint or safety. In hospitals, the use of bedrails is typically a nursing decision. In nursing homes, federal guidelines mandate a physician's order when bedrails are used as restraints. Bedrails have been associated with a number of deaths despite the fact that they are often thought to be an innocuous safety feature. Parker and Miles reviewed the ways that bedrails may cause death and offered suggestions for preventing these types of deaths.

United States Product Safety Commission files were reviewed for deaths occurring in adults who were in bed and whose death was related to the use of bedrails. Patients were excluded if other restrictive devices, such as chest or pelvic restraints, were used. Demographic data and descriptive information were collected for cases occurring from 1966 through 1996, and illustrations were made to recreate the mechanism of injury in order to categorize the types of death.

Fifty-one of the 74 deaths recorded occurred in patients older than 70 years of age, with 26 deaths occurring in patients between 81 and 90 years of age. Women were involved more than twice as often as men, with 69 percent of the deaths occurring in women and 28 percent occurring in men. Deaths were categorized into three groups. Most deaths (70 percent) were caused by suffocation resulting from entrapment between the rail and the mattress and/or the bed itself. Latch failure that resulted in the bedrail falling on the patient's head occurred in 18 percent of deaths. In these cases, the patient's head was caught between the vertical rails. The third group of patients (12 percent) died after sliding on either the abdomen or the back through the space between the head and foot rails and becoming lodged with the neck either hypo-extended or hyperextended by the floor. In four patients, the exact mechanism of injury could not be determined.

The authors conclude that bedrails should not be used in ambulatory patients. Use of bedrails may be appropriate in patients who are sedated and on life-sustaining systems. Design recommendations include limiting the space between the head and the foot rails to no more than 6 cm to prevent entrapment injuries. Other design recommendations are listed in the accompanying table.

Safety Recommendations to Prevent Bedrail-Related Deaths

Design specifications Clinical change

Bed

Specify that bed must lower to a height that allows a patient to be sitting with upper legs parallel to floor for standing up and exiting bed. Close the head-trapping triangular space created by the right angle formed by the headboard and bedrails and the rounded corner of the mattress by curving the headboard (or rails) in at the ends of the bed. There should be a standard anchoring location and system for string-type position alarms. There should be a place on all beds for retrofitting weight-based position sensors.

Beds should be maximally lower ed except during direct medical care. Alarms that detect a decrease in the amount of a confused or restless patient's weight that is centered on the mattress should be turned on at all times. Alarms that detect a patient being out of position should also be used for all persons who are confused, or restless and in restraints, or incapable of ambulating independently when awake.

Mattress

Label mattresses for specific beds. Specify maximum lateral distance between mattress sides and siderails and between mattress sides and head/foot boards. Specify that mattress and bed must be designed so that mattress cannot move toward either side or head or foot of bed. Clearly mark minimal mattress width and length on bed. Specify minimum vertical distance from mattress top to bedrail top and clearly mark this on bedrails. Specify refurbishing method that will not shrink mattresses.

Confirm that mattress is matched and fitted in relation to width and height of rails. Pending revisions of mattress design, consider placing hook and loop or other antiskid material between the mattress and the mattress deck to reduce mattress slippage to one side or toward foot of bed.

Bedrails

Label rails for specific beds. Specify latch strength and durability. Require latch switch so that patients who, when awake, can ambulate independently, can operate latch to lower bedrails themselves to prevent falls from climbing over rails. Specify headrails bar spacing so that head cannot go between bars. Specify space between head and foot rails and lateral space between rails and bed frame so that a 90-lb patient cannot slip through them. This may require curving the lower edge of the rails inward to the mattress frame.

Confirm proper selection and fitting of bedrails to bed and in relation to mattress. Use padded bedrail covers to reduce trauma and to obscure bar spaces for any agitated patient or when patient's head can pass between head rail bars.

Bedrail covers

Specify which covers go with which rails and beds and performance standards for softness and for strength at blocking a person sliding a limb between or through rails.

Bedrail covers should be used as part of the emergency management of patients who are undergoing seizure or who are extremely agitated and who are restrained and who require that both head and foot rails be in the up position. If so indicated, they should be used to close any space between head and foot rails that is greater than 6 cm.


Reprinted with permission from Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45:797–802.

Safety Recommendations to Prevent Bedrail-Related Deaths

View Table

Safety Recommendations to Prevent Bedrail-Related Deaths

Design specifications Clinical change

Bed

Specify that bed must lower to a height that allows a patient to be sitting with upper legs parallel to floor for standing up and exiting bed. Close the head-trapping triangular space created by the right angle formed by the headboard and bedrails and the rounded corner of the mattress by curving the headboard (or rails) in at the ends of the bed. There should be a standard anchoring location and system for string-type position alarms. There should be a place on all beds for retrofitting weight-based position sensors.

Beds should be maximally lower ed except during direct medical care. Alarms that detect a decrease in the amount of a confused or restless patient's weight that is centered on the mattress should be turned on at all times. Alarms that detect a patient being out of position should also be used for all persons who are confused, or restless and in restraints, or incapable of ambulating independently when awake.

Mattress

Label mattresses for specific beds. Specify maximum lateral distance between mattress sides and siderails and between mattress sides and head/foot boards. Specify that mattress and bed must be designed so that mattress cannot move toward either side or head or foot of bed. Clearly mark minimal mattress width and length on bed. Specify minimum vertical distance from mattress top to bedrail top and clearly mark this on bedrails. Specify refurbishing method that will not shrink mattresses.

Confirm that mattress is matched and fitted in relation to width and height of rails. Pending revisions of mattress design, consider placing hook and loop or other antiskid material between the mattress and the mattress deck to reduce mattress slippage to one side or toward foot of bed.

Bedrails

Label rails for specific beds. Specify latch strength and durability. Require latch switch so that patients who, when awake, can ambulate independently, can operate latch to lower bedrails themselves to prevent falls from climbing over rails. Specify headrails bar spacing so that head cannot go between bars. Specify space between head and foot rails and lateral space between rails and bed frame so that a 90-lb patient cannot slip through them. This may require curving the lower edge of the rails inward to the mattress frame.

Confirm proper selection and fitting of bedrails to bed and in relation to mattress. Use padded bedrail covers to reduce trauma and to obscure bar spaces for any agitated patient or when patient's head can pass between head rail bars.

Bedrail covers

Specify which covers go with which rails and beds and performance standards for softness and for strength at blocking a person sliding a limb between or through rails.

Bedrail covers should be used as part of the emergency management of patients who are undergoing seizure or who are extremely agitated and who are restrained and who require that both head and foot rails be in the up position. If so indicated, they should be used to close any space between head and foot rails that is greater than 6 cm.


Reprinted with permission from Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45:797–802.

Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc. 1997;45:797–802.


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