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Am Fam Physician. 1999;60(5):1546

Few interventions, specifically the use of restraints, have been shown to decrease the risk of falls or injuries in elderly patients. In fact, restraints may do more harm than good. Hanger and associates evaluated whether an intervention aimed at reducing the use of bedrails affected the incidence of falls and injury in elderly patients.

Incident and fall information was collected on all elderly patients admitted to a rehabilitation hospital unit during a 12-month period. After the first six months, a policy was instituted to discourage the use of bedrails. The policy required clear documentation about the need for and effectiveness of bedrail use. An education program was delivered concurrently to staff outlining the effects of bedrail use on the elderly. Removal of bedrails was encouraged, and the use of alternatives, such as quiet single rooms, low beds, nightlights and regular toileting regimens was advocated. Random surveys administered throughout the study period assessed the prevalence of bedrail use. Fall rates in the first six months were compared with fall rates after the policy was instituted. Patient injuries were also compared between the two periods. Serious injuries were defined as any fracture, dislocation, head injury that required neurologic evaluation, skin laceration that required suturing or plastic surgery evaluation, and any hip pain without fracture that prevented ambulation.

A total of 1,968 patients were admitted to the hospital during the study period, with 987 admissions before the policy was established and 981 after. The mean number of beds with rails decreased from 40 (out of a total of 135 beds) in the first six months to 18.5. Fall rates did not change before and after initiation of the bedrail policy, but the type of injuries did change. Serious injuries, particularly head injuries, were significantly less likely to occur after the policy was instituted. However, the number of some types of fractures, hip pain and lacerations did not change.

The authors conclude that the intervention, which combined a specific restraint-use policy with an education program, significantly reduced the number of serious injuries. Bedrails are often used around elderly patients and represent a type of restraint that deprives them of their dignity and autonomy. Alternatives, such as the use of low beds or mattresses on the floor, exist and should be considered for elderly patients who are at risk of falls.

editor's note: In an accompanying editorial, Frengley emphasizes that the use of bedrails often suggests to caregivers that the patient has physical or mental deficits, even if that is not the case. If bedrails are removed, patients may be treated with more respect. Environmental changes may be necessary to afford the elderly the best possible treatment.—g.b.h.

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