Prevention of falls from beds in the nursing home setting is often addressed by the use of full-length side rails on each side of the bed. Some studies have estimated that side rails are used in up to 70 percent of nursing-home beds. Many studies have shown that the incidence of injury in residents using side rails is higher than in those who do not have side rails on their beds. In addition, use of side rails is associated with higher rates of agitation, incontinence, injury, and death. In 1992, the Health Care Financing Administration recommended that side rails, in certain situations, could be considered restraints. Capezuti and associates analyzed data from a prospective clinical trial to determine the effect of reducing physical restraints on the use of side rails at night and to examine the relationship between side-rail use and bed-related falls and injuries.
Each patient's bed-rail use was observed twice between 10 p.m. and 6 a.m. for three consecutive nights. All bed-related falls between those same hours were recorded. Falls were categorized as any fall, fall with serious injury, and recurrent fall (two or more falls in the one-year study period). Cognitive status was determined for each resident, as were other demographic, behavioral, and functional status data.
Data from three nursing homes were included in the analysis. Of the 463 residents included, 166 were restrained at some time of day. Of this group, 64 (38.5 percent) were restrained physically with a vest or wrist restraint at night; this figure dropped to 8.8 percent by the end of the data collection period, shortly after federal regulations mandating restraint reduction were enacted. However, the use of bilateral side rails increased from 58.7 to 64.1 percent by the end of the study period. Analysis by controlling for behavioral, cognitive, and functional status showed that bilateral side-rail use was not associated with a significantly lower bed-related fall rate. It was also not associated with a lower rate of recurrent falls. The incidence of serious injury was approximately 1.6 percent in the group with bilateral side-rail use and 1.5 percent in those who used no rail or one side-rail; this was not a sufficient sample size to analyze further.
The authors conclude that federal regulations requiring a decrease in physical restraints were related to an increase, or at least no decrease, in the use of bilateral side rails. Because there is no evidence that side rails prevent bed-related falls or injury, the authors advocate an individualized intervention in patients who are at risk of falling from bed.