Bed rail algorithm for acute and community hospitals NHS Ayrshire and Arran (excluding mental health wards)

This guideline is aimed at all staff within adult inpatient settings in NHS Ayrshire & Arran with a responsibility for the provision, assessment, use, maintenance and fitting of bedrails. This includes all staff within maternity, mental health, community hospitals. The aim of the guidance is to improve the safety of patients in hospital by informing staff about the relative risks of integrated and removable bedrails, and what steps they can take to reduce the risks to their patients. This document and contents are also appropriate for community nursing staff.

Bedrails are used extensively in some healthcare environments to prevent patients falling out of bed and injuring themselves, they come either as:

• Integrated - Incorporated into the bed design and supplied with it. These cannot be removed and remain with the bed.
• Removable – These can be attached and removed as required, but may lead to an increased number of adverse events, particularly where there is a lack of maintenance or checks being undertaken prior to fitting.

From a risk management perspective, integrated bedrails are the preferred option where possible as they reduce several of the risk factors highlighted throughout this guidance.

This guideline should be read in conjunction with the:

• Bedrails documentation in the Inpatient Booklet, updated December 2020.
• Medicines and Healthcare products Regulatory Agency (MHRA) Device Bulletin 2021 safe use of bedrails 
• NHS Ayrshire & Arran Falls  Prevention Guideline (G108) Prevention and Management of Falls in All Hospital Settings  

Patients in hospital may be at risk of falling from their bed for many reasons, including poor mobility, cognitive impairment, visual impairment, the effects of their treatment or medication, and their physical condition.

Bedrails:

• should only be used to reduce the risk of a patient accidentally slipping, sliding, falling or rolling out of a bed. Bedrails used for this purpose are not considered a form of restraint and are not suitable for every hospital patient.
• will not prevent a patient leaving their bed and falling, and should not be used for this purpose.
• will restrict patients who are independently mobile and could increase the risk of injury for patients who are cognitively impaired, particularly as they may try and climb over them.
• are not generally intended as a moving and handling aid, and should only be used in assisting patients to turn in bed if specified in the manufacturers information guide.
• are not used extensively in mental health inpatients wards as the majority of patients are independently mobile, therefore the risk outweighs the benefits.

Important: Use of trolleys involves an increased risk of injury

Trolleys involve an increased risk of falls and injury than beds because they are usually narrower, higher and used for patients who are newly admitted to hospital and whose condition may not yet have been fully assessed.

 All side rails on trolleys should be in the raised position when occupied by a patient unless there are specific contraindications and the rationale documented. Rails on trolleys must be raised during the transport of patients.

Patients receiving hospital care often have impaired mobility, with the exception of mental health setting where patients are usually independently mobile. They may be less aware of their surroundings if they have cognitive impairment, visual impairment or are affected by anaesthetics, sedatives, painkillers or other medication. Their ability to remain safely in the centre of the bed can be affected by stroke, paralysis, epilepsy, muscle spasms, or other conditions including functional mental health conditions where judgment of risk may be impaired (e.g. bipolar disorder, schizophrenia). This puts them at a greater risk of falling from bed⁴.

Bedrails should not normally be used:

• if the patient is cognitively impaired or has any other mental health condition which has been assessed as impacting the patients capacity or judgment of risk and is at risk of climbing over the bedrail or exiting the bottom of the bed.
• If the patient is independently mobile, unless they have requested them.

Bedrails should usually be used:

• if the patient is being transported on their bed.
• in areas where patients are recovering from anaesthetic or sedation where they remain under constant supervision.
• where a patient is deemed at risk of falling from bed if no bedrails were in place and is not at risk of climbing over the rail.

In some circumstances a patient may request the use of bedrails. This should be considered on an individual basis and in light of the points above. However, most decisions about bedrails involve a balancing of competing risks.

The risks for individual patients can be complex and relate to:

• their physical and mental health needs;
• the environment;
• their treatment;
• their personality;
• their lifestyle.

Staff should use their professional judgement in considering the risks and benefits for individual patients in consultation with the multi-disciplinary team (MDT), resident medical officer (RMO), the patient and/or their carer/s. This should be documented in the patient records.

Decisions about bedrails need to be made in the same way as decisions about other aspects of treatment and care as outlined in NHS Ayrshire & Arran’s Consent Policy for Health Professionals (G082). Consent Policy for Health Professionals.pdf

This means:

• If the patient has capacity to understand and weigh up the risks and benefits of bedrails, when these have been explained to them, then the patient should decide whether or not bedrails are to be used. This does not apply to mental health inpatient settings where the patient is independently mobile and where other risks (e.g. ligature risk) must also be considered.
• If the patient lacks capacity, staff have a duty of care and must decide if bedrails are in the patient’s best interest.
• Staff can learn about the patient’s likes, dislikes and normal behaviour from the patient, relatives and carers as appropriate, and should discuss this with them. Relatives or carer/s cannot make decisions for adult patients (except in certain circumstances where they hold Power of Attorney extending to healthcare decisions under the Adults with Incapacity Act 2000).

NHS Ayrshire & Arran provides a leaflet for patients, relatives and carers giving information on bedrails and preventing falls.

NHS Ayrshire and Arran does not require written consent for bedrail use however discussions and decisions around assessment will be provided to patient and relevant others. The decision not to use bedrails requires to be documented and given similar priority to documentation of the decision to use them.

Mental health inpatient wards

In mental health inpatient wards, where patients are usually independently mobile, the risk of using bedrails will almost always outweigh the benefits.  Patients with a variety of mental health problems, both organic and functional, can have impaired judgement of risk, poor concentration, have difficulty following and/or retaining instruction and can be at risk of self-harm, including ligature risk from bedrails or other ligature sources. The decision in this setting to use bedrails is therefore always based on multi-disciplinary discussion including the patient, or next of kin where the patient has capacity issues. 

Use of bedrails in an adult inpatient ward where ligature risk is high, would be avoided and would require enhanced observation of that patient if it was required, to avoid ligature risk to their patients. Bedrails would therefore only be used in mental health inpatients where the patient physical health had deteriorated to the point that they were no longer independently mobile and required full assistance to transfer using a hoist and this would usually be in the context of occasional use in Elderly Mental Health Inpatient wards.

To support your professional judgement, the bed rails algorithm and risk assessment have been developed for acute and community hospitals.

Acute and community hospitals

All inpatients will have a Bedrails Risk Assessment completed on admission to hospital and should be reviewed whenever a patient’s condition or wishes change (e.g. after a fall / post-surgery / change in medication or cognitive state), but weekly as a minimum.  The rationale for the decision must be recorded and a bedrails care plan commenced as indicated. Staff also need to consider use of protective bed rails covers / bumpers in accordance with individual patient assessment. The patient may move from independent to semi-conscious and immobility to independence in the course of a few hours.

Mental health inpatient wards

Within mental health inpatient services, patients will only have a bedrail assessment completed where the patient is unable to mobilise independently and where the MDT team suspects that there is now a rationale for same due to the patient’s deteriorated physical state. If the outcome of the MDT discussion is that the benefits now outweigh the risks, then a care plan will then be formulated.  There will be no requirement for a care plan on admission due to the default position in mental health inpatients being no use of bedrails except in exceptional circumstances.

The bedrail assessment should be completed immediately following the MDT meeting to ensure it reflects this discussion fully. This will clearly outline the salient points of the MDT discussion including the risk/benefit analysis and will clearly evidence the opinion of all of those attending including the patient/NOK and RMO.

In mental health inpatient settings, all of the above regarding frequency of assessment applies to those patients who are assessed as having a deteriorated physical state as a result of acute illness.  This does not apply, however, where the patient is assessed as requiring bedrails as a result of chronic deterioration in physical state and is not expected to improve in their mobility. For example if the patient has been assessed for bedrails as a result of progressed dementia, where the patient is no longer mobile but a risk exists of them rolling out of bed, then the bedrail assessment would not require updated as long as the patient’s condition either remains unchanged or continues to deteriorate.  

In all settings staff should use their professional judgement to consider the risks and benefits for individual patients when completing the Bedrails Risk Assessment Tool  

Consider: if bedrails are not used, how likely is it that the patient will come to harm?

Consider the following questions:

1.  How likely is it that the patient will fall out of bed?
2.  How likely is it that the patient would be injured in a fall from bed?
3.  Will the patient feel anxious if the bedrails are not in place?
4.  If bedrails are used, how likely is it that the patient will come to harm?
5.  Will bedrails stop the patient from being independently mobile?
6.  Could the patient climb over the bedrails?
7.  How likely is it that the patient would exit from the bottom of the bed area?
8.  Could the patient injure themselves on the bedrails?
9.  Could using bedrails cause the patient distress?
10.  Is there a risk of entrapment if bedrails are in use?

In mental health inpatient settings and for patients with mental health conditions within all healthcare settings the following additional questions should be considered:

1. Does the patient have impaired judgement of risk?
2. Is the patient overactive or restless?
3. Is the patient able/willing to follow instructions from staff including to remain in bed if bedrails are in use?
4. Is the patient experiencing visual or auditory hallucinations which they may likely respond to and behave unpredictably as a result?
5. Is the patient (or other patients in the environment) at risk of self-harm via ligature risk from the bedrails?
6. Can the patient be managed more safely utilizing enhanced observations?
7. Would the use of bedrails be anxiety provoking/distressing for the patient due to feeling restricted?

The behaviour of individual patients can never be completely predicted, and NHS Ayrshire & Arran will be supportive when there is evidence of decisions made by frontline staff in accordance with this guideline. NHS Ayrshire and Arran’s Behaviour Monitoring Chart can be used in acute and community hospitals to monitor risk taking, patterns of behaviour and as an aid to the level of supervision required.

The Behaviour Monitoring Chart is not currently used in mental health inpatient settings as this is a key area of metal health expertise and monitoring and assessment of patient mental state and behaviour is carried out and communicated routinely in an ongoing basis

Staff should consider the combination of bed frame, type of bedrails and mattress in relation to the needs of the patient when undertaking the bed rails risk assessment.

Whenever staff use bedrails they should carry out the following visual checks:

• Are there any signs of damage, faults or cracks on the bedrails? If so, do not use the bedrail, label it clearly as faulty and have it removed for repair.
• Does the patient’s body shape (i.e. underlying physical or medical health conditions) increase the risk that their head, body or neck may become entrapped?

If using detachable bedrails:

• The gap between the top end of the bedrail and the head of the bed should be less than 6cm or more than 25cm.
• The gap between the bottom end of the bedrail and the foot of the bed should be more than 25cm.
• The fittings should all be in place and the attached rail should feel secure when raised.
• Staff should listen for the bedrail locking into place.

For patients who are assessed as requiring bedrails but who are at risk of striking their limbs on the bedrails, or limb entrapment between bedrails, the use of bed bumpers should be considered. Within mental health service bumpers are used routinely with all bedrails due to greater risks associated with patient not remaining in the middle of the bed (e.g. motor restlessness, impaired judgement of risk etc.).

Further information can be found at following link safe use of bedrails

The safety of patients with bedrails may be enhanced by frequently checking that they are still in a safe and comfortable position in bed, ensuring they have everything indicated within care and comfort documentation.

It is important that anyone involved with the manufacture, supply, fitting, maintenance and use of bed rails is aware of what constitutes acceptable bed, bed rail and mattress combinations and any subsequent safety issues.

Bed rails are included in a planned preventative maintenance scheme overseen by Infrastructure and Support Services. They ensure they are maintained in accordance with the manufacturer’s recommendations.

Bedrails are prone to wear and tear. The following table contains examples of visual cues and possible causes that may suggest the bedrail is defective and needs repaired, reported and replaced.

Staff should conduct a visual inspection to check for issues and remove and replace the bedrail if it appears defective. The following section gives guidance.

Types of bedrails (integrated and non-integrated)	Area	Issues that may indicate a problem
		Bedrails not moving freely Any signs of rust on bedrails, joints and pins Any peeling or cracked paint on surfaces Any significant free play in joints or hinges Rails that are bent, twisted or distorted Damage to any plastic hinges, handles or components.
		Locking handles or clamps do not fully engage and hold the rails securely Rail stick when raising or lowering Welded joints have visible cracks.
		Latch buttons do not engage fully Release mechanism does not operate smoothly Rail does not lock into place easily.

Beds should usually be kept at the lowest possible height to reduce the likelihood of injury in the event of a fall, whether or not bedrails are used. The exception to this is independently mobile patients who are likely to be safest if the bed is adjusted to the correct height for their feet to be flat on the floor whilst they are sitting on the side of the bed. This is particularly important in mental health inpatients settings, where patients are usually independently mobile.

Beds will need to be raised when direct care is being provided and lowered after the care has been provided. In the event of an adverse incident involving bedrails, staff should complete an adverse event report form. For further guidance on what an adverse event is refer to the NHS Ayrshire & Arran Adverse Incident Policy and Supporting Procedures

NHS Ayrshire & Arran aims to ensure bedrails are available for all patients assessed as needing them.

When special mattresses are hired, the requisition form requires the make and model of the bed / bed rail to be stated, and the company renting the mattress will be asked to confirm the mattress is compatible with the bed and bed rail in use.

Manufacturer’s instructions

Refer to manufacturer`s instructions for advice relating to individual equipment.

Cleaning recommendations

Beds, bedrails, bumpers and mattresses must be cleaned after use; in accordance to The National Infection Prevention and Control Manual . NHS Ayrshire and Arran Infection Control Policy, guidance for the cleaning of contaminated equipment (e.g. blood spills) can be accessed here.

Maintenance

Bed rail repair is the responsibility of NHS Ayrshire & Arran’s Estates Department, when notified by staff as to the requirement. All bedrails should be asset identified (or are an integral part of beds which are asset identified).

New beds and integrated bedrails are maintained under warranty with the manufacturer, and all beds with integrated bedrails are part of a maintenance contract, facilitated by Estates.

A visual check of bedrails prior to use is the responsibility of the nursing staff. Any bedrail found with defects, should not be used and reported to estates for repair.

All guidelines and policies require review using the NHS Ayrshire and Arran Impact Assessment Toolkit by staff trained in this process.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional equality and diversity issues were identified.

1. Medicines & Healthcare Products Regulatory Agency (MHRA), Device Bulletin: Safe Use of Bedrails, 2021
2. Queensland Government, Falls prevention best practice guidelines for public hospitals, Queensland Health, 2009
3. National Patient Safety Agency (NPSA), Resources for reviewing or developing a bed rail policy, London, March 2007
4. National Patient Safety Agency (NPSA), London, Safer Practice Notice 17, 26 February 2007
5. Nursing & Midwifery Council Guidelines for Records and Record Keeping, NMC, London. 2018
6. Health and Safety Executive. Safe use of bed rails. Available from: http://www.hse.gov.uk/healthservices/bed-rails.htm [Accessed 16.02.2023]
7. Health and Safety Executive. Sector information minute (SIM 07/2012/06) Bed rail risk management. Available from: http://www.hse.gov.uk/foi/internalops/sims/pub_serv/07-12-06/  [Accessed 16.02.2023]

MHRA guidance on the safe use of bed rails .