Rethinking Four Side Rail Use
By Karen Lourence, RN, 14CD staff nurse, Restraint Prevention Taskforce Member
Mary Antonelli, MPH, RN, Quality Program Director, Chair of Restraint Prevention Taskforce
Contrary to what many of us were taught in nursing school, pulling up all four side rails on a bed is not a routinely safe practice to reduce falls or to keep a confused and restless patient safe in bed. In fact, current research suggests that side rails not only fail to reduce falls, but may also increase the severity of injuries sustained from a fall over the rails or an entrapment in the rails. These findings concur with information from our own hospital’s safety reports. Last year, of the 15 recorded falls over the rails, each fall resulted in an injury. Compared to 15 randomly selected falls without rails, only three of the falls resulted in a patient injury. In light of this information and the literature, we must continue to rethink the use of side rails.
The Centers for Medicare and Medicaid Services (CMS) notes the use of four side rails to contain a patient within the bed as a restraint is inappropriate for the confused or agitated patient. Since the use of the rails does not address the behavior of the patient from exiting the bed, nor does it address the underlying cause of the agitation, the action is deemed an inappropriate intervention. It is worth noting side rails are intended to stop patients from accidentally falling or rolling out bed. However, they are not intended to stop the patient from getting out of bed.
So how are we to think about this issue? As with any issue that requires clinical judgment, it starts with the assessment of the patient and the reasoning for the use of the side rail. The list displayed at right contains situations when the use of four side rails may be appropriate and not considered a restraint. Any situation not listed is considered a restraint, and restraint management care standards are to be initiated.
The Restraint Prevention Taskforce has been working on this issue by sharing current evidence-based information with nurses, exploring alternatives to siderails, collecting data, conducting ongoing literature reviews and reinforcing this issue during walking rounds. The information is spreading, and practice is shifting to reflect the proper use of bed rails. The March 2010 restraint prevalence survey noted only six occurrences of four side rail use as a restraint out of 17 patients that were restrained. This is the first single digit result since 2006.
The goal of the taskforce is to shift the practice even further to eliminate inappropriate use of four side rails to ensure the safest environment for our patients. So the next time you find yourself pulling up that bed rail, remember to rethink it.
When Use of Four Side Rails Is Not a Restraint
Seizure precautions
During transport
Recovering from anesthesia or post-procedure sedation
Bed maintained in high position for care intervention
Used to support care interventions (e.g., extremity
positioning)
During use of therapeutic rotational bed