Exploring the use of bedrails when used to support adults: A scoping review.

Aims

To (a) identify and map the current evidence base on the use of bedrails, and (b) identify gaps that may direct future research areas.

Patient and Public Involvement

This study was designed to address concerns raised by family members and caregivers with a lived experience of bedrail use. In August 2023, the NatPSA requested that within 6 months, every person using bedrails in the UK must be reviewed and risk assessments updated⁵. Reviewing legacy bedrail prescriptions has elicited strong and divisive opinions across stakeholders, leading to the potential for legal action and some users of bedrails have approached their local MP in protest at the reviews.

Throughout this project, bedrail users, their representatives, and carers were consulted. They confirm that this is an important topic for investigation, as the consequence of prescribing or not prescribing bedrails has a significant impact on what a 24-hour care plan may look like, what equipment is needed, the financial cost of the plan, and the varying effect on a person’s freedom of liberty. They also confirmed the decision to prescribe or not prescribe bedrails could be a source of emotional distress, further adding to the validity of pursuing this area of concern.

A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA- ScR) guidelines¹⁰.

Protocol

The protocol was developed and is available in the Open Science Framework repository¹¹.

Eligibility criteria

Based on the results of the NPSA literature review², the search terms were broad and S.P.I.D.E.R¹² was selected to develop an inclusive search strategy.

Inclusion

Exclusion

Information sources

The following bibliographic databases were searched: MEDLINE, EMBASE, EMCARE, COCHRANE, CINAHL, and Bielefeld Academic Search Engine. Backward citation tracking of significant documents was performed. Gray literature¹³ was sourced from Google Scholar. Key author(s) were contacted to provide evidence where it was not publicly available. The search strategy dated March 6, 2024, is available in the appendices, located in the Open Science Framework repository¹⁴.

Search terms

“Bed rail*” OR “bedrail*” OR “side rail*” OR “siderail*” OR “cot side*” OR “cotside*” AND “adult*” OR “older person*” OR “elderly” AND “community” OR “dwelling” OR “home” OR “care home” OR “residential home” OR “nursing home” OR "supported living” OR “hospice” OR “hospital” OR “unit*.”

Evidence selection

Database search results were exported to EndNote v.21 and duplicates removed. The results were then uploaded to Rayyan, where additional duplicates were identified and removed. Title and abstract screening were performed using Rayyan, and papers were assessed according to eligibility criteria by two independent, blinded reviewers. Owing to time constraints, the first reviewer conducted full-text screening. To ensure the accuracy of the screening process, a second reviewer reviewed 10% of the papers. Because the screening results were consistent, a 10% review rate was maintained. Any differences in opinions regarding the inclusion of papers were resolved through discussion, and a third reviewer was not required.

Data extraction

Data were extracted from the papers by a single reviewer and checked by a second reviewer. This review did not include quality appraisal of the papers. Due to scarcity of scientific enquiry in this topic, data assumptions and simplification were not required. The a priori data extraction table is located in the protocol¹⁰; however, data extraction was iterative and involved continuous analysis. Extracted data were reported narratively.

Characteristics

Publication dates ranged from 1983 to 2024 and primarily originated from inpatient hospital settings in the UK and United States. Most of the published papers were reports or opinion pieces made by those working in the care of older adults.

Clinical drivers for bedrail use

Prescribers appear to consider factors from the micro and meso levels of available information, with a suggestion that macro-level influences are sometimes missing in the decision-making examples captured in the included papers^15–19.

Both the clinical drivers to prescribe bedrails and the factors that cause incidents of harm or death from bedrails share a similar number of key features (Figure 2).

Figure 2. Clinical drivers for bedrails and factors that lead to harm.

Summary of synthesized data on clinical drivers for bedrail prescription and associated causes of harm. Data were synthesized from multiple sources^6,14–40.

UK and Ireland

The primary clinical driver across all the studies was falls prevention (Table 1). Assisting bed mobility (by allowing the patient to pull on the rails to support repositioning) has also been reported, although bedrails are not designed for this purpose^1,2. In three of the five snapshot audits^16,18,19, staff reported bedrail use as a physical restraint, with the aim of preventing patients from leaving their beds. None of the audits included methodologies to explain how staff opinions were collected, nor did they include evidence of compliance with the Mental Capacity Act (2005) (or equivalent law if within the UK but outside England and Wales). Further clinical drivers for bedrail prescription were identified (Figure 2), such as patient characteristics^17–19,24, other equipment in use^17,19, availability of a clear view of the patient, and sufficient staffing to enable watchful observation⁴⁰.

Healey et al. found that patients described as ‘unable to mobilise at all’ had the highest adjusted odds ratio and were 62.5 times more likely to have bedrails raised than patients able to walk (CI 95%). Patients described as confused or on alternating pressure mattresses and electric profiling beds also had significantly higher adjusted odds ratios for bedrail use than patients on static mattresses and beds¹⁷.

US

Bedrail use in the US is defined by a consensus between law and medicine, rather than empirically driven intervention⁴⁰. In the US, bedrails are routinely used either by mandates or fear of litigation^{25,26,28,36,40}. It is also important to note that in the US, bed restraint products and beds encased in net cages are licensed and in use⁴¹. Therefore, the intent to prescribe bedrails in the US is in sharp contrast to that in the UK.

Prevalence of use

The prevalence of bedrail use reported in audits varied between 16% and 52% of total occupied, acute inpatient beds^15–19. Noore identified that patients in the geriatric ward of the district general hospital audited were significantly less likely to have raised bedrails than those in other wards in the same hospital (7% occupied beds versus 19% in other wards)¹⁵. This suggests that knowledge and experience impact the decision to prescribe bedrails.

Healey et al. found significant differences in bedrail use across seven NHS Trusts, with a lack of correlation between bedrail policy and bedrail use. No interaction effects were detected between an organisations’ levels of bedrail use and age, mobility, confusion, bed, or mattress type, yet the likelihood of full bedrails being raised in organisation B was more than 10 times that in organisation A¹⁷. This adds to the suggestion that bedrail use is driven by more than surface-level opinions captured by the staff surveys. The authors also expressed concerns that bedrail use is increasing over time, partly due to advancements in bed technology^2,18,19 and increasing patient dependency².

The balance of ethical imperatives

An anonymous commentary published in the Lancet in 1984 suggested that it is conceivable that all falls could be prevented if patients were sedated and encased in fortified beds. However, care including rehabilitation is incompatible with total falls prevention²⁵.

This sentiment was echoed in 2002 by Oliver who suggested that bedrail prescriptions should incorporate a balanced, biomedical ethical decision encompassing respect for patient autonomy (the right to choose to pursue meaningful occupations of time despite the falls risk), paternalism (we will not let you fall), beneficence (to do good for the whole person’s health and wellbeing), non-maleficence (to do no harm, either intentionally or unintentionally, that is, to act unlawfully, entrapment, or asphyxiation in bedrails), and justice (fair access to resources)⁶.

Harm

Bedrails are not inherently dangerous but are open to misuse by clinicians and may lead to rare incidences of harm^{1,2,5,7,36–38,42–44} through ill-advised clinical reasoning^{1,2,3,6,22–24,30,39,45,46}, using bedrails beyond their intended scope, poor bedrail design^21,27,44, poorly fitting bedrails, incompatibility of products, and limited learning from events affected by data quality issues^{33,34,36–38,43}.

In the US, there are an average of 20 deaths per year caused by bedrails, mainly in nursing homes. In the UK, there are an average of three deaths per year in care homes and patients’ own homes, attributed to bedrails². Deaths caused by bed rails in UK hospitals are very rare, with three reports in seven years by the MHRA². In the UK, the MHRA identifies bedrail design, patient selection, and setting—whether in a care home or a person’s own home—as key contributors to death or harm involving bedrails¹.

It has been reported that American manufacturers of bedrails often attribute deaths caused by their use to improper clinical monitoring or decision-making⁴². Similarly, in the UK, Healey advised that the risk of fatal bedrail entrapment in hospitals is not random and can be reduced by following the advice on using bedrails safely².

If harm caused by bedrails in the UK is partly predictable through choices and actions made by organisations (Figure 2), this does not appear to be demonstrated in a review of NHS clinical negligence claims regarding falls⁷. Between 1995–2006, bedrails were listed as the primary cause of harm in 11.9% of claims regarding inpatient falls, and the absence of bedrails in 10.6% of claims. All claims were settled out of court; therefore, no legal rulings establishing liability or causation of injury were available. The mean payment for each claim was £12945. Oliver et al. suggests that the low payment reflects difficulty in establishing causation secondary to frailty, multiple comorbidities, and poor documentation⁷. Clinical negligence claims, when bed rails were used and bed rails were not used, suggest that the decision to prescribe is of equal importance as the decision not to prescribe.

Poor documentation has also been identified in reviews of incident reports^{7,36,38,42,43}. Most incident reports did not specify the types of bedrails used, their compatibility with the bed frame and mattress, their maintenance status, or whether they were correctly fitted. They did not report compliance with the best-interest process for those who were unable to consent to their use. This reveals that organisations may not be able to fully learn from events.

Behaviour change within organisations

Four before-and-after studies were identified which examined the impact of bedrail reduction strategies in nursing homes and inpatient hospital settings in the US and New Zealand^32–35. Researchers approached bedrails as a negative device and strategized to reduce their use by intervening at the micro and meso levels. The authors failed to include details in their methodologies, which demonstrated acknowledgement of or control over the variables. Adherence to strategies introduced to reduce bedrail use was not reported, yet all authors presented their results as a direct outcome of intervention.

Their results cannot be interpreted from the perspective of UK clinical practice because the clinical drivers and intent to use bedrails are different (both the US and New Zealand permit the lawful use of physical bed restraints). However, the results offer some insight into behaviour change involving bedrails.

Si et al. reported that despite best efforts to reduce bedrail use, they were met with reluctance and scepticism. It was challenging and time-consuming to educate wary staff and families, conduct assessments, and discuss alternatives to bedrails³³. Hoffman et al. studied bedrail use in three US nursing homes and despite efforts from a multidisciplinary team, updated assessments, persuasion, and strategies like ‘rail rounds,’ they could not change the practice of using raised bedrails for all new admissions³⁴.

Experience of the user

Authors have speculated how a person might feel when using bedrails, but only Healey, on behalf of the NPSA, has asked. Healey conducted two focus groups using opportunistic sampling, with participants attending an outpatient clinic following a recent hospital admission. The groups were unstructured but centred on key themes. Group One consisted of people with dementia, depression, or anxiety from South England, while Group Two included Black, Asian, and minority ethnicity stroke survivors from North England⁴⁵.

All patients felt that the use of bedrails should be based on their wishes and concerns about falling out of bed, even if staff disagreed. Bedrails were considered helpful, especially for those accustomed to a double bed at home. No one reported being given bedrails against their wishes, nor did they view them as reducing their independence or dignity. The participants suggested that bedrails could have softer finishes and come in different sizes⁴⁵.

Alternatives to bedrails

Capezuti et al. suggested that by addressing patient characteristics that may lead to bedrail use with alternative, less restrictive practice, intervention can focus on patient safety while promoting humane, dignified, and ethical care³⁹ (Figure 3). Many authors have reported alternatives to bedrails, including:

Consider alternative equipment

Consider the patient

Consider operational practice which reduces bedrail use

Figure 3. Alternatives to bedrails in U.S. nursing homes.

Summary of synthesized data. Adapted from Capezuti et al., 1999³⁹.