Deaths between bedrails and air pressure mattresses

Interventions designed to prevent healthcare bed-related injuries in patients

BACKGROUND

Every patient in residential healthcare has a bed. Falling out of bed is associated with preventable patient harm. Various interventions to prevent injury are available. Bed rails are the most common intervention designed to prevent patients falling out of bed; however, their effectiveness is uncertain and bed rail entrapment can also result in injuries.

OBJECTIVES

To assess the effectiveness of interventions designed to prevent patient injuries and falls from their beds.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials 2010, Issue 2 (The Cochrane Library), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), ISOI Web of Science and Web-based trials registers (all to December 2010) as well as reference lists.

SELECTION CRITERIA

Randomised controlled trials of interventions designed to prevent patient injuries from their beds which were conducted in hospitals, nursing care facilities or rehabilitation units were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from the included studies. Authors contacted investigators to obtain missing information.

MAIN RESULTS

Two studies met the inclusion criteria, involving a total of 22,106 participants. One study tested low height beds and the other tested bed exit alarms. Both studies used standard care for their control group and both studies were conducted in hospitals. No study investigating bed rails met the inclusion criteria. Due to the clinical heterogeneity of the interventions in the included studies pooling of data and meta-analysis was inappropriate, and so the results of the studies are described.A single cluster randomised trial of low height beds in 18 hospital wards, including 22,036 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls in the bedroom (rate ratio 0.69, 95% CI 0.35 to 1.34), all falls (rate ratio 1.26, 95% CI 0.83 to 1.90) or patient injuries due to all falls (rate ratio 1.35, 95% CI 0.68 to 2.68).One randomised controlled trial of bed exit alarms in one hospital geriatric ward, involving 70 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls out of bed (rate ratio 0.25, 95% CI 0.03 to 2.24), all falls (rate ratio 0.42, 95% CI 0.15 to 1.18) or patient injuries due to all falls (no injuries in either group).

AUTHORS' CONCLUSIONS

The effectiveness of interventions designed to prevent patient injuries from their beds (including bed rails, low height beds and bed exit alarms) remains uncertain. The available evidence shows no significant increase or decrease in the rate of injuries with the use of low height beds and bed exit alarms. Limitations of the two included studies include lack of blinding and insufficient power. No randomised controlled trials of bed rails were identified. Future reports should fully describe the standard care received by the control group.

The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review

BACKGROUND

Physical restraint was introduced as the primary measure to maintain patient safety in preventing falls. However, physical restraints may lead to complications such as functional loss, immobility, delirium, pressure sore, and even falls or injuries. Despite all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling.

OBJECTIVE

The overall objective was to examine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes.

INCLUSION CRITERIA

This review considered quantitative designs, including randomised controlled trials, quasi-experimental studies, cohort studies, case control studies and case series/reports.The participants of this review were male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes.This review focused on studies that investigated physical restraint as an intervention for reducing falls among adults in acute care hospitals and nursing homes.The outcomes of interest were the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by a second search using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. All searches were limited to English Language studies and there was no limit in the timeframe.

ASSESSMENT OF METHODOLOGICAL QUALITY

The quality of the included studies was subjected to assessment by two independent reviewers using the standardised critical appraisal tools from the Joanna-Briggs Institute from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of Statistics Assessment and Review Instrument).

DATA EXTRACTION

Data was extracted from included papers using the standardised extraction tool from the JBI MASTARI.

DATA SYNTHESIS

Due to the heterogeneous nature of the study methods, the findings of this review are presented in a narrative summary.

RESULTS

Nine studies were included in the review. The majority of the findings showed that physical restraints were not associated with the reduction in falls and decreased restraint use did not contribute to more falls.

CONCLUSION

From the overall results, physical restraints are not effective in reducing falls or injuries among adults in acute care hospitals and nursing homes.National standards and application guides for physical restraints are recommended. The use of physical restraints should be assessed by trained staff based on individualised need and consideration of patient's autonomy and integrity. The awareness of appropriate physical restraint usage should be enhanced among the healthcare professionals.Large multicentre research to determine the risk and benefit ratio of physical restraints and to examine the effectiveness of alternative measures, different number of bedrails, intermittent restraint use and restraint reduction programs are needed respectively.

Interventions designed to prevent healthcare bed-related injuries in patients

BACKGROUND

Every patient in residential healthcare has a bed. Falling out of bed is associated with preventable patient harm. Various interventions to prevent injury are available. Bed rails are the most common intervention designed to prevent patients falling out of bed; however, their effectiveness is uncertain and bed rail entrapment can also result in injuries.

OBJECTIVES

To assess the effectiveness of interventions designed to prevent patient injuries and falls from their beds.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials 2010, Issue 2 (The Cochrane Library), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), ISOI Web of Science and Web-based trials registers (all to December 2010) as well as reference lists.

SELECTION CRITERIA

Randomised controlled trials of interventions designed to prevent patient injuries from their beds which were conducted in hospitals, nursing care facilities or rehabilitation units were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from the included studies. Authors contacted investigators to obtain missing information.

MAIN RESULTS

Two studies met the inclusion criteria, involving a total of 22,106 participants. One study tested low height beds and the other tested bed exit alarms. Both studies used standard care for their control group and both studies were conducted in hospitals. No study investigating bed rails met the inclusion criteria. Due to the clinical heterogeneity of the interventions in the included studies pooling of data and meta-analysis was inappropriate, and so the results of the studies are described.A single cluster randomised trial of low height beds in 18 hospital wards, including 22,036 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls in the bedroom (rate ratio 0.69, 95% CI 0.35 to 1.34), all falls (rate ratio 1.26, 95% CI 0.83 to 1.90) or patient injuries due to all falls (rate ratio 1.35, 95% CI 0.68 to 2.68).One randomised controlled trial of bed exit alarms in one hospital geriatric ward, involving 70 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls out of bed (rate ratio 0.25, 95% CI 0.03 to 2.24), all falls (rate ratio 0.42, 95% CI 0.15 to 1.18) or patient injuries due to all falls (no injuries in either group).

AUTHORS' CONCLUSIONS

The effectiveness of interventions designed to prevent patient injuries from their beds (including bed rails, low height beds and bed exit alarms) remains uncertain. The available evidence shows no significant increase or decrease in the rate of injuries with the use of low height beds and bed exit alarms. Limitations of the two included studies include lack of blinding and insufficient power. No randomised controlled trials of bed rails were identified. Future reports should fully describe the standard care received by the control group.

[Safety problems associated with using physical restraint devices on the elderly]

The use of physical restraint devices on frail elderly could have significant negative consequences on their health. Apart from complications due to prolonged immobility, the use of this procedure is associated with other serious adverse effects which occur when a person is restricted in a position which carries a risk of asphyxiation. The devices most implicated in these incidents are bedrails, vests and restraining belts. Physical restraint could also be associated as much with the sudden death of patients, due to the stress that it causes, as with injuries from falling. This article presents the recommendations which experts, manufacturers and institutions dealing with the quality of health care have issued for the safest use of this procedure. It stresses the need for better training of professionals, as well as the importance of investigating the factors which can lead to accidents with the aim of preventing them.

Physical restraint use and falls in nursing homes: a comparison between residents with and without dementia

AIMS

To estimate the use of different types of physical restraints and assess their associations to falls and injuries among residents with and without Alzheimer's disease (AD) or dementia in US nursing homes.

METHODS

Data were from the 2004 National Nursing Home Survey. AD or dementia was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. Analyses were conducted with the Surveyfreq and Surveylogistic procedures in SAS v.9.1.

RESULTS

Residents with either AD or dementia were more likely to be physically restrained (9.99% vs 3.91%, P < .001) and less likely to have bed rails (35.06% vs 38.43%, P < .001) than those residents without the disease. The use of trunk restraints was associated with higher risk for falls (adjusted odds ratio [AOR] = 1.66, P < .001) and fractures (AOR = 2.77, P < .01) among residents with the disease. The use of full bed rails was associated with lower risk for falls among residents with and without the disease (AOR = 0.67 and AOR = 0.72, Ps < .05, respectively).

CONCLUSIONS

The use of a trunk restraint is associated with a higher risk for falls and fractures among residents with either AD or dementia.

Associations of special care units and outcomes of residents with dementia: 2004 national nursing home survey

PURPOSE

We compared the rates of specialized care for residents with Alzheimer's disease or dementia in special care units (SCUs) and other nursing home (NH) units and examined the associations of SCU residence with process of care and resident outcomes.

DESIGN AND METHODS

Data came from the 2004 National Nursing Home Survey. The indicators of process of care included physical restraints, continence management, feeding tubes, and influenza and pneumococcal vaccinations. Resident outcomes included pressure ulcers, hospitalization, emergency room visits, weight loss, and falls. Analyses were conducted by using Stata SE version 10.

RESULTS

Multivariate logistic regression analyses show that SCU residents were more likely to have received specialized dementia care and specialized behavioral problem management. They were less likely to have bed rails (adjusted odds ratio [AOR] = 0.39, AOR = 0.35, ps < .01), use catheters (AOR = 0.33, AOR = 0.33, ps < .01), and yet more likely to have toilet plans/bladder training for incontinence control (AOR = 1.90, AOR = 1.62, ps < .01) than those in regular units and those in NHs without an SCU. Moreover, SCU residents were less likely to have pressure ulcers, hospitalization than those in regular units, and less likely to have experienced weight loss than those in NHs without an SCU. However, they were more likely to have falls (AOR = 1.32, AOR = 1.36, ps < .05) than those in regular units and those in NHs without an SCU.

IMPLICATIONS

Our study shows that SCU residents had, in general, better process of care than those in regular units and in NHs without an SCU. Further studies are needed to assess specific outcome changes among SCU residents and to evaluate the cost-effectiveness of having such units.

The effect of bedrails on falls and injury: a systematic review of clinical studies

BACKGROUND

around one-fourth of all falls in healthcare settings are falls from bed. The role of bedrails in falls prevention is controversial, with a prevailing orthodoxy that bedrails are harmful and ineffective.

OBJECTIVE

to summarise and critically evaluate evidence on the effect of bedrails on falls and injury

DESIGN

systematic literature review using the principles of QuoRoM guidance.

SETTING AND SUBJECTS

adult healthcare settings

REVIEW METHODS

using the keyword, bedrail, and synonyms, databases were searched from 1980 to June 2007 for direct injury from bedrails or where falls, injury from falls, or any other effects were related to bedrail use.

RESULTS

472 papers were located; 24 met the criteria. Three bedrail reduction studies identified significant increases in falls or multiple falls, and one found that despite a significant decrease in falls in the discontinue-bedrails group, this group remained significantly more likely to fall than the continue-bedrails group; one case-control study found patients who had their bedrails raised significantly less likely to fall; one retrospective survey identified a significantly lower rate of injury and head injury in falls with bedrails up. Twelve papers described direct injury from bedrails.

DISCUSSION

it is difficult to perform conventional clinical trials of an intervention already embedded in practice, and all included studies had methodological limitations. However, this review concludes that serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather than being inherent, and bedrails do not appear to increase the risk of falls or injury from falls.

Elder mistreatment in the nursing home: a systematic review

Because of their significant dependence on others for their care, nursing home residents are potentially vulnerable to abuse and/or neglect. The topic of elder mistreatment, whether in the nursing home or other living environments, received little attention from clinicians and researchers until the past 2 decades. Original research is now emerging that sheds light on the scope of the problem and the challenges to timely prevention, identification, and management. Practitioners may use this information to recognize and change factors associated with a higher likelihood of nursing home mistreatment.

Description of an advanced practice nursing consultative model to reduce restrictive siderail use in nursing homes

Researchers have demonstrated that the use of physical restraints in nursing homes can be reduced, particularly where advanced practice nurses (APNs) are utilized. We examined the link between APN practice, siderail reduction, and the costs of siderail alternatives in 273 residents in four Philadelphia nursing homes. The majority of participants were cognitively and physically impaired with multiple co-morbidities. APNs recommended a total of 1,275 siderail-alternative interventions aimed at reducing fall risk. The median cost of siderail alternatives to prevent falls per resident was $135. Residents with a fall history experienced a significantly higher cost of recommendation compared to non-fallers. Findings suggest that an APN consultation model can effectively be implemented through comprehensive, individualized assessment without incurring substantial costs to the nursing home.

Consequences of an intervention to reduce restrictive side rail use in nursing homes

OBJECTIVES

To examine the effect of an advanced practice nurse (APN) intervention on restrictive side rail usage in four nursing homes and with a sample of 251 residents. A secondary question explored the association between restrictive side rail reduction and bed-related falls.

DESIGN

Pre- and posttest design.

SETTING

Four urban nursing homes.

PARTICIPANTS

All nursing home residents present in the nursing home at three time points (n=710, 719, and 707) and a subset of residents (n=251) with restrictive side rail use at baseline.

INTERVENTION

APN consultation with individual residents and facility-wide education and consultation.

MEASUREMENTS

Direct observation of side rail status, resident and nurse interview for functional status, mobility, cognition, behavioral symptoms, medical record review for demographics and treatment information, and incident reports for fall data.

RESULTS

At the institutional level, one of the four nursing homes significantly reduced restrictive side rail use (P=.01). At the individual participant level, 51.4% (n=130) reduced restrictive side rail use. For the group that reduced restrictive side rails, there was a significantly (P<.001) reduced fall rate (-0.053; 95% confidence interval (CI)=-0.083 to -0.024), whereas the group that continued restrictive side rail did not demonstrate a significantly (P=.17) reduced fall rate (-0.013; 95% CI=-0.056-0.030).

CONCLUSION

An APN consultation model can safely reduce side rail use. Restrictive side rail reduction does not lead to an increase in bed-related falls. Although side rails serve many purposes, routine use of these devices to restrict voluntary movement and prevent falls is not supported.

Bedside safety rails: assessment of strength requirements and the appropriateness of current designs

Bedside safety rails are used extensively throughout hospitals and residential care environments as a safety device to protect people against the risk of falling out of bed. However, several adverse incidents involving body entrapment have been linked to their use, which have resulted in serious injury to the bed occupants and, in more extreme cases, fatalities. Internationally agreed standards (i.e. European Committee for Standardisation (CEN) standards) for the design and testing of bed rails have recently been developed and are targeted at improved safety requirements (European Committee for Standardisation 19972000). The purpose of the present study was to: 1) determine whether the CEN test procedure for assessing bed rail strength and rigidity requirements is consistent with human force exertions to which bed rails may be exposed; 2) carry out loading tests on bed rails currently in use throughout the UK to determine whether they comply with the current safety recommendations proposed by the CEN standards.A laboratory study was conducted to determine the force exertions of 20 participants performing seven tasks (including activities of both bed occupants and care providers), which were considered representative of the forces to which bed rails could be exposed during normal use. Forces exerted by participants were measured using a force platform and distortions of the bed rails leading to potential entrapment zones were measured using linear displacement transducers. Static load tests were then conducted, in which incremental point loading was applied at the most adverse points on each of nine different bed rails (commonly used in UK nursing and residential care homes) in accordance with the test procedure detailed in the current CEN standards. Maximum static forces exerted by participants were found to range between 250 N and 350 N, which were within the 500 N force tolerance requirements set by the standards. Dynamic tasks involving 'rolling aggressively' against the bed rail produced the highest peak force of 722 N. None of the bed rails included in this study met the requirements of the CEN test procedures, principally due to horizontal lateral displacements being in excess of 50 mm for a 500 N applied force and/or the bed rails' inability to withstand inward horizontal forces of 500 N. Bed rails used with divan beds were often unable to withstand forces greater than 300 N due to turning moments exceeding the bed rail's restraining mechanism. Current CEN standards for assessing the strength and rigidity of bedside safety rails appear to be consistent with the human forces that might arise as a consequence of the normal movement and activities of a bed occupant or care provider. Although compliance with existing standards is not compulsory, findings from the tests carried out on the selection of bed rails in current use throughout the UK highlight the need for improvements in the design and manufacture of bed rails.

Patient Choice: An Influencing Factor on Policy-Related Research to Decrease Bedrail Use as Physical Restraint

BACKGROUND

This paper shows patients' enactment of choice in mixed methods, multidisciplinary study on the use of bedrails as restraints.

APPROACH

Under the pressure of the implementation of impending legislation, patients from a Canadian elderly care rehabilitation unit were recruited to be part of this study and assigned to either a study or control group. Study group patients were exposed to a new facility policy on restraints in which bedrails were not to be used on a patient's bed except under specified conditions. Patients in the control group continued to have bedrails on a routine basis according to the facility's old policy. Following group assignments, patients could choose to crossover to either the control or study group based on their opinions about bedrails.

FINDINGS

After patients crossed over into either the study or control group, findings for the new groups differed significantly. Participants in the rails-up group had lower admission Functional Independence Measure scores (p = .001) and higher admission Cumulative Illness Rating scores (p = .000) compared to those in the rails-down group.

CONCLUSIONS

Patients have specific concerns related to the use of bedrails that might affect implementing bedrail minimization policies. Additionally, the authors conclude that patients' input into research design may increase patients' support of the protocol and help maintain study integrity.

Modification of bed systems and use of accessories to reduce the risk of hospital-bed entrapment

Despite the long history of hospital-bed use, only in the past decade have bed-related patient-safety hazards, including falls and life-threatening entrapment, been discussed publicly. Entrapment is an event in which a patient is caught, trapped, or entangled in hospital-bed components, including the bed rail, mattress, or hospital-bed frame. Since 1995, the Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations have issued patient-safety alerts about entrapment. While new beds are being manufactured without large gaps that would allow an individual's head, neck, or chest to become entrapped, it is incumbent upon healthcare providers, including rehabilitation nurses, to ensure the safety of older beds in use. This article describes a facility-based approach for identifying and managing risk related to hospital bed-entrapment to be used in rehabilitation settings.

Restraint free care in older adults with dementia

During the past two decades, significant research and several government and health care quality groups have advised against the use of physical restraints in hospitals and nursing homes, yet older adults are continuing to die, become injured or experience the iatrogenic complications associated with this practice. Deaths are usually caused by asphyxiation, but also occur from strangulation, or cardiac arrest. Older adults with dementia are at high risk for restraint use because of impaired memory, language, judgment and visual perception. In moderate to severe dementia, the risk of falls is greater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviors from delirium or dementia can precipitate staff to use restraints to prevent harm to the older adult or to others. Physical restraints should be eliminated as an intervention in older adults with dementia because they are also very likely to cause acute functional decline, incontinence, pressure ulcers and regressive behaviors in a short period of time. The purpose of this paper is to disseminate the dangers of this clinical practice and to summarize the latest research in restraint free care and restraint alternatives in the United States.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

How can we help? From "sociology in" to "sociology of" bioethics

Sociology and bioethics have an uneasy relationship. Bioethicists find sociology helpful for describing and analyzing ethical issues, but they are less enthusiastic when bioethics becomes the subject of sociological scrutiny. After review of different sociological approaches to bioethical topics -- descriptive, evaluative, and analytical -- I explain how bioethics will benefit by using the tools of sociology to answer its questions ("sociology in bioethics") and by allowing sociology to use bioethics to answer sociological questions ("sociology of bioethics").