safe and effective use of bedrails

Version 1.1 May 2018

Safe and Effective Use of Bedrails

Target Audience

Who Should Read This Policy

All Clinical Staff

Safe and Effective Use of Bedrails Policy


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Ref. Contents Page

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 4

4.0 Process 5

5.0 Procedures connected to this Policy 10

6.0 Links to Relevant Legislation 10

6.1 Links to Relevant National Standards 10

6.2 Links to other Key Policies 14

6.3 References 15

7.0 Roles and Responsibilities for this Policy 16

8.0 Training 17

9.0 Equality Impact Assessment 17

10.0 Data Protection and Freedom of Information 17

11.0 Monitoring this Policy is working in Practice 18

Appendices

1.0 The Risk of Using/Not Using Bedrails 19

2.0 Bed Rails Risk Assessment For The Use of Bedrails 20

3.0 Bed Rail Risk assessment checklist 23

4.0 Bedrails Algorithm 24



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Explanation of terms used in this policy

Bedrails - Also known as safety sides, side rails, bed guards, cot-sides: - a device which is fastened to the side of the bed to prevent the patient from falling or getting out of bed

Bumpers – Padded covers that fit over the bedrail whose function is to reduce the risk of injuries caused by the patient striking their limbs or head on the rails

FallSafe Project – A national driver that was undertaken by the Royal College of physicians that is

based on three care bundles that are a specific measurable set of multi-factorial assessments and interventions for falls

Hi-Lo Beds – An electronically operated bed that can be height adjusted to a level below that of a standard hospital bed, sometimes to floor level

NHS Never Events - Defined as ‘serious, largely preventable patient safety incidents that should not

occur if the available preventative measures have been implemented by healthcare providers’

Profile Beds – An electronically operated bed that can be height and position adjusted.



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1.0 Introduction Patients in hospital may be at risk of falling from the bed for many reasons including poor mobility, dementia or delirium, visual/impairment, and the effects of their treatments or medication. Bedrails are used extensively in care environments to prevent bed occupants falling out of bed and injuring themselves. Black Country Partnership Foundation Trust aims to take all reasonable steps to ensure the safety and independence of its patients and respects the rights of patients to make their own decisions about their care. 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 a form of restraint. Restraint is defined as “Any action that restricts someone’s liberty or prevents someone from doing something they want to do.” Bedrails will not prevent a patient leaving their bed and falling elsewhere and should not be used for this purpose. Bedrails are also not intended as a moving and handling aid. Bedrails are not appropriate for all patients and using bedrails involves risks. National data suggests around 1,250 patients injure themselves on bedrails each year, usually scrapes and bruises to their lower legs.

2.0 Purpose The purpose of the policy is to guide staff in taking all reasonable steps to ensure the safety and independence of patients while respecting their rights to make their own decisions about their care. Based on reports to the Medicines and Healthcare Products Regulatory Agency (MHRA), Health and Safety Executive (HSE) and National Patient Safety Agency (NPSA), deaths from bedrail entrapment in hospital settings in England and Wales occur less than one in every two years and could probably have been avoided if NPSA advice had been followed. Staff should continue to take great care to avoid bedrail entrapment but need to be aware that in hospital settings there is a greater risk of harm to patients falling from beds - in England and Wales over a single year, there were around 44,000 reports of patients falling from the bed.

3.0 Objectives The Policy aims to:

Ensure bed rails are prescribed and installed appropriately to minimise the risk of patient injury

Provide guidance on the safe and effective provision and use of bedrails for Trust staff

Reduce harm to patients, caused by falling from beds or becoming trapped in bedrails

Highlight the importance of balancing risks and benefits for patients who could be harmed by bedrails compared with the potential risks of injury from falls

Support patients/ staff and carers to make individual decisions around the risks of using and not using bedrails



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Ensure compliance with Medicines and Healthcare Regulatory Products Agency (MHRA) and National Patient Safety Agency (NPSA) advice

4.0 Process

Decisions about bedrails need to be made in the same way as decisions on other aspects of treatment and care as outlined in the Trust Consent Policy.

The patient should decide whether or not to have bedrails if they have capacity. (Capacity is the ability to understand and weigh up the risks and benefits of bedrails once these have been explained)

If the patient lacks capacity, staffs have a duty of care and must decide if bedrails are in the patient’s best interests. The Trust does not require written consent for bedrail use but discussions and decisions should be documented by staff in the patient’s records

The patient’s dignity, safety and comfort must be maintained at all times

Staff can learn about the patient’s likes, dislikes and normal behaviour from relatives and carers and should discuss the benefits and risks with them. However, relatives or carers cannot make decisions for adult patients (except in certain circumstances where they hold a Lasting Power of Attorney extending to healthcare decisions under the Mental Capacity Act)

The Trust will provide the NPSA Patient briefing leaflet for patients’ relatives and carers giving information on using bedrails safely and effectively in hospitals

Decisions about bedrails are only one small part of preventing falls and should not be used in isolation of other strategies. Staff should also follow the prevention guidance in the Slips, Trips and Falls Policy and the FALLSAFE procedure to identify other measures that should reduce the patient’s risk of falling not only from bed but also while walking, sitting or using the toilet. It is important to ensure that all staffs who operate bedrails are fully aware of the risk assessment process and the safety aspects to be considered and followed when working with bedrails to ensure the safety of the occupant. A risk assessment MUST be carried out for each occupant for whom bedrails are being considered. Risk assessments should then be reviewed and recorded after each significant change in the patient’s condition. There are different types of beds, mattresses and bedrails available and each patient is an individual with different needs. 4.1 Procedure for Using Specialist Mattresses with Bedrails If using mattress overlays (for management of compromised tissue viability) or a bariatric bed with a compatible size mattress, check:

There are no potential entrapment gaps at the sides and top and bottom ends especially when the mattress is compressed (when sat or laid upon)

The increased overall height of the mattress plus overlay has not rendered standard bedrails too low to be effective. Standards for adjustable and hospital beds require that the top surface of the bed rails is at least 220 mm from the top of the uncompressed mattress



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A risk versus benefit clinical judgment will then need to be made and documented as to the priority management of the greater risk (a potential fall or pressure ulcer development).

4.2 Procedure for Using Specialist Ultra Low Profiling (Hi/Low) Beds These beds are able to be lowered to a height of below 30cm (top of mattress to floor) and can be a viable alternative if the patient is at very high risk of attempting to leave their bed and fall. These patients would most likely be very confused and mobile and have high falls and fracture risks. They can be used in conjunction with impact (“crash”) mats.

Such “ultralow” beds must not be seen as a panacea to falls prevention but as a potential useful piece of equipment for carefully assessed patients. Considerations to their appropriate use should include:

A risk assessment for potential injuries to the patient from floor level furniture or fittings (radiators, lockers etc.)

The bed placed too close to a radiator creating potential for risk of burns

The bed placed too close to a wall but not flush with it, creating potential for asphyxial entrapment if the patient slides between the bed and the wall

The bed left at working height in error

Crash mats causing a trip hazard to staff, patients and others

Bedrails should not be used if:

The relevant assessments have not been completed

The risk of harm from the use of bed rails outweighs the benefits from their use

Bed rails are not compatible with the bed or other bed accessories in use e.g. mattresses

There are insecure fittings or bed rails that have parts missing

Other gaps are created by the bed, rail, mattress and head/footboard combination

The use of the bedrail is intended as a restraint

The person’s physical size and behaviour present a risk

The patient is agile enough and confused enough to climb over them

The patient would be independent if the bedrails were not in place However, most decisions about bedrails are a balance between 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 and their lifestyle. Staff should use their professional judgement to consider the risks and benefits for individual patients (see Appendix 1). If bedrails are not used, how likely is it that the patient will come to harm? Ask the following questions:

How likely is it that the patient will fall out of bed?

How likely is it that the patient would be injured in a fall from bed?

Will the patient feel anxious if the bedrails are not in place?

If bedrails are used, how likely is it that the patient will come to harm? Ask the following questions:

Will bedrails stop the patient from being independent?

Could the patient climb over the bedrails?



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Could the patient injure themselves on the bedrails?

Could using bedrails cause the patient distress? Use bedrails if the benefits outweigh the risks. The behaviour of individual patients can never be completely predicted and the Trust will be supportive when decisions are made by frontline staff in accordance with this policy. Decisions about bedrails may need to be frequently reviewed and changed. Patients in mental health settings can have rapidly changing needs when physical illness intervenes. Therefore, decisions about bedrails should be reviewed whenever a patient’s condition or wishes change but, as a minimum they should be reviewed weekly. 4.3 Documentation

A decision to use or not use bedrails must be recorded in the Patient’s Records and a care plan developed on the patient’s risk of falling out of bed – as bedrails should only be considered as one of several possible interventions

A risk assessment tool must be completed for each patient and a copy placed in the patients’ clinical record. The rationale to use or not to use bed rails must be documented with reference to the risk assessment form. Any discussions with the patient and carers must be recorded

The decision to use bed rails must be documented on the patient’s intervention plan or care plan and updated regularly

A record must be kept of any subsequent reviews, reassessments, discussions and changes in the patients’ clinical condition

Where bed rail use is discontinued following reassessment then the reasons for this must be clearly recorded

Where the potential risk of providing bedrails outweighs the benefits to the patient, alternatives to bedrails may be considered such as:

Netting or mesh bed sides

Ultra ‘low height’ beds

Positional wedges

Alarm systems to alert carers that a person has moved from their normal position or wants to get out of bed

Fall mats 4.4 Using Bedrails The Trust has taken steps to comply with MHRA advice through ensuring that:

All unsafe bedrails have been removed and destroyed.

All bedrails or beds with integral rails have an asset identification number and are regularly maintained.

The types of bedrails, beds and mattresses used on each site within the organisation are of compatible size and design and do not create entrapment gaps for adults within the range of normal body sizes.

Whenever frontline staff fit bedrails they should carry out the following checks:



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For all types of bedrail:

Are there any signs of damage, faults or cracks on the bedrails? If so, do not use and label clearly as faulty and have removed for repair;

Is the patient an unusual body size? (for example: hydrocephalic, microcephalic, growth restricted, very emaciated). If so, check for any bedrail gaps which would allow head, body or neck to become entrapped by referring to MHRA advice at www.mhra.gov.uk.

If using detachable bedrails:

The gap between the end of the bedrail and the head of the bed should be less than 60mm.

The gap between the end of the bedrail and the foot of the bed should be less than 60mm or more than 318mm;

The fittings should all be in place and the attached rail should feel secure when raised.

4.5 Reducing Risks For patients who are assessed as requiring bedrails but who are at risk of striking their limbs on the bedrails, or getting their legs or arms trapped between bedrails, the following equipment should be available - Padded Bedrail Covers/ Bumpers. The NPSA and MHRA guidance indicates that padded safety sides are “primarily used to prevent impact injuries but they can also reduce the potential for limb entrapment when fixed securely to the bed rail”. If a patient is found in positions, which could lead to bedrail entrapment, for example feet or arms through rails, or with legs through gaps between rails, this should be taken as a clear indication that they are at risk of serious injury from entrapment. Urgent changes must be made to the plan of care. These could include changing to a special type of bedrail or deciding that the risks of using bedrails now outweigh the benefits. If a patient is found attempting to climb over their bedrail or does climb over their bedrail, this should be taken as a clear indication that they are at risk of serious injury from falling from a greater height. The risks of using bedrails are likely to outweigh the benefits, unless their condition changes. The safety of patients with bedrails may be enhanced by frequently checking that they are still in a safe and comfortable position in bed and that they have everything they need, including toileting needs. However, the safety needs of patients without bedrails who are vulnerable to falls are very similar. All patients in hospital settings will need different aspects of their condition checked, for example, agitation, anxiety and pain. Consequently, observing patients with bedrails should not be treated as a separate issue but as an important part of general observation within each ward/department. 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.



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Beds will need to be raised when direct care is being provided. Patients receiving frequent interventions may be more comfortable if their bed is left raised, rather than it being constantly raised and lowered. The Trust will ensure that:

All staff who make decisions about bedrail use, or advise patients on bedrail use, have the appropriate knowledge to do so;

All staff who supply, maintain or fit bedrails have the appropriate knowledge to do so as safely as possible, tailored to the equipment used within the Trust.

All nursing staff who have contact with patients, including students and temporary staffs, understand how to safely lower and raise bedrails and know they should alert the nurse in charge if the patient is distressed by the bedrails, appears in an unsafe position or is trying to climb over bedrails.

These points are achieved through:

Ward/ house managers.

Practice development. The Trust aims to ensure bedrails and bedrail covers and special bedrails can be made available for all patients assessed as needing them. The Ward/Unit Manager should be told of any shortfall. They will endeavour to release bedrails from patients who no longer need them. If bedrails cannot be obtained, staff should explore all the possible alternatives to reduce the risk to the patient and report the lack of equipment on the Incident Report Form. 4.6 Cleaning Metal / plastic bedrails should be cleaned between each and every patient and if visibly contaminated by: Wearing apron and disposable non-sterile procedure gloves, wipe with a disposable cloth using detergent and hot water. If visibly contaminated by blood or blood stained bodily fluid they should be wiped using a disposable cloth and a solution of Haz Tabs (refer to the spillage kit). Rinse thoroughly and dry (Infection Control Assurance Policy). Bedrail covers / mesh rails, etc. should be cleaned by: Using the same procedure as above. Detachable bedrails no longer needed should be removed from beds and stored. Bedrails removed from storage for use must be wiped free of dust before reuse. New beds, bedrails or mattresses can introduce new risks and must be fully compatible with existing stock. When special mattresses are hired, the requisition form requires the make and model of bed/bedrail to be stated and the company renting the mattress will be asked to confirm the mattress is compatible with the bed and bedrail. 4.7 Incident Reporting All accidents and injuries involving the use of bedrails should be considered as an untoward incident and reported immediately via the Trust’s incident reporting system



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Datix. An incident report must be completed and the incident documented in the patient’s record. Any serious untoward incident due to the use of bed rails should be reported to the Medical Devices Agency and defective equipment should be removed from service immediately

5.0 Procedures connected to this Policy There are currently no standard operating procedures linked to this policy.

6.0 Links to Relevant Legislation Mental Capacity Act 2005. The Stationery Office Limited: London. Health and Safety at Work Act 1974, HMSO London

6.1 Links to Relevant National Standards CQC Regulation 8: General This regulation aims to make it clear that if a provider has more than one registered person (for example, a registered provider as well as a registered manager) they do not all individually need to take the same action to meet every regulation. However, they must make sure that they meet every regulation for each regulated activity they provide, and that all the registered people must comply with the requirements of the regulations. It also states that for Regulations 9 to 20A, sections 2 and 3 of the Mental Capacity Act 2005 must be considered for people who use the service who are aged 16 or over to determine whether they lack the mental capacity to consent. CQC Regulation 9: Person-Centred Care The intention of this regulation is to make sure that people using a service have care or treatment that is personalised specifically for them. This regulation describes the action that providers must take to make sure that each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves. Providers must make sure that they take into account people's capacity and ability to consent, and that either they, or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment. Providers must make sure that decisions are made by those with the legal authority or responsibility to do so, but they must work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate. CQC Regulation 10: Respect and Dignity The intention of this regulation is to make sure that people using the service are treated with respect and dignity at all times while they are receiving care and treatment. To meet this regulation, providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times. This includes making sure that people have privacy when they need and want it, treating them as equals and providing any support they might need to be autonomous, independent and involved in their local community.



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Providers must have due regard to the protected characteristics as defined in the Equality Act 2010. CQC Regulation 11: Need for Consent The intention of this regulation is to make sure that all people using the service, and those lawfully acting on their behalf, have given consent before any care or treatment is provided. Providers must make sure that they obtain the consent lawfully and that the person who obtains the consent has the necessary knowledge and understanding of the care and/or treatment that they are asking consent for. Consent is an important aspect of providing care and treatment, but in some cases, acting strictly in accordance with consent will mean that some of the other regulations cannot be met. For example, this might apply with regard to nutrition and person-centred care. However, providers must not provide unsafe or inappropriate care just because someone has consented to care or treatment that would be unsafe. See the glossary for the definition of 'relevant person' in relation to Regulation 11. CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staffs have the qualifications, competence, skills and experience to keep people safe. Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. Providers must prevent and control the spread of infection. Where the responsibility for care and treatment is shared, care planning must be timely to maintain people's health, safety and welfare. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment. CQC Regulation 13: Safeguarding Service Users from Abuse and Improper Treatment The intention of this regulation is to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment. Improper treatment includes discrimination or unlawful restraint, which includes inappropriate deprivation of liberty under the terms of the Mental Capacity Act 2005. To meet the requirements of this regulation, providers must have a zero tolerance approach to abuse, unlawful discrimination and restraint. This includes:

neglect

subjecting people to degrading treatment

unnecessary or disproportionate restraint

deprivation of liberty.



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Providers must have robust procedures and processes to prevent people using the service from being abused by staff or other people they may have contact with when using the service, including visitors. Abuse and improper treatment includes care or treatment that is degrading for people and care or treatment that significantly disregards their needs or that involves inappropriate recourse to restraint. For these purposes, 'restraint' includes the use or threat of force, and physical, chemical or mechanical methods of restricting liberty to overcome a person's resistance to the treatment in question. Where any form of abuse is suspected, occurs, is discovered, or reported by a third party, the provider must take appropriate action without delay. The action they must take includes investigation and/or referral to the appropriate body. This applies whether the third party reporting an occurrence is internal or external to the provider. CQC Regulation 14: Meeting Nutritional and Hydration Needs The intention of this regulation is to make sure that people who use services have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment. To meet this regulation, where it is part of their role, providers must make sure that people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. People must have their nutritional needs assessed and food must be provided to meet those needs. This includes where people are prescribed nutritional supplements and/or parenteral nutrition. People's preferences, religious and cultural backgrounds must be taken into account when providing food and drink. CQC Regulation 15: Premises and Equipment The intention of this regulation is to make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located, and that the equipment that is used to deliver care and treatment is clean, suitable for the intended purpose, maintained, stored securely and used properly. Providers retain legal responsibility under these regulations when they delegate responsibility through contracts or legal agreements to a third party, independent suppliers, professionals, supply chains or contractors. They must therefore make sure that they meet the regulation, as responsibility for any shortfall rests with the provider. Where the person using the service owns the equipment needed to deliver their care and treatment, or the provider does not provide it, the provider should make every effort to make sure that it is clean, safe and suitable for use. CQC Regulation 16: Receiving and Acting on Complaints The intention of this regulation is to make sure that people can make a complaint about their care and treatment. To meet these regulation providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints from people using the service, people acting on their behalf or other stakeholders. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified.



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When requested to do so, providers must provide CQC with a summary of complaints, responses and other related correspondence or information. CQC Regulation 17: Good Governance The intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice. In addition, providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity. As part of their governance, providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement. When requested, providers must provide a written report to CQC setting out how they assess, monitor, and where required, improve the quality and safety of their services. CQC Regulation 18: Staffing The intention of this regulation is to make sure that providers deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements described in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. To meet the regulation, providers must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times and the other regulatory requirements set out in this part of the above regulations. Staff must receive the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities. They should be supported to obtain further qualifications and provide evidence, where required, to the appropriate regulator to show that they meet the professional standards needed to continue to practise. CQC Regulation 19: Fit and Proper Persons Employed The intention of this regulation is to make sure that providers only employ 'fit and proper' staffs who are able to provide care and treatment appropriate to their role and to enable them to provide the regulated activity. To meet this regulation, providers must operate robust recruitment procedures, including undertaking any relevant checks. They must have a procedure for ongoing monitoring of staff to make sure they remain able to meet the requirements, and they must have appropriate arrangements in place to deal with staffs who are no longer fit to carry out the duties required of them. Employing unfit people, or continuing to allow unfit people to stay in a role, may lead CQC to question the fitness of a provider.



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If CQC considers that a breach of this regulation is also be a breach of another regulation(s) that carries offence clauses, then we can move directly to prosecution without serving a Warning Notice. For example, in situations where the care and treatment is provided without the consent of a person using the service or someone lawfully acting on their behalf, and where it is unsafe, does not meet the person's nutritional needs, results in abuse, or puts the person at risk of abuse. CQC Regulation 20: Duty of Candour The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. The regulation applies to registered persons when they are carrying on a regulated activity. CQC Regulation 20A: Requirement as to Display of Performance Assessments This regulation will apply to all providers when they have received a CQC performance assessment for their regulated activities. Providers must ensure that their rating(s) are displayed conspicuously and legibly at each location delivering a regulated service and on their website (if they have one). The regulation outlines the information that must be included. CQC has developed posters for providers and digital products to use on websites. Using these will help providers to make sure that they display all the information required under this regulation. National Institute for Health and Clinical Excellence (NICE) The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. We produce the following types of guidance: - Clinical guidelines – recommendations about the treatment and care of people

with specific diseases or conditions in the NHS in England and Wales. - Technology appraisal guidance and interventional procedures guidance –

guidance on the use of new and existing medicines, treatments and procedures in the NHS.

- Public health guidance – guidance on ways of helping people improve their health and reduce their risk of illness.

NICE encourage stakeholders to get involved in the development of their guidance at all stages. Stakeholders include national organisations that represent patients and carers, local patient and carer organisations when there is no relevant national organisation, healthcare professionals, the NHS, organisations that fund or carry out research, and the healthcare industry. 6.2 Links to other Key Policies Prevention and Management of Slips Trips and Falls Policy. FallSafe Care Bundles to reduce Inpatient Falls. Infection Control Assurance Policy. Clinical Falls Policy



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6.3 References National Patient Safety Agency. Slips, trips and falls in hospital: the third report from the patient safety observatory5

2007. www.npsa.nhs.uk. National Patient Safety Agency. Resources to support implementation of safer practice notice using bedrails safely and effectively 2007. Available at www.npsa.nhs.uk. Medicines and Healthcare products Regulatory Agency. The safe use of bedrails MHRA Device Alert DB2006 (05) November 2012 Available at www.mhra.gov.uk. National Patient Safety Agency Safer Practice Notice using bedrails safely and effectively 2007. Available at www.npsa.nhs.uk. National Patient Safety Agency (NPSA). Bedrails – Reviewing the evidence. BILD Publication Paley, S & Brooke J. (2006) good Practice In Physical Intervention “A Guide for Staff and Managers” ISBN 010540905.

http://www.npsa.nhs.uk/


http://www.mhra.gov.uk/




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7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities

Chief Executive Accountable - The Chief Executive is responsible for assuring that this policy is implemented within the Trust.

- Ensures that Operational responsibility has been delegated.

Director of Nursing and Professional Practice

Executive Lead - Responsibility for this policy has been delegated by the Chief Executive to the Director of Nursing and Professional Practice who is responsible for ensuring that this policy is discharged appropriately and has lead responsibility for its

implementation.

Trust Board Strategic - The role of the Trust Board is to have a strategic overview and final responsibility for safe and high quality care within service areas across the Trust in accordance with its Assurance Framework and strategic priorities.

Business and

Performance Committee

Accountable - A sub-committee of the Trust Board has delegated responsibility for ensuring that this policy is efficient and effective in

accordance with the Board’s Assurance Framework and Strategic priorities.

Quality and Safety

Steering Group

Responsible - The Care Governance Committee is responsible for overseeing the implementation of a systematic and consistent

approach to this policy. The group is chaired by the medical Director and provides exception and progress reports to the Executive Committee.

Service Managers,

Modern Matrons, Ward

Managers and Lead Nurses

Implement - The Service Managers, Modern Matrons, Ward Managers and Lead Nurses are responsible for ensuring that:-

- They are familiar with this policy and are responsible for adhering to the procedures.

- Staffs attend training applicable to their role and for implementing the guidance across their areas of responsibility. - Staff work to the standards set out in this policy.

Ward Staff

Adherence - All clinical staffs are responsible for ensuring that they are familiar with the policy and for adhering to the procedures referred to within the policy.

- Clinical staff using bedrails are professionally accountable for ensuring that:

- they have read and are aware of the guidelines for the use of bedrails.

- they are responsible for keeping up to date by attending bed rails training. - a risk assessment is completed and documented for patients who may require the use of bedrails.

- appropriate bedrails have been provided. - a visual inspection of the bed rails is undertaken every time they are used and should any equipment fault be

identified, the equipment is not used and appropriate action for repair/replacement is instigated immediately. - any near misses, incidents and accidents that occur as a result of using bed rails are reported as a clinical risk using the

correct incident reporting procedure (DATIX).

- any near misses, incidents and accidents that occur as a result of NOT using bed rails when their use would have been appropriate are similarly reported as a clinical risk using the correct incident reporting procedure (DATIX).

- appropriate guidance has been given to the user/carer.



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Falls Steering group Monitor - the group will lead, inform and monitor the FallSafe Programme across the Trust including the use of bedrails

8.0 Training

What aspect(s) of this policy will

require staff training?

Which staff groups require this

training?

Is this training covered in the Trust’s Mandatory and Risk

Management Training Needs Analysis document?

If no, how will the training be delivered?

Who will deliver the training?

How often will staff require

training

Who will ensure and monitor that staff have

this training?

If yes, please refer to it for details on training

requirements, and update frequencies

9.0 Equality Impact Assessment

Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

10.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4%

mailto:[email protected]

http://simple.wikipedia.org/wiki/Information

http://simple.wiktionary.org/wiki/right



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of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team. 11.0 Monitoring this Policy is working in Practice

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this

monitoring?

How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

All staffs will be given training but assessment for bedrails will only be carried out by following initial training.

4.0 Process Continuous risk assessments & Documentation Audit

The Trust Quality and Safety Steering Group

The Trust Quality and Safety Steering Group

registered nurses & FallSafe Leads


Version 1.0 June 2014

Appendix 1

The Risk of Using/Not Using Bedrails

This Tool is to support Professional Judgment only

THE RISK OF NOT USING BEDRAILS THE RISK OF USING BEDRAILS

How likely is it that the patient will fall out of bed? Patients may be more likely to slip, roll, slide or fall out of bed if they: • have fallen from bed before; • have been assessed as having a high risk of falling; • are very overweight; • are semi-conscious • have a visual impairment; • have a partial paralysis; • have seizures or spasms; • are sedated, drowsy from strong painkillers or are recovering from an anesthetic; • are delirious or confused; • are affected by alcohol or street drugs; • are on a pressure-relieving mattress which ‘gives’ at the sides; • use bedrails at home; How likely is it that the patient could be injured in a fall from bed? Injury from falls from bed may be more likely, and more serious for some patients than others, for example, if they: • have osteoporosis; • are on anticoagulants; • are older; • have fragile skin; • have a vascular disease; • are critically ill; • have long-term health problems; • are malnourished. Will not using bedrails cause the patient anxiety? Some patients may be afraid of falling out of bed even though their actual risk is low.

Would bedrails stop the patient from being independent? Bedrails can be a barrier to independence for patients who otherwise could leave their bed safely without help. Is the patient likely to climb over their bedrails? An injury’s severity can be increased if the patient climbs over a bedrail and falls from a greater height. It is patients who are significantly confused and have enough strength and mobility to clamber over bedrails that are most vulnerable. Could the patient injure themselves on their bedrails? Bedrails can cause injury if the patient knocks themselves on them or traps their legs or arms between them. The most vulnerable patients are those: • with uncontrolled limb movements; • who are restless and significantly confused; • with fragile skin. Bedrails, even when correctly fitted; carry a very rare risk of postural asphyxiation. Patients who are very confused, frail and restless are most likely to be at risk. Will using bedrails cause the patient distress? Bedrails may distress some patients who feel trapped by them.


Version 1.1 May 2018 20

Appendix 2

Bed Rails Risk Assessment For The Use of Bedrails

Name: DoB

Address GP

NHS No.

Date of assessment

Assessor

Unit

Risk assessments should be reviewed after each significant change in the patient’s condition or any incident relating to safety in bed or as a minimum of every two weeks for inpatients. The continued use (or not) of the bedrails should be recorded in the care plan and appropriate documentation. If a patient, relative/carer insists on bedrails being used, even after any potential risks have been explained, complete and follow the outcome of the risk assessment documenting their reasons and resulting action taken.

If a patient is deemed to be at risk of falling out of bed consider the following:

1 Does the patient have dementia, confusion, learning disability, agitation, unable to comprehend or are they distressed.

Yes No

Consider entrapment issues and alternatives

Continue assessment

2

Does the patient have epilepsy or other involuntary movements which may cause entrapment

Yes No


Continue assessment

3

Is the patient at risk of climbing over the bed rails

Yes No

Consider alternatives

Continue assessment

4

Does the patient have altered sensation

Yes No


Continue assessment

5

Does the patient’s physical or clinical condition increase the risk of entrapment

Yes No


Continue assessment

6

Has the patient got:

an in-dwelling catheter

a PEG tube

Yes No

Ensure all staff are aware of care needing to be taken

Continue assessment

7

Will the patient need to get out of

Yes No

Consider Continue



bed unsupervised alternative method assessment

Affix patient label

8

Does the patient have a need for a pressure mattress or profiling bed

Yes No

Ensure bed rails are compatible and use high bed rails

Continue assessment

9

Is the patient at risk of falling if bed rails are used

Yes No

Consider alternative method

Continue assessment

10

Does the patient refuse the use of bed rails?

Yes No

Consider alternative method

Continue assessment

11

Is the patient’s head small enough to pass between the bed rail bars

Yes No


Continue assessment

12

Is the patient’s body small enough to pass between the bed rail bars

Yes No


Continue assessment

13

Could the head or body get caught between the bedrails and the head board/foot board

Yes No


Continue assessment



Affix patient label

Clinical decision: What are the key factors for/against prescribing bed rails?

The reasons for/against using bed rails are:

These reasons have been explained to:

The following are the benefits and risks of any alternative options and any particular concerns of this patient/carer/family:

Resultant action: Bed rails to be fitted/not to be fitted

Comments

Signature of assessor

Date

Name of assessor

Job Title

Unit/service

Review date



Appendix 3

Bed Rail Risk assessment checklist

Yes No Is the bed rail to be used with a typically sized adult bed occupant Has the bed rail been inspected and maintained regularly, if used previously

Does the manufacturer/supplier provide any information on special considerations or contra-indications

Do you have enough from the supplier to be able to select and fit the bed appropriately

Is the bed rail suitable for the intended bed, according to the supplier’s instructions

Do the fittings or mattress allow the bed rail to be fitted to the bed securely, so there is no excessive movement

Does the benefit of any special or extra mattress outweigh any increased entrapment risk by the bed rails created by extra compression at the mattress edge

Are the bed rails high enough to take into account any increased mattress thickness or additional overlay

Have you made sure that there are no gaps present that could present an entrapment risk to any part of the patient’s body

between the bars of the bedrails - 120mm max

through any gap between the bed rail and side of the mattress - 120mm max

through the gap between the lower bed rail bar and the mattress allowing for compression of the mattress at its edge 120mm max

Is the headboard to bed rail end gap less than 60mm

‘Yes’ indicates the desired outcome ‘No’ indicates that there may be a serious risk of entrapment with the proposed combination. Review immediately. Risk assessments should be carried out before use and then reviewed and recorded after each significant change in the bed occupant’s condition, replacement of any part of the equipment combination and regularly during its period of use, according to local policy.



Bedrails Algorithm

Appendix 4

Rationale for the completion of the Bedrails assessment

Is the patient at risk of falling from bed? NB for patients at risk of climbing over bedrails alternatives must be considered (See boxes 2 and 3)

Patient does not understand purpose of bedrails due to…

Yes

Patient understands purpose of bedrails

Patient consents to bedrail use

No

Patient requesting bedrails

Bedrails could be used with caution

Bedrails inappropriate

Patient not requesting bedrails

Remember to document in nursing records Box 3

Date and time assessment made

Patient and next of kin given information on

bedrails

Rationale for decision made in care plan

Where bedrails are considered appropriate

and the patient has declined their use

Actions taken, including discussion with

next of kin

Care planning and reviews

Assessment should be made on admission; if patients condition changes; daily/weekly depending on the situation.

On admission

Patient declines bedrail use

Communication difficulties Physical and/or cognitive condition

Bedrails could be used with caution see boxes 1 &3

Bedrails inappropriate (see boxes 2/3)

Consider:

Referral to appropriate

speciality

Use of interpreter

Use of written or pictorial

information

Consider actions in patients best interests. (See boxes 1, 2 &3)

If bedrails are used consider: Box 1

Risk of entrapment and harm to limbs

Risk of patient climbing over the top

The psychological effect of bedrails to the

patient

Use of air-filled mattresses or mattress

overlays require extra height bedrails

Bariatric beds must be used with a

compatible extra wide mattress

Consider regular checks at night

Complete assessment

Alternatives to bedrails Box 2

Move patient to observable area to maximise

supervision

Ensure bed returned to lowest height after

care delivery

Ensure patient needs anticipated e.g. drinks

are accessible, regular toileting, call bell to

hand, regular checks at night



Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment,

or archiving arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

1.1 May 2018

Minor Changes made to Section 6.2-included clinical falls policy, Section 7.00- removed fall safe support group and added falls steering group and children services from Target Audience as the policy pertains to adult inpatient services.

1.0 June 2014 Policy for the new BCPFT organisation

Title of Policy Safe and Effective Use of Bedrails Policy

Unique Identifier for this policy BCPFT-CLIN-POL-0614-158

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Clinical

Executive Director whose portfolio this policy comes under

Executive Director of Nursing, AHPS, Psychology and Quality

Policy Lead/Author Job titles only

Matron for OA

Committee/Group responsible for the approval of this policy

Nursing Board

Month/year consultation process completed *

May 2018

Month/year policy approved September 2018

Month/year policy ratified and issued September 2018

Next review date May 2021

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

safe and effective use of bedrails

Documents