Are Bed Rails Killers or Safety Nets?

Last updated: August 16, 2010
bed rails

Dear Dr. Kernisan: I was surprised, when researching rehabilitation facilities for my mom, to visit a place that didn't have any bed rails on the beds. They said they were a suffocation risk but how common is that, really? She just broke one bone, and this seems like an invitation to break others.

You're absolutely right to bring up the possibility of deciding on a case-by-case basis. Using bed rails isn't considered 100 percent safe -- but then again, neither are the alternatives!

Bed rails are still included on most beds used in hospitals, nursing homes, and rehabilitation facilities, although often the rails are kept in the "down" position, especially the rails near the lower part of the bed. This allows the user to sit on the edge of the bed, and also to get out of bed. In my own experience, older people often also like to have the rails along the upper part of the bed in the "up" position; this gives them something to hang onto as they sit up or try to get in or out of bed.

It used to be relatively common practice to keep all the bed rails up if there was concern about a weak or confused older person falling out of bed. Now, however, bed rails are viewed with much more suspicion (and some facilities have even removed them), for the following reasons:

  • Risk of suffocation: Especially if there's a gap between the mattress and the rails, it's possible for a confused or sick person to get stuck and suffocate. This is pretty uncommon, however: Researchers in the United Kingdom have estimated the risk as 1 death per 20 million admissions. In the U.S., on average, the Food and Drug Administration (FDA) has recorded 20 deaths per year; in 2006, the FDA issued industry guidelines on safe bed assembly to help reduce this hazard.

  • Risk of injury: This is much more common than death. An older person can get hurt if an arm or a leg gets jammed in the bed rail. Some experts also say that clambering over a raised bed rail results in worse falls and injuries than simply falling out of bed.

  • Association with neglect: There's been legitimate concern that short-staffed or otherwise poor-quality facilities are more likely to use bed rails or other forms of restraint to inappropriately handle confused patients (such as those with dementia or delirium). Ideally, all facilities should first take other steps to minimize confusion, such as properly managing medications and incontinence, and simply responding sooner to patients' calls.

  • No clear proof that bed rails reduce falls or serious injuries: If bed rails were shown to improve safety overall, then some small risks might be worthwhile. But so far, researchers haven't been able to find definite evidence that bed rails keep people safer. (That being said, a recent review of the past 20 years worth of research also concluded that there's not much evidence that bed rails are as risky as claimed, either.)

In general, most geriatricians, including myself, feel that bed rails (especially the ones along the lower part of the bed) should be used as a last resort. It's important to first explore other strategies to minimize confusion and the risk of injury from falls. For example, in one nursing home I worked with, we used low beds and extra staffing to reduce the chance of injury among those people who were too weak to get out of bed safely. For those using a hospital bed at home, a consultation with a geriatrician or geriatric care manager can similarly help a family explore ways to minimize an individual patient's risk of falling out of bed.

In some cases, though, properly designed (and used) bed rails may be best. For example, if other strategies to keep a person in bed haven't worked, and if the person seems reassured by or indifferent to (rather than distressed by) the bed rails, it's reasonable to try them. The key is to make sure that bed rails aren't being used before other strategies have been tried. You should also check that the newer bed-and-bed-rail designs are used. The bed should have a snug-fitting mattress without any big dangerous gaps between the mattress and the bed rails.

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8 Comments So Far. Add Your Wisdom.

over 1 year ago

Wow. After hearing all of the personal reports from families, I have a solution for your problems with side rails. Invented years ago, this side rail attachment straps on the inside of the existing rail and comes with a cover (to eliminate possible entanglement problems) the system. It will allow full, 3/4 and 1/2 rails to be used with 100% safety. Your loved one will be safe in bed. Just ask me how if you are interested. I am now asking all persons in health care to give me input as to pros and cons. Thanks

almost 3 years ago

Made me aware of possible hazards & a properly fitted bed rail. Thanks

about 4 years ago

when he sat on the side of the bed and made the effort to get out. Of course he fell then but he was not entrapped. They also put the bed very close to the floor and put foam bads next to the bed (like exercise mats) so if they did fall out there was not much distance to fall. They had to watch the wanderers more and sometimes put pad alarms under them, but it at least kept them from hurting themselves.

Anonymous said about 4 years ago

The idea that not all side rails are dangerous and that there are statistics to show how small the number of fatalities really are.

about 4 years ago

I agree with the decision needing to be based on the situation and our situation calls for some sort of containment for my 90 yr old Dad when he's in bed. He suffers from anosognosia following a serious fall 2 yrs ago that resulted in a brain injury and spinal cord injury. Thankfully he is mobile with assistance but as his full time caregiver, sometimes think I lay awake at night just listening for him to fall out of bed. It has happened - he can swing his legs over the edge, but his balance is too limited for him to be able to execute an exit from the bed. I now pull his wheelchair up to the side he most frequently goes towards, and so far this seems to keep him safe. :-)

about 4 years ago

There are quite a few older and home care quality beds still in use that are not fitted with up to date siderails. The new designs on DC electric motor "low beds" should have side rails designed to the current entrapment guidelines. Problems occur due to lack of attention to the patient or equipment. The bed mattress MUST be the proper size and attached correctly and the side rails from the same manufacturer and designed for the bed. The new version "low beds" are used by faciities where the residents may fall out of be and injure themselves, so the bed is only about 12" off the floor and often they put foam pads on the floor to cushior potential falls. The bed of choice for us is from NOA Medical, which is used by professional Nursing Homes, Rehabilition and Hospice facilities. Most of the rentals for home care use do not meet these guidelines as Medicare does not cover the rental cost for an electric bed. You can rent or purchase a quality electric low bed from many dealers, to buy you are around $2000 with a healthcare mattress, bed, side rails, shipping etc.

about 4 years ago

My mother spent her last days in the only facility that could handle her issues, or WOULD handle her issues. It was a typical, short-staffed, out-of-date, skilled nursing facility, so my family was there most of the time to keep watch. We were told that bed rails were against Fed. & State laws, so they'd tuck one of those kids' swimming noodles along the edge, and put an alarm on mom. When she slept we knew she'd "travel" and worried about the set up this place had. Sure enough she got over the noodle and fell on the pad they put on the floor. She was okay that time, but it happened again!! I lost my temper, and luckily they called an ambulance this time. I told them they'd best have something in place by the time she got out in order to avoid a 3rd fall. She was lucky again, but we begged the hospital to keep her for a couple of days so that Dad and I could try to find a better place. They agreed but we had no luck, so back we went. I got a set of what they'd probably call hand rails, which were maybe 10" across, and installed those on both sides of her bed. Those were legal and would keep her in. Then they asked if we'd like to move her to a different, much nicer room with a king sized bed!! Duh! They should have put her there after the first fall. My point is that some of the reasoning behind not allowing bed railings is ridiculous and dangerous. I was furious, and I'm sure mom was humiliated, but at least it didn't happen again in the few days she had left. Short of staying there day and night to watch, you're screwed. I feel so sorry for the many people who don't have someone to watch over them.

When my dad was in the hospital they told me they dont put the rails up because that is entrapment or illegal restraint. My dad had alzheimers and that is what the told me. Also my dad slept on the very side of the bed so he was forever getting bruised by the bed rail. In one nursing home he went to for respite care the mattress was sort of recessed in the middle and there was foam on all sides of him. That kept him from rolling out of bet but didnt stop him when he sat on the side of the bed and made the effort to get out. Of course he fell then but he was not entrapped. They also put the bed very close to the floor and put foam bads next to the bed (like exercise mats) so if they did fall out there was not much distance to fall. They had to watch the wanderers more and sometimes put pad alarms under them, but it at least kept them from hurting themselves.

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