Older Patients, Wiser Care

Are Bed Rails Killers or Safety Nets?

bed rails
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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.