Do bedrails up mean you have restrained a patient?

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We have a problem at my workplace. The bedrails are considered a form of restraint and must be approved by the VMO (resident’s GP) before a nurse can apply them.

This is regardless of whether or not the resident is prone to falls; cannot weight bear; is an amputee, etc.

We are told, it is  ‘illegal ‘ to place the bedrails up, without a doctor’s order and the NOK written permission.

For those of you who work in Aged Care, what happens at your facility? Do you think the need for all the documentation is reasonable? I’d like to hear what happens elsewhere.

We have had so many falls, some very serious, all down to no bedrails up, because the NOK didn’t want to sign the ‘restraint’ form.

Elderly people, living in Aged Care facilities, often have the overwhelming urge to get out of bed at various times at night, in order to get to the toilet. Unfortunately, I know of cases where that simple urge to go to the toilet in the middle of the night has cost them their life!

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18 COMMENTS

  1. At our nursing home the family sign a permission form when they are admitted this is encouraged as a safety measure not a form of restraint. however if the resident or family member doesnt want the rail up then the AINS dont do it.However it it also important to remember that some residents with dementia will climb over rails to get out of bed and this can and has resulted in falls. ALso some residents will put their legs through the rails which makes it hard to get them out, a good protection for bedrail are the bedside protectors which are placed over the rail and can prevent the resident from getting skin tears or trying to get out of bed as for the issue of going to the toilet the nurses need to assist them through out the night if they are able to walk or they need to use a good sized pad. If residents are a danger to them selves there are other answers to bedrails such as lowering the bed to the lowest position or using a floor bed which lowers to the floor then it the resident does get out of bed they cant fall as they are on the floor

  2. I agree with everything you’ve stated here, all except the last bit about not being able to fall, because the bed is already at ground level.

    I had a resident die from a fall, from the standing position. He was already out of bed ( position / location of body when found ). You can most certainly fall / slip / trip / collapse from a standing position, and it only takes a minute or two to happen ( regardless of how vigilent you are with ’rounds’.

    All those measures you mentioned are all appropriate strategies for a range of situations. They are most likely the ‘standard’ in most facilities ( my employment facility takes all those measures ). But unfortunately, they don’t always work with every resident.

    However, we find that some family members are still in denial about their relative over certain aspects of their condition. The very fact, that the resident has needed to be admitted to a long term care facility, just doesn’t sink in with some people. When the documentation is offered to them, they seem to be suspicious, and it almost appears they think this is something the nurses do, and the doctor doesn’t know about it. ( which is another story altogether…… doctors and their role at Nursing Homes )

    Anybody else like to offer their perspective on this one ??

  3. From a totally different angle…we use them in maternity for women initially post C/S. We also use them on one side, generally, to provide a barrier that keeps the baby from falling over the edge. It’s great when mothers are learning to breastfeed lying down. One day, I returned to a mother and realized that I’d left her with two rails up. I think we’d swapped the baby from one side to the other. She’d gotten out of it, but it was definitely restraining, in that she had to climb over the end of the bed to get out. It would be an interesting exercise, if only mentally, to get into a bed with the rails up and consider how to get out. Perhaps there’s an inventor who will create something that alarms when the person gets out of bed.

    This isn’t an easy question, especially in the current environment. Private rooms mean there is less ease of observation and of requesting help. Independent adults sometimes resist the idea of being helped. Work loads prevent frequent observation. And so on. I definitely see the pluses of engaging families in a discussion about safety and the best means to prevent falls for their relative.

  4. The wheel has been invented !!

    Most Aged Care facilities DO HAVE a device that sets off an alarm when the resident gets out of bed.

    Basically, there are two types. A ‘floor mat’ type, that is placed either side of the bed. As the person stands on the mat ( getting out of bed ), the alarms go off ( in some way that staff are alerted – either by a lit sign, or a paging system )

    The other, is a ‘bed mat’ system. This is more sensitive, and goes off every time the resident ‘changes position’ in bed. It’s basically a movement sensor, but will most certainly alarm if the resident gets out of bed – regardless if the bedrails are up or down.

    In your example emiline, one may ask, why didn’t the mother use her ‘call bell’ system to call for staff assistance?

    I used to find it quite puzzling, why Private patients ( at a Private Hospital ), would rather risk falling / collapsing post op, than use a call bell to ask a nurse for help to the toilet – especially when they were very specifically told DO NOT GET OUT OF BED without a nurse assisting.

    I’ve seen some amazing sights…. people who have wrapped their two IV lines around their necks / backs, as they were juggling two IV poles, trying to get the toilet BY THEMSELVES !! ( sometimes, they are the ones puzzled, when staff find them in the toilet, trying to urinate….. ” Mr. Smith, you have an IDC – a catheter. You don’t have to get out of bed to do a wee “. Just love telling people that !!!

    • Gordo – you lack the capacity to see things from the other person’s side, obviously you have never been a patient and told DON”T GET OUT OF BED. Don’t you think that patients, confused or not, have been tolieting independently for most of their life – it’s just something that people do – second nature.
      Are you a nurse that makes patient incontinent – tell them just to wee in their pad?
      There is a big difference between safety and protecting someone’s independence and dignity (which in an RCF is the ONLY thing they have left). I am horrified at the number of nurses that think bed rails are not restraint – think again please!
      I am a clinical practice consultant in a large public hospital, one of my roles is a Fall prevention leader. It is my opinion the bed rails are indeed a form of restraint and all who think otherwise should be placed in a bed with bed rails, given a 1000ml bag of fluid over 6 hours, told not to get out of bed and when you ring the bell don’t expect an answer until 15 minutes has passed – my question is how many of you would be wet and how many would have climbed out to go to the toilet?
      Patients need encouragement and assistance with toileting 2-3 hourly, bed at the right height for the patient, mobility aid in reach, encourage walking during the daytime to promote good mobility and a bed/chair alarm (if confused) would be the correct management. Falls management is about injury reduction as well as trying to prevent falls.

      • We need better nurse:patient ratios if you want restraint use reduced. Management need to provide AINs for specialling, not “specialling within numbers”. It’s easy as a pen pusher to criticise nurses but you have to see restraint use in context of the volume of the workload nurses have. Sometimes toileting every 2hrs is not feasible when you consider vital obs, showering, beds, med rounds, running to pharmacy, running to biomed, large dressings, hanging TPN, finding free nurses to get S8s, escorting patients to CT, drawing up infusions, putting up a PCA, changing stoma bags, updating family, reading and writing the pts notes, BSLs, UWSD obs, care plan, falls risk assessment, CVAD assessment, VTE assessment, waterlow score, neurovascular obs, wound chart, AWS chart … and if a PACE 2 goes off, forget all of the above.

  5. Bed rails are NOT a rstraint IF there is a nurse in the room with the patient. This is because the bed rails a) protect the patient from a fall, and b) alert the nurse (should his/her back be turned, while attending other patients). Anyone who considers bed rails to be a restraint should be ordered to get off their butts and be there, to attend the patient, 24/7.
    In intensive care, I tell any patient who is not fully awake, alert, oriented and relaxed (in which case, what are they doing there???!!)that while I am there, they will have their arms free, but if I am not at the bedside, and there are no (sensible!) relatives at the bedside while I am outside, then I will put a soft wrist protector around their wrist, to ‘remind’ them should they move, that they need to keep their hands away from their face and the tubes etc. I ask them if they agree…(they always agree, because I have a friendly manner and smile!)and I document the conversation, and then the wrists were protected ‘for the patient’s safety’, indicating the last time they started tugging on their ETT, CVC etc. We have doctors sign a medical authority and we massage their wrists (take ‘protector’ off first) hourly.
    Losing a CVC that has inotropes, high dose antibiotics, TPN, and ESPECIALLY PROPOFOL (the one drug obviously created for nurses to administer by GOD himself!) is an indictment that the nurse is an idiot, for listening to other idiots.
    Many a patient died in relation to pulling out an ETT, CVC, chest tube, arterial line, EVD, stent, etc.
    Only intensive care nurses know how to care for intensive care patients. ICU nurses cheat Death daily and Death isn’t happy, but suck eggs!

    • Bernhard – stick your ICCU thoughts where they belong in the bin and take a long hard look at yourself – ever heard of human rights? Maybe you should consider a future in prison nursing? It would be bright!

  6. You make me laugh, Bernhard.

    Your patient’s agree with whatever you say…. not because of ” I have a friendly manner and smile “…… but because you have a cockroach hanging out of your mouth !! They will do anything you say !!! lol

  7. Here are two aged care facilities. Each one has a different ‘take’ on restraint. Both are real.

    One is restraint free (at this time). It hasn’t been easy getting there but we now have less challenging behaviours, families and residents take more responsibility (yes, I know about people with dementia – I’m getting there!. Nurses and carers have objected and fought, despite the daming evidence against restraint: skin tears, bruises, falls over rails and at the end of beds, broken bones. Yes, residents fall, despite low-low beds, alarms, sensor mats and all the other (breakable) wonders of technology. BUT the majority of residents don’t. Life as we know it has not ended. The nurses and carers have been educated to think calmy and laterally about helping residents instead of remaining fixed in a custodial way of ‘looking after’ people. even (said I was getting there!) people with dementia have become calmer and less afraid because, at least partly, because of major changes in staff attitudes.There is collaberation between relatives and the facility, regular discussions about care and the right of risk. if residents genuinely (not put on them by staff) request bed rails, of course they can have them and this is documented as their CHOICE. Some have chosen to have one rail up but most sleep happily, and don’t fall ou of bed.

    The second aged care facility has just begun the journey from ‘let’s restrain everyone (whether they NEED it or not), bed rails up on everyone, do as we tell you and nanny/nurse always knows best. In that facility, staff are just learning to speak, rather than shout. Choices for the residents (real people by the way)have been somewhat limited to: do as nurse says. Are the residents happy? Would you be? My observations see deep distress and old fashioned attitudes, demeaning to aged (so called) care in this era.

    At the first facility, nothing is perfect, but there is genuine choice. In the second, stagnation and a bullyin attitude based on fear. Am I angry about it: Oh yes.

    ITU may be different (haven’t worked there in years) so no comment. But in aged care, we need to think about the reality of peoples’ situation, right of risk and dignity. These are not prisons. Older people have a right to a life.

  8. Well, what do I say to that….?
    Thanks Maryel for your perspective.

    ( it’s a little hard to know who people really are on this (or most) forums. So, I don’t really know if you are an expert in Aged Care, or a new grad. with a real zest for Nursing fresh out of Uni. )

    I’ve heard many people relate what they think should be an ‘easy’ choice to make…. bedrails up or down. But it’s just not as simple as that WITH SOME RESIDENTS.

    No two residents with Dementia are going to act the same. In a ward of say twenty, you will have up to twenty DIFFERENT behaviours to contend with.

    Let me give an example of one individual I deal with…. ( real situation – not his real name )

    ‘John’ produces an echolalia of “help, help, help, help, help ” etc. every night ( yes, after the Sun goes down ) Thus, he was labelled with ‘Sundowners’. He can not stop calling out for help, even when staff are in the room, and talking with him. When address John, and ask why are you calling out for help… we are already here, and you don’t need any help ! John then goes off on tangents, and can not hold a conversation on a single issue.

    He constantly wants to get out of bed at night. He was trialled without bedrails, and refused to go back to bed. He lives on about 1-2 hours sleep a day !!

    During the day, when he is up and walking, he wanders into other resident’s rooms. Ladies have screamed, and visitors have complained.

    John has injured himself by falling, and he has been assaulted by other residents ( as a direct result of his intrusiveness ).

    Medication has had no effect ( the small 0.5mg dose of Risperidol the GP ordered as a regular nocte and PRN, have been useless )

    His NOK is a demanding person, who verbally abuses staff over the phone, so there is no real collaboration there. ( visits are rare )

    So, what would YOU do with John ??

    • The issue of restraint is a horrible, grey one that I spend a lot of time wrestling with as a CNC Dementia/Delirium. Restraint falls under the common law of false imprisonment, which has a number of defenses. One defense is the willing acceptance of risk, which really does not apply in healthcare, but is often used in dangerous sports. The other defense is that the patient or their person responsible consented to the use of restraint. You cannot falsely imprison someone who consents to the application of restraints. Consent from a person responsible should be taken as though the patient themselves had consented. One caveat to this is when it can be argued that a critical need situation occurs. In this situation, a person can be restrained without consent to prevent harm to themselves or to others for a short period. This allows nurses to protect the patient and others until they are able to get consent from the person responsible.

      I would recommend that the GP be approached to make a referral to the DBMAS or BASIS Team for assessment and intervention to manage the challenging behaviour. It may also be useful to try some panadol as they may have unrelieved pain or discomfort. A geriatric review may also be useful if you have access.

      Hope this helps.

      Mark

  9. Thanks Mark.

    We’ve actually gone through all of what you mentioned (even the Panadol), though he says he’s not in pain ( during a brief moment of sanity! )

    He had a delerium work up and numorous consults.

    Do you have a ‘too hard basket’? Because our John is in it!

    Something odd has just been noticed. He has no reaction to a single 10 mg. Temazepam, but after 20 mg. John slept all night & all the next day!

    The NOK demanded he have no more Temazepam, so we’re now back where we started from….

    • J sounds interesting I hope his name is not John. Mark has given a good plan. Restraint can be permissible where the person is a risk to themselves or other (although not necessarily in an ACF) which I presume J is in. It may be J is in the wrong environment bit difficult to say from here.
      If the DBMAS & a geriatrician have seen him the next line would be SMHOP and psycho-geriatrician. It should not be first line to use a sedative for treatment of BPSD. Restraint increases BPSD and falls risk sorry the literature is very overwhelming. Non-pharmacological management is the best approach

  10. I work in a large country hospital in NSW. The use of restraints chemical or physical in our ward, depends on the doctor and family. I have no problem using manacles on any pt that it is seemed necessary, I always start the shift by removing the physical restraints, explain to the pt why the restraints are being used. I always try to make a “deal” with them as long as they (don’t climb out of bed/ pull out the IVF-NG-PEG-SPC-IDC-ICCD/ attempt to punch or kick anyone) then the restraints will remain off, this works 50% of the time in my case. On night shifts, at the start I remove them off all agitated pts and guess what – around 6-7 out of 10 pt will go straight to sleep with in 15 minutes. Physical restraints should be and is the last option.

    Bed rails are not even considered as a restraint where I work.

    Chemical restraints are great if they are allowed and WORK. Haraperidol in my opinion, a complete waste of time, doctors continually chart Haraperidol, and more then often, as no effect on the pt.

    Many times doctors, not just the interns but actual physicians have decided that the pt requires a special. We then tell the Nursing Supervisor, their main response is “I’ll try to get one for the next shift” or “I don’t have anyone spare and do they really need one”. When the nursing supervisor, and if they do their round, where they be on the ward for less then 5 minutes per shift, if the pt is sleeping or not going off, then they decide they don’t need a special anymore, so staff have to explain how the pt has been though out the last shift. And when they stop providing a nurse to special a pt, they try to make the in-charge take the responsibility, but lately, I have told them that I am not accepting that the pt does not need a special and that they will remain responsible, and they go off big time.

    Restraints have their place in the current working conditions,I personally refer nursing specials.

  11. Just as an update, the ” John ” I referred to earlier, passed away about a month ago now.

    His deteriorating behaviours were linked to his poor physical prognosis.

    At least he died in in bed, sound asleep one night. As one as elderly as he should.

    • Then John was in a delirium Gordo which explains the difficulty in his behaviours.Haloperidol is the best treatment for a Delirium (acute confusional state). Please refer to the Clinical Practice Guidelines for the Management of Delirium http://www.health.vic.gov.au/acute-agedcare/delirium-cpg.pdf Oh and bed rails are a form of restraint, Restraint is not warranted most of the time and the evidence of the damage this causes an old person is overwhelming. It even has a name functional decline. Increases falls. Apparently specials should keep people active and moving there is evidence for this

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