"Farewell, bed rails!" is the message these days at St. Marguerite d'Youville
Pavilion, a long-term care center in Lewiston, ME. The rails, long used by health
care facilities as an aid to keep patients from falling out of bed, have themselves
come in recent years to be seen as a threat to patients' health.
According to the U.S. Food and Drug Administration (FDA), 358 people have been
asphyxiated in the past 19 years because of what the agency calls entrapment:
"being caught, trapped, or entangled" between bed frames and mattresses or bedding.
Another 111 were injured as a result of entrapment. Most victims have been frail
older people.1
Although the FDA's August 2004 guidance did not ban bed rails in hospitals
and long-term care centers, it did recommend that they be used only in special
cases and with great care. That was not news to the leaders and staff at St.
Marguerite d'Youville Pavilion, which had instituted such a policy the
year before.
"There is no law saying we cannot use rails, but in talking with colleagues
in other long-term care facilities, it is clear we have all had near misses,"
says Deb Fournier, the facility's administrator. "Near misses"
are cases in which a patient or resident has been successfully rescued from
entrapment.
St. Marguerite d'Youville Pavilion is a 280-bed facility, a member of
Covenant Health Systems, Lexington, MA. When the side rail initiative began
in 2003, the facility's care teams had to disabuse caregivers and family
members of an old belief — that side rails on beds automatically make the
person in the bed safer. It was a difficult sell until team members pointed
out that side rails function as a kind of restraint. Most health care facilities
gave up the use of restraints in the 1990s. "People could see that inappropriate
use of side rails is a form of restraint, and they know restraints are prohibited
in Maine," Fournier says. Even so, staff and family members continue to
worry that the elimination of side rails might lead to more resident falls,
she adds.
Kathleen Murphy, director of nursing services, said that St. Marguerite d'Youville
Pavilion introduced the change slowly. "We do not just remove the side
rails," she says. "We may use half rails for a while, or a full rail
on one side. As time goes by without a fall, we grow more confident and so do
the families."
While educating staff, residents, and family members, the facility's leaders
also inaugurated a comprehensive tracking system for falls related to side rail
use and worked to reduce both the number of resident falls rate and, more important,
the severity of injuries resulting from falls.
Initially, the facility's leaders worked with a vendor to identify which
beds could be retrofitted and which should be replaced. In the past two years,
they have bought 20 new beds and have budgeted to replace one unit (40 to 42
beds) each year. For residents at a higher risk for falls, the new beds can
be adjusted from standard height to seven inches off the floor, so that if falls
do occur, they won't cause serious injury. Safety alarms, special mattresses
and pillows, and thick rubber bedside mats have also been installed. Murphy
credits the nurses and nursing assistants for coming up with their own suggestions
for ensuring resident safety. For example, they place squeak toys between the
sheets and mattress pads to remind residents when they are getting too close
to the edge of the bed. When side rails must be used, staff set foam "swim
noodles" between the mattress and side rail to reduce the risk that a resident
will be trapped against the rail.
Since June 2004, staff have monitored the number of falls and injuries involving
the side rails, reporting that data monthly. The report also contains information
on residents' medication use, behaviors, and other quality indicators,
such as infection rate. These reports are used at weekly team meetings so that
caregivers can better analyze which practices help reduce side rail incidents.
The number of falls and injuries dipped in July, but Murphy cautioned against
drawing conclusions. "It is too soon to correlate practices with interventions,"
Murphy says.
Fournier and Murphy agree that their quality-improvement initiative is not
unique in long-term care, but, they believe, the passion the staff has put into
their effort may set it apart. "Our work in this area has nothing to do
with regulatory requirements," Fournier notes. "When trends change,
we listen and take action. One of our core values is compassion. It is our standard
and heart value. We are striving for excellence so that we can enhance the dignity
and well-being of residents in this community."
For more information on St. Marguerite d'Youville Pavilion's side-rail
initiative, contact Rose Levasseur,
staff educator and patient safety officer, at 207-777-4200.
NOTE
- U.S. Food and Drug Administration, Guidance
for Industry and FDA Staff: Hospital Bed System Dimensional Guidance to Reduce
Entrapment, Washington, DC, August 30, 2004.