Bed Rail Provision Guidance for Assessment and Provision. Clinical & Prescriber Support Special Interest Group

Transcription

1 Bed Rail Provision Guidance for Assessment and Provision Clinical & Prescriber Support Special Interest Group Issue 1: June 2011

2 Index: Page: The NAEP Clinical & Prescriber Support Special Interest Group 3 Purpose of the Guidelines Using the Guidelines Introduction Terminology 4 The Guidelines Pathway 5 Section 1 Current Situation and Risk Assessment 6 Section 2 Alternative Solutions 7 Section 3 Identification of Appropriate Equipment A) Bed Rails B) Bumpers 8 9 Section 4 Action Plan and Provision 10 Section 5 Fitting 11 Section 6 Monitor and Review 12 Appendix 1 DO NOT S 13 Appendix 2 Assessment Checklist Tool Appendix 3 Appendix 4 Outcome of Assessment/Action Plan Review Checklist Appendix 5 Reference Links / Reading List / 20 Page 2

3 The Clinical and Prescribers Support Special Interest Group The group membership includes qualified Occupational Therapists, Nurses and Physiotherapists from across the UK with specialist knowledge of community equipment and experience of working closely with Community Equipment Services. Using professional expertise and research, the group supports clinicians and prescribers and through them providers of Community Equipment Services to facilitate best practice in equipment provision to the end user. The group develops clinical guidance that provides assessment tools to assist with the selection process for the most suitable equipment to meet the needs of the end user. Health and safety, design, training, maintenance and clinical need are considered. Purpose of the Guidance To provide: Clinical guidance on the assessment process for bed rails and accessories to meet individual needs. Consistency in approach to assessment and provision as a basis of good practice. A reliable and relevant point of reference. Using the Guidelines The guidance can be utilised as a benchmark to compare and develop local guidance, taking into account existing policies and procedures Sections one to six provide points to be considered and are to be used in conjunction with the bed rail assessment checklist in appendix 1 Introduction There have been a number of incidents and fatalities involving bed rails that have led to injury or death and consequently a number of British and European standards and recommendations produced. The latest standard represents current thinking in Basic Safety and Essential Performance of the Medical Bed and is the combined effort of working groups from the International Electrotechnical Commission (IEC) and ISO. This British European Standard - BS.EN.IEC :2010 is identical to the IEC :2009 and supersedes BE EN 1970:200 and BS EN :1997 both of which will be withdrawn in April Manufacturers of medical beds and bed rails are working towards meeting these standards for April As a result of the new standards the NAEP guidelines for bed rails will reflect relevant changes to the specific measurements of the space at the head foot ends of the bed from 250mm to 318mm. Page 3

4 Bed rails are used in a variety of settings to reduce the risk of falls from a bed; however they are not intended to limit freedom of movement, meant to be used to restrain or to be used as grab rails. All prescribers of equipment should be made aware of the hazards associated with the use of bed rails and how to use them safely. But it should be noted that the MHRA (Dec; 2006) advises most bed rails are designed only to be used with adults and adolescents, not for children under 12 or small adolescents and adults. Using bed rails with children Risk assessments should always be carried out on the suitability of the bed rail for a child or small adult and reference should be made to manufacturers guidance. There ARE NO published standards on bed rails for children but there are other standards addressing the entrapment risk (BS EN 12182) which suggests that the maximum space to avoid entrapment of children s heads in static equipment is 60mm.Consideration should also be given to the suitability of the bed. Many of the alternatives to bed rails can be used with children. BS.EN.IEC :2010 (page 52), recognises that the definitions of terms adult and child are based on physical characteristics. The dimensional requirements of this particular standard are based on anthropometric data based on PATIENTS ranging in physical size from a 146 cm tall female to a 185 cm tall male. For BEDS intended for use with PATIENTS outside this range, all dimensional characteristics in this particular standard should be adjusted accordingly. Terminology For the purpose of this document the term bed rail will be adopted, although other names are often used, such as bed side rails, side rails, cotsides, and safety sides. (MHRA - Device Bulletin - Safe Use of Bed Rails. December 2006: Page 5 section 2.3) Bed rails should not be confused with bed grab handles, bed sticks or bed levers which are designed to assist a person to get in and out of bed and move in bed. They are not designed to prevent a person falling from their bed and should not be used as bed rails. (MHRA - Device Bulletin, Safe Use of Bed Rails, December 2006: page 6 section 2.4. Bed rails can be classified into two basic types: As an optional accessory supplied by the bed manufacturer Or supplied separately for use on domestic divans or metal framed beds Page 4

5 Pathway - To Assist in the Assessment for the Provision of Community Bed Rails or Alternative Solutions Current Situation & Risk Assessment Section 1 Outcome of Assessment Alternative Solutions Section 2 ACTION PLAN and PROVISION Identification of Bed Rails Section 3 Fitting Section 5 Monitor and Review Section 6 Page 5

6 Section 1 Current Situation and Risk Assessment Consider:- Person: Medical condition and future implications Medication i.e. changes in physical or medical state Ability to transfer Consider how the person moves in bed Falls - reasons for Care needs Continence issues e.g. toileting in the night Behaviour and cognitive state e.g. anxiety / fear of falls / confusion / agitation or lack of insight Height and weight Capacity to give consent. See references for England Scotland Wales and Northern Ireland Repetitive / involuntary movements Additional considerations e.g. personal choice Formal and informal Carers: Age and ability to provide care and use equipment Physical ability Cognitive ability Moving and Handling Additional considerations e.g. personal choice Current situation: The person s wishes Past and existing equipment e.g. type of bed, depth and type mattress, bed lever grab rails by the bed Care provision Present location e.g.; hospital / home / care home Other medical devices to consider e.g., peg feed, medical equipment, ventilator or oxygen tubing. Financial Implications to person and organisations: Injury to person / formal / informal carer Alterations to care package Avoidance of admission to hospital or care home / delayed discharge Page 6

7 Section 2 The Alternative Solutions to Provision of Bed Rails Examples: Inflatable systems Side wedges Extra low Variable height Extra low Variable height bed with crash mat Internal foam surrounds Sensory/motion/pressure alarms NB all the above require risk assessments Consider: Re-enablement / Rehabilitation Suitability of existing bed for fitting accessories Condition and type of mattress e.g extra dense foam Falls related to transfers Person s wishes Compatibility of combinations of equipment. e.g. mattress systems / mattress elevator / pillow lifter / mobile hoist / standing hoist Informal carers and family members understanding use and limitations of alternative solution Page 7

8 Section 3 Selection of Appropriate Equipment Please also see appendix 1: DO NOT A) Bed rail Take into account: Combination of person, mattress, bed and proposed bed rail Check bed rail meets current regulations for dimensions Local specifications of equipment see example below Local agreements Example Template for local use Manufacturers Basic features Additional Features SWL (safe working load) Other Supplier / s e.g. Length Height Gaps between bars extendable Stone / kg Compatibility Page 8

9 B) Bed Rail Bumpers Bumpers are primarily used for preventing impact injuries, but in some instances they can reduce the potential for entrapment. There is a risk of suffocation that needs to be considered. Risk Assessment must always be completed prior to prescription. Consider: Person: Risk of suffocation Diagnosis Medication Persons behaviour and cognitive state Movement within the bed Repetitive and voluntary movements Choice Consent Formal and Informal carers: Quick access for care needs if required Ability of carers to remove and refit bumper Choice Provision: Compatibility with other equipment Gap between bumper and mattress Will the bed still profile? Type and design e.g. Wipe down Foam Inflatable Mesh Easy to clean How are they secured and do they fit the bed rail Page 9

10 Section 4 Action Plan and Provision Following assessment and identification of need: Consider the implication and impact of provision on: The Person: Ability to transfer and moving in bed Entrapment issues Suffocation Injury Anxiety and agitation Consent Moving and handling Social interaction Formal and Informal Carers: Consent Ability to comprehend changes Individual needs of carer Moving and handling Training requirements Other family members Provision: Compatibility Standard stock or special order Funding and authorisation Rented equipment Local ordering procedures Maintenance and servicing Safe access for delivery of equipment by the drivers Information sharing with other agencies Local Terms and Conditions of loan of equipment Implication of reviews Page 10

11 Section 5 Fitting of bed rails Who is responsible? - Refer to local agreements / guidelines. Employer s duty of care Need to ensure that employees who are responsible for selecting, fitting and checking bed rails have received appropriate and ongoing training Employees duty of care Comply with organisations policies and procedure (Refer to Management of Health and Safety at Work Act 1999) Consider: Has the correct bed rail been selected for the bed in use Has the person fitting the bed rail had training Can the bed rail be fitted with the user in the bed Fittings are secure and meet the supplier s instructions and standards Mounting clamps, if present, are in the correct orientation Entrapment Issues Distance between the bars on the bed rails must not exceed 120 mm Distance between the end of the bed rail and the headboard must be either less than 60mm or greater than 250mm (From April 2013 equal or less than 60mm only) Distance between the end of the bed rail and the footboard must be either less than 60mm or greater the 250mm (From April 2013 less than 60mm or greater than 318mm) The top of the bed rails must be more than 220mm above the top of the uncompressed mattress in at least 50% of the length of the mattress platform, and with the bed base in a flat position Any gap between the side of the mattress and the bed rail Do the dimensions and gaps comply with current regulations Are there instructions that can be issued with the bed rails Consider gap between top of compressed mattress and bottom rail Page 11 NB: MHRA statement regarding children under 12 years and small adults please refer to introduction on page 3 and 4.

12 Section 6 Monitor and Review Follow up visits and continuing review of provision and risk assessment. Consider: Person Carers Compatibility Installation of the equipment Training requirements of staff / person / carers / relatives Change of prescription where assessed as required How frequently to review in line with local guidance for:- Position and fit of the rail clinical need / change in condition Documentation Liaising with other relevant services Page 12

13 APPENDIX 1 DO NOT Use bed rails designed for a divan bed on a wooden / slatted or metal bed frame; this can create gaps that may trap the occupant Use an air or lightweight foam mattress with divan bed rails on the divan bed as the whole bedrail assembly, including the mattress and occupant, can tip off the bed when the occupant rolls against the side Use only one side of a pair of divan bed rails; the single rail will be insecure and move Adapt or use inappropriate fittings Use mattress combinations / deep mattresses whose additional height lessens effective use of the bed rail that may permit the occupant to roll over the top. i.e. diagram of dimensions section 5 Use mattress and bed rail combinations where the mattress edge can compress introducing a gap between the mattress and bed rail therefore increased risk of entrapment Use bed levers or mattress elevators with divan bed rails as the incompatibility will compromises the safety of the equipment Use bed rails with parts missing Page 13

14 APPENDIX 2 Bed Rail Provision Assessment Checklist Tool Persons Name: DOB: NHS/CHI No: GP Name: Surgery: Assessor: Contact Details: Date: Risk Assessment Person: Y/N Comments: Is there a history of falls from a bed Does the persons medical condition put them at risk of falling out of bed Would the provision of bed rails increase the risk of injury to the person Does the person s current medication put them at risk of falling out of bed Does the person need to transfer independently Is the person able to move in bed Is there the potential for the person to climb over the bed rail or roll over the top Are there cognitive or behavioural issues that would increase the risk of entrapment Is the person at risk of suffocation Is there involuntary movement that would increase the risk of injury or entrapment Would provision have a detrimental effect on cognitive emotional state Page 14

15 Person: Y/N Comments: Is the person agitated or confused Does person have capacity to consent to provision Is the person aware of their own safety needs in bed Formal / Informal Carer: Y/N Comments: Would the provision of bed rails increase the risk of injury to the formal/informal carer. Would fitting of bed rails restrict personal / nursing / medical care requirements Do carers understand the requirements for provision and the risks involved Will carers agree to use the bed rails Is the carer able to operate the bed rail mechanism Will there be a requirement for training Current Situation What equipment has been tried Comments Why did it not work What is being used now Other household members Type of bed Type of mattress Page 15

16 Financial Implications: Y/N Comments: Increased care package Risk of admission to alternative care environment Risk of admission to acute sector Discharge package Special purchase required Alternative Solutions: Considered / Tried Y/N Comments: Use of extra low variable height bed to bring it closer to floor Crash mat to cushion fall NB - requires own risk assessment Alarm system to indicate if person attempts to move out of bed Use of wedges or bolsters Internal padding Other Bed Rail requirements Y/N Comments Standard Stock/Special Order Divan bed rails Integral bed rails Bracket / clamp on bed rails Extra height bed rails Mesh bed rails Page 16

17 Bumpers Y/N Comments Standard Stock/Special Order Are they necessary Would they present a risk of suffocation to the person Risk of entrapment / impact injuries reduced Type of bumper required Page 17

18 APPENDIX 3 Outcome of Assessment / Action Plan Name NHS/CHI: Date of Birth: Address: Telephone number: Postcode: Equipment to be provided: Special order: Y/N Authorised by Who will fit equipment? Date: Who will demonstrate equipment? Review date By: Additional information: Assessment completed by: Date: Page 18

19 APPENDIX 4 Review Check List Persons Name: DOB: NHS/CHI No; GP Name: Surgery: Assessor: Contact details: Date: REVIEW YES/NO COMMENTS Are bed and bed rail compatible Compatibility with other equipment. e.g. grab rails, bed tables Are spaces between the bars greater than 120mm Are the gaps between head and foot less than 60mm or greater than 250mm (from April 2013 greater than 318mm) Is the height from the top of the mattress to the top of the mattress greater than 220mm Are there any other gaps that may cause an entrapment risk e.g. between compressed mattress and bed rail Do the carers know how to inspect and check the bed rails and who to contact if problems occur Have the bed rails been fitted correctly Have the manufacturer s instructions been supplied with the bed rails and bumpers if supplied Have bumpers been fitted correctly If there any changes to the equipment, mattress or users condition carry out a full assessment again Page 19

20 APPENDIX 5 Reference links: British European Standard - BS.EN.IEC :2010: Medicines and Healthcare products Regulatory Agency (2007): MDA 2007/009 Bed Rails and Grab Handles. London: MHRA. Medicines and Healthcare products Regulatory Agency (2006): DB 2006(06) Safe Use of Bed Rails. London: Page 5 section 2.3 and page 6 section 2.4. Health and Safety at Work Regulations (1999): Mental Capacity Acts: yact/?lang=en Further Reading: Capezuti, E. et al (2007) Consequences of an intervention to reduce restrictive side rail use in nursing homes. Journal of the American Geriatric Society; 55: Healey, F., Oliver, D. (2009) Bedrails, falls and injury: evidence or opinion? A review of their use and effects. Nursing Times; 105: 26, early online publication. Healey, F. et al (2008) The effect of bedrails on falls and injury: a systematic review of clinical studies. Age and Ageing; 37: 4, Hignett, S., Griffiths, P. (2005) Do splitside rails present an increased risk to patient safety? Quality and Safety in Health Care; 14; National Patient Safety Agency (2007) Safer Practice Notice. Using Bedrails Safely and Effectively. London: NPSA. RCN (2007) Let s Talk About Restraint. Rights, Risk and Responsibility. London: RCN. The NAEP Clinical & Prescriber Special Interest Group trust that you will benefit from this document. If would be appreciated if you could take the time to provide feedback and information on how you have utilised this document by contacting Frances Kent Special Interest Group Chair by at: frances.kent@buckspct.nhs.uk Page 20