USING BED RAILS SAFELY AND EFFECTIVELY

SECTION: 1 PATIENT CARE POLICY & PROCEDURE: 1.26 NATURE AND SCOPE: SUBJECT: POLICY AND PROCEDURE TRUSTWIDE USING BED RAILS SAFELY AND EFFECTIVELY This policy has been produced in accordance with resources and guidance provided by the National Patient Safety Agency, the Medicines and Healthcare products Regulatory Agency and in compliance with relevant Health and Safety Regulations and local policies and procedures DATE OF LATEST RATIFICATION: 22 JUNE 2016 RATIFIED BY: TRUST HEALTH AND SAFETY COMMITTEE IMPLEMENTATION DATE: JULY 2016 REVIEW DATE: JUNE 2019 ASSOCIATED TRUST POLICIES AND PROCEDURES: Health, Safety & Welfare 16.01 Medical Devices Policy and Procedure 15.14 Reporting of Accidents, Untoward Incidents and Near Miss Situations 15.01 Advance Statements (Statements of Wishes and Feelings) Policy and Procedure 8.11A Falls: The Assessment, Prevention and Management of Patient Falls (Adult Services) Policy and Procedure 1.34 Advance Care Planning: Advance Statements Including Advance Decisions to Refuse Treatment (ADRT) and Lasting Powers of Attorney (LPA) Policy 1.30 ISSUE 3 JULY 2016

UNOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST UUSING BED RAILS SAFELY AND EFFECTIVELY CONTENTS 1.0 Introduction 2.0 Policy / Procedure Principles 3.0 Definitions 4.0 Duties 5.0 Implementation 6.0 Risk Assessment 7.0 Bed Rail Safety - The Equipment 8.0 Bed Rail Safety - The Patient 9.0 Safe Use of Equipment And Maintenance 10.0 Bed Rail Safety And Fire Evacuation 11.0 Bed Rails and Restraint 12.0 Using Bed Rails with Children 13.0 Toilet Visits 14.0 In-Bed Sheet Systems and Low Friction Devices 15.0 Turning Sheets / Slings 16.0 Adjustable or Profiling Beds 17.0 Mattresses 18.0 Inflatable Bed Sides 19.0 Bed Rail Bumpers 20.0 Community Settings 21.0 Never Events 22.0 Training Information Instruction and Guidance 23.0 Training and Nice Guidance 24.0 Supply, Purchase, Storage and Maintenance 25.0 Reporting 26.0 Target Audience 27.0 Review Date 28.0 Consultation 29.0 Relevant Trust Policies/Procedures 30.0 Monitoring Compliance 31.0 Equality Impact Assessment 32.0 Legislation and Compliance 33.0 Champion and Expert Writer 34.0 References / Source Documents ISSUE 3 JULY 2016 2

Appendix 1 Bed Rail Use and Selection Assessment Tool Appendix 2 Dimensions of Bed Safety Rails Appendix 3 Bed Rail Check List Appendix 4 Information on Bed Rail Dimensions Appendix 5 Record of Changes Appendix 6 - Employee Record of Having Read the Policy ISSUE 3 JULY 2016 3

1.0 INTRODUCTION Using Bed Rails Safely and Effectively 1.26 UNOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST USING BED RAILS SAFELY AND EFFECTIVELY POLICY 1.1 Since the mid 1970 s in the United Kingdom, there has been a culture that recommends bed rails should not be used routinely and that their use should be continually reviewed (Hignett and Griffiths 2005). 1.2 The revised Standard BS EN 60601-2-52: 2010 specifies requirements and dimensions for bed rails for use by adults. 1.3 Bed rails are used extensively in care environments to prevent bed occupants from falling out of bed and injuring themselves. 1.4 Serious and even fatal incidents can occur with bed rail use. The majority of these have involved third party bed rails and occurred in community care environments including residential and nursing homes (MHRA 2013). 1.5 Injuries that can result from bed rail use can arise from head, neck or chest entrapment which can lead to death from asphyxiation. Injuries can also arise from a person attempting to climb over the rails and falling or from striking their head against the rails (HSE 2012). 1.6 This Policy has relevance for anyone who has responsibility for the provision, prescription, use, maintenance and fitting of bed rails. This includes managers, therapists, nurses, procurement, maintenance and health and safety personnel. 1.7 The purpose of this Policy is to provide a framework around which safe practices in the use of bed rails can be determined. 1.8 The aim is to reduce harm to patients caused by falling from beds or becoming trapped in bed rails; to support patients and staff in making individual decisions on bed rail use and to ensure compliance with the Medicines and Healthcare products Regulatory Agency (MHRA) and other authoritative guidance. 2.0 POLICY / PROCEDURE PRINCIPLES 2.1 The Trust recognises its duties to ensure, so far as is reasonably practicable, that people responsible for making decisions on the use and provision of bed rails are aware of their responsibilities under the relevant health and safety legislation and guidance. 2.2 The Trust aims to take all reasonable steps to ensure the safety and independence of its patients and respects the rights of patients to make their own decisions about their care. Patients might include the particularly vulnerable such as older people, children, people with disabilities (e.g. intellectual, physical, mental health etc.) and pregnant women. 2.3 Where a patient lacks capacity to make autonomous decisions, staff will have a duty of care and must decide if bed rail use is in the patient s best interests. In such circumstances Deprivation of Liberty Screening and a Best Interests Checklist will need completing. The Trust has developed a Mental Capacity Act 2005 Assessment of Capacity document with guidance notes and a Mental Capacity Act 2005: Best Interests Checklist which can be found on the Trust Intranet (click M for Mental Capacity Act on the A-Z of Sites and Services). 2.4 Relatives or carers cannot make decisions for adult patients except in certain circumstances where they hold a Lasting Power of Attorney extending to healthcare decisions under the Mental Capacity Act 2005. ISSUE 3 JULY 2016 4

3.0 DEFINITIONS 3.1 Bed rails have been described as having several functions: a) A reminder to the patient of the perimeters of the bed b) Additional security when the patient is being transported in the bed c) As a hand-hold when patients need to adjust their body position or get out of bed d) Serving in a way that gives the patient a feeling of comfort and security (Hignett and Griffiths 2005) 3.2 Bed rails are often known by other names such as bed side rails, side rails, cot sides and safety sides. For the purposes of this policy and in keeping with guidance from the Medicines and Healthcare products Regulatory Agency, the term bed rail will be adopted. 3.3 Bed rails are classified in two basic ways: Integral = types that are incorporated into the bed design and supplied with it or are offered as an optional accessory by the bed manufacturer, to be fitted later; an example would be an adjustable or profiling bed. Third Party = types that are not specific to any particular bed model. They may be intended to fit a wide range of domestic divan or metal framed beds from different suppliers these types require careful selection and care should be taken to ensure they are suitable for children or small adults. 3.4 Bed grab handles (also known as bed sticks) are designed to aid mobility in bed whilst transfers to and from the bed take place. Bed grab handles should not be used as, or instead of bed rails. 3.5 UAnthropometry (MHRA 2013) 3.5.1 Anthropometry is the branch of the human sciences that deals with body measurements; body size, shape, strength, mobility and flexibility. Humans are variable in dimensions, proportions and shape. An understanding of this variability is required for user-centred design (Pheasant and Haslegrave 2006). 3.5.2 The horizontal and vertical gap dimensions on bed rails are determined by anthropometric data. The aim is to minimise the risk of entrapment (Smith 2011). 4.0 DUTIES 4.1 The Chief Executive will have overall responsibility for compliance with the Health and Safety Regulations cited in this policy. It is however, the duty of all employees to act responsibly to alert their immediate Manager should any health and safety shortfalls be identified. Shortfalls should be incident reported where appropriate. 4.2 Ideally, decisions to either use or not use bed rails will require a multidisciplinary approach and patients should be involved but where they lack capacity, staff will have a duty of care and must therefore ultimately decide if bed rail use is or is not a requirement. Even when there is a multidisciplinary approach, the person proposing to instigate the use of bed rails for someone who lacks capacity is the decision maker for the purposes of the Mental Capacity Act 2005. That person must demonstrate reasonable belief that the patient lacks ISSUE 3 JULY 2016 5

capacity to make a decision about the use of bed rails, and that it would be in the patient s best interests to use bed rails. The statutory best interest s checklist (Section 4 Mental Capacity Act 2005) must be followed and there must be evidence that it has been followed. Inappropriate use of bed rails may amount to restraint. Under the Mental Capacity Act 2005, Section 6, restraint will only be lawful if it is both necessary to prevent harm to the patient and its use is proportionate both to the likelihood and seriousness of harm to the patient. In addition, any act done in connection with care or treatment must amount to the least restrictive intervention. All other reasonable possibilities must have been considered prior to the use of bed rails. Always document a decision and how that decision was arrived at. 4.3 In exceptional or emergency situations, the decisions for bed rail use will take place in consultation with the most senior person available. 4.4 In Forensic Services, owing to the presence of specific safety and security risks, decisions on bed rail use will be assigned to the Responsible Medial Officer and the Clinical Team. The risk of ligature points must be considered. 5.0 IMPLEMENTATION 5.1 This Policy and any subsequent guidance or information on bed rail use will be available via the Trust Intranet site. Other means of communicating the content of this Policy will be through ongoing training and meetings including special interest groups. 6.0 RISK ASSESSMENT 6.1 A bed rail risk assessment determines whether such a device is required in the first instance and whether the choice of device is suitable for the bed, mattress and the individual bed occupant (MHRA 2013). 6.2 Healthcare providers should do a risk assessment whenever bed rails are used (Hignett and Griffiths 2005). 6.3 It is important to eliminate inappropriate use of bed rails, using them only where they have been individually prescribed but with regular review of their use (Oliver et al. 2010). 6.4 The risk assessment should be revised if the bed, mattress, occupant or bed rail changes (HSE 2012). 6.5 The decision to use bed rails for any person regardless of size should always be based on a risk assessment (Smith 2011). 6.6 When bed rails and bed safety equipment are prescribed, issued or used, it is essential that any risks are balanced against the anticipated benefits to the user. The possible combinations of bed rails and mattresses, together with the uniqueness of each bed occupant means that a careful and thorough risk assessment is necessary if serious incidents are to be avoided. 6.7 Risk assessments should be carried out and recorded before bed rail use. The assessment should be reviewed if, for example, there has been a significant change in the bed occupant s condition, if any part of the equipment is replaced or if the mattress is changed. When carrying out a bed rail risk assessment, it will help if you ask the following questions: a. Is the person likely to fall from their bed? b. Are they likely to want to climb over the rails or make uncontrollable movements? ISSUE 3 JULY 2016 6

c. Having considered the above, are bed rails the most appropriate option? d. Will any of the following be used to reduce the risk of the patient falling out of bed: The use of netting or mesh bed sides The use of inflatable bed sides The use of an ultra-low bed The use of position wedges The use of a bed movement alarm system The use of a fall/crash mat 6.8 Always consider whether your chosen option will increase risks in any way. For example, will the use of inflatable bed sides affect a person s breathing should they lie too close to them. Also, will not being able to see through the bed sides make them anxious and will the use of a fall / crash mat create a tripping hazard? 6.9 Those at greater risk from bed rail use include: Older people Children Any person with communication problems or confusion People with dementia People who have repetitive involuntary movements People who have impaired or restricted mobility 6.10 It is recognised that some safety options may not be acceptable to patients and carers / relatives. Patient safety must be balanced against the wishes of patients and carers / relatives. They should be included in discussions to establish an acceptable level of risk and any such discussions must be documented and kept with the patient s records. 6.11 It is crucial that a sensible balance is sought between the risks of harm from falls and the risks of harm from impaired independence (Oliver et al. 2010). 6.12 Discussions to determine bed rail use must therefore include: Patients / carer s / relatives as appropriate The imparting of relevant information on associated risks and benefits Assurance of compatibility between type of bed rail, mattress and bed Evidence to justify any contraindications for bed rail use 6.13 This policy does not contraindicate bed rail use for all patients with dementia. These patients each have different levels of cognitive impairment and different abilities. Some will also have other illnesses and all will need the same individualised assessment of the risks and benefits of bed rails as with any other patient. 6.14 If a patient s condition changes; if they fall out of bed, climb or attempt to climb over the rails, suffer an entrapment or contact injury or any adverse effect, the patient must be reassessed immediately. ISSUE 3 JULY 2016 7

normally Using Bed Rails Safely and Effectively 1.26 6.15 Bed rails should Unot U be used: If the patient is agile enough and confused enough to climb over them If the patient would be independent if the bed rails were not in place If the patient was likely to want to get out of bed to go to the toilet 6.16 Bed rails UshouldU usually be used: If the patient is being transported on their bed In areas where patients are recovering from anaesthetic or sedation and are under constant supervision If in-bed systems, low friction devices or turning sheets / slings are being used 6.17 Where a patient or carer / relative insists on the use or non-use of bed rails in opposition to the multidisciplinary team s opinion, this must be clearly documented in the patient s case notes. Further discussions about alternative care management must take place. 6.18 Where bed rails are indicated a care plan must be formulated for their use. 6.19 The rationale behind the decision making for the use of bed rails must be documented on the risk assessment form. 6.20 On discharge from hospital, all future care providers must be advised of the patient s needs regarding the use / non-use of bed rails. This information must be included in the patient s discharge plan. 6.21 A Bed Rail Use and Selection Assessment Tool has been provided with this Policy in Appendix 1. This must be completed before bed rail use. 6.22 In Appendix 2 are details of important bed rail dimensions. Bed rail dimensions require careful consideration. The Medicines and Healthcare products Regulatory Agency (MHRA) 2010 inform us, for example, that bed rails that are too low due to their design or adjustment will not prevent the bed occupant from rolling out. Assessments therefore should include the height from the top of the bed rails to the top of the sleeping surface including any overlay mattresses and also the sleep pattern movement of the bed occupant. 7.0 BED RAIL SAFETY - THE EQUIPMENT 7.1 Risks associated with bed rail use will be compounded when other safety aspects are ignored. Safety checks should be tailored to the equipment in use. Anyone working in a care situation where bed rails are in use should always be alert to any bed rail hazards and carry out a suitable check (see Appendix 3). 8.0 BED RAIL SAFETY - THE PATIENT 8.1 Patients assessed as requiring bed rails can still be at risk of striking their limbs or getting trapped. Risk of entrapment must be taken into account. The risks associated with using bed rails can outweigh the benefits. For example, a person might try to climb over a bed rail. 8.2 Strategies that can be put in place to reduce risks to patients when bed rails are in use include: ISSUE 3 JULY 2016 8

Frequent patient position checks Meeting care needs (such as toileting) Placing vulnerable patients in easily observable areas Keeping the bed at its lowest position (except for the independently mobile patient) The use of padded bed rails, covers, bumpers, mesh rails, inflatable protectors Ensuring proper fitting, type and maintenance 9.0 SAFE USE OF EQUIPMENT AND MAINTENANCE 9.1 Regulation 4 of the Provision and Use of Work Equipment Regulations 1998 states that equipment should be used to carry out those tasks for which it was intended and in the conditions for which it was intended (HSE 2008). 9.2 It is important that anyone involved with the manufacture, supply, fitting, maintenance and use of bed rails is aware of what constitutes acceptable bed, bed rail and mattress combinations and any subsequent safety issues (HSE 2012). 9.3 Bed rails should not be used to manoeuvre the bed, nor should they be used as a patient positioning aid unless the manufacturer specifically states that they can be used in this way. Bed grab handles (also known as bed sticks) are designed to aid mobility but they should not be used as, or instead of bed rails. 9.4 Only authorised and suitably qualified personnel should carry out repairs or service activities. Check with the manufacturer on the frequency of servicing. 9.5 Bed rails should be included in planned preventative maintenance schemes. They should be maintained in accordance with the manufacturer s recommendations. 9.6 Inappropriate use by staff and patients can cause material fatigue. Poor maintenance and storage can also cause damage to bed rails and their various components. 9.7 Bed rails found to be unsuitable or in poor condition should be withdrawn from use and appropriately disposed of. 10.0 BED RAIL SAFETY AND FIRE EVACUATION 10.1 The Trust Fire Safety Policy 16.03 section 6 informs us that where necessary a Personal Emergency Evacuation Plan (PEEP) must be completed for any person who may require assistance in order to evacuate the building. In such emergency situations the safest option might be to leave a person in bed and evacuate both bed and patient. If this were the case then bed rails would need to be raised and secured in place before the bed was moved. 10.2 Lowered bed rails might impede a lateral transfer from a bed. If such a transfer might be required, then a check should be made as to whether the patient would be able to transfer from bed to wheelchair using for example a lateral transfer board. 11.0 BED RAILS AND RESTRAINT 11.1 Hignett et al. (2013) expressed concern, that in a study they conducted on bed rails use, there were examples of their use to restrict the movement of patients who were described as confused. 11.2 Bed rails should only be provided for the correct reasons and not for restraint. Cases of death by asphyxiation or entrapment have been recorded when rails have been supplied in inappropriate situations (Ruszala and Alexander 2015). ISSUE 3 JULY 2016 9

P percentile P Using Bed Rails Safely and Effectively 1.26 11.3 If the client is confused and attempting to climb out of bed, the bed should be lowered to reduce the risk of injuries from a fall Some beds are designed to be extra-low and can be lowered to a few inches from the floor for sleeping but raised for other purposes. Crash mats can be provided for low beds, but these may constitute a tripping hazard for carers and clients (Ruszala and Alexander 2015). 11.4 Bed rails are not designed or intended to limit the freedom of people by preventing them from intentionally leaving their beds; nor are they intended to restrain people whose condition disposes them to erratic, repetitive or violent movement (MHRA 2013). 12.0 USING BED RAILS WITH CHILDREN 12.1 Most bed rails are designed to be used only with adults over 1.5M (4 11 ) in height. This is the average height of a 12 year old child. 12.2 An example from Anthropometric Estimates for British 12 year olds (Pheasant and th Haslegrave 2006) gives 1490mm for the 50P boy and 1500mm for the 50P percentile girl. This data produces an average of 1495mm or 1.495M. 12.3 For the child or small adult, bar spacing and other gaps will need to be reduced. It is important therefore to seek guidance from manufacturers when purchasing or assessing bed rails for these individuals. The Medicines and Healthcare products Regulatory Agency recommend that all gaps between bed rail bars should be a maximum of 60mm. 13.0 TOILET VISITS 13.1 When a patient is likely to want to get out of bed to go to the toilet, bed rails pose a risk. In such situations an ultra-low bed and a pressure sensor pad will be the better option (Ruszala and Alexander 2015). 14.0 IN-BED SHEET SYSTEMS AND LOW FRICTION DEVICES 14.1 In-bed systems are used for turning and positioning people who have reduced mobility. Base sheets are sometimes used so that the bed occupant can take advantage of its low friction properties to help turn themselves in bed. Some suppliers recommend that bed rails should be used with these systems when patients are left unattended (Ruszala and Alexander 2015). 15.0 TURNING SHEETS / SLINGS 15.1 Some sheets and slings are designed to be used in conjunction with a hoist to turn a dependent patient in bed and are sometimes used with a single carer. When this equipment is used, the bed rail must be raised on the side towards which the patient is being turned (Ruszala and Alexander 2015). 16.0 ADJUSTABLE OR PROFILING BEDS 16.1 Mostly adjustable or profiling beds feature integral bed rails. Some have a single piece rail along each side. In such examples caution is required when the bed profile is adjusted because entrapment hazards can be created which are not present when the bed is horizontal. 16.2 Split bed rails feature a pair at the head end and a pair at the foot end. Caution is also required with these designs because the space between the head and foot sections may vary according to how the bed profile is adjusted. Again, profiles other than in the flat position may cause entrapment hazards. th ISSUE 3 JULY 2016 10

16.3 With adjustable or profiling beds, care should be taken to use the bed rails as instructed by the manufacturer. 17.0 MATTRESSES 17.1 A low pressure setting on dynamic mattresses can lead to an unsatisfactory gap between the mattress and the bottom of the bed rail. Lateral movement of the mattress or bed rail can also create an entrapment space. 17.2 Poorly fitting mattresses or mattresses that are too thin or easily compressible at the edges, can create dangerous gaps (HSE 2012). 17.3 Always assess whether a patient could trap their head in the horizontal space between the mattress and the inside of the bed rail. 17.4 The vertical distance from the top edge of a bed rail to the surface of an uncompressed mattress should be equal to or greater than 220mm. Where a special or overlay mattress is used and the vertical distance does not reach this standard, a risk assessment is required to assure equivalent safety. 17.5 When a mattress overlay is used, the vertical distance between the top of the mattress and the top of the bed rail will be reduced. This creates a risk of the bed occupant rolling over the top, so extra height bed rails may be required. Furthermore, due to the soft easily compressible nature of the overlay or mattress edge, a larger gap can be created between the side of the mattress and the bed rail. 17.6 Third party bed rail assemblies (including the mattress and bed occupant) can tip off the bed when an air mattress or lightweight foam mattress is used. This can happen when the bed occupant rolls against the bed rail and the mattress weight is not enough to hold the assembly in place. 17.7 Mattress dimensions and type should be a match for the bed type. Care should be taken to ensure that the use of a certain mattress does not introduce a risk of entrapment. 18.0 INFLATABLE BED SIDES 18.1 Inflatable or padded bed sides are not generally adjustable. They may need to be used with a mattress of particular dimensions. Inflatable bed sides may change shape if the bed occupant leans on them or if they lose air. 18.2 A risk assessment should take these factors into consideration including whether a person s breathing might be affected if pressed up against an inflatable side section. 18.3 Some inflatable or padded bed sides are designed to house the mattress in its own pocket or compartment. This feature greatly reduces entrapment risks. Such bed sides need to be fully inflated to be effective. They may even deflate over time, so regular checks should be made to ensure this does not happen. 18.4 Some inflatable bed sides have velcro fastenings on the corners or which allow for a side to be folded down for access. Checks should be made therefore to ensure that these are secure and in good condition. 18.5 ALWAYS FOLLOW MANUFACTURER S INSTRUCTIONS. 19.0 BED RAIL BUMPERS 19.1 Bed rail bumpers, padded accessories or enveloping covers are primarily used to prevent impact injuries. They can also reduce the potential for limb entrapment. Caution needs to ISSUE 3 JULY 2016 11

be exercised however, because bumpers that can move or compress may themselves introduce entrapment risks. Such equipment should be properly and securely put in place according to manufacturer s instructions. 20.0 COMMUNITY SETTINGS 20.1 Guidance from Sidhil tells us that when third party bed rails are being fitted to a divan bed and there is no headboard, then the bed should be pushed firmly up against the wall to achieve a less than 60mmm gap between wall and bed rail end. 20.2 Given the level of risks that can exist around the bed, it is vital that any purchaser ensures that the product they buy complies with the relevant Bed Rail Standard and that they have proof of compliance. 20.3 In community care environments, it is common for beds and bed rails to have been acquired from different sources. Sometimes the sources may be unknown and the bed rails therefore might be unsuitable for the bed. 20.4 Domestic divan beds are likely to have third party type bed rails. These will not be specifically tailored for a specific bed or mattress size and density. In such cases, it is essential that the selection process for bed rail use is risk assessed. 20.5 With third party bed rails it will be essential that they are the correct type for the bed and mattress and that they are fitted correctly. In particular, using only one side of a pair of bed rails when the other side of the bed is against the wall should be avoided. This is because a single rail (bed rail side) may be insecure and move. 20.6 If mattress combinations create additional height which lessens the effectiveness of the bed rail, thus permitting the bed occupant to roll over the top, then extra height bed rails will be required. 20.7 Mattresses that easily compress to create a vertical gap between the top of the mattress and the underside of the lowest rail should be avoided. 20.8 Care should be taken therefore to install and use these types of bed rail as instructed by the manufacturer. Regular checks and appropriate maintenance can prevent bed rail incidents. 21.0 NEVER EVENTS (MHRA 2013) 21.1 Never Events are serious incidents that are wholly preventable. They are classed in this way because guidance or safety recommendations are available at national level and should be implemented by all healthcare providers. 21.2 A Never Event type incident has the potential to cause serious harm or death, but such results do not necessarily have to apply for an incident to be categorised as a Never Event. 21.3 The Never Events Policy and Framework was revised in 2015 by the NHS England Patient Safety Domain. Never Events are published and the reasons for their occurrence investigated. They must be reported to the Care Quality Commission. 21.4 The revised Never Events List for 2015/16 includes chest or neck entrapment within bed rails, or between bed rails, bed frame or mattress, where the bed rail dimensions or the combined bed rail, bed frame and mattress dimensions do not comply with Medicines and Healthcare products Regulatory Agency (MHRA) guidance. This includes all NHS funded ISSUE 3 JULY 2016 12

healthcare settings and NHS funded care homes and equipment provided by the NHS for use in patient s own homes. 22.0 TRAINING INFORMATION INSTRUCTION AND GUIDANCE 22.1 Regulation 8 of the Provision and Use of Work Equipment Regulations 1998 states the employers shall ensure that persons who use work equipment have, where appropriate, written instructions pertaining to the use of work equipment. This includes adequate health and safety information. 22.2 Information and instructions should cover the conditions in which the work equipment can be used, the way it can be used, any foreseeable difficulties and how to deal with them. 22.3 In the case of bed rail use, it will be important for those using them to be familiar with the manufacturer s or supplier s instructions and any in house instructions resulting from any training. 22.4 Regulation 9 of the Provision and Use of Work Equipment Regulations 1998 states that employers shall ensure that adequate training in the use of equipment shall be provided including any methods which may be adopted when using the work equipment. 22.5 The training required will depend on the activity involved with the equipment (HSE 2008). 22.6 Some circumstances might prevail whereby relatively little information, instruction or training will be required. Examples include: Where the carer is sufficiently experienced and familiar with the bed rail. Where bed rail operation is relatively straightforward and a sufficiently experienced and informed person is available to instruct. Where the bed rail operation has been demonstrated by the bed rail supplier or company representative. 22.7 During any patient handling training or update, carers should take the opportunity to raise safe bed rail use as a topic for the training programme if they are involved with or likely to become involved with bed rail use. 22.8 In patient care areas, there might be a Key Mover / Link Worker who will be able to give instruction on the safe use of bed rails. A Physiotherapist, Occupational Therapist or other suitably qualified health practitioner may also be able to give instructions to staff on the safe use of bed rails. 22.9 Managers will have a responsibility to make sure that their staff have received adequate levels of instruction and training if it is deemed necessary due to any risks associated with the safe operation of bed rails and concerning patient safety. 22.10 Newly recruited, inexperienced staff, students or bank staff will require information and an appropriate level of instruction or training in the safe use of bed rails with adequate supervision until they become sufficiently familiar with the equipment. 23.0 TRAINING AND NICE GUIDANCE 23.1 NICE guidance (CG161) 1.2.3.1 refers to providing information to family members and carers about when and how to raise and lower bed rails. ISSUE 3 JULY 2016 13

23.2 Guidance (CG35) 1.8.2.2 related to Parkinson s disease: diagnosis and management in primary and secondary care. It relates to the provision of assistive devices such as a bed lever or rails to aid with moving and turning, allowing the person to get more comfortable. 24.0 SUPPLY, PURCHASE, STORAGE AND MAINTENANCE UThe following will apply mostly to third party bed rails 24.1 All those involved with the supply, purchase, storage and maintenance of bed rails must be suitably trained and knowledgeable on bed rails to a level that reflects their responsibilities. 24.2 All equipment purchases should be made in conjunction with the Provision and Safe Use of Work Equipment Policy 16.18. 24.3 Any bed rails purchased must be compatible with the host bed and mattress and availability must match need. 24.4 Those involved with purchasing bed rails must be aware of where to get compatible equipment. 24.5 Nursing staff must make sure they know who to contact for information on bed rails. They must also know where bed rails and accessories are kept if they are not one of the integral type. 24.6 New and different equipment can introduce new and different risks. Purchasing staff need to know who to go to for advice on bed rails if they are not one of the integral type. 24.7 Companies should confirm how, when and where their equipment can be used including information on correct maintenance and cleaning. 24.8 Integral rails / beds must have an asset identification number and be regularly maintained according to manufacturer s instructions. 25.0 REPORTING 25.1 Section 5.3 of the Risk Management Policy and Procedure 15.01 states that it is the responsibility of Managers to ensure that the staff they have responsibility for follow Incident Reporting Policy and Procedure and to ensure that an Incident Report is completed. Section 5.4 states that it is the responsibility of employees to report all accidents, incidents and near miss situations as soon as possible. For the purposes of this Policy 1.26, this also includes bed rail related incidents even when there has been no harm. 25.2 Upon being notified of the incident, the receiving Manager will complete an Online Incident Record (Form IR1 and IR2). Online reporting automatically forwards the report to the Risk Department. 25.3 Management investigation into the incident is recorded on the IR2 and should be completed within ten working days. 25.4 If there is a serious incident involving bed rails this must be reported in line with Policy 15.01. An Incident and Serious Incident Guidance Pack is available on the Risk Management section of the Trust Intranet. 26.0 TARGET AUDIENCE 26.1 This Policy applies to all managers and healthcare practitioners involved with the physical healthcare of patients within the Trust. As well as front-line staff, this Policy is also ISSUE 3 JULY 2016 14

applicable to those involved with the supply, purchase, storage and maintenance of bed rails. 27.0 REVIEW DATE 27.1 This Policy will be reviewed in 3 years or in light of organisational or legislative changes. 28.0 CONSULTATION Manual Handling Advisory Group Trust Health, Safety and Security Committee Trust Medical Devices Team Physical Healthcare Group Equality and Diversity Steering Group Executive Leadership Council 29.0 RELEVANT TRUST POLICIES/PROCEDURES Health, Safety & Welfare Policy and Procedure 16.01 Reporting of Accidents, Untoward Incidents and Near Miss Situations - 15.01 Manual Handling and Back Care 16.09 Provision and Safe Use of Work Equipment Policy and Procedure- 16.18 Fire Safety Policy and Procedure 16.03 Deprivation of Liberty Safeguards Mental Capacity Act 2005 Policy and Procedure 8.12 Being Open When Patients Are Harmed (incorporating Duty of Candour) Policy 15.11 Informal Patients to Take Leave From In-Patient Care Policy 1.04 30.0 MONITORING COMPLIANCE 30.1 Incident reports will be monitored for recordings of bed rail related incidents with appropriate follow up or investigation by the Health and Safety Department. 31.0 EQUALITY IMPACT ASSESSMENT 31.1 This policy has been assessed using the Equality Impact Assessment Screening Tool. The outcome of the Initial Screening Assessment was that the policy would have no adverse impact on, or result in positive discrimination of any of the diverse groups detailed. This policy and procedure applies to all Trust employees and patients/clients/service users inclusive of diversity strands. The aim of this policy and procedure is to ensure appropriate selection and safe use or non-use of bed rails. It accordingly takes into consideration the needs of key protected and vulnerable groups including people with disabilities (e.g. intellectual, physical, mental health etc.), older people, children and pregnant women. The overall outcome of adherence to this policy and procedure will be the safety and wellbeing of patients and care staff ensuring a positive impact on all parties affected. 32.0 LEGISLATION AND COMPLIANCE 32.1 This Policy has been developed with due consideration to: ISSUE 3 JULY 2016 15

The Health and Safety at Work Act 1974 The Management of Health and Safety at Work Regulations 1999 The Provision and Use of Work Equipment Regulations 1998 The Mental Capacity Act 2005 33.0 CHAMPION AND EXPERT WRITER 33.1 The Champion for the document is Executive Director of Forensic Services and the Expert Writer is Bill Varnam, Back Care Manager. 34.0 REFERENCES / SOURCE DOCUMENTS Health and Safety Executive. 2008. PUWER 1998. Provision and Use of Work Equipment Regulations 1998. Open Learning Guidance. HSE Books Health and Safety Executive. 2012. Sector Information Minute (SM 07/2012/00) Bed rail risk management available from: 20TUhttp://www.hse.gov.uk/foi/internalops/sims/pub_serv/07-12-06/U20T [accessed 30 October 2015] Hignett, S. and Griffiths, P. 2005. Do split-side rails present an increased risk to patient safety. Quality Safety Healthcare. 14: pp 113-116 Hignett, S. Sands, G. Fray, M. Xanthropoulou, P. Healey, F. and Griffiths, P. 2013. Which bed designs and patient characteristics increase bed rail use? Age and Ageing. 42: pp 531-535 20TUhttp://www.england.nhs.uk/patientsafety/never-events/U20T [accessed 20-10-15] MHRA. 2013. Safe use of bed rails. Medicines and Healthcare products Regulatory Agency Oliver, D. Healey, F. and Haines, T.P. 2010. Prevneting Falls and Fall-Related Injuries in Hospitals. Clinical Geriatric Medicine. 26: pp 645-692 Pheasant, S. and Haslegrave, C.M. 2006. Bodyspace Anthropometry, Ergonomics and the Design of Work. Third Edition. Taylor and Francis: pp 7, 273 Ruszala, S. and Alexander, P. 2015. Moving and Handling in the Community and Residential Care. National Back Exchange: pp 28, 30-31, 52, 56 Smith. J. (Ed). 2011. The Guide to the Handling of People a systems approach. Sixth Edition. Backcare in collaboration with National Back Exchange: p206 20TUwww.carebase.netU20T 20TUhttp://www.england.nhs.uk/patientsafety/never-events/U20T [accessed 20-10-15] ISSUE 3 JULY 2016 16

BED RAIL USE AND SELECTION ASSESSMENT TOOL UAPPENDIX 1 This Assessment Tool should be used in conjunction with Policy 1.26 Using Bed Rails Safely and Effectively and form part of the patient s care plan. Deprivation of Liberty Screening and a Best Interests Checklist may also need completing. Hospital/Premises: Ward/Unit: Name of patient for whom bed rail use is under consideration: DoB: NHS Patient No: Date: Condition / Diagnosis PART A [Do any of the following describe the patient s bed rail use circumstances] YES NO The patient needs to be transported in their bed The patient is recovering from anaesthetic or sedation and will be under constant supervision The patient s previous care plan indicated bed rail use The patient and/or relatives insists on bed rail use PART A Follow up instructions: Where patients need to be transported in a bed or are recovering from anaesthetic or sedation, bed rails would normally be used, in which case go to Part D. Continue completing the form if: The patient s previous care plan indicated bed rail use. In situations where the patient or relatives insist on bed rail use. In situations where in-bed sheet systems, low friction devices or turning sheets / slings will be used. If relevant: Complete Deprivation of Liberty Screening and Best Interests Checklist documentation in compliance with the Mental Capacity Act 2005 PART B [Continuation of assessment] YES NO Is the patient cognitively impaired * Is the patient confused * Does the patient have unpredictable behaviour * Does the patient have unpredictable movement * Is the patient likely to become agitated * * All these circumstances can lead to the patient falling out of bed or sustaining an injury ISSUE 3 JULY 2016 17

PART B Follow up instructions: Answering YES to any of the above questions informs you that careful consideration is required before bed rail use is agreed. Bed rails would not normally be used if such conditions prevailed. BEFORE BED RAIL USE IS AGREED ALL REASONABLE ALTERNATIVES SHOULD HAVE BEEN EXPLORED. Examples: Bed (patient) movement alarm systems Ultra-low bed Position wedges Fall/crash mat (which can introduce tripping and manual handling hazards) Mesh or inflatable bed sides Having considered the above, if a decision has been made to find an alternative to bed rail use go to PART D otherwise continue. PART C [Continuation of assessment] YES NO Is a bed rail that properly matches the bed frame available * Does the vertical distance between elements (between rail gaps) measure less than 120mm Can you confirm that the mattress does not impede bed rail operation Are the bed rails high enough to accommodate any increased mattress thickness or overlay Can the bed rail be fitted and used safely and securely * Can you confirm that the patient s body shape and size will not impede bed rail operation or effectiveness Can you confirm that the patient s behaviour and/or movement is not likely to cause them to climb over or strike the bed rails Will the head end and foot end gaps meet bed rail dimension standards (Head end = less than 60mm and Foot end either less than 60mm or greater than 318mm) Can training / instruction in the operation of the bed rails be provided Can regular checks and maintenance be provided * * These parameters will usually apply to Third Party Bed Rails ISSUE 3 JULY 2016 18

PART C Follow up instructions: Answering YES to UallU of the above questions informs you that bed rail use for the specified patient will be appropriate in this case subject to careful monitoring and reassessment when patient and equipment circumstances change. Now complete the declaration in PART D. PART D [Declaration for use or non-use of bed rails (* delete as required)] The patient will need to be transported or will be recovering from anaesthetic or sedation, OR in considering PARTS A, B and C of this Bed rail Use and Selection Assessment Tool, it has been decided that in this particular case, bed rail use *is / *is not appropriate Briefly summarise the reasons for this decision including patient turning and positioning activities Person(s) carrying out this assessment Printed Name(s) & Designation(s): Signature(s): Review Date: NB: The risk assessment should be revised / reviewed if the bed, mattress, bed occupant or bed rail changes or if there has been any form of near miss or bed rail related incident. ISSUE 3 JULY 2016 19

UAPPENDIX 2 STANDARDS FOR BED RAIL DIMENSIONS Standard EN 60601-2-52 came into effect in April 2013. Among the list of specifications covered in the standard are bed rails including their design, strength and rigidity. Common areas causing non-compliance of bed rail standards are: The use of third party bed rails or a mattress that is ill suited to the bed The use of special pressure-relieving mattresses that reduce the required 220mm vertical distance from the surface of an uncompressed mattress to the top of the bed rail in which case alternative bed rails might be required The use of standard adult beds for children this means that the rail distances will be incorrect Bed rails that are not designed for the bed may leave unsafe gaps Ill-fitting bumpers can cause gaps bumpers that are fitted permanently to the rails will offer more security ISSUE 3 JULY 2016 20

UAPPENDIX 3 BED RAIL CHECK LIST Frequent visual and safe operation checks are recommended. This check is UnotU to determine whether bed rails should be used but to check the integrity of bed rails already in use post assessment. These checks will be particularly pertinent to third party bed rails. Periodically check that: CHECK 1. The bed rails, if third party designs are fitted correctly and are compatible with the bed and mattress and still properly in position. OK NOT OK N/A 2. The bed rails operate (go up, lock/unlock, lower) properly. 3. No parts are missing, damaged or showing signs of wear. 4. All fixtures and fittings are secure. 5. Any mattress change or overlay has not reduced effective bed rail height. 6. Any accessories such as bumpers or covers are properly intact, attached and clean. 7. Any accessories are not presenting any risks to the patient. 8. The bed rails are clean. REMEMBER: If the bed, mattress, bed occupant or type of bed rail changes, review the risk assessment. Report any concerns immediately or as soon as you reasonably can to your Line Manager. Do not use faulty or incorrect equipment. ISSUE 3 JULY 2016 21

UAPPENDIX 4 INFORMATION ON BED RAIL DIMENSIONS 1 = > 220mm vertical distance from the top of an uncompressed mattress to the top edge of the side rail 2 = < 120mm vertical distance between elements (between rail gaps) and between bottom of side rail and mattress platform 3 = < 60mm gap between head board and end of side rail 4 = < 60mm or >318mm gap between foot board and end of side rail 5 = < 60mm vertical distance between open end of side rail/s and mattress platform 3 4 Head board 1 2 Foot board 2 Mattress 5 ISSUE 3 JULY 2016 22

INFORMATION ON BED RAIL DIMENSIONS 1 = > 220mm vertical distance from the top of an uncompressed mattress to the top edge of the side rail 2 = < 120mm vertical distance between elements (between rail gaps) and between bottom of side rail and mattress platform 3 = < 60mm gap between head board and end of side rail 4 = < 60mm or >318mm gap between foot board and end of side rail 5 = < 60mm vertical distance between open end of side rail/s and mattress platform 6 = < 60mm or >318mm gap between split side rails when bed is flat or in most disadvantageous position 3 6 4 Head board 1 2 Foot board 2 5 Mattress 5 ISSUE 3 JULY 2016 23

INFORMATION ON BED RAIL DIMENSIONS This shows the gap between side rail and mattress in plan elevation. 7 = 120mm. The product dimension standard is checked by using a 120mm aluminium cone positioned between the mattress and the side rail to determine if gap is acceptable or not. 7 Side rail Head board Foot board Mattress ISSUE 3 JULY 2016 24

UAPPENDIX 5 The Policy for: Using Bed Rails Safely and Effectively Issue: 03 Status: Author Name and Title: APPROVED Bill Varnam, Back Care Manager Issue Date: 19 JULY 2016 Review Date: JUNE 2019 Approved by: Distribution/Access: EXECUTIVE LEADERSHIP TEAM Normal RECORD OF CHANGES DATE AUTHOR PROCEDURE DETAILS OF CHANGE April 2012 Bill Varnam 3.06 Policy moved from Section 3 to Section 1 New Section 8 Fire Evacuation and Bed rail Use. Minor updates throughout New Appendices 1 and 2 inserted. Nov 2015 Bill Varnam 1.26 Amended to widen scope to reflect Trust Services and in-line with revised Bed Rail Standards for bed rail dimensions. Equality Impact Assessment also updated. June 2016 Bill Varnam 1.26 Expanded information on vulnerable adults and incident reporting. ISSUE 3 JULY 2016 25

EMPLOYEE RECORD OF HAVING READ THE POLICY UAPPENDIX 6 UTitle of PolicyU: UUsing Bed Rails Safely and Effectively I have read and understand the principles contained in the named policy. 0BPRINT FULL NAME SIGNATURE DATE ISSUE 3 JULY 2016 26