Developing and validating a risk assessment tool for using bedrails

VOL: 103, ISSUE: 20, PAGE NO: 30-31

Margaret Goodman, MSc, MA, BA, DipN, FETCert, RGN; Judith Smith, BSc, Dip Specialist Practice, RGN, ONC; Mollie Gilchrist, MSc, MA, PGCE, BA; Leanne Buck, RGN

Margaret Goodman is senior lecturer and research facilitator in practice; Judith Smith is practice facilitator; both at Coventry University and University Hospitals Coventry and Warwickshire NHS Trust; Mollie Gilchrist is principal lecturer, Coventry University; Leanne Buck is ward manager, Rugby St Cross Hospital, University Hospitals Coventry and Warwickshire NHS Trust.

Abstract: Goodman, M. et al (2007) Developing and validating a risk assessment tool for using bedrails. www.nursingtimes.net

Abstract: Goodman, M. et al (2007) Developing and validating a risk assessment tool for using bedrails. www.nursingtimes.net

Aim: To test the validity and reliability of the Coventry Bed Rails Use (CBRU) tool.

Method: The study consisted of three stages: training in the use of the tool and applying it to patient scenarios; three separate patient assessments using professional judgement, an experienced CBRU tool user and a novice one; and assessment using the modified tool by an experienced and novice CBRU user.

Results: There was fair overall agreement between registered nurses and expert opinion, when choosing colours in the tool from five patient scenarios. When used on the wards, there was high agreement overall between professional judgements and novice CBRU users on bedrail use, and fair agreement between experienced and novice users. Use of the amended tool resulted in very high agreement between experienced and novice users.

Discussion: The outcomes from the novice CBRU users and professional judgement showed a high level of agreement in decisions, while there was less agreement between the expert users and professional judgement. These discrepancies may represent differences in attitude. Use of the amended tool resulted in very high agreement.

Conclusion: The tool should be implemented in adult inpatient areas with an education programme about the risks of inappropriate bedrail use, followed by an audit. Further research on its use in other clinical areas should be carried out.

The use of bedrails as a way of preventing patients falling from their beds and sustaining injuries is now common practice in many healthcare settings (MHRA, 2006; Jehan, 1999). Bedrails can be used as physical restraints or as a safety device.

Bedrails become physical restraints when they restrict a patient's movement or hinder them when attempting to get out of bed unaided. While this cannot be regarded as good practice, it may be linked with inadequate assessment (Govier and Kingdom, 2000) or lack of insight to consider alternatives for safe management of patients at risk of falling.

Ten years ago bedrail use in the acute care sector was around 8% and 4% in geriatric settings (O'Keeffe et al, 1996). More recently bedrails appear to have become an integral part of everyday practice and are regarded as the 'common sense' intervention for any patient considered to be at risk of falling from bed. Audit evidence suggests that nurses and other healthcare practitioners pull up bedrails when they are fitted to a bed without really considering whether or not they are needed (Govier and Kingdom, 2000). Research evidence, however, indicates that instead of preventing injuries to patients, bedrails are actually responsible for causing injury and even death (Parker and Miles, 1997; Gray and Gaskell, 1990). The latest MHRA bulletin (MHRA 2006) reported that there have been serious incidents and deaths associated with the use of bedrails, and suggested that these could have been prevented by an adequate assessment of the risks involved. Raising the rail on a bed increases the height from which a patient can fall by a minimum of 18 inches. Even bedrails themselves are a potential hazard, because there are gaps in the solid surface, between the rails and at the head and foot of the bed, where, for example, arms and legs can become entrapped.

Background

In our trust, an incident on a rehabilitation ward, when an 80-year-old woman got her knee stuck in a metal bedrail, distressed the patient and the staff involved. This prompted a consideration of the policy for bedrail use. The policy directed staff to carry out an assessment before using bedrails, but gave no specific guidance on how to undertake such an assessment. The nurse manager concerned sought help from her practice facilitator and a literature search was undertaken to find a suitable assessment tool.

However, it soon became evident that there were no bedrail risk assessment tools readily available for use, and those that were available were complicated and not suitable for everyday use on a busy ward.

Assessing the risk of bedrail use

The MHRA (2006) suggested that most of the risks associated with the use of bedrails can be avoided if thorough risk assessments are carried out. Nevertheless, guidance as to what should be included in such an assessment tends to be broad and appears to be largely dependent on professional judgement and experience.

The MHRA advice on the safe use of bedrails (2006) stated that the assessment should look at the likelihood of a person falling from their bed and whether their physical or clinical condition increases the risk of entrapment. It also stated that some groups are more at risk than others, including older people and adults, or children, with:

• Communication problems or confusion;
• Dementia;
• Cerebral palsy;
• Very small or very large heads;
• Repetitive or involuntary movements;
• Impaired or restricted mobility.

Risk assessment tools for the use of bedrails include those by Donius and Rader (1994), Everitt and Bridal-Nixon (1997) and Capezuti et al (1998).

Any assessment tool has to be user-friendly and allow quick assessment of the pertinent risk factors to promote regular review of patients' suitability for the use of bedrails. None of the tools found met these criteria, nor have been validated for use.

The lack of effective and easy-to-use risk assessment tools for bedrail use means that nurses' professional judgement tends to be the only justification given for their use. While this is perfectly acceptable, there may be inconsistencies and it raises the possibility of assessments not being evidence-based. However, a consistent and evidence-based approach can be achieved by the use of a risk assessment tool suitable for use in any setting.

The absence of a simple and effective means of assessing patients at risk - and suitability for bedrail use - led us to devise our own tool. This tool was piloted on the rehabilitation ward and appeared to help the bedrail use decision-making process. It also led to a noticeable decrease in the use of bedrails and number of incidents resulting from their inappropriate use. After numerous modifications, the assessment tool became the Coventry Bed Rails Use (CBRU) tool, and this article describes the validation study.

Developing the CBRU

In assessing the risk associated with the use of bedrails, the primary aim is to decide whether they are actually required. Such decisions will include an assessment of the likelihood of a patient falling from his/her bed; a determination of whether using bedrails is the most appropriate solution to prevent a fall from bed; and suitability of bedrail use in relation to risk of injury from either falling or the rails themselves.

The CBRU tool works on the premise that the majority of patients do not require bedrails on their beds, but that when there is a perceived need, assessment of the risks involved in their use is essential. It uses two factors in assessing whether a patient is at risk of injury if bedrails are used: level of orientation and mobility. These factors are incorporated into a matrix thatis used to determine whether bed rail use is appropriate. Five colours are used: red means that bed rail use is not recommendedand the other four colours give a range of times for reassessment if bed rails are used.This is based on the evidence that an individual with normal cognitive abilities would not ordinarily be considered to be at risk of falling. However, as soon as an individual displays any reduction in cognitive ability, which has the potential of leading to irrational or unpredictable behaviour, they can be said to be at some risk of falling from their bed. The mobility of such patients will also contribute to the level of risk, because their range of movement will impact on outcomes of inappropriate behaviour.

There are no firm directives given in the CBRU about whether or not to use bedrails, simply recommendations based on evidence from the literature and adverse event reports. Guidance on the timing of reassessment is also included in the CBRU. Further, if the reassessment times of the recommendations are not followed, the variance chart, which is an integral part of the CBRU, facilitates documentation of the rationale for not following the guidance.

As the CBRU uses colours, we approached a number of nurses with colour blindness and have been assured that they had no