Bedrails occupy a unique position in healthcare fire safety, serving both as protective devices and potential hazards. In emergency evacuations, the presence or absence of bedrails can significantly impact resident safety, staff efficiency, and evacuation outcomes.
This article examines the careful balance required when making decisions about bedrails in healthcare settings, particularly in the context of bed evacuation during fire emergencies. The goal is always to protect resident safety and dignity whilst ensuring effective emergency response.
Bedrails Must Never Be Used as Restraint
Bedrails should never be used as a form of restraint. Their purpose is to enhance safety, not restrict residents’ freedom of movement. In Ireland, bedrails are classified as a physical restrictive practice and must be reported to HIQA when used.
However, the decision to remove bedrails should not be made hastily, especially when bed evacuation forms part of the emergency strategy. A thorough, individualised assessment is necessary to weigh both benefits and risks.
The Bedrail Dilemma: Benefits vs Risks
Benefits of Bedrails
- Prevent falls during bed evacuation
- Secure resident during ski sheet transfer
- Provide psychological reassurance
- Aid resident repositioning
- Support during transfers in/out of bed
- Facilitate reaching for bedside items
Individual Assessment Required
Risks of Bedrails
- Entrapment causing injury or death
- Falls from climbing over rails
- Skin injuries from rail contact
- Psychological distress if used as restraint
- Delayed evacuation if improperly fitted
- Damage to evacuation equipment straps
The Seven Zones of Bed Entrapment
FDA/HBSW Identified Entrapment Zones
The U.S. Food and Drug Administration (FDA) and Hospital Bed Safety Workgroup (HBSW) have identified seven potential zones where entrapment can occur. Understanding these zones is essential for safe bedrail assessment.
Within the Rail
Openings within the bedrail structure itself. Head or limbs can become trapped if spacing between rail bars exceeds 120mm (4¾ inches).
Under the Rail, Between Supports
Gap under the rail between rail supports. Risk of head entrapment if space exceeds 120mm.
Between Rail and Mattress
Gap between the bedrail and mattress edge. One of the most commonly reported entrapment zones causing asphyxiation.
Under Rail at Ends
Gap between mattress surface (compressed by body weight) and the lowermost portion of the rail at rail ends. Risk of neck entrapment.
Between Split Rails
Space between segmented or split bedrails when both are raised. Risk increases with articulating bed positions.
End of Rail to Headboard/Footboard
Gap between the end of the bedrail and the side edge of the headboard or footboard.
Between Headboard/Footboard and Mattress
Space between the mattress end and the headboard or footboard, especially if mattress shifts or compresses.
Bedrail Incidents: The Evidence
Sources: FDA Hospital Bed Safety Data; BMC Geriatrics (2022) Irish Nursing Home Study
Risks of Absent Bedrails During Evacuation
Increased Fall Risk
Without bedrails, residents with limited mobility face greater risk of falling out of bed during the rush and confusion of an emergency evacuation, potentially causing fractures and other injuries.
Ski Sheet Complications
Evacuation sheets (ski sheets) work by securing residents within their mattress. Without bedrails, residents may slide off during the securing process or whilst being moved to floor level.
Heightened Anxiety
Bedrails provide psychological reassurance, helping residents feel secure. Their absence during stressful emergencies can increase anxiety, making residents less cooperative during evacuation.
Evacuation Plan Disruption
Fire evacuation plans typically account for bedrail presence. Unexpected absence may require procedural changes, causing delays and potential confusion amongst staff.
How Bedrails Support Safe Bed Evacuation
Containment During Transfer
Bedrails help contain residents whilst staff prepare evacuation equipment and secure straps, preventing rolling or movement that could cause injury.
Structured Evacuation Process
Staff can lower bedrails in a controlled sequence during evacuation, maintaining a predictable process that works consistently across different residents.
Protection During Movement
When moving beds through doorways or corridors, bedrails protect residents from contact with door frames, walls, and other obstacles.
Psychological Security
Familiar bedrails provide continuity and security during the disorienting experience of emergency evacuation, reducing resident distress.
Evacuation Equipment Compatibility
Evacuation sheet straps can fall out from under the mattress and become damaged by bedrails when the bed is raised or lowered. Staff must check that straps are properly stored and undamaged during routine inspections.
When selecting evacuation equipment, ensure compatibility with the bed frames and bedrails in use. Some evacuation sheets include press studs or pockets to keep straps secured and protected from rail damage.
Individual Bedrail Assessment Process
Every decision about bedrails must be based on individualised assessment, considering the resident’s specific needs, the evacuation context, and regulatory requirements.
Clinical Assessment
Evaluate mobility, cognition, behaviour patterns, and medical conditions affecting movement
Fall Risk Evaluation
Assess likelihood of falling from bed with and without bedrails in place
Entrapment Risk Check
Measure entrapment zones and assess resident vulnerability to entrapment
Evacuation Consideration
Factor in bed evacuation requirements and equipment compatibility
Consent Process
Obtain informed consent, explaining benefits and risks clearly
Document and Review
Record decision, add to restraint register if applicable, schedule regular reviews
Irish Regulatory Context
HIQA Requirements for Bedrails
Restrictive Practice Classification
Bedrails are classified as physical restrictive practices in Ireland. Their use must be reported to HIQA quarterly as part of statutory notifications.
Restraint Register
All bedrails in use must be recorded on the centre’s restraint register, including documentation of assessment, consent, and regular reviews.
Individual Assessment Requirement
Each resident must have an individual risk assessment completed before bedrails are implemented, documenting benefits, risks, and alternatives considered.
Thematic Inspection Programme
HIQA’s Restrictive Practice Thematic Inspections (commenced June 2023) specifically assess bedrail use, documentation, and reduction efforts.
When Bedrails Are Not Considered Restraint
Bedrails are not classified as restrictive practices when:
- They are used for therapeutic or non-behavioural purposes (e.g., positioning support)
- The resident can operate the bedrails themselves
- The bedrails are partial, allowing the resident to get in and out of bed freely
Bed Evacuation Equipment
Understanding evacuation equipment helps inform bedrail decisions. Common bed evacuation aids include:
Ski Evacuation Sheets
Fitted under the mattress, these sheets secure residents within their mattress using straps, allowing the mattress to be slid from the bed frame to the floor and then to safety.
Evacuation Sledges
Specialised devices placed beside the patient. The resident is transferred onto the sledge, secured, then evacuated. Suitable for stair descent.
Evacuation Chairs
For residents who can be safely transferred to a seated position. Not suitable for all residents but useful for those with some mobility.
Best Practice: The Balanced Approach
The most effective approach balances bedrail safety benefits against entrapment risks, considering both daily care needs and emergency evacuation requirements. This involves:
- Conducting thorough individual assessments that include evacuation planning
- Using bedrails only when benefits clearly outweigh risks
- Selecting properly fitting bedrails that meet dimensional safety standards
- Ensuring bedrails are compatible with evacuation equipment
- Training staff in both safe bedrail use and bed evacuation techniques
- Regularly reviewing bedrail decisions as resident needs change
Key Takeaways
- Never use bedrails as restraint: Their purpose is safety enhancement, not movement restriction
- Individualised assessment is essential: Every bedrail decision must be based on the specific resident’s needs and circumstances
- Seven entrapment zones: FDA guidance identifies seven areas of risk, with Zones 1 to 4 accounting for 80% of incidents
- Consider evacuation context: Bedrails play an important role during bed evacuation, providing containment and security
- Equipment compatibility: Ensure bedrails work safely with evacuation sheets and other emergency equipment
- Document and review: Record all bedrail decisions on the restraint register and review regularly
- Train staff appropriately: Staff must understand both bedrail risks and evacuation procedures
Phoenix STS: Healthcare Fire Safety Services
Phoenix STS provides comprehensive training and consultancy to help healthcare facilities navigate the complex balance between resident safety, regulatory compliance, and effective emergency evacuation.
Training
Practical Support
Ensure Your Staff Are Properly Trained
Phoenix STS offers CPD-accredited training in evacuation equipment use, bed evacuation techniques, and healthcare fire safety. Our courses help staff understand the balance between bedrail safety and evacuation effectiveness.
References
- FDA: A Guide to Bed Safety – Bed Rails in Hospitals, Nursing Homes and Home Health Care
- FDA: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment
- HIQA: Guidance on Restrictive Practice for Designated Centres for Older People
- BMC Geriatrics: Incidence and type of restrictive practice use in nursing homes in Ireland (2022)
- HSE (UK): Safe use of bed rails
- Department of Health: Towards a Restraint Free Environment in Nursing Homes
Disclaimer
This article is provided for general informational and educational purposes only. While every effort has been made to ensure accuracy, this content does not constitute clinical, legal, or fire safety advice. Healthcare providers should conduct individualised assessments for each resident and consult with qualified professionals regarding bedrail use and evacuation planning. Phoenix STS accepts no liability for actions taken or not taken based on this article.
