Maine Care Center Reduces Use of Bed Rails

November-December 2004

"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.


  1. 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.


Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Maine Care Center Reduces Use of Bed Rails

Copyright © 2004 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.