Bed Rails – Procedure for Safe and

Effective Use

CLIN-0047-v7

Status: Approved

Document Type: Procedure

Overarching Policy: Medical Devices Policy

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Contents
1. Introduction.......................................................................................................3
2. Purpose .............................................................................................................4
3. Who this procedure applies to......................................................................... 4
3.1. Roles and responsibilities................................................................................4
4. Related Documents ..........................................................................................5
5. Procedure ..........................................................................................................5
5.1. Risk assessment...............................................................................................5
5.2. Fitting Bed Rails ...............................................................................................7
5.3. Consent .............................................................................................................7
5.4. Record Keeping ................................................................................................7
5.5. Ongoing assessment, review and maintenance ............................................. 7
5.6. Using bed rails on children’s beds .................................................................. 8
5.7. Specialist beds/cot beds ..................................................................................8
5.8. Using third party bed rails safely e.g. non-integral ........................................ 9
5.9. Using integral bed rails safely ......................................................................... 9
5.10. Using electric profiling beds safely ................................................................. 9
5.11. Using pressure-relieving mattresses and overlays safely ........................... 10
5.12. Bed rail bumpers ............................................................................................ 10
5.13. Procurement ................................................................................................... 10
5.14. Incident Reporting .......................................................................................... 11
6. Definitions ....................................................................................................... 11
7. How this procedure will be implemented ...................................................... 12
7.1. Training needs analysis ................................................................................. 12
8. How the implementation of this procedure will be monitored ..................... 12
9. References ...................................................................................................... 13
10. Document control (external) .......................................................................... 13
Equality Analysis Screening Form .......................................................................... 15
Appendix 1 - Risk Assessment Tool for Provision of Bed Safety Rails ................ 19
Appendix 2 - Bed Rail Fitting Checklist ................................................................... 23
Appendix 3 - WHEN TO USE BED RAILS Decision making flowchart ................... 25
Appendix 4 - Bed rail dimensions and safe use of bed rails MHRA ...................... 26
Appendix 5 – Approval checklist ............................................................................. 37

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1. Introduction
In this section describe:
• Why this procedure is needed
Bed rails are used in healthcare to prevent occupants falling out of bed and injuring
themselves. Patients in hospital may be at risk of falling from bed for many reasons
including poor mobility, dementia or delirium, visual impairment, and the effects of their
treatment or medication.

• How this procedure links to Our Journey to Change (OJTC) and has been developed with
OJTC in mind.

To co-create a great experience for our patients, carers and families, so you will
experience:

• Outstanding and compassionate care, all of the time.

• Access to the care that is right for you.
• Support to achieve your goals.
• Choice and control.

This procedure is aligned to the organisational journey to change and its work to create
safe and personalised care that improves the lives of individuals with mental health needs,
a learning disability or autism.

This procedure supports the trust to co- create a great experience for all patients, carers
and families from its diverse population by allowing access to care that is right for the
individual and ensuring the correct equipment is in place and used safely, correctly and in
the least restrictive way.

To co-create a great experience for our colleagues, so you will be:

• Proud, because your work is meaningful.
• Involved in decisions that affect you.
• Well led and managed.
• That your workplace is fit for purpose.

This procedure supports the trust to co-create a great experience for our colleagues by
ensuring they have the correct skills, knowledge and training to provide the best possible
care.

To be a great partner, so we will:

• Have a shared understanding of the needs and the strengths of our communities
• Be working innovatively across organisational boundaries to improve services.
• Be widely recognised for what we have achieved together.

This procedure supports us to work hand in hand with our community equipment service
providers and across health and social care settings to meet the needs of our communities.
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2. Purpose

Following this procedure will help the Trust to:

• Ensure staff understand and follow the procedure for risk assessment of bed rails;
• Comply with National, Medicines and Healthcare Related Products Agency (MHRA) and
Local Guidance.
• Reduce harm to patients caused by falling from beds or becoming trapped in bed rails;
• Support patients and staff to make individual decisions around the risks of using and not
using bed rails.

3. Who this procedure applies to

This procedure applies to all staff caring for patients in Inpatient areas of Tees, Esk and Wear
Valleys NHS Foundation Trust (the Trust).
Employees of the Trust who work in the community where bed rails are supplied via home loans
services, e.g. Medequip or Teesside Community Equipment Stores (TCES), staff should follow the
relevant local protocol for using this equipment. Where no local guidance is available, staff
members will use the most suitable guidance document as agreed by head of profession.

3.1. Roles and responsibilities

Role Responsibility

Manager • Ensuring all staff are aware of and follow this procedure and are
aware of their own roles and responsibilities to ensure safe
practice.

Modern Matrons • Ensuring this procedure is implemented.

Ward Managers • Following the procedure and ensuring staff are trained.

Inpatient and Community • Nursing staff to undertake assessment for the use of bed rails,
Employees • Ensure bed rails are used safely and effectively in line with Trust
policy and Local Community Policy e.g. TCES or Medequip
• All staff involved in assessment or provision of bed rails to be
aware of up to date national guidance
[Link]://[Link]/government/publications/bed-rails-
management-and-safe-use and
[Link]

Back Care Advisor • Provide advice for the safe moving and handling of patients where
bed rails are used.
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Occupational Therapist • Provide advice on the safe use of bedrails and undertake
assessment and provision of bed rails in the community where this
is within their professional role/ remit.

Respect Compassion Responsibility

• Listening • Kind • Honest

• Inclusive • Supportive • Learning

• Working in partnership • Recognising and • Ambitious

Celebrating

4. Related Documents

Medical Devices Policy

Policy for Consent to Examination or Treatment
Decontamination of Equipment Procedure
Human Rights and Equality, Diversity Policy
[Link]
Health and Safety Policy
Harm Minimisation (Clinical risk assessment and Management Policy)
Restraint policy Safe use of physical restraint techniques

5. Procedure

5.1. Risk assessment

Bed rails should only be used to reduce the risk of a patient accidentally:
 slipping;
 sliding;
 falling or rolling out of a bed (bed rails used for this purpose are not a form of restraint,
where restraint is defined as ‘the intentional restriction of a person’s voluntary movement
or behaviour.’)
And
 Where other lower risk options are not suitable
 Where bed rail is suitable for use with bed, environment, and patient size/ needs.

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 Bed rails:
 will not prevent a patient leaving their bed and falling elsewhere;
 are not intended as a moving and handling aid.

A baseline assessment of the patient’s ability to maintain a safe environment should be made and
documented immediately on admission to the clinical area. This should be reviewed as indicated
in the patients care plan after 2 weeks or if the patient condition changes. An individual risk
assessment (see Appendix 1) must be completed prior to bed rail usage with any patient.

Bed rails should not usually be used:

• if the patient is agile enough and/or confused enough, to climb over them;
• if the patient would be independently mobile if the bedrails were not in place.

Bed rails should be considered:

• if the patient is being transported on their bed;
• in areas where patients are recovering from anaesthetic or sedation and are under
constant observation (ECT suites).
• Patients who experience severe anxiety may request bed rails to make them feel safe.

Some clinical conditions can mean that clients are at greater risk of injury or entrapment – for
example those with:
• acute or chronic confusion showing signs of agitation or challenging behaviours. They are
unaware of the risks and limitations imposed by their disabilities;
• involuntary movements or muscle spasms;
• epilepsy;
• micro- or hydrocephalus presenting a particular risk of entrapment;
• sensory impairment who may not be aware of trapped limbs;
• learning disabilities affecting their ability to understand safety issues;
• communication difficulties; unable to understand safety issues or alert others when in
danger.
• People who may self harm with the help of electric beds or bed rails EFA-2010-006 - Self
harm associated with profiling beds ([Link])

Bed rails should be used if the benefits outweigh the risks.

The risk assessment is intended to highlight the potential risks but does not replace clinical
reasoning or judgment. The decision to provide or not provide remains that of the clinician
after careful consideration of the risks and benefits to the patient and wherever possible a
multidisciplinary approach should be taken.
The behaviour of individual patients can never be completely predicted, and the Trust will
be supportive when decisions are made by frontline staff in accordance with this
procedure.

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5.2. Fitting Bed Rails

The choice of correct bed rail/ bumper and correct fitting of a bed rail is essential to avoid
accidents and injuries to patients. Two members of staff who have the relevant competence must
fit bed rails and complete the bed rail fitting checklist (Appendix 2) before the patient occupies the
bed to ensure safety. If the bed rails are fitted in trust facilities by staff outside the trust (e.g.
equipment suppliers/ equipment services), trust staff must still ensure they are fitted correctly and
safe prior to use.
For community equipment provision, beds and bed rails should be fitted by the community
equipment provider/ supplier and checked using a bed rail checklist by the prescribing trust
clinician.

5.3. Consent

Decisions about bed rails need to be made in the same way as decisions about other aspects of
treatment and care as outlined in Policy for Consent to Examination or Treatment

5.4. Record Keeping

• Record the decision to use or not use bed rails for a patient on service specific electronic
care record.
• Complete the Trust’s bed rails risk assessment tool for each patient where bed rails are
considered for use and place a copy in the patient’s clinical record.
• Document the rationale to use or not to use bed rails with reference to the risk assessment
form and cross reference in safety summary. Record any discussions with the patient and
carers.
• Record any subsequent reviews, reassessments, discussions and changes in the patients’
clinical condition.
• Record the reasons for discontinuing bed rail use following reassessment.

5.5. Ongoing assessment, review and maintenance

Decisions about bed rails need to be reviewed and changed. If either bed, mattress
(including mattress toppers), bed occupant or bed rail changes, an immediate
reassessment is needed. Even stable patients in rehabilitation or mental health settings
can have rapidly changing needs when physical illness intervenes. Changes to patient
behaviour/ sleeping habits such as attempts to move into positions that pose risk of
entrapment or attempting to climb over rails also require changes to risk assessment and
require review of bed rail use. Nursing staff should review decisions about bed rails
whenever an in- patient’s condition or wishes change, but as a minimum review this every
24 hours and ensure regular cleaning and safety checks of rails/ bumpers.
In community settings, home carers should maintain regular safety checks and cleaning
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 and contact the relevant community team if there are any changes that indicate a need to
review.

5.6. Using bed rails on children’s beds

Most bed rails are for use only with adults and adolescents. Suitability of the bed rail for the
individual child or small adult must always be risk assessed, as bar spacing and other gaps (e.g.
between the bed base and mattress/rails) may need to be reduced.

Manufacturing standard BS EN 50637:2017 specifies that all gaps between the rail bars
should be a maximum of 60mm. There was no standard prior to this, therefore Trust staff
will need check the gap width on older beds prior to their use.

When purchasing or making assessments of bed rails for children, seek guidance on
suitable rails from the manufacturers and assess their compatibility with the size of the
individual and the specific circumstances of use.

A risk assessment must be carried out involving the parent(s)/carer(s) of the child (A child is
identified as person under the age of 18years) to determine what the child usually sleeps in and
what will provide a safe environment for the child. If a cot is used, the cot sides are permanently
fixed, and must be used when the child is asleep, or unattended by an adult. The assessment must
consider the mobility of the child, and whether they will be likely to climb over the cot sides.

If a child usually sleeps in a bed, the assessment, with the parent(s)/carer(s), should determine
whether bed rails are needed to keep the child safe.

5.7. Specialist beds/cot beds

Specialist beds and cot beds can be used for children and adults. These beds can be made-to-
measure for the needs of each individual. All beds must be used as per the manufacturer’s
instructions and a full risk assessment completed before use to comply with MHRA and BS
EN60601-2 Standards. Trust staff to be aware of the change in guidance from MHRA (2020) in
relation to the maximum bed rail gap width of 60mm and check this for older beds.
Effected decontamination of bed rails and bed bumpers must occur for specialised cleaning refer
to Appendix 2 in the Decontamination of Equipment Procedure.

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5.8. Using third party bed rails safely e.g. non-integral
Third party bedrails:
 are not specific to any particular bed model; they are intended to fit a wide range of domestic,
divan or metal framed beds from different suppliers;
 must be assessed for each use to ensure suitability for use with the bed and meeting the
dimensions outlined in Appendix 4;
 should be fixed in matching pairs to the correct sides of the bed and as per manufacturers’
instructions.

Third party bed rails are different from bed grab handles (bed sticks) which are designed
as mobility aids and not to prevent patients falling out of bed – as these can pose similar
risks, staff need to be aware of up to date safety warnings and guidance, and undertake
related risks assessments (MHRA) – these types of equipment are not covered by this
document.
For all types of bed rail, staff should refer to the MHRA advice for guidance. Web Links are
given in Section 9 - References

Before each use all bed rails must be inspected for any signs of damage, faults or cracks.
Any defective bed rails must be quarantined and either reported for repair or condemned
(as appropriate). Defective bed rails must NOT be used and should be disposed of
immediately in line with the Trust Medical Devices Policy.

5.9. Using integral bed rails safely

Integral bed rails are those that are incorporated in the bed design and supplied with it or offered
as an optional accessory e.g. electric profiling bed. Beds that have integral bed rails must be used
as per manufacturers’ instructions. Split bed rails must be used with both parts of the bed rail in
the upright position.
Bock beds have integral bed rails. When these bed rails are fully elevated and the bed rails
locked, they provide a non-collapsible rail. Deaths from non-collapsible rails are a patient safety
‘never event’.

All units that use Bock beds must complete a full risk assessment on each patient which
may indicate the removal of these bed rails for certain patients.

5.10. Using electric profiling beds safely

Electric profiling beds must be used as per the manufacturer’s instructions. Take extra care with
profiling beds to ensure there is no possibility of entrapment once the bed is adjusted to a differing
profile from horizontal, as potential entrapment hazards can be created in different configurations
and present possible risk of accidental or intentional harm to self by the patient. Staff will reflect
consideration of this Sin bedrail risk assessment, related support plans and safety summary on
electronic record system.

All instructions for the use of hired beds must be handed over to the nurse in charge on
arrival.

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5.11. Using pressure-relieving mattresses and overlays safely

Staff must consider the combined height of the mattress plus overlay as this increases the
overall height. This may allow the patient to roll over the top of the bed rail.
The need for extended height bed rails must be assessed for use in this situation.

The hazard of entrapment between the mattress and the bed rails may be exacerbated due
to the easily compressed nature of the mattress. A risk assessment must be carried out.

When using a Bariatric bed that requires a pressure-relieving mattress, ensure this is a Bariatric
pressure-relieving mattress.

5.12. Bed rail bumpers

Bed rail bumpers, padded accessories or enveloping covers are primarily used to prevent impact
injuries. They can also reduce the potential for entrapment when securely fitted to the bed or rail
according to the instructions for use. All accessories must be risk assessed to ensure they are fit
for purpose and risks management is optimised, as they can also add their own inherent risks. For
example mesh bumpers may cause friction burns and breathable materials may need to be
considered if there is a risk of asphyxiation.

Be aware that bumpers can move or be compressed introducing entrapment risks.

Bedding/ duvets should only be used as emergency interim measure as they can move to
impact on gap width and increase entrapment and asphyxiation risks.

5.13. Procurement

New beds, bed rails or mattresses can introduce a new risk if they are not fully compatible with
existing stock. To reduce the risk, all purchase orders from Trust premises for beds, bed rails or
mattresses must be agreed the Medical Devices Management Group for authorisation. All orders
should provide supporting evidence to justify the reason for purchase. See Medical Devices Policy

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5.14. Incident Reporting

All accidents and injuries involving the use of bed rails are an untoward incident and must
be reported immediately.

You must:
• Raise a Datix incident;
• Document the incident on the patient’s electronic care record;
• Inform the Patient Safety Team of all incidents involving bed rails for investigation;
• Report any serious untoward incident due to the use of bed rails to the Medicines and
Healthcare Regulatory Agency (MHRA) yellow card scheme [Link]
• Remove all defective equipment from service immediately and quarantine.
• Keep the defective equipment and do not dispose until after any investigation can be
undertaken.

6. Definitions

Term Definition
Integral (split rail) These types are incorporated into a profiling hospital bed
design. These are commonly provided within a hospital setting
Straight rail design Attaches to profiling beds
Third party These types are not specific to any particular bed model. They
are intended to fit a range of domestic divan or metal framed
beds from different suppliers. Sometimes these types may be
called Trombone Rails. These differ from bed grab handles/ bed
sticks in both purpose and design.
Bumpers These are padded covers that fit over the bed safety rails. Their
function is to reduce the risk of injuries caused by limbs or head
striking the metal rail and reducing risk of injury when limbs
protrude between rails.
Extended Height Bed Rails Either an extra height rail or an extender bar can be fitted to a
compatible rail

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7. How this procedure will be implemented

• This policy will be published on the Trust’s intranet and external website.
• Line managers will disseminate this policy to all Trust employees through a line
management briefing.

7.1. Training needs analysis

Staff/Professional Type of Training Duration Frequency of Training

Group

All staff on wards who Cascade training from n/a At induction referencing
will use bed rails. staff competent in using the procedure.
the equipment.
Equipment provider
company available for
support/training if
required.

Occupational Therapy Within core training. n/a Responsible to keep own

skills updated as per
(for community provision
HCPC requirements. No
and additional inpatient
specific method
advice)
mandated.

8. How the implementation of this procedure will be

monitored
In patient settings.
A bed rail audit will be carried out in all inpatient areas that use bed rails to monitor compliance
with this policy. Results will be discussed at the Medical Devices Group.
Audit plan to be developed in Jan 2022.

Community
Bed rail prescription will be monitored within clinical supervision and their use reviewed regularly.
Community equipment services will review their beds and bed rails policy on a regular basis in
conjunction with prescribers.
Community equipment services regularly review the bed rail equipment provided and their contract
with suppliers, and lead on any medical device or field safety issues.
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9. References
• EFA-2010-006 - Self harm associated with profiling beds ([Link])
• Medicines and Healthcare products Regulatory Agency (MHRA) (2020) The Safe Use of
Bed Rails:
[Link]
• MHRA Device Alert 2007/009 (2007) Beds Rails and Grab Handles [Link]
• NPSA Safer practice notice Using Bed Rails Safely and Effectively [Link]
• NPSA resources to support implementation of safer practice notice Using Bed Rails
Safely and Effectively [Link]
• NPSA (2007) Slips, Trips and Falls in hospitals [Link]
• NICE (2004) Falls: the assessment and prevention of falls in Older People.
• BS EN 50637:2017 “Medical electrical equipment. Particular requirements for the basic
safety and essential performance of medical beds for children”.
• BS EN 60601-2-52: 2010+A1:2015 “Particular requirements for the basic safety and
essential performance of medical beds”.

10. Document control (external)

To be recorded on the policy register by Policy Coordinator
Date of approval: Virtual approval by medical devices group – concluded by email
by 29th Dec 2021 (to be minuted at medical devices group
meeting 12th Jan 2022)
Next review date: 29 December 2024
This document replaces: CLIN-0047-v6 Bed rails - procedure for safe and effective use
This document was approved Name of committee/group Date
by:
Medical devices 29 December 2021
committee
This document was ratified by: Name of committee/group Date
n/a
An equality analysis was 21 December 2021
completed on this document
on:
Document type Public
FOI Clause (Private
documents only) n/a

Change record
Version Date Amendment details Status
6 05 Dec 2017 Published

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6 Oct 2020 Review date extended to 05 June 2021 Published
6 06 July 2021 Review date extended to 05 Dec 2021 Published
7 29 Dec 2021 Full review with minor amendments. Approved
Amendments include transfer to new template
and minor wording changes throughout with
review of links and practice guidance.

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 Equality Analysis Screening Form

Please note; The Equality Analysis Policy and Equality Analysis Guidance can be found on InTouch on the policies page
Name of Service area, Directorate/Department Medical Devices Committee
i.e. substance misuse, corporate, finance etc.
Policy (document/service) name CLIN-0047-v7Using Bed Rails Safely and Effectively Procedure
Is the area being assessed a; Policy/Strategy Service/Business plan Project

Procedure/Guidance √ Code of practice

Other – Please state

Geographical area Trust wide

Aims and objectives To set standards in practice to ensure the delivery of patient care is carried out safely and
effectively by trust staff.
Start date of Equality Analysis Screening 12/09/2021
(This is the date you are asked to write or
review the document/service etc.)
End date of Equality Analysis Screening 21/12/2021
(This is when you have completed the analysis
and it is ready to go to EMT to be approved)

You must contact the EDHR team as soon as possible where you identify a negative impact.

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1. Who does the policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan benefit?

Trust staff and patients and those who care for them.

2. Will the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan impact negatively on any of the
protected characteristic groups below?

Race (including Gypsy and Traveller) No Disability (includes physical, No Gender (Men, women and No
learning, mental health, sensory and gender neutral etc.)
medical disabilities)
Gender reassignment (Transgender No Sexual Orientation (Lesbian, Gay, No Age (includes, young people, No
and gender identity) Bisexual and Heterosexual etc.) older people – people of all
ages)
Religion or Belief (includes faith No Pregnancy and Maternity No Marriage and Civil No
groups, atheism and philosophical (includes pregnancy, women who Partnership
belief’s) are breastfeeding and women on (includes opposite and same
maternity leave) sex couples who are married or
civil partners)
If this procedure is followed, it will prevent any potential for negative impact as there is mitigation included in the procedure to ensure that any
negative impact is reduced or removed completely.

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3. Have you considered other sources of information such as; legislation, codes of practice, best Yes
practice, nice guidelines, CQC reports or feedback etc.?

Sources of Information may include:

• Feedback from equality bodies, Care Quality • Staff grievances
Commission, Equality and Human Rights Commission, • Media
etc. • Community Consultation/Consultation Groups
• Investigation findings • Internal Consultation
• Trust Strategic Direction • Research
• Data collection/analysis • Other (Please state below)
• National Guidance/Reports

4. Have you engaged or consulted with service users, carers, staff and other stakeholders including people from the following
protected groups?: Race, Disability, Gender, Gender reassignment (Trans), Sexual Orientation (LGB), Religion or Belief, Age,
Pregnancy and Maternity or Marriage and Civil Partnership

Yes – Please describe the engagement and involvement that has taken place

We have consulted with a range of Trust staff with knowledge of bed rails and their use – working group and out for wide consultation
previously. This version contains minor changes for approval and will be approved by the medical devices group.

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No – Please describe future plans that you may have to engage and involve people from different groups

5. As part of this equality analysis have any training needs/service needs been identified?

No Please describe the identified training needs/service needs below

A training need has been identified for;

Trust staff No Service users No Contractors or other outside No

agencies
Make sure that you have checked the information and that you are comfortable that additional evidence can provided if you are
required to do so
If you need further advice or information on equality analysis, the EDHR team host surgeries to support you in this process, to
book on and find out more please contact team.

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Appendix 1 - Risk Assessment Tool for Provision of Bed Safety Rails
This assessment tool is an aid to assist your clinical judgement in making decisions about the safe and appropriate use of bed rails. It is not a prescriptive
scoring system.

NHS No _________________________________________

Client Name_____________________________________________DOB______________________Height_______________Weight___________

Ward/Unit______________________________________________________________________________________NHS No __________________

Assessor Name________________________________________Title_______________________________________Date_____________________
RISK ASSESSMENT CHECKLIST Risk Comments
Existing Equipment Y N
Have alternative measures been considered? e.g.
Using a mattress on the floor, High- low beds, Floor bed, Telecare devices,
Side wedges/ Posey wedges, Non-metal bed rails
Does the client have a wooden slatted based or metal framed (non-hospital Bed rails not suitable
type) bed
Does the client have a divan? Consider length, width and height See dimensions guide
What mattress is on the bed? Foam, sprung or pressure relieving?

What is the overall height of the mattress(s)?

Social Situation Y N Comments
Will the client be left in bed for prolonged periods of time during the day or
night?
Will the rails be in use day and night?
Assessment Checklist – The Client Y N Comments

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Has the client fallen out of bed and why?
Why is client trying to get out of bed?

Did the client and/or their carer request the Bed rails and why?

Do they have a medical condition that affects their sleeping position?

What is the client’s preferred sleeping position?
Can the client transfer into and out of the bed during the day and night?
Does the client need to get out of bed during the day and night?
Would the client be able to raise and lower the bed rails independently?
Is the client confused or agitated or present with challenging behaviour?
Is the clients head or body small enough to pass through and become See dimensions guide
trapped in the bed rails or any gap between the mattress and the rail,
headboard or footboard? Is the client within height recommendation for rail
considered (e.g. above 1.5m for most adult bed rails?
Does the client suffer from involuntary movement or seizures that may lead Do bumpers reduce risk of injury?
to limb strike?
Will the client attempt to climb over the bed rails or out of the bottom of the If yes do not issue
bed?
Does the client understand why and how to safely use the bed rails?

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Assessment Checklist – The Environment Y N Comments
Does the client use a mattress variator? Do not use bed safety rails with a mattress variator

Does the client use a pillow lifter? ? Risk of falling over rails when raised into a sitting position and /or
entrapment between pillow lifter and rail
Does the client have other equipment that may interfere with access to and
operation of the bed rails e.g. IV lines, catheters, wheelchairs, hoists?
Is there clear access to both sides of the bed? Create access
Assessment Checklist – The Carer Y N Comments
Can the carer follow instructions and demonstrate the ability to safely raise
and lower the rails and remove/attach bumpers?
Does the carer understand the importance of and be able to take
responsibility for monitoring the bed rails
Other Comments

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
OUTCOME OF ASSESSMENT
Y N Comments
Have alternatives to bed safety rails been considered/ trialled? Hi-lo bed, hip protectors, side wedges
Does the Assessment indicate the use of bed safety rails and bumpers?
Is the bed rail suitable for style of bed and size/ height of patient?
Is the client aware of their responsibilities?
Other Comments

Signature of assessor

………………………………………………………………………………………………………………………….

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Appendix 2 - Bed Rail Fitting Checklist
FITTING CHECKLIST Y N Comments
Do staff fitting bed rails have access to fitting instructions and are
competent in fitting rails?

Are all parts present and in good condition?

Are the spring clips fully engaged in the cross bars under the mattress?

Does the rail move away from the side of the bed?

Are there gaps that could cause entrapment (for children bed rails
maximum 60mm)?

Is the top rail 220mm above the top of uncompressed mattress? If less than
this an extended height rail is required.

Does compressed mattress create a gap with risk of entrapment?

Are bumpers air permeable and compatible with the bed safety rails?

Is there a gap between the bumper and the mattress?

Are all dimensions in accordance with safety standards as in Appendix 4,

cover at least 2/3rd of the length of the bed and fitted to both sides (MHRA).

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Are the bed safety rails compatible with the bed and type of mattress
(consider light weight mattress impact on bed rail stability, MHRA 2020)?

Is the rail fitted correctly and securely in the up position?

Has the client/carer been supplied with an Information booklet? Date

When to Re-assess
• If the bed or mattress is changed
• If the clients medical or mental condition has changed
• If the rail has been moved out of position
Date of Formal Review Assessment

To be completed by:

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
 Appendix 3 - WHEN TO USE BED RAILS Decision making flowchart

IS THE PATIENT AT RISK FROM FALLING OUT OF BED?

If any hazard is apparent, the device should not be used

YES NO Bed rails inappropriate and

should not be supplied

CONSIDER ACCEPTABLE ALTERNATIVES TO

Has the patient/family asked Is the patient unconscious Is the patient Is the bed & mattress BED RAILS:
for bed rails? or has a reduced level of agitated or confused combination appropriate • Use of variable height/ low bed
consciousness? and likely to fall out for use with bed rails and • Side wedges
bed rail bumpers? • Falls mat/ Additional mattress on the floor
YES • Mesh or netting bed sides
YES • Alarm Systems
YES YES
RISK ASSESSMENT SHOULD BE
Does the patient understand Bed rails and bed rail
Does the patient UNDERTAKEN
the purpose of bed rails? bumpers may be used Has consultation with
understand the purpose • Before ordering from
with caution. the patient/family • Following delivery
of bed rails and bed rail
bumpers? taken place? • Every three months
• When significant condition/environment
changes occur
YES NO YES
YES NO SAFETY CHECKS PRIOR TO THE USE OF BED
RAILS
Bed rails and bed rail • Risk of entrapment & damage to limbs
bumpers may be used with Bed rails and bed rails bumpers Is the patient able to Order bed • Risk of patient climbing over the top
caution and only with the may be used with caution and participate in decision rails and • Ensure the bed rail is compatible with bed
patient’s informed consent. with the patient’s informed making and give bed rail frame and mattress depth
Have alternatives been t informed consent? bumpers • Consider psychological effect or using bed
discussed? rails
• The supports must be fixed at the head end of
the bed, not the foot end
YES • Has the environment risk been reduced to AS
NO SAFE as reasonably practicable?
COMPLETE RISK ASSESSMENT
AND DOCUMENT
Ref: CLIN-0047-v7 Page 25 of 38 Bed railsdate:
Approved and 29
bed rail bumpers
December 2021 may be
Bed rails and bed rail bumpers may be
Bed Rails – Procedure for safe and effective use usedamended:
Last with caution, discuss2021
29 December with
used with caution and only with the family/carers, consider alternatives
patient’s informed consent
Appendix 4 - Bed rail dimensions and safe use of bed rails MHRA

See over page

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Bed rail dimensions in BS EN 60601-2-52:2010+A1:2015 Medical Electrical Equipment. Particular requirements for basic
safety and essential performance of medical beds (for adults).
Description Ref on New combined standard Notes
diagrams (see BS EN 60601-2:2010
below)
Height of the top edge of the side 1 ≥220mma a
Where a speciality mattress or mattress overlay is
rail above the mattress without used and the side rail does not meet ≥ 220mm a risk
compression assessment shall be performed to assure equivalent
safety.
Gaps between elements within 2 < 120mm
the perimeter of the side rail and
between the side rail and
mattress platform
Gap between head board and 3 <60mm c b
Side elevation between head board and side rail
end of side rail c
Most disadvantageous angle between head board
and side rail
Gap between foot board and end 4 <60 or >318mme d
Side evaluation between foot board and side rail.
of side rail
e
Most disadvantageous angle between foot board
and side rail
Distance between open end of 5 <60mm f
The gap between the open end of the side rail and
side rail(s) and mattress platformf head board is not relevant to this ID
Gap between split side rails 6 <60 or >318mmh g
when in flat position
h
When in most disadvantageous position
Gap between side rail and 7 Perform testi 120mm aluminium cone is positioned between
i

mattress in ‘plan’ elevation mattress and side rail to determine if gap is

acceptable or not

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Diagram of side view of bed with split side rails

Head board
Foot board

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Diagram of side view of bed with cantilever side rails

Foot board
Head board

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Diagram of bed in plan view

Head board Foot board

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
Bed Rail Dimensions in BS EN 50637:2017 Medical electrical equipment. Particular requirements for the basic
safety and essential performance of medical beds for children.
Diagram
Description BS EN 50637:2017 Notes
Reference
Fully enclosed openings within a side rail, head/foot
A1 <60mm
board, mattress support platform
Fully enclosed opening defined by the side rail, its
A2 <60mm7
supports and the mattress support platform
Partially enclosed opening defined by the head
A3 <60mm
board, mattress support platform and side rail
Except when gap
Partially enclosed opening defined by the foot board,
A4 <60mm between side rail and
mattress support platform and side rail
foot board is >300mm
Except when gap
Partially enclosed opening between segmented or
A5 <60mm between side rails is
split side rail and the mattress support
>300mm
Partially enclosed opening defined by lowest point of
a side rail, the adjacent side rail support and mattress
A6 <60mm
support platform, to the outside of the side rail
supports
Other openings defined by accessories (e.g. IV poles,
fracture frames) and side rails, head or foot boards
A <60mm
and or mattress support platform. Not shown in
figures.

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
 Diagram
Description BS EN 50637:2017 Notes
Reference
Distance between mattress support platform and the <40mm AND Angle between mattress support
lowest point of the side rail outside the side rail platform and side rail interface >75° over the entire
support AND The angle between the side rail and B range of mattress heights from minimum
mattress support platform at the range of the recommended height minus 2 cm to the maximum
mattress height defined by the manufacturer ± 2 cm recommended mattress height plus 2 cm.
Gap between head board and adjacent side rail C1 <40mm
Gap between segmented or split side rails with both
C2 <40mm OR >300mm
side rails raised
For a gap >300mm: the gap shall be >300mm or
<400mm for the entire vertical distance
For all medical beds except junior beds: gap between
side rail and foot board. Other openings defined by
accessories (e.g. IV poles, fracture frames etc.) and C3 <40mm
side rails, head board, foot board, and or mattress
platform
For junior beds: gap between side rail and foot board.
Other openings defined by accessories (e.g. IV poles,
C4 <40mm OR >300mm
fracture frames etc.) and side rails, head board, foot
board, and or mattress platform
For a gap >300mm: the gap shall be >300mm or
<400mm for the entire vertical distance
Region defined by side rail/head board/foot board Cone tool does not
D1 Perform test
and the mattress for cribs and cots sink below the

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
 Diagram
Description BS EN 50637:2017 Notes
Reference
mattress surface by
50% or more of its
60mm diameter.
Region defined by the side rail/head/foot board and Perform test OR Gap between side rail/head/foot
D2
the mattress for junior beds and oversize cots board and mattress <30mm
Cone tool does not sink below the mattress surface
by 50% or more of its 60mm diameter.

Note that 50637:2017 defines different sized beds: cots, oversized cots, cribs and junior beds. Please see the text of the standard for full
definitions or contact the manufacturer of a particular bed in your control that complies with this standard.

Compliance to this standard requires the use of specific measurement tools, rather than basic distance measurements alone. It is intended to
be used by manufacturers. For this reason, it is recommended that end users do not use solely these measurements as the sole basis for
evaluating suitability of a bed rail installation

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021
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Blank page

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 Appendix 5 – Approval checklist
To be completed by lead and attached to any document which guides practice when submitted to
the appropriate committee/group for consideration and approval.

Yes/No/
Title of document being reviewed: Not Comments
applicable

1. Title
Is the title clear and unambiguous? Y

Is it clear whether the document is a guideline,

Y
policy, protocol or standard?
2. Rationale

Are reasons for development of the document

Y
stated?

3. Development Process

Are people involved in the development

Y
identified?

Has relevant expertise has been sought/used? Y

Is there evidence of consultation with

Y
stakeholders and users?
Have any related documents or documents
that are impacted by this change been Y
identified and updated?
4. Content

Is the objective of the document clear? Y

Is the target population clear and

Y
unambiguous?
Are the intended outcomes described? Y

Are the statements clear and unambiguous? Y

5. Evidence Base

Is the type of evidence to support the

Y
document identified explicitly?

Are key references cited? Y

Are supporting documents referenced? Y

6. Training

Have training needs been considered? Y

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 Yes/No/
Title of document being reviewed: Not Comments
applicable
Are training needs included in the document? Y
7. Implementation and monitoring

Does the document identify how it will be

y
implemented and monitored?

8. Equality analysis

Has an equality analysis been completed for

Y
the document?

Have Equality and Diversity reviewed and

y
approved the equality analysis?
9. Approval

Does the document identify which

Y
committee/group will approve it?
10. Publication

Has the document been reviewed for harm? Y

Does the document identify whether it is

y public
private or public?
If private, does the document identify which
clause of the Freedom of Information Act 2000 n/a
applies?

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Bed Rails – Procedure for safe and effective use Last amended: 29 December 2021