The practice of using bilateral, full-length (or four halflength) siderails for nursing home residents currently is questioned by policy makers, advocates, and clinicians. As nursing homes work toward meeting the Health Care Financing Administration's (HCFA) mandate to examine siderali use, administrators and staff need to implement interventions that support safety and individualize care for residents. The HCFA's guidelines specifically direct nursing homes to develop care plans that target residents' individual safety needs (HCFA, 1997).
The five categories of problems that often result in siderali use are:
* Memory disorder.
* Impaired mobility.
* Injury risk.
* Sleep disturbance.
This article describes interventions that foster safety while in bed or when exiting from bed, and gives rationale for their selection. The authors believe no one intervention represents a singular solution to fall prevention. Rather, a range of interventions tailored to individual needs should be employed. The Table provides a list of interventions. A variety of interventions that increase the ability to transfer independently and safely, with minimal reliance on alarms requiring staff vigilance and assistance, are recommended strongly.
ROLE OF MEMORY IN BED SAFETY
Ability to exit safely from bed depends on mobility and memory skills. Approximately 45% of nursing home residents have impaired memory (Cowles, 1996). Siderails are used mosdy with this group (Miles, 1996; O'Keeffe, Jack, & Lye, 1996). The anticipated effect of siderali use is to remind memory-impaired residents to stay in bed or to seek assistance when getting out of bed. Unfortunately, many memoryimpaired older adults view siderails as barriers, rather than reminders.
Memory is not a singular process. Researchers currently are classifying memory as declarative and procedural (D'Esposito & Alexander, 1995; Zola-Morgan & Squire, 1993). Declarative memories are considered to be the "what" of knowledge, while procedural memories are thought of as the "how to" of memory.
Procedural memory may be spared in many neurodegenerative disorders, such as Alzheimer's disease (Danner, Beck, Heacock, & Modlin, 1993; D'Esposito & Alexander, 1995). It is more important for older adults with dementia to remember how to use devices (frequently referred to as carry over) than to describe a specific technique. Thus, to assess carry over, one may ask for a demonstration, versus asking, "What did you do with the walker yesterday?". To promote procedural memory, repetition and consistency in use of a device or technique will encourage carry over and enhance safety. This requires aroundthe-clock use of assistive devices, rather than episodic use during prescribed therapy sessions. Although rehabilitation modalities are critical components of restraint-free care (Patterson, Strumpf, & Evans, 1995), they are underused because of false assumptions about efficacy for cognitively impaired older adults.
The ability to move in bed and to transfer and ambulate safely is critical to prevention of falls and serious injuries. Mobility in bed can be facilitated by a trapeze if there is full shoulder mobility and adequate upper extremity strength. Transfer enablers attached to or adjacent to the bed require less range of motion of the shoulder joint. An OT should be consulted regarding a trapeze, transfer enabler, half or quarter siderails, and prescription of upper extremity strengthening exercises. Siderails (of any length) with widely spaced vertical bars, or siderails not situated flush with the mattress have been associated with asphyxiation deaths because of rail and in-bed entrapment and should not be used (Parker & Miles, 1997; Todd, Ruhl, & Gross, 1997). Any type of transfer enabler also should be evaluated for potential entrapment problems. For those who cannot move in bed, call bells that are sensitive to very light pressure are an effective means for seeking assistance for those with appropriate cognitive capacity.
Transferring safely in and out of bed requires upper and lower extremity strength, and knowledge of correct transfer techniques. In both situations, evaluation and treatment by physical therapists (PT) and OT may be necessary. Additionally, recreational therapies such as dancing and tai chi have demonstrated effectiveness in promoting balance and coordination (Wolf et al., 1996). Several environmental interventions also can promote safe transfers. Mechanical support for transfers includes bed grab bars, bed handles attached to the bed frame or mattress, transfer pole with or without a weight-bearing support bar, and upper half or quarter siderails with narrowly spaced vertical bars and specifically designed to promote transfer. These devices should be placed on residents' stronger side. Generally, residents should transfer out of bed toward the stronger side and return toward the weaker side. If a fall should occur, residents then will be cushioned by the bed. It also is more difficult to rise from a highly compressible mattress. A firm mattress or a board placed under the mattress can facilitate standing. Folding bed boards are hinged to follow the contours of hospital beds. Bed wheels should be locked or removed to promote stability.
INDIVIDUALIZED INTERVENTIONS TO PREVENT BED-RELATED FALLS
Bed height is crucial to safe standing. Bed height is the distance between the floor and the top of the mattress, with a resident sitting on the mattress. Although no reports of optimal bed height could be located, studies of chair height suggest a seat height that is approximately 100% to 120% of the lower leg length facilitates rising (Alexander, Koester, & Grunawalt, 1996; Weiner, Long, Hughtes, Chandler, & Studenski, 1993). Increased seat height requires less knee extension, forward leaning, and strength of lower extremity muscles. The lowest standard bed height in most American nursing homes is approximately 21 inches, which is a height best for residents with a lower leg length of 17 to 21 inches. The authors measured lower leg lengths of 233 residents in one nursing home and found 75% of residents had lower leg lengths of less than 17 inches. Low beds (approximately 14 to 20 inches above the floor, including 6 inches for the mattress) are becoming readily available. Beds can be manually, hydraulically, or electrically adjusted to a range of heights between 14 and 26 inches, and should be individualized to promote transfers. Very low beds (7 to 13 inches above the floor, including 6 inches for the mattress) may place residents too close to the floor for safe standing (Donius & Rader, 1996). The selection of mattress should be based on recently published safety recommendations proposed by Parker and Miles (1997) to prevent siderail-related injuries and deaths.
A nonskid rubber-backed rug or bath mat placed at the side of the bed or near the bathroom also promotes stability when standing. For residents who require human assistance, an open intercom between the residents' rooms and the nursing station, or the use of nursery monitors facilitates staff-resident communication. Staff awareness of residents at risk for falling may be enhanced through a fall prevention system such as "spot the dot." Color-coded "dots" placed on room doors of at-risk residents remind staff to observe residents whenever they pass their room. Other residents at high risk for falls may benefit from pressure-sensitive or position-changing alarms that alert staff when unassisted attempts to get out of bed occur. However, alarms require adequate availability of staff to respond to residents needing or wishing to get out of bed.
Residents who are unable to transfer safely because of dizziness or postural hypotension should be evaluated by a nurse practitioner or physician to determine etiology. This includes a careful medication review, as well as instruction of careful transfer to the toilet, rising slowly, and prevention of the Valsalva's maneuver.
Inability to ambulate safely secondary to lower extremity problems of pain, weakness, sensory impairment, limited range of motion, or contractures usually requires evaluation by a physician, nurse practitioner, or PT or OT. Pain management includes both administration of analgesics and other treatments (e.g., heat). Evidence exists of inadequate pain treatment in older adults with dementia, and therefore, routinely scheduled (not p.r.n.) analgesia is recommended strongly (American Geriatrics Society Panel on Chronic Pain in Older Persons, 1998). Weak muscles require reconditioning, strengthening, and range of motion exercises. Prescription of assistive devices include aides such as walkers with wheels that are easier to push. Limited joint mobility may be reversed with stretching exercises performed during rehabilitation sessions and regularly on the nursing unit, as part of the nursing home's restorative nursing program. For other individuals, orthotics, individually fitted by PTs, may promote safe ambulation. Unit-based walking programs in nursing homes have improved endurance (MacRae et al., 1996).
Occasionally, residents slip and fall because floor surfaces or footwear lack adequate traction. Antiskid acrylic floor wax, nonskid rugs, and skid-proof strips near the bed can prevent slippage. Residents should be reminded to use footwear, especially low-heeled shoes with good traction, when ambulating to the bathroom. For individuals who cannot remember to wear slippers, skid-proof slippers or socks may need to be worn in bed. In one study of a nursing home dementia unit, 38% of falls were attributed to slippage on urine. Use of treaded slipper socks in bed reduced falls at night by 9% (Meddaugh, Friedenberg, & Knisley, 1996). Residents with foot problems should be referred to a podiatrist for treatment or prescription of appropriate bedtime footwear.
Low-lighting also contributes to fall risk. Some residents sleep undisturbed with lights on in the bathroom or with nightlights near the bed or bathroom. Increased accessibility of lighting, with a pull cord close to the bed or a bedside light which is sensitive to gentle touch, may be used. Motion-sensitive lights that automatically respond to movement are helpful in providing light, especially with cognitively impaired residents, and in alerting staff. Low buff on waxed floors reduces problems with glare.
Difficulty negotiating between bed and bathroom can be remedied by rearranging furniture and other objects (e.g., rolling tray tables) to create obstacle-free paths or compensate for specific physical problems (e.g., central vision loss because of macular degeneration). For example, use of a siderali on a resident's weaker side encourages only one path to the bathroom. If used, the unilateral siderali should be a full siderali only, with narrow-spaced vertical bars. Two half siderails on the same side are not recommended because individuals have slipped through the space between the head and foot rail and died as a result (Food and Drug Administration, 1995; Parker & Miles, 1997; Todd et al., 1997). Other measures such as outlining a path to the bathroom with fluorescent tape that contrasts with the floor and walls, reducing the distance to the toilet by moving the bed closer to the bathroom or commode, and providing a rest stop (e.g., a chair placed midway between bed and bathroom) may facilitate safer ambulation. The ability to understand verbal or visual reminders are particularly important skills. For example, notes reminding residents to ask for help are inappropriate for individuals who can no longer read or process written material. Instead, placing a walker next to the bed often promotes its use. An illustration of a toilet on the door of bathroom is far more effective than the word "toilet" because ability to read is lost with many forms of dementing illnesses. Using a "stop" sign or material and vinyl strip across doorways, and knob locks may reduce spatial disorientation.
After reaching the bathroom, residents may encounter difficulty in transferring on and off the toilet. As with bed height, toilet height should be approximately 100% to 120% of lower leg length. An occupational therapist (OT) should be consulted to fit a secured raised toilet seat or grab rails. Skid-proof strips near the toilet and accessible, glare-free light help prevent falls. Residents must be aware of proper transfer techniques and prevention of Valsalva's maneuver. An OT or PT can teach residents or nursing assistants exercises to improve transfer abilities, such as strengthening of hip extensorabductor and ankle plantar-flexor muscles. Providing easily removable night clothing, especially for residents with limited manual dexterity, may be helpful. An intercom or alarm cord in the bathroom will alert staff of potential or actual falls. Contrasting colors for commode seat and sink may reduce injury risk in residents with impaired vision.
Residents at high risk for fall-related injuries from bed "may benefit from siderails, unless he or she is likely to crawl over it" (Donius & Rader, 1994, p. 26). Because siderails add 2 feet to the potential fall height, likelihood of injury is increased (O'Keeffe et al., 1996). Bed bumpers on mattress edges, full body-length pillows, regular pillows, children's swimming noodles (i.e., foam tubes approximately 3 inches in diameter and 3 to 5 feet in length), or rolled blankets under the mattress edge remind residents of bed perimeters without adding height to the bed. Also, unlike metal siderails, these interventions do not cause skin trauma or far more serious consequences (Donius & Rader, 1996).
For residents who are unable to stand safely but who accidentally may roll out of or unsafely exit from the bed, a bed height less than lower leg length is recommended. It may be appropriate to place the mattress directly on the floor or to use platform beds rising just a few inches off the floor (Rader, 1995). Very low beds are between 7 and 13 inches above the floor, including 6 inches for the mattress, and are not meant to facilitate transfers. Moreover, because very low beds make it difficult for staff to assist residents, staff need proper training in body mechanics to prevent personal injuries. Recently, beds that can be electrically adjusted from 23 inches down to 7 inches above the floor have become readily available. More expensive options include low beds that can be adjusted manually, electrically, or hydraulically to a height of 14 to 16 inches for chair transfer, as well as to 26 inches for staff comfort when assisting residents.
The risk of fall-related serious injuries is increased when falls occur on hard surfaces. Flooring specifically designed to reduce the impact of falls also reduces the likelihood of hip fracture (Nevitt & Cummings, 1993). While egg-crate foam mattresses can be placed near the bed to cushion falls, they are difficult to stand on safely and to clean. The preferred bedside cushion is flat on both sides, is at least 2 inches thick, and has a nonslip surface. A standard physical therapy mat can be used, as well as mats which fold in half for easy storage, designed for this purpose. Hip pads also have reduced the incidence of hip fracture in individuals who fall (Lauritzen, Petersen, & Lund, 1993).
Alarms sensitive to resident position changes (e.g., from lying to standing) decrease falls (Innes, 1985; Widder, 1985). Pressure-sensitive alarms sound as shifts in weight occur on a pad placed over the mattress (Hendrich, 1988a, 1988b). Alarms require individualization of delay time to minimize the number of false alarms. A call bell attached to clothing will sound when residents rise and disconnect the cord from the socket. In addition to lighting residents' paths, motion-sensitive lights alert staff that residents are ambulating to the bathroom. A very expensive option is video monitoring of residents' rooms.
To reduce the likelihood of injuries (e.g., skin tears) in individuals with involuntary movements during sleep or individuals who choose to use siderails but are prone to injury, position residents in the center of bed and use body length pillows, siderali pads, or bumpers. Refer to an OT for molded foam cushions to promote proper joint positioning.
Traveling to the bathroom is the most frequently reported activityrelated risk factor for falls. Nocturia increases fall risk for several reasons, including sudden change in position, need to locate the bathroom quickly, and low or absent lighting (Stewart, Moore, May, Marks, & Hale, 1992). "Elimination rounds," intended to anticipate residents' bathroom needs, can reduce falls (Ross et al., 1992). Also, use of urinals and bedpans may reduce frequent trips to the bathroom. Reduce the distance to the toilet by placing a bedside commode (without wheels) on residents' strongest side, specific to the residents' size. Treaded socks and rubber-backed rugs can prevent falls because of slipping on urine. Residents should be referred for medical evaluation if the number of episodes increases in frequency or if residents display any other signs of urinary tract infection (UTI).
Incontinent residents get out of bed because their beds are wet. The etiology of the incontinence should be evaluated by the residents' primary care providers or a continence speciahst. In addition to individualized elimination rounds, promote a dry bed with extra-absorbent incontinence pads, bed pads, and incontinence covers for cushions or pillows.
Sleep disorders can result in frequent and unnecessary trips out of bed. Symptoms that contribute to sleep disruption, such as anxiety, depression, restless leg syndrome, paroxysmal nocturnal dyspnea, and sleep apnea, require careful evaluation (Vitiello, 1997). Because several medications have been associated with sleep impairment, a thorough pharmacologic review should be performed by primary care providers. Long-term use of sedative hypnotics may exacerbate sleep disturbances and depression. In addition, poor sleep habits, such as excessive daytime napping, lack of regular exercise, infrequent daylight exposure, and caffeine overuse, can alter normal sleep patterns (Vitiello, 1997).
Some sleep problems simply are because of lack of comfort or inability to relax. Environmental white noise can be used to promote relaxation and sleep. Researchers using white noise report a significant reduction of agitation in nursing home residents (Burgio, Schilley, Hardin, Hsu, & Yancey, 1996). Based on the individual residents' preferences, music, talk shows, or other radio or television programming may promote sleep. Music with a heartbeat-like rhythm (e.g., lullabies, classical music) can promote restfulness. For individuals who find it difficult to sleep alone, a body-length pillow may be helpful. Residents' comfort in bed should be evaluated critically, with consideration of the mattress for firmness and quality, as well as any need for egg-crate, air mattress, or sheepskin mattress pads. Specific positions may promote comfort (e.g., side lying with bent knees for individuals with back pain). Pillows or cushions and leg separator pads can be used to facilitate positioning. For individuals with significant peripheral vascular disease, the use of heel pads or a bed cradle (i.e., metal or plastic frame placed at the foot of the bed; the top sheet and blankets are placed above the cradle) may be preferred. Appropriate, scheduled pain management also will promote comfort and facilitate sleep.
Until recently, use of full bilateral siderails was considered a routine and necessary intervention to prevent bed-related falls. However, current research demonstrates siderails may lead to serious injuries and death (Feinsod, Moore, & Levenson, 1997; Parker & Miles, 1997; Todd et al., 1997). Siderali reduction, similar to other physical restraints, requires attention to individualized assessment and careful selection of interventions tailored to promote resident safety and quality of life. Simply removing siderails without addressing residents' underlying needs, including, but not limited to, the five categories of problems described in this article, is substandard practice. Individualized assessment, or knowing the patient, means evaluating residents' risk factors for falls as well as assessing residents' typical response patterns (Evans, 1996). Individualized intervention implies a decision-making process with choices addressing residents' needs, acknowledging the uniqueness of the individuals, and promoting humane, dignified care practices (Happ, Williams, Strumpf, & Burger, 1996). The following case studies exemplify the process of individualized assessment and care.
CASE STUDY 1: AT RISK FOR FALLS BECAUSE OF RECENT STROKE
Mrs. Smith"'', a 72-year-old nursing home resident, has hypertension and a recent left cerebrovascular accident, resulting in right hemiparesis, aphasia, and dysphagia. Despite urinary urgency, she usually can ambulate independently with a walker and transfer to and from the bed and toilet. One night she is found sitting on the floor in the bathroom, complaining that she slipped on urine. She is assisted back to bed and noted to be free of injury. All four half rails are raised, and a call bell is placed within reach in an effort to limit future attempts to get out of bed unassisted. She verbalizes anger regarding the siderali use because it makes her feel dependent on the staff. A comprehensive, interdisciplinary assessment finds she has had an extension of her stroke with increased left hand and leg weakness and left foot drop, and laboratory results reveal UTI. After the UTI is resolved, her urgency incontinence persists, and a timed voiding program to anticipate her needs is initiated.
A left leg brace is used per the PT to compensate for the left ankle weakness. Independent commode transfers using only the upper right half rail is recommended by the OT evaluation. A commode is placed at Mrs. Smith's left bedside at night to eliminate the risk of slipping on urine and the need to put on the brace.
Interventions to promote safe transfers include bed height adjusted to her leg height; a mattress board used to increase firmness; a nonskid, rubber-backed rug placed at bedside; raised-tread socks worn to bed; and a cordless press-on light located on the bedside table. A PT/OT exercise and transfer program, with written instructions for resident and staff regarding strengthening and balance, is initiated. This plan is meant to promote safe, independent toileting. She no longer has to communicate with staff verbally or by call bell to use to the bathroom.
CASE STUDY 2: HIGH RISK FOR SIDERAIL-RELATED FALL AND INJURY
Mrs. Rand, who is 93 years old, was admitted to the facility 6 months ago with contractures of all her major joints; severe dementia; history of multiple strokes, arthritis, and osteoporosis; incontinence of bowel and bladder; and requiring complete assistance with all her activities of daily living. Her nursing assistant reports Mrs. Rand frequently is combative when staff attempt to change her diaper at night. She has been found on the floor next to her bed numerous times, and many of these falls have resulted in skin tears and facial lacerations. Staff placed both full-length siderails in the up position, with vinyl pads on them to prevent falls and injuries. However, Mrs. Rand continued to fall, and last week, she broke her hip. Because of her contractures and state of health, she is not a candidate for surgery. None of her falls have been observed, and it is assumed she falls from the bottom part of the bed. Mrs. Rand is given an anti-anxiety agent at hour of sleep in an effort to reduce her combativeness with evening and continence care.
Because Mrs. Rand does not have the potential to transfer or walk independently, the physical examination focused on documenting her contractures and her response to range of motion of her joints. Mrs. Rand withdrew her limb, rapidly blinked her eyes, grunted, and then attempted to hit the examiner. Environmentally, the height of her bed in the low position was measured to be 23 inches from the linoleum floor.
It was concluded Mrs. Rand was:
* At high risk for siderali and fall-related injuries from bed because of unsafe behaviors, high bed position, and osteoporosis.
* Receiving inadequate pain management for her hip fracture, arthritis, and contractures.
* Receiving inappropriate use of an anti-anxiety agent.
Because bilateral, full-length, padded siderails were an ineffective measure, her standard bed was replaced with an electrically controlled, adjustable-height bed that places her approximately 7 inches above the floor. Mats were placed on each side of the bed. Body pillows were used on both sides. A referral to the nurse practitioner resulted in an order for Ibuprofen 400 mg every 6 hours and a tapering reduction schedule of her anti-anxiety agent. Mrs. Rand's response to this intervention was monitored with a pain assessment tool for nonverbal individuals. She has not had any injuries in the past month. The staff reports her episodes of combativeness have been reduced greatly.
These cases demonstrate use of bilateral siderails can be reduced safely with nursing home residents. The assessment process and the rationale for use of each fall prevention intervention needs to be documented carefully (Foltz-Gray, 1998). Similar to physical restraints, siderails have been viewed as a singular solution to prevent bed-related falls, although this has never been proven scientifically (Capezuti, Strumpf, Evans, & Maislin, 1998, 1999). Bed-related falls occur because of myriad problems and, thus, compel nurses to employ a variety of individualized interventions (Table). Reduction of siderails requires administrative support, both through policies that reflect a restraint-free, or at least minimal restraint use goal, and financial resources to purchase new equipment. Although most of the interventions suggested in this article cost relatively little, interventions for those at high-risk for injury (e.g., low bed) can be expensive acquisitions. Research demonstrating cost savings from avoidance of siderail-related injuries, coupled with effective prevention of fall-related injuries from bed, is needed to encourage nursing homes as well as payers (e.g., Medicare, Medicaid, managed care companies) to embrace significant siderali reduction (Bum, 1999).
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INDIVIDUALIZED INTERVENTIONS TO PREVENT BED-RELATED FALLS