Side Rail Silliness

Posted By Patricia Ramsey, RN on Sep 6, 2014 in Basic CNA Principles, Healthcare Laws | 1 comment

Side rails must be used to promote safety.  Right? I mean, everyone knows this is true. Ask anyone on the street. We have seen it in movies and on TV. Many nurses will even tell you that side rails are essential and should always be used.

The simple fact is that side rails are considered a restraint. “What?” you may ask. Let me explain. When you have a child and you don’t want them running around unattended, where do you put them? In a crib or a playpen. This is designed to keep them in a confined area – usually against their will. In a clinical setting, if you have a patient you don’t want moving around unattended, putting up the side rails can help keep them in bed.  Usually against their will. The difference here? Nothing…well except that the patient is an adult with the right of self-determination and independence. Putting the side rails up to keep a patient in bed interferes with the patient’s rights and is considered a restraint.

Let’s put this in perspective for you. At your home, you can get up and walk around anywhere and anytime you choose. Want to go to the bathroom? Get a drink? Grab the remote? All allowed. At any time. Midnight snack? Sure! No one is standing there saying, “No, you can’t” or “It’s not safe” or “You might fall”. No matter your physical ability or current mental state, you can determine the actions that you think are appropriate for yourself and choose to take those actions because you are the one that will suffer the consequences. Now, take that same person (you) and put them inside a medical establishment and all of a sudden OTHER people want to determine what you can and cannot do. Most people will not sit still for such treatment. After all, you are an adult and have been taking care of yourself for YEARS. How dare someone else think they can do a better job? Very few people like being treated like a child once they are an adult.

But it’s for safety! I hear your argument. It’s been the same argument for years. We all agree that we don’t want patients falling out of bed. But do side rails really prevent this? Let’s see. How many of you have a “falling out of bed” problem – outside of alcohol? Probably not very many. That’s because we develop spatial awareness during childhood. You probably moved from a crib into a “big-boy” or “big-girl” bed by the age of 2. You probably mastered the art of sleeping in this bed by age 3 without falling out. And you’ve been sleeping safely in a bed ever since. But is that because it is YOUR bed and you are just used to it? Do you ever nap on the couch? Go to a hotel? Sleep at a friend’s house? And do you manage to stay in THOSE beds while sleeping? Yep, you have mastered spatial awareness – meaning you can sleep pretty much anywhere safely because your brain is still aware of the space around you – even when you are sound asleep. So, just because a patient is in an unfamiliar bed doesn’t mean they need side rails to keep them there. Most people can do that all by themselves. Even asking a patient to turn on their side does not require side rails…most people can turn on their sides without safety devices like side rails and still manage to stay in bed. Go ahead and try it…I’ll wait. See? You probably shifted your weight to the middle of the bed subconsciously so that you were not near the edge.  Neat, huh?

But not all patients fit this profile. Patients may not be their normal selves when they are in a hospital or healthcare facility. So what about those patients who DON’T have spatial awareness – those that have dementia or are on medications or are confused or have limited mobility? There are a million reasons that these patients may need special care. But the point is that these people need SPECIAL care. Not routine…SPECIAL. This specific situation would be identified by the nurse and a care plan would be developed to direct the staff on the best method to promote safety for this person. Maybe that patient’s care plan might say to ambulate the patient with assistance when they get restless. Or it may instruct the staff to provide activities until later in the evening. The care plan may instruct caregivers to use side rails DURING a skill to prevent a patient from falling (especially with immobile patients). Every situation is different and would require a patient-specific plan (see the article on care plans here for more information on this topic).

If the RN thinks that a patient requires side rails for safety when there is no caregiver at the bedside, they must get a doctor’s order. That’s right – all side rails require a doctor’s order once a caregiver leaves the bedside. Since they are considered a restraint, they cannot be used without professional collaboration and oversight. What’s more, the prescribing doctor must come in and physically examine the patient within 4 hours of providing the order and the patient must be checked on every 15 minutes (with appropriate documentation) and released from the restraint every 2 hours for feeding, elimination or other activities of daily living. With this amount of oversight and legal requirements, side rails are not used very often. And nurses are encouraged to find creative alternatives to side rails that do not restrict mobility or independence but still encourage safety.

So putting those side rails up on a patient’s bed after care has been completed is not allowed. And that patient that wants to wander at 2am? Yep, allowed to do so.

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