Standards of Medical Care Based on Consensus Rather than Evidence: The Case of Routine Bedrail Use for the Elderly

Abstract

An 88-year-old male patient wrs found on his hands and knees on the floor beside his bed. The bedrails were up."-From an indent reporr fikd b-j a nurse at the Stillman Infirmary, University Health Sovices, Haward Uniuersity, in May 1980. F inding elderly patients lying on the floor beside their beds despite the presence of elevated bedrails seems paradoxical: how can a patient fall out of bed when the bedrails are up? Surprisingly, this paradox constitutes one of the leading incidents plaguing hospitals in the United States today.' It exemplifies a much larger problem created, we believe, by the uncritical adoption of measures designed to enhance patient welfare, but which may in fact undermine it. This article documents our ~~~ ~~Dr. Rubenstein is Physician and Chiefof the Allergy Clinicat University Health Services at Hanvlrd Uniwrsity in Cmnbndge, Masahusetts. Ms. Miller is Profemr of Law at Boston University School o f h w , in Boston, Marsachusetts. Dr. Postel is Deputy Director, Chief of Professional services, and Chief of Medicine at Uniuersity Health Services of Haward Uniuersity. Ms. Euam is Superuisor of the Inpatient Nursing Service, Stillman hfirmau, Qt University Health Services of Harvard Uniwrsity. The authors greatly appreciate the mistance provided by the Committee on Qualio Assurance and Utilization Rwiw at Haward's University Health Seruues; Judith S. Rubewein, Ed.D., educational comltanr; and the nurses of Stillman Infirmary.

Side Rail Use and Bed‐Related Fall Outcomes Among Nursing Home Residents

“…An early descriptive study evaluating the effectiveness of side rails in fall prevention found that among 16 hospitalized adults who fell from their beds, side rails were raised in 14 (88%) of the cases 2 . In numerous studies of falls and injuries, researchers have noted a significant incidence of falls and injuries with side rail use, 3–11 and several editorials and reviews of the falls literature discourage their use 12–17 .…”

Physical Performance Measures That Predict Faller Status in Community-Dwelling Older Adults

“…The most serious consequence of a fall is death due to the fall itself or due to complications from the fall. In fact, 50% of older adults who are hospitalized for a fall die within one year of the fall (20). A second serious consequence of a fall is a debilitating injury, such as a hip fracture.…”

MODELS OF GERIATRIC PRACTICE: Progress Toward a Restraint‐Free Environment in a Large Academic Nursing Facility

“…Second, we did not include data on the prevalence of bedrails. Interpretive HCFA regulations regarding bedrails are currently undergoing change in New York State, and studies to determine the effect of bedrails on accident prevention are needed 10 . A third limitation is that we present a descriptive study rather than a controlled clinical trial demonstrating safety of restraint reduction.…”