Bed Rails: Benefits, Entrapment Risks and Safer Alternatives

What bed rails are for

Bed rails, also called side rails or bed guards, are barriers attached to the side of a bed. They come in several forms:

• Full-length or half-length rails fixed to a hospital bed frame, often dropping down or folding when not in use.
• Portable or clip-on rails that fit under the mattress of an ordinary bed, with a leg or strap to hold them.
• Bed assist handles or bed canes, short handles fixed to the side of the bed to help a person sit up, turn and stand, without enclosing the person.
• Padded bumpers or covers that fit over rails.

Legitimate reasons to use a rail include:

• helping a person who is mobile but weak to turn over, sit up or push up to stand;
• helping a person to hold on while positioned on their side, such as for care;
• offering a reminder of the bed's edge for someone who is at risk of rolling but is otherwise safe;
• supporting a person with a physical condition, such as severe muscle spasms, as advised by a clinician.

Rails are not a fix for restlessness, confusion or wanderers; see bed safety for restless sleepers. They are also not a way to restrain a person.

The risks

Entrapment. The greatest danger is a limb, head or chest being caught in a gap: between the rail bars, between the rail and the mattress, between the rail and the headboard or footboard, or under the rail. A frail or restless person can slip through and become trapped, particularly if the mattress is thin, compressed or pushed to one side, or if the rail is loose. Entrapment can cause compression of the chest and neck and may be fatal. Many safety authorities have issued warnings about this risk.

Climbing over. A person who is confused, determined or restless may try to climb over the rail. This can mean a fall from a greater height than if they had simply stepped out, with a heavier landing. A rail that is a hindrance rather than a help can make confusion and agitation worse.

Restraint. Using rails to stop a person leaving the bed can count as restraint. Restraint is a serious step with legal and ethical implications, can be harmful, and may frighten and distress the person. It should not be done without a medical decision and consent where possible. See dignity and consent in care.

Injury from the rail itself. Bruising or skin tears from banging against hard rails, particularly in people with fragile skin, spasms or tremors.

Loss of independence. If a person can get out of bed alone but rails stop them, they may become more frail from lack of movement or have more accidents trying to get to the toilet.

Poor fit. Rails that are not made for the bed, are loose, bent or worn, or are fitted with wrong accessories, are hazardous.

Who may benefit, and who should not use rails

Rails may be useful for:

• people who are alert and understand how to use them, with weak muscles or pain who need a handle to turn or sit up;
• people who have been assessed as at risk of rolling out of bed through illness, while otherwise safe from entrapment;
• people with a bed height and mattress that allow safe fitting.

Be very cautious, and get professional advice, for:

• people with dementia, delirium or confusion, who may climb over or become trapped;
• people who are restless, agitated or have involuntary movements;
• very thin or frail people, whose bodies could slip through gaps;
• people with medical devices or tubes that may catch;
• people who try to get up independently to use the toilet.

In many care settings, rails are no longer used as routine, and a risk assessment is done before they are used.

How to check a rail for safety

If rails are used, check each of these before the person lies down, and regularly afterwards.

1. Fit. The rail must be designed for the bed and mattress. Do not use a rail meant for one bed on another. 2. Mattress fit. The mattress must be the right size and be firm enough, so that there is no gap between the mattress and the rail. A thick or soft mattress that compresses can change the gap. 3. Gaps. Check the space between bars, between the rail and the head and foot ends, and between the rail and the mattress. Manufacturers and safety bodies set maximum gap sizes, such as limits meant to prevent the head, neck or chest passing through. Follow the instructions of the manufacturer and ask your therapist or supplier for the specification. If a fist or a small head could pass through, the gap is too large. 4. Stability. Push, pull and shake the rail. It should not move, shift or flex. Check the locking mechanism, bolts, clamps and straps. 5. Height. The top of the rail should stand well above the mattress surface, according to guidance, but this depends on the mattress thickness. 6. Edges. No sharp edges or loose parts. 7. Release. Know how to lower or remove the rail quickly in an emergency or to provide care. 8. Condition. Replace rails that are bent, cracked, rusted or have missing parts. 9. Padding. If padding is used, check it does not add thickness that creates gaps, and that it does not become a hazard itself. 10. Check often. At least daily when in use, and after any change such as moving the bed or replacing the mattress.

A rail attached to a hospital bed is usually safer than a portable one on a domestic bed, as long as both bed and rail are intended for one another.

Safer alternatives to consider

Before using rails to prevent falls, think about what the real problem is.

• Lower the bed. A low bed, lowered to near floor height, means a fall is shorter, and a crash mat reduces injury. See bed choices for dementia.
• Floor mats. A soft crash mat beside the bed cushions a fall. Mats can be trip hazards for people who walk, so use them only when the person is in bed or at risk of rolling out.
• Bed handles or assist bars. A bed cane or handle gives something to hold to sit up and stand, without enclosing the person.
• A wider bed or bolsters. A wider surface or soft edge bolsters (properly fixed) can stop rolling.
• Raised edge mattress. Some mattresses have a firm edge or raised sides to define the sleeping area, in line with the bed.
• A suitable bed height so feet touch the floor; see bed height and getting out of bed.
• Sensors and alerts. A bed or chair sensor, motion sensor or door sensor alerts carers when someone gets up; see door sensor guide and night safety for a parent alone.
• Regular toileting and checks. Many falls happen when a person is trying to get to the toilet; see bladder training and timed toileting and bedside commode and urinal routines.
• Treat causes. Pain, hunger, thirst, noise, light, medicines and infection all cause restlessness. Ask a doctor to review.
• Night lighting. A night light helps people find their way; see motion-sensor night lights.
• Closer supervision. Sleeping nearby, using a baby monitor, or sharing night duty; see night-time caregiving routines.
• Positioning aids to keep a person on their side; see positioning a bedridden parent.

Using rails with dignity and consent

If rails are used, tell the person why, and ask their view. For a person who lacks capacity to consent, the decision should be made in their best interests by the family with the doctor, and reviewed regularly. Document the reason, the type of rail, the checks and who agreed. Do not use rails because of a shortage of carers. Offer to leave the rail down when someone is with the person.

When to ask a professional

Ask a doctor, occupational therapist or physiotherapist to assess whether rails are suitable, especially for a person with dementia, confusion, restlessness or frailty. A nurse can show how to check and use rails safely. The supplier should supply the manufacturer's safety instructions and the correct rails for your bed. Call an ambulance immediately if someone is trapped or injured. Get urgent medical care if a person has fallen from bed, is injured or shows new confusion.