The Cost of Reducing Bed Side Rail Use

Abstract & Commentary

By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California. Dr. Ferris reports no financial relationship to this field of study.

Synopsis: Intensive intervention using Advance Practice Nurses reduced the use of side rails on nursing home beds and lowered the rate of bed-related falls and injuries.

Source: Capezuti E, et al. Consequences of an intervention to reduce restrictive side rail use in nursing homes. J Am Geriatr Soc. 2007;55:334-341.

After baseline assessments of bed side rail use in 710 residents of four urban nursing homes during late evening and bedtime hours, consent was obtained for individual evaluation of 80% of the 376 residents who had side rails applied. A master's prepared gerontological Advanced Practice Nurse (APN) conducted individual evaluations and worked with nursing staff and interdisciplinary teams including physicians, social workers and physical therapists, spending 3-6 months at each home. A resident-specific intervention care plan was prepared and presented to the unit staff, including meetings with each facility's nursing director. Educational sessions were provided to each nursing shift at all four institutions and to facility committees, including the quality improvement committee. The APN also participated in each resident's multidisciplinary care conference, and worked with administrative staff to develop purchasing alternatives to side rails.

Post intervention assessments at one month and one year after completion found a 51% reduction in the use of restrictive side rails, accompanied by a statistically significant reduction in the bed-related falls rate from 0.115 to 0.061. Bed-related serious injuries decreased from nine to five after the intervention.


While it might seem logical that utilizing side rails for confused nursing home residents would protect them from falling out of bed, geriatric research has consistently shown this to be false. In fact, the use of side rails actually increases the number of falls and even deaths as residents try to climb over them and become entrapped. Over the past 21 years the FDA has collected 691 reports of side rail entrapment resulting in death or injury, recently issuing guidelines for the manufacture of hospital beds associated with reduced risks of death and injury, and ways to assess existing beds.1

Despite the adverse outcomes of using bed side rails, it has proven very difficult to dissuade staff from continuing to use them. Numerous interventions and educational programs have been attempted, only to find later that the rails are still being used.2

This article reports a successful intense intervention involving Advanced Practice Nurses in a 3-6 month program, particularly if the institution's management supported the change. A tremendous effort was made to reduce a tiny number of injuries. With continued regulatory focus on this issue, it's likely that a huge amount of resources will have to be devoted to reducing side rail use until safer beds are manufactured.


1. U.S. Food and Drug Administration. Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (on-line). Available at Accessed May 11, 2007.

2. Sullivan-Marx EM, et al. J Am Geriatr Soc. 1999 Mar;47:342-348.