30 American Nurse Today Volume 10, Number 1 www.AmericanNurseToday.com

An enclosure bed can be usedas part of a patient’s plan ofcare to prevent falls and pro-

vide a safer environment. This spe-cialty bed has a mesh tent connect-ed to a frame placed over astandard medical-surgical bed. Al-though it’s considered a restraintbecause it limits the patient’s abilityto get out of bed, an enclosure bedis less restrictive than other typesof restraints. It can be used as analternative when a vest restraintwould cause more agitation andwrist restraints aren’t appropriate.

My 750-bed academic medicalcenter became interested in the en-closure bed in 2007 as a way todecrease patient falls and patient-sitter costs. We’ve seen the enclo-sure bed have a calming effect onpatients and give them more free-dom than wrist and ankle re-straints. Our hospital rents the bed;for a 24-hour period, the dailyrental expense is much lower thanthe cost of a patient sitter. (See Alook at the enclosure bed.)

Indications Use of the enclosure bed hinges onthe patient’s behavior, so a patient-specific comprehensive assessmentmust be done. The bed may be in-dicated for patients who are at highrisk for falls; are confused, impul-sive, restless, or agitated; are unableto ask for assistance or respond toredirection; or who climb out ofbed when it’s unsafe to do so.

Other patients who might bene-fit from an enclosure bed includethose with Alzheimer’s disease orother types of dementia, traumaticbrain injury, seizure disorder, Hunt-ington’s disease, or developmental

delays. The bed also may be indi-cated for patients recovering fromstroke, as well as for patients withdelirium associated with alcoholwithdrawal who have completedtreatment for acute withdrawal.

Inclusion criteriaTo be considered for the enclo-sure bed, the patient must be athigh risk for falling and mustdemonstrate one or more of thefollowing:• impulsiveness• agitation• inability or unwillingness to ask

for assistance or respond to redi-rection

• unsteady gait• wandering behavior.

A history of falling alone isn’tenough to warrant use of the en-closure bed or other restraints.

Exclusion criteria Patients shouldn’t be placed in an

enclosure bed if they are violent,combative, self-destructive, suicidal,or claustrophobic. Although thebed has small holes for one or twoI.V. lines and an indwelling urinarycatheter, patients with multiplelines generally are excluded. If thepatient becomes increasingly agitat-ed, terrified, or distraught after be-ing placed in the bed, cliniciansmust reassess the situation and trya different intervention.

Evaluation periodBefore our hospital decided to addthe enclosure bed to our approvedspecialty rental inventory, staffnurses and other providers con-ducted an evaluation to identify pa-tient risk behaviors that could bemanaged in this bed. The hospitalconducted a 6-month trial of theenclosure bed, during which staffused the bed and completed anevaluation tool. The tool askedspecific questions about staff com-

Focus on...S

afe Use of Re

straints Enclosure bed: A protective and

calming restraint Learn about an alternative to more restrictive restraints.

By Jennifer L. Harris, RN, MS, NE-BC

A look at theenclosure bedThe enclosure bedshown here (manufac-tured by Posey Co.) isfor adults and children.A casing over the mat-tress is attached to thesides, preventing thepatient from slippingunderneath. The proce-dures used to elevatethe head of the bedand change bed heightare the same as thosefor a standard med-surg bed.

www.AmericanNurseToday.com January 2015 American Nurse Today 31

fort level with the bed, ease of use,family response to the bed, andwhether the bed met the patient’sneeds.

Education and implementationBased on staff feedback and posi-tive patient outcomes during theevaluation, the enclosure bed wasadded to potential interventions toprevent falls and to provide a saferenvironment for patients. Our facil-ity has developed processes to re-quest or order the bed, monitor thepatient while in the bed, and dis-continue the bed.

The enclosure bed was intro-duced as a type of restraint toproviders who have the authorityto order restraints. Staff nurses re-ceived education on indications forthe bed, how to operate it, anddocumentation requirements. Nurs-ing staff at the unit level workedwith provider teams to implementthe enclosure bed.

Education consisted of reviewingthe procedural checklist, watchingan instructional video and complet-ing a self-learning module on re-straint use. During the demonstra-tion on how to zip the panels anduse the locks on the zippers, nurs-es had the chance to get into thebed to see what it’s like.

Required processes Before an enclosure bed is request-ed, nursing staff must review withthe provider team the behavior thatputs the patient at risk for falls andinjury, as well as for impulsive be-havior that harm the patient orstaff. One example is an impulsivepatient with early-onset dementiawho is hitting and kicking at staff.

As with all restraints, an enclo-sure bed requires a provider re-straint order that must be renewedevery 24 hours. Before a patient isplaced in the bed, staff try less re-strictive options, such as distrac-tion, bed and chair alarms, reduc-ing stimuli, and moving the patientto a room closer to the nursing sta-

tion. Once the decision to use anenclosure bed is made, cliniciansmust educate the family about thebed, its function, the reason for us-ing it, how the panels are zippedand unzipped, and how the bedcontributes to a cocoon-like envi-ronment. If family members aren’tavailable in the hospital, the chargenurse contacts a family member byphone to explain the change in thepatient’s care.

Using a restraint flowsheet, nurs-ing staff document the patient’s re-sponse to the enclosure bed andthe frequency with which they metthe patient’s care needs during beduse.

When the patient’s behavior im-proves, the enclosure bed is dis-continued. The specialty bed coor-dinator is notified and the vendorpicks up the bed.

Placing the patient in the bedBefore using the bed, inspect it forproper assembly. Then unzip thebed and adjust the head of thebed. Once the patient has beenplaced in the bed, sit in a chairnext to the bed for a few minuteswith the sides unzipped to helphim or her get acclimated. Adjustthe head of the bed so the patientcan sit in it comfortably. Then zipthe sides and see how the patientreacts to the enclosure. If the pa-tient will be left alone, place a callbutton within reach.

The patient’s activity scheduleshould include getting him or herout of the bed multiple times aday. Staff should assist the patientto ambulate at least three timesdaily. The patient should sit in abedside chair for all meals, if ableto tolerate ambulation and activity.According to the Centers forMedicare & Medicaid Services’ Interpretive Guideline §482.13(e)(6), “a temporary, directly super-vised release…for the purposes of caring for a patient’s needs (e.g. toileting, feeding, or range-of-motion exercises) is not considered

a discontinuation of the restraint.As long as the patient remains under direct staff supervision, therestraint is not considered to bediscontinued because the staffmember is present and is servingthe same purpose as the restraint.”

OutcomesIn our hospital, the enclosure bedwas incorporated quickly into thesafety plan for med-surg patients.The adult med-surg nursing staffhas used the bed with more than200 patients. On average, patientsstay in the bed about 6 days; nopatient falls or injuries have oc-curred. In some facilities, using thebed decreases overall sitter expens-es. Our experience has shown aslight reduction in sitter hourswhen the bed is used.

Based on our positive experi-ences and patient outcomes, wewill continue to use the enclosurebed as an option for fall preventionand patient safety.

Several patients have been dis-charged from our hospital with aplan of care that included an enclo-sure bed. In the home, the bed canbe used for patients with agitationsecondary to dementia or for pedi-atric patients with significant chron-ic neurologic or behavioral prob-lems. The experience the familiesgained with the enclosure bed inthe hospital helped provide a safedischarge plan for several patients.

Involving staff with an initial tri-al of the bed, identifying appropri-ate patient criteria, and educatingstaff, patients, and families aboutthe bed’s benefits have contributedto successful implementation ofthis specialty bed. •

Visit www.americannursetoday.com/?p=18950 for information on caring for a patientin an enclosure bed, using the enclosure bedwith pediatric patients, and a list of selectedreferences.

Jennifer L. Harris is a senior advanced practice nurseat the University of Rochester Medical Center-StrongMemorial Hospital in Rochester, New York.

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