Capezuti (right) has approached the task of making bed siderails safer
by working with a variety of experts in health care, law, social work,
science, and engineering. Here Capezuti consults with Jennifer Coates,
an MSN-MPH student in gerontology, and Martha Niblack, a resident at Wesley
At any given moment
in a hospital or nursing home, an elderly patient risks falling from bed
and suffering a serious or fatal injury. Elizabeth Capezuti is doing everything
in her power to prevent that.
Ironically, the injuries she seeks to avoid are often caused by devices
meant to keep patients from harm. An internationally known research scholar
in gerontological nursing, Capezuti has questioned the routine usage of
bed siderails and other physical restraints in the care of frail older
patients. Her research focuses on developing nonrestraint interventions
to enhance patient mobility and dignity, and her efforts have led to new
guidelines governing hospital bed safety. Last fall, she brought her expertise
to Emory to assume the Independence FoundationWesley Woods Chair
in Clinical Gerontological Nursing Scholarship, supported by a previous
endowment to nursing from the Independence Foundation in Philadelphia
and by funding from Wesley Woods. Already, she is boosting interdisciplinary
research and benefiting students enrolled in the Gerontological Advanced
Practice Nurse Program.
One of the things I want to do at Emory is to be involved at all
levels, says Capezuti, who came from the University of Pennsylvania
School of Nursing. Im directing the GNP program, but I also
want to work with faculty to infuse more geriatric content into the undergraduate
and doctoral programs, so we can get students excited about the field.
Without more faculty role models, we are not going to get the number of
students and nurses that we need to care for our older population. Thats
why this new appointment is so important to me.
Blazing trails in long-term care
Capezuti knows what its like to get inspiration from faculty role
models. As a nursing undergraduate in the mid-1970s, she was inspired
by her own geriatrics instructors and chose to work in a nursing home
right after college. At the time, few in health care foresaw the coming
tide of changing demographics, with people age 85 and older now comprising
the fastest-growing population segment.
My background is unusual because there wasnt a lot of strength
in geriatric nursing when I entered the field, she says. When
I attended Herbert Lehman College in the Bronx, there were two women on
the faculty who would later become the leading experts in geriatric nursing
in the country. They loved working with older people and knew their work
was important. They were ahead of their time.
Capezuti followed in their footsteps. After earning her masters
degree, she joined Penn in 1984 as a geriatric nurse practitioner and
instructor. Among her colleagues were Neville Strumph and Mathy Mezey,
her former Herbert Lehman instructors who had moved to Penn.
Liz has been on the cusp of rising interest and specialization in
gerontology, says Strumph, now interim dean of nursing at Penn.
She is among the early stars educated at the masters and PhD
levels in gerontology who is making important contributions to the field.
Under her mentors guidance, Capezuti evolved as a nurse scholar
with interests in elder abuse and nonrestraint interventions to prevent
falls and injuries among older patients. Initially, she focused on removal
of vest and belt restraints, in which some patients became entangled and
died of asphyxiation. These interventions are not very dignified
or positive in keeping people mobile or active, says Capezuti. They
have just the opposite effect. I wanted to come up with new interventions
and test the ones we had to see how effective they were in promoting safety,
rehabilitation, and quality sleep, while preventing falls and injuries.
Her program of research grew, and Capezuti zeroed in on restraints used
at night, including bed siderails. Studies from the past 20 years clearly
show that elderly patients can entrap themselves in the rungs of a siderail
or between the mattress and siderail. Confused or in pain, some patients
try to get out of bed by climbing over the siderail, which adds 2 feet
to the height of a fall. Siderails have also been shown to contribute
to emotional stress, urinary incontinence, and infections.
Raising rails, reducing liability
To understand these outcomes, Capezuti went back to the root of problem.
Last year, she and Boston College nursing historian Barbara Brush searched
through archives around the country to learn how bed siderails came into
use. They found that nurses seldom used them before 1950 because rails
to be manually attached to the bed. This practice changed when manufacturers
began making hospital beds with affixed rails that nurses could raise
and lower easily. Widespread siderail use coincided with another phenomenonhospitals
growing concern over liability.
Patients and families were able to sue hospitals for malpractice,
Capezuti explains. Insurance companies began to look at falls from
beds and realized that if rails were raised, a jury was likely to decide
in favor of a hospital. Hospitals knew that using bed siderails reduced
their insurance claims, even though studies showed they werent effective
in preventing falls. Raising rails protected them from liability.
It wasnt until the 1980s that health care and government experts
began questioning this common practice and searching for suitable alternatives
that would assist patients. Rails were never designed to do that,
explains Capezuti. They were meant to impede people. We dont
want to keep people in bed. We want to get people mobile and out of bed.
Solutions from all angles
Capezuti has searched for solutions from all angles, working with lawyers,
social workers, engineers, and scientists, in addition to health care
experts. Among her collaborators is Julie Braun, a Chicago lawyer who
co-wrote an article with Capezuti on the legal and medical aspects of
restraints and bed siderails in nursing homes for the DePaul Journal
of Health Care Law. Included are some practical methods for preventing
falls and entrapment injuries, developed by Capezuti with input from fellow
nurses and physicians. Bed bumpers, full body pillows, and rolled blankets
can be placed to remind patients of the edge of the bed. A nonskid mat
by the bed can prevent slipping. A low height of 6 inches to 13 inches
makes nursing home beds safer for patients who habitually climb around
or over bed siderails. Most important, an involved health care team can
provide individual care plans that protect patients and reassure their
Despite growing evidence that siderails do not prevent falls and can lead
to entrapment injuries, administrators, nurses, and physicians remain
concerned with the legal implications of changing their usual practice.
This fear is reinforced by the perception that failure to use siderails
exposes hospitals to legal liability. Capezuti and Braun are using funding
from the Food and Drug Administration (FDA) to examine all reported legal
cases of bed-related falls among older adults in nursing homes and hospitals.
Their project will evaluate the effect of recent Health Care Financing
Administration (HCFA) siderail policy on current case law. Ultimately,
their project could influence implementation of this policy by demonstrating
legal support for changing practice paradigms.
Capezuti is also testing the effect of individualized interventions and
new devices in removing siderails and preventing bed-related falls with
more than $200,000 in funding from several private foundations. In addition,
Capezuti and physicist Steve Lane have a $390,075 small business innovation
grant from the National Institute of Nursing Research to design an air
bag that inflates when a patient tries to get out of bed. When that happens,
the patient encounters a soft cushion of air, instead of an unfriendly
siderail. The device has sent its inventors back to the drawing board
for some refinement. We found that once the air bag inflates, patients
think hmm and turn around and go back to sleep. So the result
is partly what we wantedto deter them from becoming entrapped or
falling. But the idea is also to help them get out of bed safely,
As the depth of her research expertise has grown, so has her clout in
advocating change and raising awareness. For the past year and a half,
Capezuti has served on the FDAs Hospital Bed Safety Workgroup. Charged
with regulating use of restraints as medical devices in hospitals and
nursing homes, the FDA issues medical bulletins and safety alerts regarding
their use. But updating hospital and nursing home staff on bed siderail
use is difficult. Health care facilities are deluged with FDA alerts on
any number of topics. And because there are no national statistics, experts
often disagree on just how many injuries and deaths are caused by bed
siderails. Thanks to Capezuti, HCFAS newly revised guidelines give
more weight to the issue.
I worked with HCFA to change the standard to say you cant
raise a rail without a reason for it, she explains. You also
have to carefully assess the situation. Is the bed safe? Does the mattress
fit correctly? What is the persons risk of becoming entrapped? The
federal government has been quick to respond to this with new regulationsso
quick that many clinicians dont know about them or question why
we need them. Theres still not a lot of awareness.
Capezuti believes that is changing. We are hearing more from hospitals
and nursing homes about bed siderail accidents, she says of her
work with the Hospital Safety Bed Workgroup. We dont think
there are more cases. We think more people are reporting entrapment or
falls as the cause
Ouslander, MD (right), played a key role in bringing Elizabeth Capezuti
to Emory as a member of the nursing faculty and associate director of
nursing sciences for the new Center for Health in Aging at Wesley Woods.
absolute right choice
Her work regarding the care and safety of older patients did not go unnoticed
by those at Emory. Her move from Penn was prompted in part by an invitation
from Joseph Ouslander, chief medical officer at Wesley Woods Center, to
help lead its new Center for Health in Aging. Once fully established, the
center will offer research, teaching, and educational programs in aging
and geriatrics for students and faculty in medicine, nursing, and public
health. Eventually, the center will include other university partners and
provide educational programs for community agencies and the public.
Dr. Capezuti has a major role in strengthening the ties in gerontology
between Wesley Woods and the School of Nursing, says Ouslander, director
of the new center. She is the associate director for nursing sciences,
where she will continue her research and develop new collaborations, and
is involved with interdisciplinary training for nursing and medical students.
It wasnt hard for Capezuti to make up her mind about coming to Emory.
The nursing school is led by Dean Marla Salmon, a former colleague from
Penn. Last year, faculty members Christi Deaton and Patricia Clark completed
postdoctoral fellowships in gerontology at Wesley Woods, supported by a
Woodruff Foundation grant that also brings visiting scholars in the field
to campus. And there is ample opportunity for Capezuti to continue her research.
On Monday mornings, for instance, she does rounds at Atlantas VA nursing
home with Ted Johnson, assistant professor of medicine, to study the healing
of pressure ulcers from the perspective of nurse and physician.
Emory was the absolute right choice for me, says Capezuti. Dean
Salmon and Dr. Ouslander are the kind of people you want to work with. Theyre
always looking at tomorrow. As we collaborate and learn from each other,
we will come up with ways to improve the health of the elderly.