Bed/Trolley Management & Mattress Monitoring

Senior Charge Nurses

• Ensure the protocol is followed by all staff
• Communicate with staff in relation to patient method of transfer e.g. chair, trolley, bed
• Allocate cleaning responsibilities for beds/trolleys
• Faulty beds/trolleys are reported appropriately General Services
• Ensure patients are transported safely using appropriate method of transfer
• Allocate cleaning responsibilities for beds/trolley.

Beds are allocated to clinical areas and will remain within the ward
ensuring accountability for cleaning, maintenance and repair.

• Ward staff to inform staff transferring patients of the method of patient transfer
• Where possible, patients will walk or be transported on a chair or trolley to receiving ward
• If not possible, staff will collect a clean, empty bed from receiving ward first
• Staff on receiving ward will move patient to clean bed
• If it is required, then staff will transfer patient to the receiving ward on clean bed.
• To assist will patient comfort, long stay patients in Emergency Department can have a bed sourced.
• Patients attending Radiology to be transported on a chair, trolley or their bed if required. If patient is transported on bed, nursing escort required.

The following patients will require transportation on their current bed:

• Patients where it is clinically inappropriate to move into a new bed but transfer to another ward is essential
• Patients who are asleep between the hours 9:00pm – 7:00am
• Patients going to and from Theatre and Endoscopy who are unable to walk or be transported in a chair
• Patients attached to traction apparatus
• Patients who require specialist beds/mattresses will remain on these beds in the event of transfer e.g. spinal beds, bariatric beds. Beds will be returned to the parent ward as soon as clinically appropriate.

Mattress cover and foam insert, and pressure-relieving qualities are checked for damage, fluid ingress and effectiveness:
• After each patient’s discharge OR
• On a weekly basis
Inspection Steps:
• Fully strip the mattress of all linen and pillows
• Check the outer surface of the mattress cover (top, sides, and
underside) for:
o Tears, scratches, punctures or staining/marks
o Signs of fluid penetration or contamination
• Unzip or remove mattress cover and examine:
o The inner surface of the cover for staining or damage (See
pictures in appendix B)
• The foam insert for:
o Marks, damp patches, or odours.
o Signs of degradation (e.g. crumbling, loss of shape, or firmness)
• Lift the mattress to inspect the surface in contact with the bed/trolley
frame for wear or damage
• Assess the mattress for pressure-relieving
• Check for uneven wear, dips, twists, or loss of support. (see pictures in
appendix B)
• Confirm the mattress is appropriate for the patient’s pressure ulcer risk
level (e.g. static foam vs. dynamic air)
• If unsure consult Tissue Viability Microsite for Guidance.
Actions if issues are found:
• Damaged mattress covers must be replaced
• If foam insert is visibly contaminated or degraded, the entire
mattresses must be replaced
• Nurse in charge must be informed of any faults or concerns
Nurse in charge to:
• Contact Procurement to order a replacement mattress cover or full
mattress
• Arrange for uplift and disposal of condemned mattresses
The following link includes the process and form for returning an
Air Mattress in BGH only: http://intranet/resource.asp?uid=46433

Documentation:
• The template in Appendix A must be completed to confirm that every
mattress has been checked on a weekly basis
• Any faults and actions taken must be recorded in the equipment
maintenance log.

Please refer to the National Infection Prevention Control Manual (NIPCM)
specifically Safe management of care equipment
National Infection Prevention and Control Manual: Chapter 1 - Standard
Infection Control Precautions (SICPs

Bed Trolley Management Mattress Monitoring Protocol V1