Keeping patients safe during transfers requires proper staff education and equipment.
By Terri Lynn Kazanjian, MS, PT, And Audrey Link Archer, DPT
Whether you're a 6-foot body-building enthusiast or a petite 5-foot-2-inch couch potato, it all comes down to technique, rather than muscles, when transferring patients in the rehabilitation setting.
Having the right equipment to facilitate those techniques is important, as are teamwork and education, particularly on keeping patients safe from injury during transfer.
Because manual lifting and transfers are high-risk patient handling tasks that could lead to injury, it's vital that all staff use safe, appropriate transfers during the patient's rehab process.
Before performing any transfer, be aware of the patient's cognitive status, ability to communicate and/or understand verbal cues, physical limitations in all extremities and orthopedic weight-bearing precautions.
To avoid injury, assess whether you need a second person to assist before attempting to transfer the patient.
Four types of transfers exist: mechanical lifts, sliding board, stand pivot and squat pivot transfers, which are addressed below:
• Mechanical lift. Use a mechanical lift to complete a transfer if a patient is dependent or needs maximal assistance for sitting balance. Mechanical lifts are also necessary when patients have weight-bearing restrictions on bilateral lower extremities or are restricted to perform active transfers by the physician. A mechanical lift and a body sling are required for the lift transfer.
Two primary types of slings exist, which may, or may not, include support for the head. A full body sling covers the posterior surface of the patient from the shoulders to the back of the thighs/knees. A second type of sling also supports the patient's body, but has divided legs that cross between the patient's legs and support him on the posterior surface of the thighs.
To complete the mechanical lift transfer from the bed to the wheelchair, place the sling under the patient by rolling him from side to side. For safety reasons, make sure the sling is in the correct position. Next, place the wheelchair at a 90-degree angle from the bed, with the back of the wheelchair placed against the foot of the bed. Make sure the brakes are locked. If the wheelchair is a recliner or a tilt-in-space, it should be reclined/tilted for easier positioning into the chair. Place the widened base of the lift under the bed and lower the arm to attach the sling.
The chains or hooks of the lift are attached to the net with the shorter length of chain/loops at the head/shoulders of the sling. The longer length of chain/loops are attached at the lower end of the sling. This will encourage a seated position. Certain types of slings have loops made out of the material as part of the sling, instead of chains and metal stays.
The lift is raised and moved 90 degrees to straddle the wheelchair. The legs of the base of the hoyer should be positioned behind the back wheels of the wheelchair and the front casters. The patient is lowered into the wheelchair with the assisting person pressing on the person's knees to encourage the pelvis and hips to land correctly in the wheelchair. The pelvis should be placed toward the back of the seat.
• Sliding board. The sliding board transfer is used when a patient has the upper extremity and trunk strength to maintain a sitting posture and can assist in lifting weight off the buttocks to scoot. Clinicians need a gait belt and sliding board.
To perform a transfer from the bed to the wheelchair, place the wheelchair at a 30-degree angle to the bed, with the brakes locked. Have the patient sit on the edge of the bed with assistance, if needed. Place the gait belt on the patient, and remove the armrest of the wheelchair closest to the bed.
Then have the patient lean away from the wheelchair and place the board under the buttocks and upper thigh area, taking care not to pinch the patient's skin. Have the person return to the upright seated position and place his feet on the floor slightly behind the knees.
The transfer requires a series of push-ups by leaning forward and away from the wheelchair to unweight the body, straightening the upper extremities, and depressing the shoulders to lift the buttocks and scoot toward the wheelchair. Multiple scoots should be used to complete the transfer. The patient shouldn't slide or be pulled across the board, since sliding places shearing friction on the patient's skin. This increases the patient's risk of skin breakdown.
The assisting person can help the patient by lifting his buttocks and assisting with the lateral movement to scoot.
The patient needs to reposition the hands and feet to gain a firm surface to push before each scoot during the transfer. To avoid pinching, make sure the fingers or hands aren't under the board.
Once in the wheelchair, the patient should lean away from the bed so the board can be removed to complete the transfer. The armrest should be returned to the chair.
• Stand pivot. Commonly practiced on a rehab unit, the stand pivot transfer is used with patients who can stand for a short time, have adequate hip, knee and ankle range of motion and strength, and good sitting balance. Clinicians need a gait belt.
To complete a stand pivot transfer, put the gait belt on the patient. Place the wheelchair next to the bed at a 30-degree angle, with the brakes locked. Help the patient scoot forward to the edge of the bed. The patient's feet should be placed flat on the floor just behind the knees, and the person assisting the transfer should cue the patient so the two move together as a team. The patient should come to a standing position.
Then have the patient pivot the feet, moving the buttocks toward the wheelchair. The patient's feet must pivot with the body to eliminate twisting at the knee and ankle. The patient slowly lowers to sit in the wheelchair. If he has a weak leg, the staff person assisting should guard the leg to make sure it doesn't collapse during the transfer.
• Squat pivot. A modification of the stand pivot transfer is the squat pivot transfer, for which a patient must have good sitting balance and upper extremity strength. During this transfer, therapists employ the same steps as in the stand pivot transfer, except that the patient doesn't come to a full standing position. Instead, he maintains a squat position while lifting the hips, using the upper extremities to move from one surface to another.
Use the squat pivot transfer with patients who have limited trunk control, and limited knee or hip extension strength. The squat pivot transfer also can be used with patients who have limited knee or hip extension range of motion that inhibits them from being able to maintain a standing position.
Transfers are a key skill needed for a patient to regain independence. On a rehab unit, therapists and nurses work as a team to determine the appropriate transfer to facilitate the progression toward independence.
Proper staff education and equipment will ensure safe and successful transfer outcomes. n
Terri Lynn Kazanjian, MS, PT, is therapy supervisor and Audrey Link Archer, DPT, is a senior physical therapist at the Shepherd Center in Atlanta.
Sharing PT Competencies
Body mechanics, transfers and lifting are common elements of nursing and rehab education. In addition to this training, the following recommendations should help the nursing staff, who are at high risk for injury:
· Share orientation cross-training competencies with nurses to review transfer skills.
· Provide online intranet transfer education material for easy reference accessibility.
· Conduct an annual competency to review transfers, lifts and equipment.
· Provide appropriate transfer and lift equipment on the floor, including mobile or ceiling lifts, drop arm/bedside commodes and sliding boards.
· Have a communication system in place between nursing and physical therapy to share types of transfers recommended for the nursing staff.
· Achieve management buy-in if a second person is occasionally needed for safe transfers.
–Terri Lynn Kazanjian, MS, PT, and Audrey Link Archer, DPT
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