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November 2004


Better Lifts and Transfers

By Lisa Jenkins, MPT, and Michel Egersett, PTA

How many times do you walk from one place to another as you go about your business in a typical day? For instance, moving from your bed to a chair for breakfast, from your chair to your car to drive to work, from car to desk...to lunch...to meetings? There are most likely all sorts of "lifts" and "transfers" you accomplish quite easily throughout the day.

Chances are you never even think about how often you get up and move. But for many long-term care residents, the inability to complete those moves is the main reason they are in a nursing home environment. This inability has taken away some or all of their independence. It also puts a heavy burden on the nursing facility's staff members who assist them in moving around to accomplish activities such as bathing, walking, socializing, and getting to and from appointments.

As a necessary component in any long-term care environment, lifts (ie, a mechanical device to assist with the moving of an individual from one surface, such as a bed, to another one, such as a chair) and transfers (ie, assisting a patient to move from one position to another) typically can involve lifting excessive weight while being in an unusual position and can place physical stress on the caregiver. This presents many challenges for management and staff.

By far, the most common problems involve staff injuries related to manually lifting and transferring residents. Typically, these are musculoskeletal injuries (eg, affecting muscles, joints, ligaments, tendons, blood vessels, and nerves). Especially prevalent, in our experience, have been strains and sprains involving the back, carpal tunnel, and rotator cuff injuries, and sciatica. For the facility staff that potentially means pain, swelling, restricted movement, and, most crucial, lost work time. For facility management, it may translate into staffing concerns that need to be addressed to prevent any negative effect on the quality of care, continuity of care, and staff morale.

We have found that many facilities and caregivers also experience challenges as a result of:
  • Difficulties in finding additional personnel to assist with transfers and in coordinating help to return the patient to bed
  • Increased time demands related to moving the more dependent residents
  • Repetitive physical demands on the caregiver's body
  • Special concerns regarding individuals with cognitive problems
  • Limited maneuvering space when working with large lift equipment

To address the injuries, OSHA's Guidelines for Nursing Homes recommend that facilities develop a systematic method of addressing key concerns. Creating a specific plan will help management and staff more efficiently identify ergonomic and medical issues; determine problems and hazards; assess staff and equipment; ensure adequate staff education and training; implement correct techniques, procedures, and body mechanics; and ensure the utilization of appropriate lift devices.1

FOUR-STEP APPROACH
Implementing a workable solution to meet all of these challenges requires planning, and we have found that most successful facilities employ a multifaceted approach encompassing four key steps.

Step One: Analysis of facility and resident needs. A thorough assessment is generally required to determine how well the facility is doing now, and where improvements need to be made. The focus should be on four key areas:
  • Resident needs-Each patient should be evaluated to determine what techniques should be used to move residents within the facility. The choice of procedure and equipment ultimately needs to be made based on the person's condition, size, physical capabilities, cognitive abilities, and rehabilitation potential, plus any contraindications. A multidisciplinary approach is recommended, involving nursing staff, therapists, physicians, and the resident.
  • Staff-Take a close look at each staff member's education, training, skills, and abilities, as well as current staffing ratios. Inadequate staffing or untrained personnel can be a safety hazard for residents and caregivers. Evaluate training and educational programs to ensure that all employees are kept up to date on correct lift device usage, techniques, and body mechanics. The goal for scheduling should be to meet state-published guidelines, while also taking into consideration patient needs. For instance, if the minimal ratio is six to one, but a significant amount of lift/transfer assistance is needed within the facility (ie, to take residents to the bathroom, for instance, which could mean getting them up, dressed, and then back into bed), the staffing ratio may need to be adjusted to meet that need.
  • Potential problems and hazards-Employee feedback on past transfer performance can provide valuable information, as well as conducting a review of injury reports and emergency evacuation plans. For example, does the machine work if the power is out? Not all electrical devices have battery backup, and you may need to move residents quickly in an emergency.
  • Equipment performance-It is crucial to conduct a thorough evaluation of all mechanical devices to be sure everything is in proper working order and being used correctly.

Step Two: Provide appropriate education and training. Education is key to this systematic process. It is important to verify that every staff person who has the potential to be involved with a lift or transfer is prepared. The major goals should be to ensure that each person:
  • Understands the physical demands that lifts and transfers present and knows how to apply appropriate body mechanics principles to reduce stress and injury. This should include teaching caregivers such factors as how to bend at the knee, keep arms close to their body, and shift their own body weight safely, etc.
  • Learns how to perform each technique safely and use the equipment. Include specifics such as checking for bed and machine heights to ensure that there is room for staff member(s) to maneuver around equipment, beds, and chairs in the room.
  • Knows how to choose the correct lift/transfer technique based on resident condition, capabilities, and care plan.
  • Understands appropriate communication strategies for assisting cognitively impaired patients to ensure their safety and cooperation with the person assisting them.
  • Knows the correct terminology to prevent communications errors among staff members and between staff and residents.

Ideally, education and training should be completed during the orientation process to avoid having untrained care givers in a position to perform lifts. We have found that most facilities try to provide more extensive training than in the past, and suppliers tend to be more readily accessible for questions and product demonstrations. Along with added safety, a nursing home can save a great deal of money in lost workdays. A facility in Ohio, for example, determined that a $280,000 investment in equipment and training saved them $55,000 annually in employee turnover costs and over $130,000 a year in decreased workers' compensation costs.1

Step Three: Implement appropriate procedures and policies. Developing a comprehensive plan for implementation is another key to success in reducing injury and maintaining resident safety during lifts and transfers. Decisions must be made about which techniques and mechanical devices to use for specific residents and circumstances and should be clearly indicated on each care record.

Step Four: Monitor the results. The last step is to have a plan for ongoing monitoring of the staff's safety record. Knowing which injuries occur under what circumstances and where equipment has been successful in reducing injury will help to determine when changes need to be made for specific residents or situations.

RECOGNIZING THE OPTIONS
Utilizing machines to assist with resident lifts and transfers has been an option for several decades. In most cases, the devices have been improved or updated in recent years as manufacturers have strived for technological advancement and better patient outcomes. One key difference is that equipment is more widely used and expected, compared to 10 or 20 years ago. Also, there is an increased use of hydraulics and lighter weight hardware, which makes it easier to use, more accessible, and more maneuverable in a small space.

Options for lifting and transferring residents range from sling lifts, cushions, and transfer boards/sheets to sit-to-stand lifts and overhead lifts. Some of the technological improvements available include electric beds, transfer benches, swivel pivot discs, grab bars, toilet seat risers, and ceiling-mounted lifts, which allow transfers with minimal staff assistance. However, the most essential and basic piece of equipment continues to be the gait/transfer belt. Because gait belts can be used for a wide variety of transfer needs, proper training should be regularly provided as part of new employee orientation, along with training on proper body mechanics.

Preventing injury is, of course, vital in a long-term care setting, and these devices relieve much of the physical stress and staff injuries. Many facilities, in fact, are now mandating no-lift policies requiring that residents who need any kind of assistance with lifts and transfers receive mechanical assistance to ensure safety and injury prevention. OSHA's guidelines recommend that manual lifting should be minimized in all cases and eliminated whenever possible.1

Despite the many benefits and conveniences of this technology, it does, however, present its own challenges. It is important to remember that by using mechanical devices, we may be enabling functional disuse in patients, who are becoming more and more mechanically dependent for personal movement. We have noticed that when some individuals are restricted in their attempts to transfer themselves manually, it leads to frustration, diminished self-worth, and then resistance to the lift machines-and that can increase the chance of injury.

Sometimes, it is simply a matter of making small, creative changes that improve the outcome. For example, in one of our facilities a person could have been helped with a sit-to-stand machine, but his room provided inadequate space for moving the machine close to him. The therapists surveyed the room and its furniture, and determined that moving the bed against the wall and changing its height would create the space needed for the sit-to-stand machine. The machine could be maneuvered into the room and under the bed, providing optimal position for the patient to participate with the transfer. This allowed him to develop functional transfer skills while decreasing the burden on the caregivers.

MAXIMIZING THE BENEFITS
The key to taking full advantage of the benefits and minimizing the downside is in the skilled intervention of professional therapy staff who can determine when to use a mechanical device and what type to use. Staff can then provide what the patient needs while minimizing injury to the caregiver. Also, in some situations, therapy personnel may be the only caregivers working with the resident on transfer training. That may amount to just 1 hour a day, 5 days a week, yet how many times does a typical person change position throughout the day?

For a resident, that change in position, whether it is accomplished manually or by a mechanical lift, can have numerous benefits. For instance, if a person is in bed all day and only sees the ceiling, it affects the way he or she views the world. Being able to sit up and take in the environment will change the individual's perception of the surroundings. That also increases neurological stimulus, which in turn can help in the healing process. If a tilt table is utilized to transfer him in a supine position and move him into a standing position, neurological input goes into the neurons in the person's joints, sending feedback to the brain. The therapist can work on training for balance and proprioception, as well as self-image and interaction with the environment. This kind of activity helps improve breathing capacity, digestive and elimination ability, and visual and sensory input, and can dramatically improve the person's quality of life.

Utilizing a multifaceted, systematic approach focused on assessment, policy implementation, equipment options, education, and training can help facilities meet the challenge of ensuring that each patient's needs are met in the safest, most injury-free way. Therapists and other caregivers will benefit from the safer, less stressful procedures, while enhancing independence, comfort, dignity, and self-esteem for residents.

Lisa Jenkins, MPT, is a clinical specialist for the southeast division of RehabWorks and a certified clinical instructor in Heathrow, Fla.
Michel Egersett, PTA, is director of facility operations for RehabWorks in Port Orange, Fla.

REFERENCES
  1. Ergonomics: Guidelines for Nursing Homes, US Department of Labor. Available at: www.osha.gov/ergonomics. Accessed September 2, 2004.

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