Watch Your Back

Subscribe | Advertise | About Us | Contact Us | Home

July 2005

By Michael Dionne, PT

Clinicians need to use good transfer technique when moving a bariatric patient

Medical facilities need to recognize the importance of a systematic, safe way to transfer those within the population of size. The consequence of misguided technique can be catastrophic. Much of what I have developed derives from clinical experience and my unique perspective as an expert reviewing court depositions. Applying mobilizing forces toward a therapeutic goal for a very dependent patient of significant size requires step-by-step considerations to maximize safety.

My safety-training programs incorporate hours of manual techniques. I teach these techniques only from a guarding perspective. It has been my belief that you cannot work with the population of size without adequate equipment. In the 1980s, we did all the mobilization by manual technique. We bolted beds together, and for my own innovation, I would bolt a bed to a fabricated wall frame and stand a completely dependent patient of size for as much as an hour. The accomplishments were very bold and aggressive for the clinicians of the day. We were left to our fabrication skills, because there simply was no equipment available.

Risk managers have come to realize the litigious aspects of fabrication. Now, more than 20 years later, manufacturers of health care equipment have revolutionized our ability to meet the needs of this special patient population safely.

My understanding of safe patient management grew through both clinical experience and the review of depositions. I found that when working with the population of size, you could not define assistance levels. Most of the injurious failures I reviewed became obvious in the use of functional independence measures (FIM). These scales define the level of assistance a patient requires to complete a task. Its associated jargon plagues health care providers even today.

As I state in the program, “If you can’t define the level of assistance, how can you defend it?” I recall reviewing a terrible patient fall where a patient of size sustained bilateral dislocated knees. The documentation noted the patient’s functional level as “moderate assistance,” or about 50% of the task. I directed the attorney to ask the clinician, “What did the clinician mean by providing 50% of the task during assisted activity?” Even more specifically, how is a 130-pound caregiver able to perform 50% of a given task, for a patient who weighs 800 pounds? The line of questioning leaves the caregiver in an indefensible position. All they can do is look at the jury. Since we cannot define assistance levels when working with those of size, we cannot defend assistance levels.

Given the very high injury rates among health care providers, equipment must be used. There is simply no excuse for injurious events occurring during patient transfer. If a clinician finds that a patient of size has physical dependency, the clinician should use equipment to place that patient in a posture where activity can be safely progressed within a nonexertion level.

RISKY BUSINESS
Clinicians who have daily contact with those of size who are dependent quickly realize that you cannot place your back at risk on a day-to-day basis. Too many good therapists and nurses have sustained lifting-related injuries and are forced to leave the health care industry. There is no safe manual technique that can be applied beyond guarding and minimal-assistance activity.

The reason I cite minimal assistance as safe is that it is considered a nonexertion level of assistance activity. Minimal assistance is considered 25% assistance or less of the task including physical cues. A clinician can defend a nonexertion level of manual technique. I strongly encourage medical facilities to develop on-site no-manual-lifting protocols.

Oddly enough, much of the old jargon still remains today. An overhead page can still be heard in some hospitals: “Paging Dr Strong to room 232. Repeating Dr Strong go to Room 232.” This is a common cue for all the strong caregivers to run to room 232 and assist in a dead lift of a patient from the floor. Today, any caregiver should be able to use a mechanical lift to transfer a patient, no matter how dependent that patient is.

Another holdover for the caregiver is the desire to assist patients no matter what the cost. If a patient falls to the floor, most caregivers will rally to the need, group around the patient, and proceed to lift that patient back to the bed. If you tell a group of health care providers not to lift the patient from the floor because they could hurt their back, they go ahead and do it anyway. If you tell the same group not to manually lift a patient from the floor because that patient will sue them, then the mechanical lift becomes the technique of choice. Identifying these mistakes during an employee’s orientation can greatly reduce the number of injuries.

During initial mobilization efforts, a patient’s ability to contribute to a manual-transfer task may be minimal or unknown. For this reason, safe dependent sequencing should be utilized until the patient physically demonstrates otherwise. Nontherapeutic staff should use a mechanical conveyance and adhere to the lift-free environments or lifting policy as designated in their facilities.

ANATOMY OF A PROPER TRANSFER
The following sequence assumes the patient’s ability to participate in a nonexertional manner and that dependent patients are indicated for mechanical mobilization.

Initial preparation includes reducing the shear and frictional forces upon the patient’s skin while simultaneously reducing the resistance that caregivers would physically experience during the mobilization effort. Preparation may include maximizing the inflation of the air-mattress overlay and placement of a Gortex sheet, silicone-based transfer sheets, transfer mattress, or other frictional-reducing devices between the patient’s undersurface and the bed’s mattress. This is usually accomplished via a log roll.

Flat spin the patient with the transfer sheet so that friction occurs between the sheet and the bed rather than between the patient’s skin and the bed, until you accomplish a perpendicular supine posture. Pad the leading edge of the bed to avoid any potential bed trauma to the patient’s posterior thigh surface. Avoid side-lying postures in patients whose mobility status is unknown.

Once the flat spin is complete, deflate all air-driven devices such as the air-mattress overlay and transfer mattress. It is very important to deflate such devices to establish a true deck height and preset safe orthopedic alignment for final positioning.

Preposition the patient’s thigh to a level position. The knee joint should align with the hip joint. Even on beds demonstrating a very low deck height of 14 inches, footstool placement to level the thigh in preparation for trunk elevation is key. Keep in mind we have no intention of having the patient step on the footstool. The footstool is strictly limited to positioning activity in the sitting posture. This is perhaps the most common error in initial mobilization of the dependent patient of size that I have observed in deposition review. If the thigh is downsloping, weight-bearing occurs on the posterior aspect of the thigh at the leading edge of the bed’s surface. During trunk elevation, the patient may begin to slide toward the floor. This becomes a tragic slide that is impossible to stop. The best way to prevent this compensatory slide is through prepositioning.

Once the thigh is level, the caregiver can elevate the patient’s trunk toward a sitting posture. Encouraging patient participation is key during a therapeutic progression.

Anytime the caregiver is directing their visual field away from the patient’s lower body, physical contact should be maintained with the patient’s knee. This allows constant proprioceptive input for the provider that the patient is safe when the provider’s attention is directed toward monitoring telemetry or when reassuring the patient during mobilization. Should the patient begin to slide, the provider would simply lower their trunk to a supine posture, thereby stopping the slide and centralizing their line of gravity onto the bed.

Log-rolling the patient of size for peri-care or wound care can be safely performed through the incorporation of an air-mattress overlay with rotation function. A mechanical lift and sling may also be used to assist in log-roll activity when placing or removing a friction-reducing barrier or transfer sheet. I have also applied a stirrup-and-pulley system to overhead traction equipment to allow the patient to elevate a leg upward using their own upper extremities. This technique can greatly reduce the nursing workload and at the same time handle the patient with dignity. This is another way to empower the patient during the power-building rehab process.

Expandable-support-surface beds can greatly reduce back-injury rates for staff, since rolling the patient to the far side of a wider bed is less stressful when compared to narrow bed frames. Rolling on a narrow bed frame subjects both the caregiver and the patient to unsafe stress and shear forces.

The above assumes “Therapeutic progression in a nonexertion event” toward a sitting scooting transfer technique. Nursing staff should continue to use mechanical lifts until the patient demonstrates consistent performance from a guarding perspective or until the patient has passed the Egress Test ™. The Egress Test is a screening tool that protects nursing by indicating mechanical conveyance prior to consistent mobilization.

MAXIMIZING TECHNIQUE
Maximizing technique and good prepositioning are key to a successful manual transfer. Position the bed against the wall with the brake locked so it cannot move. The air-mattress overlay must be deflated, and the bed set on a low deck height. Typically, the debut transfer is from the bed to a wheelchair. I usually place a lift sling in the wheelchair prior to transfer to ensure safe conveyance back to bed should the patient become fatigued. The bed should be about an inch higher than the wheelchair, allowing gravity to assist in the direction of travel toward the wheelchair. Place the front nearest corner of the wheelchair next to the bed, as close to the patient’s thigh as possible.

Having the patient in a sitting posture while placing two transfer sheets under the patient greatly reduces frictional resistance during a manually directed sitting/scooting transfer. The two sheets provide a backup should one sheet become pulled out accidentally. The lower sheet covers the transfer distance from the bed to the wheelchair.

Again, prepositioning is very important during therapeutic progression. The patient’s thigh should be level throughout the task. Often, placing a footstool under the patient’s foot achieves the level thigh posture. Avoiding a reclined trunk, especially for the anxious patient, is very important to keep the patient’s ischial tuberosity from positioning inline with the femur resulting in a ski-slope effect that could result in a fall. For the patient sitting vertically, the ischial tuberosity provides a valuable hook upon the sitting surface.

During a manual transfer by the therapy team, the lead therapist blocks the anterolateral aspects of the patient’s knee nearest the wheelchair. For the client of size, it is better to have good control of the knee closest to the transfer direction than to attempt to control both knees. The lead therapist initiates the transfer by cueing the patient to lean forward and scoot toward the wheelchair in an inch-by-inch progression. The therapist should stop to make any adjustments as needed, particularly to prevent forward translation of the patient’s hips.

The lead therapist should have directed the team, monitoring the wheelchair position during the transfer. The goal is to allow pause in the technique and correction should undesired movement of the wheelchair or patient posture occur as the patient’s body weight begins loading onto the wheelchair seat. A slow, therapeutic progress allows for correction. Fast transfers go wrong fast and do not allow for correction. Such an event would result in a “stranded transfer” and potential fall.

During the inch-by-inch progression, the team gets ready to begin the transfer and the lead therapist cues the patient to lean forward as comfortably as possible. The patient may participate by placing their upper extremities upon the support surface or holding onto the therapist mid-arm. The benefit of the forward head is to unweight the patient’s gluteal region. This is the same head-hips relationship that one would use in transferring a patient who has sustained a high level of spinal cord injury. The patient first shifts their head forward and toward the wheelchair, then contributes, along with the therapist, in shifting their hips toward the direction of the wheelchair. The speed of travel should be a gradual, inch-at-a-time progression.

Keep in mind the direction of travel should allow the patient’s gluteal surface to track over the adjoining surfaces at a point nearest to the wheelchair wheel without risking skin shear. This technique should be used by experienced rehab practitioners in a nonexertion progression only toward a level of independence. Moderate and maximal assistance activity needs to be accomplished with a mechanical conveyance.

Michael Dionne, PT, is an employee of Northeast Georgia Medical Center Inc, and is the founder of www.bariatricrehab.com in Gainesville, Ga. He has become nationally recognized for his seminars “Transfer and Mobilization of the Severely Obese Patient for Rehabilitation Professional” and “Staff Safety at the Transfer Work Station for Nursing.” He may be contacted at Choice Physical Therapy Inc at (770) 532-4327 in Gainesville, or via e-mail at .

RESOURCES
Dionne MA. Dionne’s Bariatric Ergonomics: Transfers & Mobility of the Obese Patient, manual techniques, safety seminar. copyright 1992-2005.

Dionne MA. Dionne’s Bariatric Ergonomics: Transfers & Mobility of the Obese Patient, Egress Test ™ , safety seminar. copyright 1992-2005.

LOOKING FOR EXPERT ADVICE?

Experts here are available to answer all your questions!

Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER

Interactive Media

Resources

	Calendar
	Consumer Resources
	Media Kit
	Advertiser Index EAB Reprints Submit an Article

ADDITIONAL ONLINE RESOURCES

Allied Media
24X7mag Clinical Lab Products (CLP) Orthodontic Products The Hearing Review Hearing Review Products Rehab Management		Physical Therapy Products Plastic Surgery Practice Imaging Economics RT Magazine Sleep Review