August/September 2005

Transfer Dependent

By Anne Kilpatrick Lorio, MSPT

Numerous devices and methods are available to therapists who need to move a medically fragile patient

When writing this article, I did a literature search on injuries using transfer devices, but it yielded few results. I was able to obtain more information when I examined falls from incident reports taken from hospitals. Numerous articles point to patient falls as the number one reason for incident reports. "Falls are consistently the largest single category of hospital inpatient incidents in reports published since the 1940s."¹ The research shows that patient falls can lead to increased length of stay in hospitals, increased risk for injury, a drop in self-confidence, and increased costs to the hospital itself.²

In order to decrease falls with the medically fragile patient, it is important to have a good understanding of who might be at risk for falling, when they might fall, and where. One study by the Joanna Briggs Institute found that patient characteristics of falling include: increased age, altered mental status, history of falls, certain medications, impaired mobility, and special toileting needs.³ Rehabilitation units are even more likely to reports falls as the patients work on regaining independence and mobility after injuries related to cerebrovascular accident, spinal cord injury, or traumatic brain injury. A study by Vlahov et al looked at the epidemiology of falls in rehab hospitals and found an increased risk of falls when transferring to or from the wheelchair.⁴ More than one study found the patient's room the most common place for falls.

There are several types of transfers to get the patient in and out of bed. These transfers can be divided into two major groups: dependent transfers and assisted transfers. Only dependent transfers will be discussed—both manual techniques and equipment options.

DEPENDENT TRANSFERS
Before specially adapted equipment for transfers was introduced, hospitals had to rely on dependent manual techniques to get the patient in and out of bed. The following techniques are the most common forms of dependent manual transfers.

Sliding transfer using a draw sheet. When trying to move a patient from the bed to a rolling cart, you can use the draw sheet that is underneath the patient and the assistance of three people. One person is positioned by the head, one is around the pelvis, and one is by the feet.⁵ The person by the head will lead the transfer, and with all equipment secured, they then use the draw sheet to quickly slide the patient from the bed to the rolling cart. Even though this transfer will not take very long, it requires extensive lifting and at least three hands. The slide can also shear the client's skin; especially with the medically fragile patient, you want to decrease the risk of skin breakdown during transfer activities.

Three-person carry. If a slide technique cannot be used when transferring a patient from the bed to a cart, then you can do a dependent three-person carry. The cart is positioned at a right angle to the bed. Three people are stationed in the same spots as for the draw-sheet technique. The strongest person will be at the trunk/pelvis. The tallest person will be at the head and will "lead" the transfer.⁵ Sliding the forearms with palms up underneath the patient and rolling the patient toward the therapists, bringing the patient's weight closer to the lifter's base of support, they will lift the patient. On command, the lifters will stand, pivot the patient, and place them on the rolling cart. This technique is even more labor intensive than the draw-sheet method and puts the patient at risk for falls.

Two-person lift. This technique is used to move the patient from the wheelchair to the floor, and vice versa. One therapist will stand behind the patient and wrap their arms around the client's trunk, grabbing opposite forearms. Another therapist will support the patient underneath the legs. On the same count, they will lift the patient up and over to the floor, making sure to use appropriate body mechanics when lifting. This technique requires heavy lifting and can put the therapist in an awkward position. It also puts the client at risk for falls.

Dependent stand pivot. The therapist stands in front of the client, using their legs to block the patient's knees. Then they wrap their hands around the client's buttocks, and position the client's hands around their shoulders. The therapist then stands up, using a rocking motion to develop momentum that will help offset the client's buttocks from the chair.⁵ The therapist then pivots and rotates the patient, sitting them on the surface to which they are transferring them.

TRANSFER EQUIPMENT

Overhead lifts can be used to aid in the transfer of medically fragile patients. Often they are permanently mounted to the ceiling with a secure rail system.

Overhead lifts. Numerous types of power-operated overhead lifts are on the market. Some overhead lifts are permanently mounted into the ceiling with a secure rail system. Others can be mounted using telescoping poles into the ceiling or a post system. These lifts then can be transported and moved into different locations. Overhead lifts require the use of only one caregiver or therapist to move the client in and out of bed. A net or sling is positioned under the client, with the net above the client's shoulders and below the buttocks. The net or sling will then be fastened to the lifting device. Using the handheld controller, the caregiver will then lift the patient up and out of bed, making sure to keep the legs up high if they are positioned in a net. This device takes the burden of the heavy lifting off the caregiver. An overhead lift takes up less space in the room, making moving from one surface to another clutter free. Overhead lifts are costly and not covered by many insurance companies for home use. But if used appropriately, they are a very safe way for transferring the medically fragile patient. The Shepherd Center, Atlanta, now has mounted ceiling overhead lifts in all patient rooms and in all areas of the rehab gym. These lifts were installed in 1995, and have significantly decreased the incidence of staff injury during transfer activities.

Manual lifts. These lifts can be manually controlled using hydraulics, or they can be power operated. A manual lift can be used by a single caregiver, but it is much easier to operate with two people. The net is placed under the client, similar to its placement when using an overhead lift device. Chains connect the net to the lift. Make sure that you are able to roll the lift underneath the patient's bed. Also, this lift will roll easier if you have hardwood flooring. Thick carpet can make using it very difficult. If carpet removal is not possible, I recommend placing a floor mat on the transfer area. Position the chair at the foot of the bed. If it is a rear-wheel-drive chair, position it perpendicular to the bed, with the head of the chair at the foot of the bed. If it is a front- wheel-drive chair, then position it parallel to the bed with the chair facing the head of the bed. Widen the base of the lift to make sure it can roll under or around the chair. During the transfer, one person operates the lift, and another person holds onto the patient's legs. Using the hydraulics or the power-operated lift, the caregiver then lifts the patient up and over into the wheelchair. A manual lift is a more affordable lift option, plus it offers portability. Some find the manual cumbersome and difficult to use without the assistance of at least one other person.

Besides the standard manual and overhead lifts, other devices have been created to help make transfers safe and easy, especially for the home-based client, such as a streamlined "transfer machine" designed for safe, efficient transfers that contribute to the health of the patient as well as the health of the caregiver.⁶

STEPS FOR SAFE TRANSFERS
To ensure safety for the medically fragile patient, and decrease the incidence of falls with transfer-related activities, it is important to know and understand the steps required for a safe transfer. If you follow the SAFE method for transfers, then you should decrease the risk for falls in the medical setting.

Step One: Secure the patient and environment. Make sure that the net or sling is placed appropriately underneath the patient. Make sure that the lift that you are using is secure and in good working order. Lift devices in health care settings should be inspected frequently by the biomedical department. Check for cracks or loose parts. If you have any questions regarding the equipment, then do not use it with the patient until it has been cleared for use. Make sure that the bed you are transferring from is locked and that the chair or cart you are moving the patient to is also locked. Also make sure that the patient does not exceed the weight limit for the device.

Step Two: Ask for help if you need it, especially if the client is large or difficult to transfer. It is always better to have too much help than not enough when transferring a patient.

Step Three: Fully inspect the transfer area before you do the transfer. Make sure that the environment is clear of all hazards or clutter. If the client is attached to a ventilator or has a Foley catheter or any other tubing attached, assign someone to be in charge of the tubing to make sure that nothing pops off or gets pulled from the patient.

Step Four: Education is key for safe transfers. Make sure that whoever operates the lift knows exactly how to use it in all situations. Educate the patient so that the patient can verbalize all the appropriate transfer steps.

Anne Kilpatrick Lorio, MSPT, is a physical therapist, senior team, Multi Specialty Care Unit, Shepherd Center, Atlanta.

REFERENCES

1. Morgan VR, Mathison JH, Rice JC, Clemmer DI. Hospital falls: a persistent problem. Am J Public Health. 1985;75:775-777.
2. Jones WJ, Simpson JA. Preventing falls in hospitals. Hospital Topics. 1991;69:30-34.
3. Joanna Briggs Institute. Falls in hospitals. Best Practice. 1998;2:1-6.
4. Vlahov D, Myers AH, al-Ibrahim MS. Epidemiology of falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil. 1990;71:8-12.
5. Minor MAD, Minor SD. Patient Care Skills. Stamford, Conn: Appleton & Large; 1990:226-283.
6. www.easypivot.com. Accessed August 13, 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  Archives  · December 2008  · November 2008  · October 2008  · August/September 2008  · Fall 2008 Product Directory  · July 2008  · June 2008  · May 2008  · April 2008  · March 2008  · All Archives  Newsletter  · Rehab Today Resources Classifieds Calendar Consumer Resources Media Kit Advertiser Index EAB Reprints Submit an Article