Patient Transferring Challenges

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by Susan Gallagher Camden, RN, PhD, CBN, HCRM

Certified bariatric nurse, licensed healthcare risk manager, and wound ostomy continence nurse, Houston, Texas

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INTRODUCTION
When considering patient movement and handling equipment, the question is often, “What is the weight limit of this piece of equipment?” We seldom ask, “What is the weight limit on the human body?” Research conducted by William Marras at Ohio State University and Thomas Waters at the Centers for Disease Control sought to answer that query. The answer is that the maximum recommended weight limit for lifting by a human being is 35 pounds. However, this weight limit decreases when the person who is doing the lifting is performing the activity in a restricted space, is lifting with his or her trunk twisted, or if the load is being lifted to the side of the body, all of which often occur when lifting a patient. Members of the bariatric team are routinely faced with a number of occupational hazards while caring for larger, heavier patients in a variety of settings. Patient lift and transfer activities place clinicians at risk for occupationally related musculoskeletal disorders (MSD). This article examines patient and caregiver safety in patient handling, discusses movement theory, offers options for patient transfer activities in the acute care facility, describes the role of the physical therapist as an important resource, and presents the Virginia Veterans Integrated Service Network 8—VA VISN 8—Bariatric Toolkit as a framework for change and practice.[1]

What are the risks?
Patient lifting and transferring account for many back, shoulder, and neck injuries in healthcare personnel. These injuries are so serious that the American Nurses Association (ANA) has become actively involved caregiver injury prevention. In fact, the ANA launched the Handle With Care® campaign in 2003 to prevent back and MSD injuries among healthcare workers.[2] The Handle with Care® campaign seeks to mount a profession-wide effort to prevent back and other musculoskeletal injuries through greater education and training and increased use of assistive equipment and patient-handling devices. The campaign also seeks to reshape nursing education and federal and state ergonomics policy by highlighting the ways technology-oriented, safe-patient handling benefits patients and the nursing workforce.[2] Nurses face not only MSD injuries associated with heavy lifting and awkward postures, but there is also the factor of age. The average age of a nurse is currently 47-years old.

There are a number of problems with MSD, the greatest of which is the threat of career-ending injuries. There is also a higher susceptibility to future injury as well as fear of injury.[3,4] The organizational impact of MSD includes the high cost of worker’s compensation insurance, increased sick leave, pain, fatigue, and diminished productivity.[5] As a result of concerns related to MSDs, the revised National Institute for Safety and Health (NIOSH) Lifting Equation was recently published, which indicates that the maximum weight that should be lifted manually by a healthcare worker under ideal conditions is 35 pounds, and that the weight limit should decrease as the lift became less than ideal (i.e., causing caregivers to reach, twist, or stand in awkward positions when performing a task).[6] Unlike industry, patient care providers cannot selectively modify the load size, shape, or response to the activity in a way as to promote safe manual handling; therefore, there are seldom “ideal” conditions.[7]

Finding solutions
The manner in which safe patient handling and movement training is provided, including how-to methods for transferring patients, has changed. Healthcare workers can no longer rely on body mechanics for lifting, moving, or repositioning patients.[8] Training is best accomplished by an ergonomist, a therapist (occupational therapist [OT] and/or physical therapist [PT]), or an on-unit safety mentor. Training should include use of equipment, which must be integrated into the policies and procedures of the individual facilities. Resources need to be allocated to obtain lifting equipment so that the standards of safe patient handling can be met. Caregivers can be instrumental in communicating their realistic needs for practical resources as well as those of their colleagues and patients.

Preparing for transfer activities
From a practical perspective, key assessment factors that must be obtained before any transfer include understanding the patient’s ability to follow instructions, to physically assist with the transfer, and their willingness to cooperate. The next step is to review an algorithm for the task to be performed. Determine the number of caregivers, type of equipment, and techniques for each task. Check the weight capacity of all equipment, slings, bands, lifts, and other devices. Clear the area of obstacles. Remove chairs, tables, or floor-based equipment, as they may pose a threat to safety. When lifting a patient, it may be necessary to ask visitors to leave the room as they may threaten patient dignity. Make sure all equipment is in good working order, batteries charged, slings or bands at hand. Beds or other equipment should be adjusted to proper height, which is generally considered to be waist or elbow height for the majority of caregivers participating in the task. The procedure to be performed is best reviewed with the patient and caregivers just before proceeding.[9]

What this means in Weight Loss Surgery
Although body mass index (BMI) is the criterion most often associated with obesity-related limitations, one study examined threats to quality of life attributable to waist circumference and found that those with the largest waist circumference reported difficulties in bending, stooping, kneeling, and walking.[10] In addition, patients with morbid obesity report joint pain, instability, decreased mobility, functional limitations, peripheral neuropathy, and other conditions that interfere with transfer activities.[11] Obesity is also an independent risk factor for falls.[12] Recent research suggests excess weight and weight maldistribution impact balance and postural sway.[11] For example, an extreme anterior or posterior position of the body’s center of mass relative to the ankle joint and potential health-related factors, such as muscular atrophy, are likely to exacerbate the risk of falling in an individual who is obese.[12] Each of these factors is thought to increase the risk of functional limitations that lead to falls. Increased obesity correlates with impaired postural balance and falls even in younger individuals aged 40 and below.[11]

Operative risks, abdominal incisions, pain, sedation, uncertainty, and the fear of injury will worsen a patient’s impairments and functional limitations, and may also create new deficits. On bariatric surgery units, patients who are delayed in their recovery may need assistance in their initial transfer activities. Moving a bariatric patient from a supine to a sitting position on the side of the bed is a common activity. The patient’s level of pain, fatigue, and inability to cooperate are all variables that make this task high risk.

Vertical transfers and lateral lifts pose special risks that may lead to MSD injuries, such as lower back and shoulder injuries. Vertical transfers are transfers in which the patient starts and ends in a seated position, such as a transfer from bed to chair, chair to toilet, wheelchair to bedside chair, or car to wheelchair. This transfer is especially dangerous because it may require a combination of lifting, pushing, and pulling toward the transfer site. Clinicians may be asked to reach across from one surface to another, which further leads to excessive push/pull forces. To compound the problem, the patient may be sedated, in pain, or weak from surgery or other procedures. Sudden movements or cognitive difficulties threaten safety as do combative patients or those in fear of injuring themselves or others. Because of the threat this transfer activity poses, it is imperative that caregivers refer to an appropriate algorithm to determine the safest method for the vertical transfer. The method used may be one of the following: ceiling lift, floor-base patient lift, bed that converts to a chair, gait/transfer belt, standing pole, or slide board. The determination largely depends on the patient’s ability to bear weight, follow instructions, and cooperate with care.

Most patients having had weight loss surgery (WLS) are relatively independent preoperatively, cooperative, and are able to follow instructions. Therefore, little support may be necessary. However, a deconditioned patient with morbid obesity who has experienced a long hospitalization will require more specific intervention in patient transferring. Readers are encouraged to become familiar with the Bariatric Toolkit.[1] The guidelines were developed to offer various technological solutions to assist in the care of obese patients. Authors of the Bariatric Toolkit contend that weight combined with atypical body mass contribute to an increased risk of injury to the caregiver and patient during handling and movement tasks. The premise was that lack of knowledge across healthcare settings in terms of tasks, such as transferring the patient in and out of bed and other activities, posed unnecessary challenges. The algorithms set forth in the Bariatric Toolk were designed to assist caregivers in selecting the safest equipment and techniques based on specific patient characteristics. Algorithm #1 of the Bariatric Toolkit addresses bed to chair, chair to toilet, and chair to chair transfers (Figure 1).[1]

Case study: Algorithm #1
This case analysis is based in part on a case presented in the Bariatric Toolkit. Consider reviewing the Bariatric Toolkit and using it as a framework to train staff members on safe patient handling and movement tailored to the unique needs of your patient care unit. To that extent, consider Anna, a 380-pound woman who is unable to bear weight. Three weeks ago, she underwent WLS and developed an anastomotic leak with delayed intervention. Her condition is slowly improving. She needs to go to the X-ray department and is currently in the intensive care unit (ICU). Which method is the most efficient and safest to accomplish this task? Consider the following:
•    Transfer Anna with an air-assisted lateral transfer device to a stretcher and manually push the stretcher to the X-ray department.
•    Transfer Anna to a cardiac chair and push the chair to the X-ray department.
•    Leave Anna in the bed and use the powered feature of the bed to transport her.
•    Use a sit-to-stand lift and transfer Anna to an expanded capacity wheelchair.

Let’s discuss each of these options. The first option is the air-assisted lateral transfer device and stretcher. This option raises the following questions that you may want to consider: How difficult is it to insert the lateral transfer aid under Anna? Is Anna able to turn to her side to assist in inserting the device? Is the air-assisted lateral transfer device wide enough to use for Anna? Can the stretcher safely support 380 pounds? How many caregivers will it take to push Anna on the stretcher, assuming it can support 380 pounds? Can the X-ray be taken while she is on the stretcher or will another transfer have to be done in X-Ray department?

The second option is transferring Anna to a cardiac chair, and then manually pushing the chair to transport her to the X-ray department. Questions pertaining to this option might be the following: What equipment and method will be used to transfer Anna to a cardiac chair: a ceiling lift, a floor-based lift, or a lateral transfer aid? How will you insert the sling if using a lift? Is Anna able to turn to her side to assist in inserting the device? The cardiac chair provides a flat surface for the transfer and then can be changed into a seated position for transport. A seated posture may be preferable for Anna, especially if she has breathing difficulty. How many caregivers will it take to push Anna on the chair, assuming it can support 380 pounds? Is it easier to push this chair or push a stretcher? Can the X-ray be taken while she is on the cardiac chair or will another transfer have to be done in the X-ray department?

The third option is to leave Anna in the bed and use the powered feature of the bed for transport. Questions that you may want to consider are the following: Is a powered transport device available? If the bed that Anna is using has a powered feature built in, what is involved in activating this feature? Is Anna cooperative? Is Anna lying on a low air loss mattress? By unplugging the bed to transport her, does this deflate the low air loss mattress and negate the pressure relief features? How much force is required to use the powered bed versus pushing the occupied cardiac chair or stretcher? How many caregivers are needed to push or steer the bed? On arrival to the X-ray department, can the X-ray be done while Anna is in bed or is a transfer required?

Finally, the fourth option is to use a sit-to-stand lift and transfer Anna to an expanded capacity wheelchair. This clearly is not an option for Anna as she cannot bear weight, therefore only the first three options are available to this patient.

As you can see, the decision as to which option to use is based on a number of factors, such as resources available in the facility, number of caregivers, medical stability, sitting tolerance of the patient, weight capacity of equipment, route from critical care to X-ray department, size of elevator or doors, floor coverings, but most importantly, how much force is required for the caregiver to perform the essential tasks. Some of the transfers can be eliminated, which reduces the stress on the caregivers. Elimination of nonessential transfers should be the first option when possible.

Role of the physical therapist
In addition to the Bariatric Toolkit, a clinical expert, such as a PT or an OT, can be an important resource. The goal of the PT/OT is to identify factors that impact functional limitation and mobility, some of which effect transfer activities. Burlis explains that when performing a comprehensive physical therapy exam, an appearance and postural analysis identifies the patient’s weight maldistribution, which is sometimes described as apple or pear.[13,14] An apple shape refers to a patient with upper body obesity. Pear shape is a term commonly used to describe low waist-to-hip ratio or a patient whose weight is distributed over the lower trunk. Flexibility, sensation, and proprioception are indicators of the patient’s level of independence with functional activities and ambulation. A measure of endurance is obtained through a six-minute walk, a three-minute step test, or a bicycle or treadmill test. During the examination of endurance, baseline and activity vital signs are obtained for screening purposes and to help understand the patient’s tolerance. Postural control is analyzed to assess the individual’s ability to correctly align himself during static and dynamic activities so that movements, such as transfer activities, are efficient, safe, and occur with the least amount of pain and greatest amount of stability possible.[13]

Interdepartmental transfer
Transfers can occur in the patient’s room or from department to department. A transport gurney is often the option for the patient who is nonobese; however, caregivers may reconsider this method of transportation for patients who are larger and heavier. Keep in mind every transfer poses the threat of injury to the patient and caregivers. Ask the question, “Is it possible to transport the patient in his or her bed?” and if so, how can safety be maximized? For example, prior to transporting the patient, map out the route using the path with the fewest obstacles. Consider floor coverings; linoleum or tile floors are preferred over carpeted. Avoid narrow, populated hallways with sharp turns. Current bed designs provide for frames that collapse and expand allowing easier passage through narrower doorways. Use a powered-drive system whenever possible. Be aware of the total weight of the patient, the bed, and the caregivers to ensure this does not exceed elevator weight limits. Have the patient maintain semi-fowlers position (a semi-upright sitting position at 45–60 degrees), as research suggests many patients breathe better in this position.15 Sufficient numbers of caregivers need to be available depending on the patient’s condition. According to the Bariatric Toolkit, the dependent bed-bound patient will require three caregivers: One to maneuver the bed, one to open doors and clear the path, and another to protect patient tubes and equipment and generally attend to the patient.[1]

Summary
Transferring activities can place caregivers at risk regardless of the patient’s weight; however, larger, heavier patients may pose a number of additional risks for several reasons. Greater weight, the maldistribution of weight, and the instability of the patient serve to add challenges to an already difficult task. Clinical experts, such as PTs and OTs, offer special tools for assessment and recommendations for safety based on the patient’s unique circumstances. The Bariatric Toolkit provided to caregivers from the VA VISN 8 Patient Safety Center provides algorithms designed to guide caregivers in safe patient transfers and other activities. A team effort with the goal of promoting patient safety and preventing caregiver injury provides the best practice model for transferring activities.

Patient Transferring Equipment

AirPal™ Patient Air Lift Transfer System

BariMaxxl® II bariatric bed using the EZ Lift™
battery-powered electric patient lift/transfer system

The AirPal® Rapid Airway Management Positioner® (RAMP®)

Aspect High-Tilt™ Flouroscopic Procedure Table

Aspect High-Tilt™ Flouroscopic Procedure Table

Sidebars:

Revised NIOSH Lifting Equation

The National Institute of Occupational Safety and Health (NIOSH) convened an ad hoc committee of experts who reviewed the literature on lifting and recommended criteria for revising the original equation for defining the lifting capacity of healthy workers. The committee used the criteria to formulate the Revised NIOSH Lifting Equation, which can be used to calculate a weight limit for a given manual-lifting task so that nearly all workers who have no conditions that would increase their risk of musculoskeletal injury, could perform that task over an eight-hour shift without increasing their risk of developing lower back pain. A user’s guide, Applications Manual for the Revised NIOSH Lifting Equation, was published in 1994. The revised equation was based on a complex calculation of numerous factors. The lifting equation recognizes limitations, such as patients who can be unpredictable because they might have muscle spasms, be combative, resist movement, or are heavier than they appear. Additionally, a patient’s movements during a lift can create loads within the lifter’s spine greater than those created by the slow, smooth lifting of a stable object.

The implications of a 35-pound maximum weight limit for patient lifting are that many tasks that healthcare workers perform would be unacceptable. Except in pediatrics, few patients weigh less than 35 pounds. While strictly applying such a weight limit may strike some as unreasonable, it might be justified. The rate of injury among workers handling patients shows that current approaches to preventing back injuries resulting from the manual handling of patients, such as training in biomechanics and the use of back belts are simply not working. The 35-pound limit should help in identifying tasks for which the use of assistive lifting equipment would be the safer alternative not only to the task at hand but to the longevity of the clinician’s health and safety.

Selection from:
Waters TR. When is it safe to manually lift a patient? Am J Nurs. 2007;107(8):53–59.

Reducing the risk of falls among the obese

Postural balance is improved in individuals who are obese following weight loss with a weight reduction program lasting as little as three weeks combined with balance training. Studies have examined the influence of obesity on postural stability in younger individuals and factors associated with falls in well-functional older individuals, as well as health-related quality of life in adults who are middle-aged and obese. However, little is known about whether poor balance and falls are related to health-related quality of life in individuals who are older and obese.[8]

References
1.    United States Department of Veterans Affairs. Safe Bariatric Patient Handling Toolkit. Updated January 14, 2009. http://www.visn8.med.va.gov/patientsafetycenter/safePtHandling/ToolKitBariatrics.asp. Access date: August 7, 2009.
2.     De Castro AB. Handle With Care®: the American Nurses Association’s campaign to address work-related musculoskeletal disorders. Online J Issues Nurs. 2004;9(3). Retrieved June 5, 2009 from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/Number3September30/HandleWithCare.aspx
3.    Camden SG. Caregiver injury. In: Rosenthal RJ, Jones DB (eds). Weight Loss Surgery: A Multidisciplinary Approach. Edgemont, PA: Matrix Medical Communications, 2005:217.
4.    Fourtes LJ, Shi Y, Zhang M, Zwerling C, Shootman M. Epidemiology of back injury in university hospital nurses from review of workers’ compensation records and a case-control survey. J Occup Med. 1994;36(9):1022–1026.
5.     Nelson A. Safe Patient Handling and Movement. New York: Springer Publishing Company. 2006.
6.     Sedlak CA, Doheny MO, Nelson A, Waters TR. Development of the National Association of Orthopaedic Nurses Guidance Statement on Safe Patient Handling and Movement in the Orthopaedic Setting. Orthopaedic Nursing. 2009;28(2):S2-S8.
7.    Lloyd JD. Biodynamics of back injury: manual lifting and loads. In: Charney W, Hudson A (eds). Back Injury Among Healthcare Workers: Causes, Solutions, and Impacts. New York, NY: Lewis Publishers CRC Press Company, 2005:29.
8.     Nelson A, Baptiste A. Evidence-based practices for safe patient handling and movement. Online J Issues Nurs. 2009:9(3). Retrieved June 1, 2009 from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/Number3September30/EvidenceBasedPractices.aspx
9.     Nelson A, Motacki K, Menzel N. The Illustrated Guide to Safe Patient Handling and Movement. New York: Springer Publishing Company, 2009.
10.    Hans TS, Tiijhuis MA, Lean ME, Seidell JC. Quality of life in relation to overweight and fat distribution. Am J Public Health. 1998;88(12):1814–1820.
11.     Fjeldstad C, Fjeldstad AS, Acree LS, et al. The influence of obesity on falls and quality of life. Dyn Med. 2008;7:4.
12.     Corbeil P, Simoneau M, Rancourt D. Increased risk for falling associated with obesity: mathematical modeling of postural control. IEEE Trans Neural Syst Rehabil Eng. 2001;9:126–136.
13.     Burlis T. The obesity factor. Phys Ther Prod. 2006:1:32–36.
14.    Mitka M. Obesity’s role in heart disease requires apples and pears comparison. JAMA. 2005;294:3071–3072.
15.    Winslow EH. High Fowler’s won’t always ease breathing. AJN. 1996;96(2):59.

Category: Past Articles, Review