Transfers

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Original Editors - Naomi O'Reilly and Robin Tacchetti

Top Contributors - Naomi O'Reilly and Jess Bell   

Introduction

A transfer can be viewed as the safe movement of a person from one place or surface to another and an opportunity to train an individual to enhance independent function, and is considered to include all assistance provided to transfer or move a patient that can include manual assistance and/or use of assistive devices, which includes use of a hoist. Transfers can include vertical transfers from a seated-to-seated position (wheelchair to toilet) or supine-to-seated position (bed to wheelchair) and horizontal or lateral transfers from one flat surface to another (bed to stretcher).

Research shows that injuries to health and social care workers happen most frequently during patient transfers, with up to one third of workplace injuries to staff in hospitals and nursing homes occurring when moving patients. Transfers also also increases the risk to patients of injury, pain, and negative health outcomes. Likewise infrequent use of assistive technology may also restrict opportunities for patient movement, mobilisation, and weight-bearing activities, which can compromise patients’ recuperation, rehabilitation, and overall health. Successful and safe patient transfers rely on understanding each patient’s specific needs while simultaneously adhering to evidence-based guidelines, and rely on a thorough assessment. The therapist must must choose the most efficient and safest method to transfer a patient while taking into consideration the safety of both the patient and the clinician.

Evidence supports the positive effect of movement and mobilisation on the quality and speed of a patient’s recovery and their ability to preserve current levels of physical capability. It is also well known that early mobilisation is crucial for positive patient outcomes including decreased incidences of pneumonia, falls, skin tears, and length of stay in Intensive Care Units and acute care settings and increased quality of life, while insufficient movement put patients at high risk of immobility-related adverse events, such as pressure injuries, reduced range of motion, reduced muscle strength, muscle atrophy and reduced mobility.

Indications

Indications for transferring a patient vary depending on the patient population, but typically transfers are indicated for patients who have difficulty moving on their own and require assistance with moving independently from one position to another safely. Patients should always be encouraged to move independently but when assistance is required, they should be encouraged to assist in as much of the movement themselves as possible.

The following are just some of the indications

• Safety
• Comfort
• Support Patient Care Tasks
• Support Patient Procedures
• Prevent Secondary Complications of Immobilisation
• Support Activities of Daily Living
• Support Rehabilitation

Contraindication and Precautions

There are no general contraindications for transfers. Transfers may be contraindicated for specific conditions or following specific procedures, however more commonly specific precautions may be in place to maintain safety during transfers, typically seen within hospital settings, in intensive care units or on post-surgical wards. The following precautions should be considered in the following conditions;

1. Hip Arthroplasty. Associated movement precautions based on the method of surgical replacement. Traditionally, these precautions stay in place for 6 weeks following the joint replacement, although current evidence does not routinely support the use of these hip precautions in patients post total hip arthroplasty for primary hip osteoarthritis to prevent dislocation.
   • Anterior Approach - Avoid hip external rotation, active abduction and flexion beyond 90°
   • Posterior Approach - Avoid hip internal rotation, adduction across midline, and flexion beyond 90°
   • Lateral Approach - Avoid hip external rotation, active abduction, and extension
2. Post Spinal Surgery. Spinal precautions are guidelines or restrictions put in place to protect the spine and reduce risk of further injury after spinal surgery, spinal trauma, or suspected spinal instability.
   • Restrictions in forward flexion following spinal surgery limit patient's ability to assume certain positions comfortably and may require modifications to their transfers to avoid excessive bending, twisting, rotation or flexion of the spine. Clear communication and understanding of the specific precautions and their impact on positioning are vital to ensure patient safety and optimal outcomes.
3. Spinal Cord Injury.
4. Osteoporosis.
5. Stroke or Acquired Brain Injury.
6. Weight-bearing Status. Weight bearing refers to how much weight or force is put through a specific limb. It is common for a reduced amount of weight bearing to be prescribed following a specific surgery or injury. Adherence to this reduced weight bearing status is vital for optimal recovery, as prematurely increased weight bearing can delay healing.
   • Reduced weight bearing status can be applied to either an upper or lower limb.
   • Weight-bearing status can significantly impact on the type of transfers available to the patient and the level of support required.
   • Patients who are non-weightbearing or restricted from bearing weight on a specific limb may require additional support, stabilisation or assistive devices during transfers.

Principles of Transfers

The following principles guiding transfers should be considered in relation to the short‐ and long‐term goals of rehabilitation and management for each specific patient. Each patient has unique needs and preferences so before transferring a patient, it is important to assess the situation and environment, conduct an individualised assessment considering patient's medical condition, mobility limitations, and comfort preferences and consider the following principles to help you decide how much the patient can assist and what method of transfer should be used.

1. Encourage Patient Participation
2. Support Patients Natural Movement
3. Distance and Height of Transfer
   • Distance;
     • As short as possible between surfaces
   • Height;
     • Allow for ergonomic work postures based on the shortest person assisting
4. Communication
   • Use of Cues
     • Sensory cues including auditory, tactile and visual cues are commonly used in rehabilitation settings and have been shown to be beneficial in motor learning and motor performance including improvement in movement and mobility in many conditions including stroke, spinal cord injury, Parkinsons Disease, and dementia.
     • Cues are used to enhance communication by directly prompting a person to take action or respond, or indirectly inferring that a response is wanted. Commonly clinicians may use a range of cues to support transfers, which often increase patient engagement in the process.
5. Preparation for Transfers
6. Body Mechanics

Factors Affecting Transfers

Levels of Assistance

1. Independant
   • is able to transfer independently and safely.
   • no assistance required.
2. Stand By Assistance
   • requires no physical assistance
   • may require verbal cues.
3. Contact Guard Assistance
   • is cooperative and reliable, but requires therapist to maintain contact with patient.
4. Minimal Assis;
   • is cooperative and reliable, but needs minimal physical assistance with the transfer.
   • requires minor physical exertion from health and social care worker during transfers
   • is able to perform 75% of the required activity on their own.
5. Moderate Assist
   • requires more than minor physical assistance.
   • often needs equipment to assist with transfers.
   • is able to perform 50% of the required activity on their own.
   • therapist provides 50% of assistance
6. Maximum Assist;
   • requires full physical assistance for all transfers.
   • may be unpredictable and uncooperative.
   • requires equipment to assist with transfers
   • is able to perform 0-25% of the required activity on their own
   • therapist provides 75% of assistance
7. Dependent;
   • Patient unable to assist and does not actively participate in the transfer.
   • The clinician performs all aspects of the transfer.

Overview of Transfers

Each patient has unique needs and preferences. Conducting an individualised assessment, considering patient's medical condition, mobility limitations, and comfort preferences, is essential for providing dignified and respectful positioning care.

Assistive Devices for Transfers

1. Sliding Sheets; A sliding sheet or any short sheet can be used as a sliding aid. There are also specially designed roller sheets. These are made of special fabrics that have low-friction inner surfaces. The layers of fabric roll or slide over one another during the patient transfer.
2. Transfer Belts; A transfer belt is placed around the patient's waist and secured snugly. The belt can be adjusted to fit different patients and usually fastens with velcro and a buckle. If the transfer belt has loops, hold these loops to support the patient more firmly during transfer; if the belt does not have loops, hold onto the belt itself. You should use a transfer belt with patients who can partially support their own weight but need assistance. Studies show that using a transfer belt increases patient satisfaction. Lifting patients manually without a transfer belt may cause the patient discomfort under the arms. Patients also prefer the transfer belt because they feel more secure.
3. Transfer Boards; Transfer boards are also used, which are small pieces of rigid wood or plastic used to bridge the gap between two surfaces.. These may use various low-friction or roller technology transfer boards also available so that the patient can be pulled across easily.
4. Sit to Stand Hoist: Device used to assist patients from a sitting to standing position.
5. Hoist; A hoist is a mechanical lift or hydraulic lift, that can be free standing or attached to a ceiling, used to move patients who cannot bear weight, who are unpredictable or unreliable, or who have a medical condition that does not allow them to stand or assist with moving.

Summary

References