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. Preparation for Transfers
   • • Check for precautions
     • Complete your assessment before moving and handling
     • Confirm weight-bearing status
     • Determine level of assistance
     • Determine assistive devices required
2. Encourage Patient Participation
   • • The amount of assistance each patient will require depends on the patient’s previous health status, age, type of illness, and length of stay.
     • Engaging patients in the transfer process by seeking their input and involving them in decision-making empowers them and promotes respect. Encourage the patient to perform as much of the transfer as possible and only provide
     • Support the patients natural movement patterns
3. Ergonomics. The science of fitting the physical demands of the transfer to the therapist to prevent injury, and improve therapist and patient comfort during the transfer process.
   • • Distance between Surfaces;
       • As short as possible between surfaces
     • Height of Transfer Surfaces;
       • Allow for ergonomic work postures based on the shortest person assisting.
4. Body Mechanics. Involve the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during positioning, transferring, and mobilising patients. Proper body mechanics allows individuals to carry out activities without excessive use of energy, and it helps prevent injuries for patients and health care providers Always consider the principles of proper body mechanics prior to any transfer - assess the environment, plan the transfer, avoid stretching and twisting, ensure wide stance, stand close to patient as possible, face the direction of movement.
   • • Upper Limbs
       • shoulders relaxed and low
       • elbows close to the body  
       • wrists neutral
       • not squeeze strongly with the fingers
     • Spine
       • subjected to the most strain during patient transfers
       • maintain a neutral spine
       • minimise rotation or twisting of spine
     • Lower Limbs
       • knees and feet are aligned
       • wide stance - shoulder width apart
       • bend knees with lifting
5. Communication. Clear and compassionate communication enhances patient's understanding, and cooperation during transfers.Patient should be informed about transfer and their role and to try and perform as many steps as possible independently.
   • • 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.
     • Commands and Counts
       • Commands and counts synchronised with all participants.
       • Rehabilitation professionals at the head of the patient should give the commands when more than one person assisting with transfer.

Levels of Assistance

The level of assistance a patient requires during transfers is dependent upon the patient's size, physical, cognitive, and medical capabilities. Therapists determine assistance levels by subjectively grading the patient's assistance requirement during specific patient handling tasks, and should be based on the assistance level required by the patient and not the perceived effort level by the therapists during patient assistance. This provides for continuity of care, so if another therapist is transferring the patient they will have an idea of the amount of assistance that particular patient requires. and can be used to track the patient's progress in a rehabilitation program.

1. Independant
   • is able to transfer independently and safely.
   • no assistance required.
2. Supervision
   • may require assistance with set up for transfer
   • requires no physical assistance during transfer
   • may require supervision
3. Stand By Assistance
   • requires no physical assistance
   • may require verbal cues.
4. Contact Guard Assistance
   • is cooperative and reliable
   • occasional loss of balance
   • requires therapist to maintain contact with patient.
5. Minimal Assist;
   • is cooperative and reliable.
   • 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.
   • therapist provides 25% assistance
   • typically requires only one person to assist with transfer
6. 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% assistance
   • may require two persons to assist with transfer
7. 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% assistance
   • typically requires two persons to assist with transfer
8. 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.

Table.1 Overview of Transfers

Transfer	Description	Assistive Devices
Sliding Board Transfer	Sliding board transfers are typically used for patients who are unable to bear weight on their legs, have paralysis or limb loss in the lower limbs. Positioned at the edge of the bed Lean to one side while placing one end of the sliding board sufficiently under the proximal thigh Other ended of the board should be positioned under the destination surface Patient should not hold onto the end of the sliding board in order to avoid pinching the fingers Patient should place the lead hand 4-6 inches away from the sliding board and use both arms to initiate a push-up and scoot across the board Therapist should guard in front of the patient and assist as needed as the patient performs a series of push-ups across the board	Sliding Board Transfer Belt
Sit to Stand Transfer	feet are flat on the floor place hands on the armrests of the chair or next to side on bed patientpush up with her arms as you pull her close to your body as you move into a standing position	Transfer Belt Turn Table Sit to Stand Device
Squat Pivot Transfer	The squat pivot transfer is useful for patients who can support some of their weight but are unable to achieve a full stand. Position surfaces close together ~90 degrees. Remove armrests from wheelchairs. Assist or instruct the client to scoot to the edge of the origin surface. Angle the client’s heels towards the destination surface. Block the client’s knees with your knees. Instruct the client to push off the surface while shifting their weight “nose over toes”. Support the client at gait belt, waist, or buttocks and assist in guiding the transfer towards the destination surface. Never grasp under the weak arm or the weak arm. Get close to your client. You can have your head on the side of the destination surface, but the client will not be able to see where they are going. Instruct the client to reach for the destination surface. Assist in lower the client onto the destination surface.	Transfer Belt Turn Table Sit to Stand Device
Stand Pivot Transfer	The stand pivot transfer is useful for patients who can support most of their weight by standing but are unable to take steps to move from one place to another Positioned at the edge of the wheelchair or bed to initiate transfer Therapist can assist the patient to keep feet flat on floor while bringing the head and trunk forward Therapist should assist as needed with their feet Therapist guard or assist the patient through transfer and instruct the patient to reach back for the surface before they begin to sit down Once stand pivot is performed, therapist should assist as needed to ensure control with lowering the patient to destination surface	Transfer Belt Turn Table Sit to Stand Device
Stand Step Transfer	Chair to Bed Stand Step Transfer with Assistance Place the chair at the side of the bed on a slight angle. Move yourself forward to the edge of the chair. Make sure your feet are flat on the floor. Therapist should hold your hand and arm. They should hold your arm steady and should not pull on it. Place one hand on the arm support of the chair. Therapist should should already be holding the other hand or arm. To get up, lean forward and push down with your arms and legs and, if needed, on the therapist’s hand. Once up, your assistant should just guide and support you. Turn by taking small steps. As you descend, the therapist should hold your arm without pulling it. They can also put their hand behind your shoulder. They should guide you as you lower for a slow descent.	Transfer Belt
	Independent Chair to Bed Stand Step Transfer Place the chair at the side of the bed on a slight angle. Move yourself forward to the edge of the chair. Both your feet should be flat on the floor. Put both hands on the arm supports of the chair. Lean forward and push yourself into a standing position using your arms and legs. Stand for a moment to get your balance. Turn slowly, with small steps, until your back faces the bed you are transferring to. Step back until you can feel the edge of the bed against your legs. Lean slightly forward as you bend your hips and knees. Reach with your hands for the edge of the bed to give you support as you sit down. Sit down slowly.	Transfer Belt Mobility Devices

Assistive Devices for Transfers

Assistive devices for transfers are tools or equipment designed to assist individuals in achieving optimal body positioning and support for enhanced comfort, function, and independence. These devices are particularly beneficial for individuals with mobility limitations, physical disabilities, or medical conditions that affect their ability to maintain proper posture and positioning. Assistive devices also allow the the healthcare worker to position and transfers patients in a way that reduces risk for injury to themselves and their patients.

Assistive devices that can be utilised for transfers include slide sheets, transfer belts, sliding boards, turn tables, sit to stand devices and hoists.

Read more detail about the wide range of assistive devices available to support patient transfers here.

Summary

Positioning is a useful multidisciplinary therapeutic tool that can be individualised to a patient’s unique needs and limitations. Evidence-based findings suggest that positioning can significantly impact a patient's comfort and rest. The choice of transfer should be individualised to the patient's needs and preferences, and the timing and frequency of position changes may be important considerations. Regular evaluation of the effectiveness of the transfer strategy is essential to ensure that the desired goals are being achieved.

References