1 These guidelines have been formed with the opinion that in healthcare settings, manual lifting should be avoided whenever possible. Therefore, there needs to be a mechanism for licensed healthcare professionals to make an assessment of whether a patient can perform a transfer independently or with minimal supervision and assistance, or if the patient requires a lift. In the instances that the patient requires a lift, mechanical means are preferred. Assessments for transfers and repositioning should include three aspects: assessing the working environment, assessing the capabilities of the patient, and assessing the capabilities of the caregiver. Characteristics of the working environment include the amount of space that is available for the transfer, whether the floor is even or uneven, whether the floor is slippery in relation to the worker s footwear, the equipment available, lighting, temperature, humidity and ventilation. Characteristics of the patient include the patient s ability to assist with the transfer, the patient s weight, height, and likelihood of shifting or acting in an unpredictable way. The capabilities of the caregiver include knowledge of proper handling techniques and proficiency in use of patient handling equipment. Strength, flexibility and fitness level are also important factors. An additional item to be considered is the work/recovery time required. The more strenuous a maneuver and more frequently it is performed, the more rest time is required for muscle fatigue to abate and for the employees to recover to the point where they can safely perform the handling activity again. This assessment is concerned with patient capability only. Although both the working environment and the capabilities of the caregiver need to be assessed, they will not be addressed here. This assessment is primarily intended to identify those patients who possess the capability to perform an independent transfer or a stand-by or very minimal assist transfer supervised by the caregiver. Please note that only licensed healthcare professionals perform these assessments. Although other healthcare workers may be delegated the task of performing the transfers, the responsibility for assessment falls entirely on the licensed healthcare professional who has the education to perform them. The degree to which these tasks are delegated may vary from facility to facility dependent on the orientation and training of employees. However, in all cases the liability for accurate assessment remains with the licensed healthcare professional ASSESSMENT When assessing a patient s readiness for transfers/repositioning, the following items should be taken into consideration: diagnosis and medical stability, the patient s weight and height, level of cooperation and comprehension, ability to bear weight, ability to support body with arms, and balance. 1. Diagnosis and Medical Stability Diagnosis and medical stability determine the frequency with which comprehensive patient capability assessments are required, with more unstable patients requiring more frequent assessments. Medical conditions often affect a patient s ability to transfer/reposition
2 themselves and may limit the healthcare member s options in assisting the patient. The following conditions are likely to affect the transfer/repositioning process and should be considered when identifying patient capability and equipment that may be needed to move the patient. Bilateral amputation Colostomy Contractures/muscle spasms/spasticity Fractures Falls (history of) Medical equipment (IV s, chest tubes, splints, traction, etc.) Pressure sores Postural hypotension Severe osteoporosis Total joint replacements Wounds and healing incisions 2. Patient s Weight and Height This helps determine what assistance to use, if required. Weight Height 3. Patient s Level of Cooperation and Comprehension Cooperative (may need prompting, able to follow 1 to 2 step commands) Unpredictable and Variable This category encompasses comprehension, language barriers and deafness as well as confusion, agitation, etc. 4. Patient s Ability to Bear Weight The patient must have the ability to bear full weight on at least one leg for standing transfers. Ability to bear weight can be assessed by asking the patient to use their leg(s) to push up in bed. If the patient is able to push up in bed in a straight, controlled, safe manner, then they have the ability to bear at least partial weight. Further testing can be progressed to at bedside. Can patient bear weight? Yes, full Yes, partial 5. Ability to Support Body with Arms Many patients need the ability to support their body weight with their arms. This is particularly true of those who need to use crutches and those who need to use sliding boards during transfers. A quick assessment of the ability to support the body weight with the arms is to ask the patient to perform a chair push-up while sitting in a wheelchair or armchair. If the patient can lift their trunk while seated back in the chair (using their legs only minimally at
3 most), then they do have the ability to support themselves with their arms. Please note, this test can be performed at bedside, but is sometimes more difficult without arm rests, as a patient s hands will sink into the mattress, making it difficult to lift the body. In all cases the patient s feet should be on the floor or on footrests. Can the patient support themselves with their arms? Yes 6. Balance Two minutes of sitting at bedside, with the arms folded in the lap and the trunk unsupported, would indicate adequate balance for sitting transfers. Sitting unsupported with the eyes closed and sitting unsupported while turning the head from side to side and up and down are additional tests that help indicate adequate balance for standing transfers. Is balance adequate for two minutes of unsupported sitting, unsupported sitting with eyes closed, and unsupported sitting with head movement? Yes 7. Bedside Assessment Scenario An assessment at bedside may be as follows: Hello Mr. Smith, I am, and I m here to. (Medical diagnosis is already known; other medical conditions are being assessed.) Can you push yourself up in bed for me? (Assess comprehension, cooperation, and ability to bear weight.) Good. Would you please sit up on the side of the bed? (Assess ease of movement, interference from and/or apprehension about medical equipment, and need for minimal assist for arm or leg movement, as well as continued assessment of comprehension and cooperation.) Please fold your arms in your lap now. I d like to ask you a few questions while you do that. (Balance assessment as well as time for follow-up questions from previous items, blood pressure check, vital signs, and/or patient education opportunity.) Could you remain sitting with your arms folded and close your eyes? (Balance.) You can open your eyes. Can you turn your head? Can you look up and down? (Balance.) I d like you to put your hands down on the bed beside you and lift yourself so you can sit as far back on the bed as possible. (Assesses ability of the arms to support body weight and partial weight bearing with the legs.) Assuming all ability is present up to this point
4 I d like you to stand now (with appropriate equipment or devices as indicated by the medical conditions present and for safety). (Final check of comprehension, cooperation, balance, weight bearing and (if an ambulatory aid is used) ability to support body weight with arms.) 8. Algorithm A possible algorithm for using this assessment for bed to chair transfers would be as follows: The patient is medically unrestricted or able to compensate, with adequate balance Is the patient able to bear weight? Yes Full Stand-by for safety as needed only. Yes Partial Can patient comprehend/cooperate? Yes Use seated transfer aid with transfer belt, up to standing pivot transfer (if partial weight bearing allows a functional stance). No Use mechanical lift or stand assist device. No Unable Can patient comprehend/cooperate? No Use mechanical lift. Yes Can patient support body with arms? No Use mechanical lift. Yes Use seated transfer aid
5 SAMPLE PATIENT CAPABILITY ASSESSMENT - READINESS FOR TRANSFERS AND REPOSITIONING Name: Date: Diagnosis: 1. Check conditions likely to affect transfers/repositioning: Bilateral amputation Medical equipment Colostomy Pressure sores Fractures Postural hypotension Contractures/spasms/spasticity Severe osteoporosis Falls (history) Total joint replacements Wounds/incisions Other 2. Weight Height 3. Level of Cooperation/Comprehension Cooperative (may need prompting, able to follow 1-2 step commands) Unpredictable or Variable Comments: 4. Ability to Bear Weight? Yes, full Yes, partial (enough for functional standing? Yes No 5. Ability to Support Body with Arms? Yes 6. Adequate Balance? Yes Care Plan: Transfers: Repositioning: Equipment and Personnel Required: Signature:
6 References: 1. Canadian Centre for Occupational Health and Safety: Ergonomic Patient Handling Policy Guidelines Corlett, E.N., Lloyd, P.V., Tarling, C., Troup, J.D.G., Wright, B.: Guide to the Handling of Patients, Fourth ed. Published by IMPACC in cooperation with the National Back Pain Association and The Royal College of Nursing, Greenville, ME, Patient Safety Center of Inquiry (Tampa FL) Veterans Health Administration and Department of Defense: Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement, Lewis, C.B., McNerney, T.: Clinical Measures of Functional Outcomes The Functional Outcomes Toolbox, Learn Publications, Washington, D.C., Written by: Christy L. Stout, M.S., P.T.