A new era in lift/transfer: the ergonomics expert who helped develop the Beverly Enterprises/OSHA settlement offers guidance toward a new approach. (Feature Article).

After many years of controversy and argument, Beverly Enterprises, Inc., and the Occupational Safety and Health Administration (OSHA) settled an enforcement action that began in May 1991. OSHA had issued citations to five Beverly-owned Pennsylvania nursing homes in response to complaints that workers were suffering back injuries related to lifting and transferring residents. The citations had been issued under OSHA's General Duty Clause, which states that an employer must provide its employees with a workplace free from recognized hazards that cause or are likely to cause serious physical harm.

Beverly contested those citations, and a long legal process ensued. Through 11 years of litigation, the situation took many turns and ran parallel with OSHA's development of an Ergonomic Management Standard.

As an occupational and safety health professional who is very interested in methods to reduce the risk of occupational injuries to healthcare workers, I had closely followed this case. About a year ago I was contacted and told that OSHA and Beverly wanted to try to work toward a settlement agreement and wanted an independent expert on the issues of resident lifting and worker safety to help with the process. I was asked to consider working with both sides on the settlement agreement. As I entered the process, I viewed it as an excellent opportunity for everyone involved to work together constructively, with an eventual "win-win" outcome. Potential outcomes included:

* OSHA achieving success in implementing programs to protect healthcare workers at high risk for occupational injuries.

* Beverly Enterprises implementing a management program that would help reduce occupational injuries to its workforce and, in the process, hopefully, reducing financial burdens and yielding other benefits for the organization.

* Healthcare workers experiencing an improvement in the quality of their work life.

Residents becoming safer and more comfortable through the implementation of new and improved methods of lifting and transferring.

Initially, my hope for these outcomes might have seemed unrealistic. Now that a settlement has been reached, however, I believe the opportunity exists to achieve many of these benefits. I further hope--and it is the reason I am writing this article--that these benefits will disseminate beyond the Beverly organization and result in improvements for the entire healthcare industry.

Much of my role in the settlement process involved helping to structure the lift program's policy and guidelines that have been incorporated into the settlement agreement. A very important part of this guide was the development of "Preferred Methods for Lifting and Transferring Residents." These provide guidance for what are considered to be the best and safest methods to lift or assist residents, based on their dependency level. The intent was, in this manner, to help facilities incorporate methods of transferring into each resident's specific care plan, rather than make it a separate concern. Thus, the method for lifting or assisting is determined by the resident's classification, as obtained from MDS reports using the standard dependency classifications already used in long-term care.

Determining Preferred Procedures for Lift and Transfer

Based on the resident's classification from the MDS reports, specific methods of transferring and lifting will be designated. Different methods might be necessary for different tasks and will be so designated. These designated methods will be clearly recorded and accessible to all staff that perform lifting and transferring tasks and will be included in the resident's care plan. Should a resident's mobility or need for assistance vary throughout the course of a day, or from day to day, this will be noted in the resident's care plan. The care plan shall give the caregiver explicit guidance as to when it is appropriate to employ a different method of lifting or transferring and how to make that determination. The scope of the caregiver's discretion in this matter shall be clearly delineated. Where questions remain, the caregiver shall employ the method of transferring providing the highest level of protection to him/herself and the resident. This information can be communicated through the means of charts or st ickers located on the resident's bed, door and/or wheelchair; at nurses' stations or offices; or through other means determined by the facility. As appropriate, the caregiver will meet with the staff that conducted the initial assessment to provide any information relating to a perceived change in the resident's condition.

Preferred Procedures by Resident Classification

Total dependence, Class 4. All residents classified as total dependence (Class 4) shall be lifted and transferred between beds, chairs, toilets, and bathing and weighing facilities by means of a full-sling mechanical lift device. In some situations another means of transfer might be required, but the first option considered should not involve manual lifting.

Extensive assistance, Class 3. All residents classified as extensive assistance (Class 3) shall be lifted and transferred between beds, chairs, toilets, and bathing and weighing facilities with the aid of a mechanical lift device. A full-body-sling lift is appropriate for all transfers. However, depending on the resident's condition and weight-bearing capabilities, a stand-assist lift might be used, as determined appropriate by professional staff conducting resident assessments. The choice of lift shall be noted in the resident's care plan. Use of a full-sling lift may always be substituted for the stand-assist lift at the discretion of the caregiver for the protection of the resident or caregiver. When mechanical lifts are determined as necessary, first options should not involve manual lifting and transferring.

Supervised/limited assist, Classes 2 and 1. An individualized resident-handling plan shall be developed for each resident whose mobility level is assessed as requiring supervision or limited assistance (Class 2 or 1). This plan shall be developed by professional medical staff, which may include nurses or physical therapists. The basics of this plan will be included in the resident's care plan.

In some cases, supervision/limited assistance residents might require a stand-assist lift or aids. Aids might be mounted on the bed or free-standing and include walking aid devices. The electric height adjustment of a bed can also be used to assist these residents to a standing position. Residents who require assistance in standing might also be unsteady on their feet and require a walker for assistance. These nonpowered assist devices provide safety and support to residents, while allowing them to use and maintain their current abilities. The use of gait belts with handles or transfer belts that allow the caregiver to get a firm grasp on the resident might also be appropriate for this class of resident. Other lifting aid devices, such as sliding boards, which provide a bridge and means for the resident to slide from a bed to chair in a seated position, can also be considered.

The resident's care plan shall specify which transfer or lifting devices are needed, as well as the number of caregivers required to assist in the transfer. Depending on the resident's condition and ability to assist him/herself in the transfer process, two caregivers might occasionally be required for the transfer. In some situations, because of a resident's weight, a mechanical lift might be specified for safety to protect against an unexpected event during the transfer process.

Independent residents, Class 0. Independent residents (Class 0) are normally capable of bearing their own weight and walking without assistance. They do not normally require mechanical assistance for transferring, lifting or repositioning. However, a resident's condition can vary due to any number of factors, and caregivers should be trained to be alert to a resident's changing abilities. Anytime a resident is unable to bear weight or come to a standing position and must therefore be lifted, and extensive assistance is required during the lift or transfer process, both the resident and caregiver are at risk of injury. Mechanical lifting devices and lifting aids might be required, regardless of how the resident was classified originally.

Procedural Guidelines

Lifts from floor. In almost all situations in which a resident must be lifted from the floor, a full-sling mechanical lift will be required. However, a resident who has fallen to the floor must be assessed for injury prior to being lifted. Training will be provided to nursing staff regarding whether to move the resident and when a mechanical lift should be ruled out because of resident injury. A plan will be specified in advance for moving and lifting residents in these situations. Such a plan will specify a minimum number of caregivers needed to assist in any manual lift, as well as the need for specially trained or selected caregivers. Special training shall be provided when such manual lifts are required. When a resident has fallen and can regain a standing position with minimal assistance, a transfer belt or gait belt with handles can be used as a lifting aid, provided that an adequate number of staff members is available to provide needed assistance.

Repositioning. When possible, attempts should be made to minimize the need for repositioning residents. When residents require frequent turning or repositioning for therapeutic needs, treatment surfaces on beds should be considered as an alternative to meet therapeutic needs and minimize the need for frequent repositioning. Proper and optimum use of bed control adjustments should also be used to minimize the need. Proper bed adjustment can minimize occurrences of a resident's sliding down in bed. When this does occur, and repositioning in bed is required, bed controls and features shall be evaluated and used to the fullest extent possible to maximize ergonomic protection to the caregiver. When possible, beds should be raised to an appropriate height for repositioning. When beds can be set for the Trendelenburg position (i.e., the head of the bed is lower than the foot of the bed), this feature should be used to facilitate the repositioning process.

A variety of friction-reducing devices and small hand slings are also available to assist in the repositioning process. The use of a mechanical lift should be considered when a major bed repositioning is required. All repositioning in beds shall be performed by at least two caregivers. When residents are capable of assisting themselves, they should be involved in the repositioning process.

Appropriate chairs and chair adjustments should be used to minimize the need for repositioning of residents in chairs. Features such as "tilt in space" should be sought for chairs to help maintain proper positioning of a resident. When there is a need to reposition a resident in a chair, proper use of a stand-assist lift should be considered as a first option. Gait belts, transfer belts and hand slings can be used to facilitate the process. When these lifting aids are used, at least two caregivers should be involved.

Situations in Which Mechanical Lift Devices Cannot Be Used

Unusual situations in which mechanical lift devices cannot be used shall be identified in advance, and specific lifting procedures shall be designated for them. For example, when a resident weighs in excess of the safe lifting capacity for the standard mechanical lifts at a facility, appropriate mechanical lifts able to accommodate higher weight limits should be obtained. Standard mechanical lifts will normally accommodate 350- to 400-lb residents. More substantial lifts will accommodate 600-lb residents, and bariatric lifts are available that can lift residents weighing up to 1,000 lbs.

Because of a resident's medical condition, a mechanical lift might not be appropriate. Other methods of transfer might include the use of transfer chairs. These chairs bend back flat into a stretcher configuration. When these transfer chairs are employed, lateral transfer devices should be used. These include mechanically powered transfer devices that pull the resident across one surface to another and friction-reducing devices that facilitate the sliding of a resident from one fiat surface to another.

In other situations where mechanical lifting devices are not appropriate, lifting aids such as sliding boards, transfer belts and gait belts with handles might be specified by the medical professional. In these situations, the minimum number of caregivers needed to assist in the transfer, as well as any need for specially trained or selected caregivers, will be identified and special training provided.

Combative and mentally impaired residents. It is expected that in most situations, a combative or mentally impaired resident requiring a lift can be lifted using the appropriate mechanical lifting aid device. However, combative or uncooperative residents might require more caregivers to assist in the process. In the unusual circumstance when the appropriateness of a mechanical lift for a particular resident must be re-evaluated because of a resident's mental condition or behavior, the evaluation shall be made by a member of the facility's professional staff and noted in the resident's care plan. In such a circumstance, a specific plan for lifting and transferring that resident will be made in advance, specifying the number of caregivers needed to assist, as well as the need for specially trained or selected caregivers.

Conclusion

These "Preferred Methods" are intended to maximize the safety of residents and staff during lift or transfer processes. The keys to achieving this are to individualize their use, allow for flexibility in determining selection and incorporate them routinely into each resident's care plan. Although they were devised to assist a specific organization--Beverly Enterprises--in revising its processes along OSHA-approved lines, they should be of general use throughout the nursing home industry.

Guy Fragala, PhD, PE, CSP, is director, Department of Environmental Health and Safety, University of Massachusetts Medical School. For further information, phone [phone] or fax [phone].