Evaluating and improving resident transfers.

Technology to reduce the strain on staff and discomfort for residents is constantly improving

As we constantly evaluate and try to improve our resident care environments, resident transfer methods are appearing ever more frequently on our "to do" lists. Resident safety and protection of staff from occupational risks are at stake.

From an occupational safety perspective, disability associated with occupational back pain has been a major ongoing issue in nursing facilities. Beyond the impact on workers' careers and quality of life, costs associated with worker's compensation - both direct costs from medical bills and compensation payments for injured workers, and related indirect costs - are becoming unacceptable financial burdens in an already hard-pressed industry. We have come to realize that many of the occupational injuries suffered in our facilities result from the difficult manual transfers of residents.

As for resident safety, we have found many situations in which residents are being dropped or bumped, sometimes resulting in serious injury - again, often a result of awkward manual transfer methods.

In this article, we focus on one of the most common and difficult resident transfer situations encountered in our facilities: transferring residents between beds and chairs (with a typical situation depicted in [ILLUSTRATION FOR FIGURE 1 OMITTED]). Because of the frequency and difficulty of this task, it is one of the leading causes of both occupational and resident injuries. We report a totally redesigned transfer process that eliminates lifting between beds and chairs. We also present an overview of a study done at a long-term care facility that compares the physical exertion felt by workers between traditional transfer methods and this new transfer method, as well as data regarding residents' feelings of comfort and security during the transfer process.

Redesigning the Transfer Task

Over recent years there have been several efforts to redesign transfer tasks between beds and chairs to eliminate lifting. The traditional approaches have involved either full-sling lifts or stand-assist-type lifts. Though these lifts have improved and minimized lifting, there has been some resistance to their widescale use and acceptance. Some of the issues raised have included the time involved in using lifting aid devices, the availability of devices when needed, dignity and comfort issues related to residents, space restrictions and the additional costs of new equipment.

Other approaches might be examined in redesigning transfer tasks. Considerations would include minimizing the need for new equipment, and avoiding overcomplicating the redesign. Any new method should be simple and easy to perform, and should not increase the time required to perform the transfer.

One can begin by considering equipment already located in the room, such as the bed and a chair. The transfer process could be facilitated by modifying chair design and ensuring that the bed is height adjustable. In the study we conducted, a new chair was introduced that can convert easily into a flat stretcher configuration. By positioning such a chair next to a height-adjustable bed, the need for any resident lifting is eliminated. Rather, the resident is slid across a continuously level surface. This type of transfer is a common one and often uses drawsheets as an aid. Considerable effort is still required, however, to slide the resident across the surface; meanwhile, workers must often reach across beds and stretchers to conduct the transfer. To address this, a lateral transfer aid can be provided that reduces the surface friction from sliding the resident from bed to chair or from chair to bed. This device uses smooth pieces of fabric as contact surfaces that slide and allow the support to move in a continuous motion. The reduced surface friction makes it much easier to slide the resident. Handles placed continuously around the edge of the transfer aid minimize horizontal reach by the worker and further reduce stress to the musculoskeletal system [ILLUSTRATION FOR FIGURE 2 OMITTED].

This chair design, similar to those used in the acute care industry (e.g., the Converta-litter, the Stretchair and the Totalift-2), is now being introduced to the long-term care industry. It is marketed as the TranSit Chair, available from Hill-Rom Long Term Care. Hill-Rom also provides the Resident TranSit Assist, a friction-reducing lateral transfer aid that works with the TranSit chair.

Evaluation

The design makes sense and should work well. How well does it work? Recently, we conducted an evaluation, a small study involving a Wisconsin facility with 119 residents, 56% of whom were dependent and non-weightbearing, who had agreed to take part in this test. Data were to be compared with data collected from two control sites. Most of the transfers at the control sites were performed with two workers using a gait belt to manually lift residents between beds and chairs. There were also some stand-assist and full-sling lifts available at one of the control sites, although most of the transfers were done manually.

The study instrument selected had been used in previous studies to gather subjective ratings from both workers and residents. Each time workers conducted a transfer, they were asked to rank the level of physical exertion they perceived for the body parts under study on a scale from 0 to 10 (increasing in difficulty of exertion). In previous studies this approach had been found to be just as valuable and accurate as more labor-intensive biomechanical modeling evaluation techniques. (Owen, BD, Garg A, Jensen R. Four methods for identification of most back-stressing tasks performed by nursing assistants in nursing homes. International Journal of Industrial Ergonomics 1992; 9:213-20.) A similar approach and rating scale were used to collect data relating to resident comfort and security (ranging from 0 to 7 as discomfiture increased).

For traditional manual transfer methods, measuring exertion to the lower back, the average perceived exertion rating felt by workers was 5.68. When considering the whole body, the average exertion rating was 5.64. It is safe to say that workers felt that manual transfers between beds and chairs were difficult to perform and resulted in a high level of exertion. When rating the new transfer method, workers reported that exertion felt on both the lower back and whole body to have dropped significantly. For the lower back the average exertion rating recorded was 3.36, and for the whole body it was even lower - 2.47.

Residents were asked to express their responses to this new transfer technique. The number of resident responses recorded is much lower than from workers, because not all residents were capable of commenting. There were 24 responses recorded for residents transferred with the new method and 7 by those transferred with traditional manual lifting techniques. When considering comfort and security, the averages recorded for the old method were 3.71 and 3.42, respectively. The residents felt somewhat uncomfortable and insecure during the transfer. With the new no-lift method, comfort and security ratings achieved were .75 and 1.16, respectively. The residents felt extremely comfortable and secure when transferred using the new, redesigned lateral transfer process.

Summary and Conclusions

The need for improved and redesigned transfer methods becomes more apparent each day. More facilities are looking for simple options to improve their methods of transfer, and the above study documents the effectiveness of one. In the future we will see more techniques developed to redesign the resident transfer process and further evaluations of their effectiveness.

Bernice D. Owen, PhD, RN, is professor of nursing at the University of Wisconsin-Madison School of Nursing, and Guy Fragala, PhD, PE, CSP, is director of environmental health and safety at the University of Massachusetts Medical Center-Worcester.