Improving Resident Transfers.

This facility executed a multistep plan to improve the safety and comfort of resident transfers for both residents and staff

A fundamental aspect of caring for residents in long-term care facilities is assisting frail and disabled people to transfer in and out of beds and wheelchairs, and on and off toilets, commodes and shower chairs. Many nurses and caregivers have been inappropriately trained to lift residents under the arms or to position two people on either side of the resident for two-person transfers.

The "under arm" method can be painful for residents and caregivers and can cause L5-S1 compressive forces that exceed the maximum level recommended by the U.S. Department of Health and Human Services. [1] It also prevents the use of good body mechanics. This method has been described as "deplorable, inefficient, dangerous to the caregivers, and painful and brutal for the patient." [2] Nevertheless, one study [3] reported that 98% of manual lifting transfers involved grabbing residents under the arms. Another study [4] found that 83% of surveyed nursing educators instructed their students in the "under arm" method, and 94% of surveyed nurses witnessed its use in the clinical setting.

Numerous studies have reported that nursing home personnel rank among the highest for work-related back injuries. In 1984, nursing personnel ranked 5th in job-related back injury claims when worker's compensation claims were analyzed, [5] and in 1995 the Bureau of Labor Statistics [6] reported that when all professions were compared, nursing assistants in long-term care facilities had the highest rate of back injuries. The Service Employees International Union found in l999 [7] that more than 18% of nursing home workers become injured or ill on the job, with trunk and back injuries accounting for more than half their injuries. Little has been done in the industry overall to explore or promote transfer training programs.

Many facilities have resorted to the use of mechanical lifts as a preventive strategy to avoid staff injury. Some advocates are pushing for a "zero-lift" policy--i.e., staff performing no direct lifting whatsoever. [8] The use of mechanical lifts, however, does not eliminate staff injury; even more importantly, it does not take into account the benefits of weight-bearing transfers for frail older people in long-term care facilities. The physiological benefits of weight bearing include maintaining muscle strength and range of motion in joints, improving circulation, maintaining bone density and increasing alertness. In addition, residents have the psychological benefit of increased self-esteem from actively participating in their care and improved comfort during transfers.

Despite our emphasis at the Providence Benedictine Nursing Center (PBNC) on teaching safe weight-bearing transfer techniques and individualizing transfers to meet residents' needs and abilities, we continued to have problems with poor transfer techniques, inconsistent implementation of individualized transfers, an increase in the use of mechanical lifts and an increase in staff injuries. We therefore designed a quality assurance (QA) project to address these concerns.

The PBNC is a 130-bed, nonprofit skilled nursing facility in Oregon, with 25 rehabilitation beds averaging a 17-day length of stay and 105 long-term care beds averaging a 1- to 3-year length of stay. PBNC employs approximately 90 certified nursing assistants (CNAs). We estimate that during care activities, a CNA performs 25 transfers during one 7.5-hour shift. In an effort to improve transfer training skills, PNBC's physical therapy (PT) staff instituted a transfer training curriculum for new CNAs in the early 1990s.

The more recent QA project had three principal goals, the first of which had its own subset:

1. Increase use of the most therapeutic weight-bearing transfer technique to promote the greatest functional independence for residents. This would involve:

a. decreasing use of mechanical lifts except where determined by nursing, PT and the resident to be the safest and most therapeutic method of transferring;

b. eliminating two-person "side by side" or "under the arm" transfers;

c. educating staff in appropriate transfer methods to ensure compliance with individual resident care plans.

2. Increase accuracy of transfer information in bedside care plans and on wall signs by providing consistent, appropriate and concise instructions.

3. Decrease the number and cost of injuries to staff during transfers.

Four types of data were collected: staff skill in transferring residents, information from the Bedside Information Sheets (BSIS) and wall signs, staff perceptions of correct transfer techniques, and staff injuries.

Transfer skills were evaluated using a "transfer skill" evaluation form. This included specific criteria for safe, therapeutic transfer techniques specific to frail elderly residents and reflected the standards taught in the PBNC transfer class. Categories of information included:

* whether the appropriate transfer was performed as described in the BSIS

* how equipment used in the transfer was prepared

* the caregiver's body mechanics

* how the resident was prepared

* whether the resident's knees were blocked during transfer

* whether orthopedic precautions were followed

* whether the lift was done in a slow, controlled manner

* whether the resident expressed or demonstrated discomfort

A physical therapist observed transfers and recorded performance using the evaluation form. Both weight-bearing transfers and mechanical-lift transfers were observed. The staff and residents were aware of and agreed to the therapist's presence and purpose for observation. Transfers were selected randomly and followed the resident's care schedule.

Two CNAs and one RN from both the day and evening shifts from each of five units were observed for a total of 3O observations. The therapist instructed staff to: "Perform the transfer you normally would do with this resident."

Bedside Information Sheets were audited for accuracy. The sheet is kept at the resident's bedside and condenses the information in the resident care plan so that caregivers don't have to refer to the chart each time they approach a resident. Created by the Resident Care Manager (RCM), an RN responsible to keep the information updated, the BSIS addresses the type of transfer to use, as well as other pertinent resident information.

Wall signs were also audited. The signs were created by the PT department and prescribe an individualized transfer method for the resident, including an illustration showing the resident's and staff member's position during the transfer. Wall signs are posted at each bedside, so caregivers can refer to the instructions quickly and easily.

The audit evaluated whether the type of transfer identified on both the BSIS and wall signs was complete and accurate. To be considered complete, a BSIS and wall sign had to include: (1) the number of caregivers needed for the transfer, (2) the type of transfer to be performed and (3) the amount of physical assistance necessary from caregiver(s) (i.e., minimal, moderate or maximal assistance).

All RNs, LPNs and CNAs were surveyed to assess their understanding of various transfer techniques, the number of transfers they performed, the types of transfers most frequently used and where staff felt they had learned the most about transfers.

Employee injury information was taken from the facility's incident reporting forms. Injuries were tabulated by unit, time of day, type of transfer and type of injury. Factors examined in this project included:

* injuries that occurred during transfers or assistance with bed mobility

* injuries resulting in worker's compensation claims

* missed workdays

* modified workdays

* cost to the worker's compensation insurance company (Although this is not a direct expense to the organization, it affects the premiums for worker's compensation insurance, which is a direct expense.)

* Lost Workday Case Incident Rate (LWDCIR) (as compared to the Oregon state annual average.)

Results

Of the 30 transfers observed, 25 were weight-bearing transfers and 5 were mechanical-lift transfers. Only one of the weight-bearing transfers was an "under arm" transfer, but other problem areas were evident--for example:

* Of the 26 specific criteria on the transfer skills evaluation, only 10 were met more than 50% of the time.

* One unit with a high staff injury rate scored only 33% on skills.

* Staff performed the transfer as indicated in the BSIS 68% of the time.

* 36% of the time, staff reminded residents not to hold on to staff members' necks or shoulders.

* Two-person transfers were done safely in regards to staff body mechanics 50% of the time.

* 70% of residents appeared or reported that they were comfortable during the transfer.

* 53% of the time good body mechanics were observed with weight-bearing transfers.

* 10% of the time good body mechanics were observed with mechanical-lift transfers.

The audit of BSIS and wall signs revealed that weight-bearing transfer descriptions were complete and accurate less than 37% of the time. Staff were receiving only part of the information needed to perform transfers safely.

The results from the transfer survey distributed to nursing staff were as follows:

* Many types of transfers were being performed, with most being stand/pivot transfers.

* Staff felt most unskilled with draw-sheet transfers and sliding board transfers.

* Staff felt they learned the most about transfers in the annual transfer class, in the CNA training classes (same curriculum) and in training by PT on the units.

* Reported barriers to doing the most therapeutic transfers were not enough time, resident behavior issues and poor teamwork.

* 93% reported doing two-person transfers with one in front and one in back, as instructed in PBNC transfer classes.

* One-third obtained transfer information from fellow staff; two-thirds obtained it from wall signs and care plans.

* 50% indicated that they had hurt their backs during a transfer.

* 50% reported that they suffer from back pain.

* Supervising RNs performed far fewer transfers, and 50% reported they are not comfortable with their transfer skills.

* A large percentage thought they would benefit most from more education and more PT intervention with residents.

A review of employee injury reports in the previous six months indicated that:

* a total of 25 injuries occurred during transfers or assistance with bed mobility, with 13 of these resulting in worker's compensation claims;

* of the 13 worker's compensation injuries, 85% were related to transfers;

* these worker's compensation claims constituted just under 50% of the total worker's compensation claims for the facility for the previous six months;

* the worker's compensation claims relating to transfers and bed mobility resulted in 84 days of time lost and 240 days of modified work;

* trends by unit or time of day were not apparent;

* information from the worker's compensation insurance company indicated that $46,582 was spent on these claims in the previous six months;

* LWDCIR for the facility was 11.38, compared to the statewide average of 9.9 in 1996. [9]

Results of the transfer skills evaluations were reviewed with each unit, emphasizing their successes and then addressing problem areas. Over the next six months, PT and nursing staff implemented the following changes:

Wall signs were redesigned to more clearly communicate the transfer criteria. Illustrations were changed to include more detail regarding staff and resident positioning.

As for transfer training, there was no easy way for staff, after going through the training, to refer to information learned. The therapists created, therefore, an easy-to-follow, one-page synopsis. This was laminated and posted on each nursing unit and given to each class participant.

A one-page "transfer continuum diagram," showing how a resident might proceed on the continuum of transfers from independent to dependent as abilities changed, was also created. This was meant to discourage turning routinely to a mechanical lift as a resident became more dependent, and to assist RNs in determining the type of transfer that would keep the resident as independent and functional as possible. This Transfer Progression Continuum was also laminated and posted on each unit.

The PT department set up a regularly scheduled time (in 1- to 2-hour blocks per month) to help develop individualized transfer plans and answer questions regarding specific residents. For particularly difficult transfers, therapists gave an in-service on the specific transfer technique and videotaped it so absent staff could watch later.

Incomplete information on the BSIS indicated that the RCMs needed additional training on the types of transfers and the information needed for staff to perform transfers appropriately. Nursing administration and the PT department scheduled a special training session for the five RCMs. Content included the transfer progression continuum, how the transfer should be described in the BSIS and when it was appropriate to refer to PT to re-evaluate the transfer technique being used.

Because staff surveys had indicated that 50% of RNs were not comfortable with transfers themselves, and because of the importance of their supervising the CNAs in this, training sessions on transfers, the continuum, and initial audit results were scheduled specifically for the RNs, as well. RNs were encouraged to assist with transfers more frequently to improve their skills and their ability to supervise transfers, and to help raise staff awareness of the importance of correct transfer techniques. The transfer class synopsis was made available on each unit as a resource for RNs to use to ensure transfers were being performed correctly on their shifts. RNs were also required to attend the transfer class annually.

Physical Therapy, with the assistance of experienced CNAs, instructed staff members in proper use of mechanical lifts, with emphasis on body mechanics, indications and contraindications for use, and pros and cons related to resident function. This, too, was videotaped and made available for staff reference.

Staff identified a need for training in one area in particular: how to interact with confused and agitated residents to avoid injuries related to their behaviors. This was addressed with an in-service by PBNC's Mental Health Nurse.

In addition to the above interventions, there was a renewed administrative emphasis on requiring all staff to attend the annual transfer class before they could receive their annual evaluation and raise. This helped motivate staff to attend the 2-hour transfer class offered monthly. The focus of the transfer training class is specific to frail elderly people and includes:

1. Body mechanics and physiological benefits of various weight-bearing transfers.

2. Scoot method vs. traditional stand/pivot method (Figure). In the scoot method, the resident is transferred in two or three small scoots as opposed to one pivot movement. This helps protect the caregiver from extreme back twisting. The resident benefits by the smaller, slower movements of the scoot transfer; these decrease fear and increase participation in weight bearing during the transfer. This method also decreases twisting of the resident's hips and ankles, which are vulnerable to injury with the stand/pivot method.

3. Use of assistive devices (i.e., transfer belts, sliding boards and draw-sheets).

4. Preparing the resident for transfer and proper cueing techniques.

5. Knee block to prevent buckling of the resident's knees during transfer.

6. Two-person lift technique, with one in front and one behind the resident (as op-posed to one standing on either side, also known as the "under arm" technique.

Six-Month Follow-up Results

Transfer skills evaluations were repeated six months after the first data collection. A therapist spent time on each unit during both day and evening shifts, watching transfers and recording observations. Each unit showed excellent improvement (Table 1). In fact, 14 specific criteria were found to have been met more than 80% of the time.

After the initial six months, the BSIS described the transfer accurately 42% of the time--only a slight improvement from the 37% at baseline. With added support from the Director of Nursing and a repeat in-service to the RCMs, the accuracy of the BSIS transfer description improved to 77% after an additional six months.

The staff injury rate improved greatly (Table 2).

Conclusions

The project has continued for the last two years, during which the following interventions have continued:

* Every six months incidents are reviewed and tracked for number and type related to transfers and bed mobility, as well as for any trends that might need special intervention.

* Every six months an audit of the BSIS and wall signs is conducted.

* Every six months transfer skills evaluations are conducted on each unit, and goals for the next period are established.

* CNAs who are highly skilled in resident transfers now assist with training in the transfer training classes.

Transfer training classes have expanded to include employees at all levels of care in the PBNC system, including the home health agency, assisted living center and adult foster homes. This provides continuity of care to residents at all levels.

* When an incident occurs involving a transfer or bed mobility, the staff member might be referred to PT staff to discuss the transfer and possible modifications that can be made to avoid repeated injury.

* The regularly scheduled time spent by the PT staff consulting on the units was not continued because of other demands upon the PT department. The communication between staff on the units and PT remains positive, however, and is more frequent than prior to the project.

In general, although the benefits seen during the first six months of the project did not continue at the magnitude of the first six-month evaluation, there has been a measurable improvement over the two years of the project. Injuries, time lost and modified workdays continue to remain lower. Scores on the transfer skills of staff remain high, demonstrating that staff know how to use the information given in classes. Transfer training classes have had a positive effect in increasing staff safety awareness, improving communication and, ultimately, improving residents' comfort. The two-person "under arm" transfer method has been eliminated and replaced by more therapeutic methods that encourage weight bearing and active participation.

The use of mechanical lifts continues to be monitored for appropriateness. The number of lifts used has remained constant at 15 to 20 for 130 residents. Close review of injury data showed that injuries do occur with use of mechanical lifts, especially when staff places and removes the slings on residents. This task involves reaching and bending over beds, causing poor body mechanics and increased back stress. Observation of staff technique also revealed twisting of the caregiver's back because of straining to maneuver the lifts around small areas. The effort required to maneuver the machines can be even greater if the floor is carpeted. Institutions need to be aware of these facts when considering purchase of mechanical lifts.

Administrative support has been essential in generating results by providing PT staff time for data collection, evaluations and in-services of staff. These cost-saving interventions have taken limited time and resources and have provided many benefits for the facility and its residents. There is a renewed spirit of teamwork and more interest in doing the transfer most appropriate for each resident. Additional ideas have been generated to continue to improve resident transfers and reduce injuries, including greater emphasis on bed-mobility training, back stretching and strengthening classes at work, and increased PT involvement in staff training.

The QA program implemented by PBNC has reduced costs by reducing injuries and subsequent modified and missed workdays. In addition, it has improved quality of care by improving the transfer experience for residents.

In sum, gathering and reviewing data on clearly identified problem areas has focused our intervention efforts. Much can be done collaboratively, and there is a great benefit in working as a team to address these challenges. This evidence should provide encouragement to others to undertake similar training projects that make a long-term impact.

Jennifer Wood, LPTA; Theresa Raudsepp, MSPT; Lois Miller, RN, PhD; and Emily Dazey, NHA, are with Providence Benedictine Nursing Center, Mt. Angel, Oregon. For further information, phone [phone].

References

(1.) Garg A, Owen BD, Carlson B. An ergonomic evaluation of nursing assistant's job in a nursing home. Ergonomics 1992;35:979-95.

(2.) Hardicre J. Put your back out of danger. Nursing Standard 1992; 7(5):54.

(3.) Garg A, Owen BD. Reducing back stress to nursing personnel: An ergonomic intervention in a nursing home. Ergonomics 1992; 35:1353-75.

(4.) Owen BD, Welden N, Kane J. What are we teaching about lifting and transferring patients? Research in Nursing and Health 1999;22:3-13.

(5.) Klein B, Jensen R, Sanderson L. Assessment of worker's compensation claims for back strains/sprains. Journal of Occupational Medicine 1984;26:443-8.

(6.) Bureau of Labor Statistics, U.S. Department of Labor, Washington, DC (1995, April). News (USDL-94-600).

(7.) Service Employees International Union (SEIU), "Caring 'Til It Hurts," Internet article April 1999.http://www.nursinghomes.org/care.html

(8.) Andres RO. Resident transfer: Scientific testing begins. Nursing Homes/Long Term Care Management 1998;47:60.

(9.) Oregon Occupational Health and Safety Administration (1996 and 1997). Instructions for computing lost workday case incidence rates (LWDCIR) for an individual firm. Chapter 437, Oregon Administrative Rules. (SIC code 8050).