There are numerous details to consider when mobilizing individuals in a facility or at home. It is important to recognize that moving a patient, client, or loved one can be a high risk activity, and safety is paramount regardless of setting. Research has shown cumulative damage to the spine occurs when lifting weights greater than 35 pounds. The movement with which the lift is performed must also be dignified and promote optimal function for the individual.
A facility must have clear written policies and procedures that promote a culture of safety. This practice maximizes patient and staff safety during lift use, repositioning efforts, and transfers. Safe patient handling and mobility (SPHM) programs can make a significant impact on overall facility safety as well as costs related to injuries. In addition, patient outcomes may improve with the use of SPHM programs and technology.
Having support from a facility’s upper management is important in establishing a SPHM program. Getting this support often is referred to as “winning over your C suite” (CEO, CFO, COO).” Using research and presenting data can help assure buy-in.
Forming an interdisciplinary team is critical to guarantee collaboration with multiple departments. The team works together for problem identification, forming a common language, and developing policies and procedures to assist with implementation and sustainability.
Clearly written expectations that are accessible and understandable create ownership of a successful SPHM program. These promote a culture of safety and improve education and communication within a facility. The program also assists in family education and training to establish safe mobilization methods when providing care for a loved one in the home.
Several mobility assessment tools are available for hospital facilities, and the pros and cons of each should be considered before making the final decision about which will best meet a facility’s needs. Madonna Rehabilitation Hospital, Lincoln, Neb, developed a tool currently used facility-wide across the continuum of care. The transfer tool and algorithm developed at the facility was based on the work by Audrey Nelson and the VISN 8 Patient Safety Team. This tool examines the various components of a transfer including: level of assist, number of staff, type of transfer, assistive device/equipment, and special considerations (eg, cognition, weight bearing, and precautions). The transfer tool assists the registered nurse in the mobility assessment to determine the most appropriate mobilization method. The written policies were also clear-cut regarding not lifting greater than 35 pounds and not lifting from the floor.
A patient’s height and weight, ability to support weight, balance (sitting and standing), and ability to follow directions, cooperate, and be consistent, are considered during the mobilization assessment. The ability of the person being mobilized will determine equipment type and the number of individuals required to assist.
The transfer assessment tool is updated in a timely manner to facilitate communication to direct care staff. Based on the level of care, the tool is updated weekly on the hospital side of the facility, quarterly on the long-term care side of the facility, or more frequently, depending on status change.
Common language use and understanding across disciplines benefits both the patient and staff. Madonna found this essential when developing policies and procedures. The assessment tool facilitates communication to staff for early mobilization. Studies have shown that earlier mobilization can impact length of stay and discharge locations. Prior to the development of SPHM policy/procedure, nursing would wait for the therapist’s recommendation before mobilizing. Communication to staff and family assures they are fully aware that a patient may have two different transfer levels, depending on the time of day or between disciplines. Using communication tools and face-to-face conversations assists in providing the most appropriate transfer method for staff. Further information may be required for patients and families to increase their understanding of different methods used.
Education and training is vital for staff using the mobilization assessment, transfer techniques, and equipment. There is a need for common language, knowledge, and practice. This benefits all parties involved in the transfer. Patient instruction maximizes the ability to participate and improves cooperation. Having clinical staff well-educated about transfer techniques and equipment eases the transition to the caregiver for the home setting, if appropriate, and facilitates a patient’s direction of their care.
• Instructional videos, hands-on training, and competency help to build a basic foundation for the facility staff.
• Instruction and training in different mobilization techniques includes stand pivot, squat pivot, slide board, and 2-person.
• Among all individuals involved in a transfer, sharing small but important suggestions about transfer techniques can help ensure the success of a mobilization (eg, patient hand placement and direction of weight shift).
• Having a strong foundation can assist with managing the unexpected while mobilizing a patient.
• Knowing a patient’s limitations and barriers can assist with making decisions about transfer type and equipment selection.
• Staff should be knowledgeable about the various equipment options. Demonstration, practice, and empathy can assist with proper use and sling positioning.
• Empathy experience allows facility personnel to gain insight into the transfer method and improves the ability to relate to concerns a patient potentially may have.
• Assess the equipment needs by activity and patient participation.
• Does the equipment meet the needs of the facility?
• Are ceiling or floor lifts able to be lowered to the floor in the event of a fall?
• Is the toilet in the restroom accessible by the patient if using a sit-to-stand lift?
• Is there space under the bed for the floor lift legs to allow access to the bed surface?
• Ask questions about equipment options, accessibility to environment to be utilized, and test or trial equipment to assist with equipment selection and improvement based on facility need.
Total lifts, which are available in ceiling/overhead configurations, are of great use in hospital rooms and gym areas. They are readily available for transfers and repositioning. They also improve access and safety of equipment when floor lift legs don’t fit under the equipment or bed. Floor lifts are a great alternative if ceiling lifts are unavailable or if needing to access different areas within a home or facility. This type of lift works well for individuals who may be unable to support their own weight, maintain balance, and cooperate or follow simple directions.
A total lift is designed to lift the total person. The patient does not need to participate, and requires maximum assist or greater. Two types of total lifts include:
• Ceiling lifts: Installed in room or over area to be utilized, readily available, not portable.
• Floor lifts: Portable from room to room, limited by lift legs positioning. (For proper positioning, ensure the leg of the lift fits under the bed or equipment.)
Equipment that provides stand assist is also important for optimum patient transfers. Sit to/from stand lifts work well with individuals who are able to support their own weight (on at least one leg), maintain balance, and follow directions, but who perhaps have difficulty with the transition into standing or require greater than moderate assist. This lift may improve a person’s ability to access a restroom or commode for toileting. The device also may allow a person to increase weight-bearing activity during the day.
A sit-to-stand lift requires the individual to participate, follow directions, maintain balance, and load at least one leg. The device is portable from room to room and can be limited by lift legs positioning.
An additional equipment consideration for patient transfers and handling is sling selection. Depending on the individual’s situation, type of lift and task to be completed will determine size and positioning of the sling. Make sure the correct sling is used with the correct piece of equipment.
HOW DID YOU DECIDE?
If the patient has had a stroke and tends to push posteriorly, a sit-to-stand device may not be the most appropriate. This device may inappropriately reinforce the patient’s movement pattern. A total lift transfer may be the safest method to utilize until the patient is able to sit midline and demonstrate anterior weight shift without resistance. During therapy sessions, a slide board may be used with techniques to inhibit pushing and facilitate anterior weight shift. Communication between nursing and therapy staff is crucial to developing an appropriate patient mobilization plan and facilitating the progression of nontherapeutic to therapeutic mobility.
If the patient is independent with sitting balance, able to assist with lift-off using the upper extremities, but unable to follow lower extremity weight-bearing precautions, a slide board transfer may be appropriate. The transfer method may change once the patient is able to demonstrate weight-bearing status and safety.
The method selected depends on the mobilization goal and the participation/skill level of the person being mobilized. Allowing for nontherapeutic transfers to be completed can improve the patient’s ability to participate in other tasks. A patient’s involvement in a mobilization task can be compromised by pain, anxiety, fear, strength/weakness, motor control, or the ability to motor plan.
Using equipment for performing patient transfers also can be of benefit when transitioning to therapeutic mobilization. Equipment can provide the patient with support to ease fear of falling and anxiety, increase the number of repetitions during practice, improve performance, and increase the ability of the therapist to facilitate. A patient can progress from nontherapeutic transfers to therapeutic transfers as medical stability and physical ability allow. Progression of functional mobility skills can impact home/community access, burden of care, and discharge location.
MOBILIZATIONS AT HOME
Home access, caregiver support, and financial resources can play a role in discharge planning and location. SPHM programs need to be used in the home setting as well as the inpatient facility. Providing education and helping patients and their families determine safe mobilization methods could decrease the risk of injury and improve the longevity of the caregiver.
Patient and caregiver fatigue also needs to be considered. Finding a balance between use of lift and manual transfers can be appropriate. Using a lift may allow for less effort and stress on the patient and caregiver. Conserving energy for both may allow for participation and engagement in other tasks at home and in the community. If the caregiver becomes injured, the patient’s need for regular and safe mobilization may be compromised.
Education and training can help patients direct their care while promoting safety at home, especially if they have multiple caregivers. Allowing caregivers to practice with equipment and techniques within the facility—under supervision—promotes safety and carryover at home. In the home setting, floor lifts, using friction reducing sheets to assist with repositioning, and using a slide board may be options to promote the well-being of the patient and reduce caregiver injuries.
On admission: The RN completes the mobility assessment tool to determine the transfer method. Using factors such as weakness, fatigue, decreased balance, and confusion, the RN determines the most appropriate transfer method is the total lift. The lift will be used when mobilizing the patient from the bed or wheelchair.
Initial physical therapy evaluation: The physical therapist discovers the patient has bilateral lower extremity weakness, with the left side weaker than the right. Sitting balance at the edge of the bed with feet supported on the floor required maximum assist for midline sitting. Bed mobility is maximum assist of two people, as well as the initial slide board transfer from the bed to the wheelchair. The patient continues to be confused, has a fear of falling, but is able to follow directions. Initially, a lift may be used for energy conservation to promote improved patient participation with sitting balance activities in therapy sessions. Following improvement in strength and balance, the patient demonstrates the ability to participate in a slide board transfer. As the assist level decreases, the therapist should recommend a different transfer method to the nursing staff.
Michelle Claycomb, PT, MSPT, CCS, works as an inpatient physical therapist at Madonna Long Term Care Hospital in Lincoln, Neb. She also serves as the current SPHM program leader for the facility. For more information, contact [email protected].
The author wishes to thank Sandy Stutzman, Margaret Arnold, Tami Rudder, Brian Claycomb, and Linda Brettmann, for their assistance in development of this article.
Note: Patient examples and photos are not related.
Butler LA, Claycomb M, Stutzman S, Shutzer-Hill D. Reducing patient movement-related injuries through the development, implementation, and sustainability of a ccomprehensive safe patient handling and movement program. American Journal of Safe Patient Handling and Movement. 2012;2(1):19-27.
Nelson A. Safe Patient Handling and Movement: A Guide for Nurses and Other Health Care Providers. New York: Springer Publishing Co; 2006.
Waters TR. When is it safe to manually lift a patient? Am J Nurs. 2007;107(8):53-58.