Making recommendations for in-home transfer devices requires careful consideration of patient needs and technology options.
Mrs X is currently an inpatient diagnosed with secondary progressive multiple sclerosis who requires two people to assist her when performing a stand pivot or unlevel slide board transfer. Her husband is her primary caregiver who previously performed these transfers independently. With his wife’s recent exacerbation and prognosis, however, lift systems may be needed at home after she is discharged.
There are many factors to consider when choosing a lift system. Funding is one area that has a large impact and varies greatly among patients. Medicare guidelines require that a lift be deemed medically necessary via letter of medical necessity, signed by both therapist and physician. Most health insurance companies follow Medicare or similar rules, whereas workers’ compensation or automobile insurance companies may have different guidelines. If deemed necessary, Medicare will cover 80% of the cost and maintenance associated with its approved lift system.1 Portable lift systems can be rented, purchased, or rented to own.
Two versions of portable lifts are available: sit to stand (STS) lifts and floor-based lift systems (FBLS). To use the STS lift, a patient must be able and permitted to accept weight through at least one lower extremity. The patient also needs sufficient trunk and hip range to come to an upright standing position and the ability to assist with upper extremities to avoid slipping out of the lift. STS lifts are designed to use belts, straps, or vests that fit around the patient (typically under the arms), rather than a sling. An STS lift will transfer a person between seated positions; consequently, a patient must be able to maintain a seated position with close stand-by assistance.
Without sufficient trunk control to maintain sitting balance, two caregivers are required. Thus, an FBLS is a better choice. The FBLS is a sling lift, commonly ordered for home use, and designed for patients who are dependent for mobility. Before deciding which lift system is most appropriate, many therapists fit the patient to a sling to determine overall comfort and safety of the transfer.
There are many variations of slings used with each lift system. Although the basic concepts are the same across brands, the options vary. While many companies have slings designed for assisted ambulation, only slings primarily used for transfers will be addressed in this article.
The primary differences in slings are size, material, and shape. The patient’s weight is the primary factor to consider when choosing a size, although height and body shape also are factors, as well as potential fluctuation in weight and height in the future. At a minimum, materials include a standard cloth (usually polyester) and a mesh. The latter option is recommended for showering to allow for easy drainage and faster drying for daily use. The different shapes allow for variation in strap length, openings for toileting, and length of back. The strapping options and the general shape of the sling allow the patient to be in different positions (seated, reclined, supine, variable hip angles). Angle may be important for patient comfort contractures, spasticity/tone, fractures, bracing, sores, etc. Appropriate shape may vary based on a patient’s abilities, such as whether the patient requires head support. The opening for toileting decreases the risk of skin breakdown and potential poor repositioning of the sling.
Options for Compatibility and Adjustability
Other options include position of pads for comfort and handles to assist with proper positioning on a chair, bed, toilet, and shower chair. The chosen sling should be compatible with all other equipment used throughout the day. In addition to a mesh sling for showering, it is a good idea to have at least two slings to allow for cleaning in cases of soiling.
Depending on the brand of lift system, there may be options to change the spreader bar (where the sling attaches). Lifts are usually selected based on the type of sling and the number and placement of loops, but if the deciding factor is the spreader bar, you can choose from a two-, four-, or six-point system. A four- or a six-point spreader bar is used more typically if the lift needs to be able to perform floor transfers or if the patient is of bariatric size.
Floor-based lift systems have options for the base (leg) height. Depending on what the lift needs to fit under, there may be a need to have a base height that provides greater or less furniture clearance. The base expands as either a “U” or “V” shape. The base can be maneuvered manually or electronically, as can the arm that lifts and lowers the sling. For home use, insurance companies generally don’t cover an electronic version for either option; it is deemed a convenience, unless a physician determines the caregiver is physically incapable of maneuvering the manual version. The base needs to be adjustable to fit underneath furniture and around wheelchairs or toilets. If the lift needs to be used on carpet, dual front casters can be added.
For a patient who may be transferring to a vehicle that is not wheelchair accessible, some lift devices are capable of car transfers and can then be folded for portability. Ease of folding (tools may be required) and the caregiver’s ability to load the lift system in and out of the vehicle should be considered.
Considerations and Benefits of Overhead Lift Systems
Another option for Mrs X would be an overhead lift system. The variations available with an overhead lift system include speed of lift (up and transverse), maximum height clearance, ability to perform floor transfers, and track configuration. The speed of lift dictates the amount of time the patient is suspended in the transfer position. The maximum height clearance in conjunction with the ceiling height will determine ability to clear surfaces while suspended. The track can be straight, curved, or transverse depending on the coverage needed to perform all transfers.2 There are also many small variations such as charging options, ease of use of controller, display options, and return to base mechanisms, among others, that vary depending on brand.
Once a lift has been chosen that fits weight capacity (again leaving room for fluctuation), the biggest decision involves the length of the track and where the track needs to travel. In homes, overhead lifts are used most frequently between a patient’s bed and the toilet and/or shower commode chair.
The primary benefits of an overhead lift system are space, ease of use for caregiver, and aesthetics. The potential drawbacks of an overhead lift system include versatility, cost, and permanence. Overhead lifts can be used to preserve space in a smaller home environment where there is not much room to maneuver a portable lift. Compared to a portable lift, an overhead lift (also known as a ceiling lift) is easier for a caregiver to use and leads to decreased maneuvering of a patient while suspended. Fewer transfers will be required with an overhead lift. Aesthetics are not a singular reason to use an overhead lift, but keep in mind that a patient’s quality of life may be affected by the aesthetics of their living environment.
The versatility of an overhead lift is limited by where the track allows access. Portable lifts can be taken between rooms and even to the car. The permanence of an overhead system applies to both the need for a patient to own the home and the permanence of the condition that requires the lift. The home frequently requires modifications to open the bedroom and bathroom, allowing for track access. The cost of an overhead lift system is a large drawback, especially considering many people who have overhead lifts installed also own portable lifts. All lift systems have weight capacities, ranging from 350 pounds to 600 pounds, and possibly more for bariatric systems.
Multiple Points of Access
Once Mr and Mrs X decided on a lift system, they brought up multiple accessibility concerns including Mrs X’s ability to enter the front door independently, and access to the second floor of their home, the shower, and their vehicle. Home-based door opening systems can be installed and controlled in a variety of manners dependent upon the company, including keyless entry pads or remote controls that can be connected to specialty switches and wheelchair controls. It is recommended that homeowners consult a contractor and relay their specific needs.
Regarding the second floor, there are three options: an elevator, a seated chair lift, and a wheelchair platform stair lift. The most efficient—and most costly—option for mobility is the elevator, which requires extensive home modifications. The stair lift requires that a person have sufficient trunk control and sitting balance to safely use. The seated stair lift, unfortunately, is not an option for Mr and Mrs X because they would need another wheelchair and lift system for the second level of their home. The wheelchair platform lift is more expensive than the seated stair lift, but there would be no need to purchase a second wheelchair. Depending on the amount of time Mrs X will spend on the second level, another lift may still be needed. The shape of the stairwell also may eliminate some options.
Bathroom equipment would be necessary to increase the safety of Mr and Mrs X when toileting and bathing. There are a range of options that would be considered including grab bars, commode chairs, shower transfer benches, and rolling shower chairs with or without commode openings. More information regarding Mrs X’s condition as well as the Xs’ home setup and openness to modifications would further direct these decisions.
When considering a portable ramp for access to a vehicle, curb, or small in-home rise, the primary considerations are weight capacity, length of ramp, portability, and durability. Weight capacity must include the patient and power wheelchair or the patient, manual wheelchair, and caregiver. The length of the ramp will dictate the gradient, which directly impacts the patient’s and/or caregiver’s burden and safety. The ramp’s portability depends on how it can be disassembled and the composition/weight of materials used to build it.
When discussing accessibility issues with patients and caregivers, it is always recommended to collectively trial products to determine the level of safety for the patient and caregiver, as well as ease of use and affordability. Discussions with durable medical equipment representatives and insurance companies also can be helpful when making a decision. RM
Christina Platko, PT, DPT, works with brain injury, multiple trauma, and oncology patients at Mary Free Bed Rehabilitation Hospital, Grand Rapids, Mich. She completed a neurological residency focused on brain injury.
Elizabeth Ramey, PT, DPT, works primarily with brain injury, multiple trauma, and oncology patients at Mary Free Bed Rehabilitation Hospital. She received her DPT at Grand Valley State University. For more information, contact [email protected]
1. Durable Medical Equipment (DME) Coverage. http://www.medicare.gov/coverage/durable-medical-equipment-coverage.html. Accessed March 12, 2014.
2. Matz M. Patient Handling (Lifting) Equipment Coverage & Space Recommendations. 2007. http://www.visn8.va.gov/patientsafetycenter/safepthandling/coveragespacerecs.doc. Accessed March 3, 2014.