Mobility for Nonambulatory
or Bed-bound Patients
The science of physical medicine with respect transferring patients is still in its infancy. The basic methods of transferring dependent or nonambulatory patients have changed little since the early days of nursing. Cranes, slings, boards, and transfer sheets or mats that are used to hoist, lift, or slide patients have all been around for decades.
Recently, many healthcare institutions and some state governments have instituted mandatory "no lift" policies to protect healthcare workers from injury. These older devices, which are described below, allow healthcare workers to implement such policies to varying degrees however almost every device has serious limitations.
First, of all the moderately-priced mechanized patient transfer devices available, only lifts are normally used to move patients to mobile chairs or wheelchairs, and therefore have the distinct advantage of offering patients wheelchair-like mobility. Other devices usually transfer patients only to heavier and more specialized stretcher chairs or gurneys. Second, many of the other mechanical transfer devices listed below are too expensive for most home and institutional use. Third, the major drawback of virtually all of these transfer devices is that they require that patients be hoisted, slid, bent, compressed, dragged, or manually repositioned during transfer. Fourth, both the manual transfer devices such as sliding sheets and power-assisted manual transfer devices such as pressurized sliding mats still exert considerable stress on the caregiver's spine during transfer. Using these devices can still lead to caregiver occupational injuries.
Here is a list of the drawbacks and limitations of commonly used transfer devices.
The biggest problem with lifts is caregiver "buy-in". The safe patient handling literature has many stories of nurses who refuse to use lifts for various reasons. Healthcare administrators lament the number of lifts that sit gathering dust and the wasted money spent buying lift equipment that their staff refuses to use. Much time and money is spent in training and coaxing caregivers to use lifts when they would rather move patients using other less complicated methods. Caregivers are even threatened with loss of access to disability payments if they become injured because they resist using mechanical devices for patient transfer. The rise of "lift teams" is an attempt to create specialists whose only job is patient transfer. This is being done in part because so many floor nurses or nursing aides resist using lifts. The fact that there is a high employee turnover in these lift teams may be a further indication that repeatedly using lifts for patient transfer is a difficult and stressful job.
Another problem is that floor lifts usually require that two caregivers be present during patient transfer. Lift makers are sometimes vague on their safe usage requirements and about whether it is safe to transfer patients with one caregiver present. However if pressed for information, they will usually admit that two caregivers are required. Requiring two or more caregivers puts an unnecessary burden on healthcare institutions which are often under-staffed. In contrast, the NoLifting system usually requires only one caregiver to transfer a patient.
Another issue is that the patient in most cases must be bent and compressed into a semi-sitting position as the flexible sling is raised to hoist the patient above the bed. This can be both frightening and painful for a wide variety of patients. Healthcare workers often find it necessary to calm the patient's anxiety by assuring them that they will not be dropped during transfer. The pain and fear may also cause some patients to become agitated and combative which can lead to caregiver injuries.
One of the most serious drawbacks of using lifts is patient safety. Lifts can be dangerous because the patient can be dropped if the sling is of the wrong type or size for the patient, rips during transfer, or is not positioned, wrapped, or fastened correctly. Institutions usually must buy and nurses need to select the correct sling from multiple kinds of slings, and one large lift maker has over two hundred slings from which to choose. Choosing the correct sling can require additional research and training. Caregivers must be trained in the use of these slings which often involve complex activities of folding, sliding, and positioning parts of the sling while also threading and pulling straps through and around various rings, eyelets, and other straps. The correct use of a particular type of sling can be complex process requiring a good memory and considerable manual dexterity.
The hydraulic components of hydraulic lifts when poorly maintained can also fail during use resulting in the caregiver dropping the patient. The fact that the patient can be dropped is a source of potential liability for healthcare institutions.
Raising patients in slings also treats them like factory parts or bundles of construction material to be hoisted and moved by a crane. This process is understandably considered undignified and dehumanizing by some patients and their family members.
Lifts also require changes in the position of the patient which can result in a rapid drop in blood pressure for certain types of patients (such as quadriplegics). This serious medical condition usually requires that the transfer be halted, and scheduled for a later time. This can make planning difficult for healthcare workers who cannot predict how long it will take to transfer the patient and this, in turn, makes it difficult to keep appointments for other medical services.
Patients who must lay in prone positions (on their stomach) and patients who cannot bend at the waist cannot generally be transferred using lifts. Flexible slings usually force the patient to bend at the back, hips, and knees as the person is hoisted. However, most patients on their stomachs cannot bend backwards in a crescent shape when being hoisted. Thus, both patients who cannot bend at the waist and patients who must remain on their stomachs due to a variety of medical conditions will be difficult to transfer.
When a person is transferred to a mobile chair or wheelchair using a lift, sometimes the sling is left underneath the patient. Pulling out the sling from under the patient sometimes requires tugging and partially lifting the patient. This defeats the purpose of the lift which is to avoid lifting the patient. When the sling is left under the patient, it can become uneven or wrinkle, and collect moisture. This can lead to stress on the skin and increase the probability that the patient may eventually develop pressure ulcers.
If the sling is removed, it must be put back under the patient before transferring the patient back to the bed. This requires yet more effort to slide and pull the sling under the patient which can lead to occupational injuries.
With some slings, the caregiver must use considerable energy tugging and lifting the patient to position the patient upright in the mobile chair at the end of the transfer process. Lifts also increase the probability that the patient will develop pressure sores or ulcers because the slings can exert pressure (friction and shear forces) on small areas of skin during transfer encouraging skin breakdown. The sling's uneven pressure may thus cause skin bruising and abrasions.
Floor lifts usually have relatively small wheels which can jam and catch on carpeting and other objects when the hoisted patent is being moved laterally. This can result in jolting and vibrating a hoisted patient. They require that the area under the patient's bed be cleared of paper, clothes, or other obstacles which can interfere with the lift's rolling ability.
Some hospital beds and many examining tables such as radiology tables have bases or parts that extend to the floor. These patient support structures do not allow the lift's wheeled base to fit under them making it very difficult to move patients to and from these beds or tables with floor lifts.
Floor lifts are commonly used to move dependent patients from beds to mobile chairs. This means that the patient's room needs to be large enough to fit the hospital bed, the lift, the lift's path of movement as it is swung around to position the patient over the mobile chair, and the mobile chair itself. Many homes and even some long term care institutions have rooms that are too small to accommodate all this equipment. Patients in these environments have difficulty using floor lifts for transfer. A study on the use of mechanical lifts at the Washington University School of Medicine notes that one of three reasons given by nurses for not using lifts is "lack of maneuvering space". ² Patients with serious illnesses in acute care settings tend to require a wide variety of equipment in their hospital rooms. This can leave little room for lifts in the room even when mobile chairs are not being used as when a lift is only used to move the patient to a bedside commode.
Since the lifts used in facilities are usually costly, they must be shared among multiple patients. This can create scheduling conflicts, and adds to the planning and logistical burden of busy caregivers.
Lifts are complex and time-consuming to use, requiring perhaps twenty steps to transfer a patient. Lifts are also bulky and not designed to move the patient very far (usually to an adjoining commode or bedside mobile chair). Storing, maintaining, cleaning, transporting, and scheduling the use of these large complex pieces of equipment places an unnecessary burden on many medical organizations and caregivers.
For lifting devices that use ceiling or wall tracks rather than floor hoists, the cost of installation of the tracks is considerable, and the limitations on patient mobility even more pronounced. In private homes, the track installation process is complex and time-consuming, and the tracks usually must be removed when no longer needed or before the house is sold.
Many of the objections to lifts could be summarized by the statement that lifts are basically not patient-centric devices. It is the author's contention that the vast majority of patients who have been moved using a lift would prefer to avoid this method of transfer in the future if there were any reasonable alternative.
In spite of all these limitations, lifts are the primary mechanisms used to define the "best practices" for prevention of musculoskeletal injury by researchers who study the ergonomics of patient handling at OSHA.³
Air-Assisted Sliding Lateral Transfer Aids
Pressurized mats which create air bearings (air pumped through small holes) to reduce friction so patients can slide more easily between beds and gurneys have some serious limitations. First, patients must be rolled and the relatively thick mat must be placed under them prior to transfer.
Though friction is reduced, caregivers must still expend considerable energy sliding the patient. One study which evaluated friction-reducing lateral transfer devices ranked three low-friction sliding sheet products ahead of the two air-bearing systems tested.4 These air-bearing systems ranked fourth and fifth out of eleven products tested. Two-thirds of the ranking was based on the force required to slide the patient, and its effect on the caregiver's spine.
The first figure measured the spinal loading or compression of the caregiver's spine at L5, and the second figure measured the force that must be exerted by the caregiver's upper extremities when using the device during transfer. One conclusion that can be drawn from this study is that these mechanized air bearing systems require more effort than sliding patients out of bed on low-friction sheets (a manual patient handling method). They are therefore far from frictionless and the force required to use them is significant. This means they can still lead to the musculoskeletal injuries in caregivers that they are designed to prevent.
Following transfer, the mat will often need to be removed from beneath the patient which requires additional rolling. The mats are thick when inflated (a common model is eight inches thick) and can create a feeling of instability in patients. The blowers required to pump the air for these systems are fairly large, and the noise they generate will be continuous during the transfer process. The blowers also require an electrical outlet be used during transfer which is not required by the NoLiftingTM Patient Transfer System.
The biggest limitation of these mats is that they can usually only be used to move patients to gurneys and transfer chairs. Transfer chairs are often too expensive for most facility or home use ($6,000 to $12,000). Transfer chairs are also usually bulky with limited mobility and difficult to maintain and store. Gurneys do not allow for a mobile chair's flexibility with respect to positioning the patient in a seated position, and therefore have most of the same problems associated with keeping the patient bedridden.
Friction-Reducing Sliding Lateral Transfer Aids
Other mechanical chair systems have thin, sliding platforms with cranks. The platforms can be moved next to patients rolled on their sides in bed using the crank. The patient can then be rolled partially onto the platform. The disadvantage of these systems is they usually require multiple caregivers to drag the patient (using a sliding sheet) fully onto the platform prior to transfer. Once the patient is centered on the platform, the platform supporting the patient can be moved back over the mobile chair using the manual crank.
The much simpler sliding sheet systems that use low-friction sheets for manual patient handling (without cranks or helper mechanisms) are inexpensive but they only reduce the effort required to transfer patients. Caretakers must still manually pull and slide patients off the bed. They also can require specialized gurney/wheelchair combination chairs or transfer chairs whose problems have already been mentioned above. Some, however, work with standard gurneys, but gurneys do not allow the patient to sit up fully (as with a mobile chair). They are also not very mobile and meant for transport only. Finally, the patient is still being dragged across the bed and onto another surface, which may be painful for some patients and dangerous for caregivers.
Another mechanical bed design converts the entire bed to a very large mobile chair by dropping the portion of the mattress beneath the patient's feet and raising the back rest portion to a vertical position. These mobile beds are expensive, bulky (usually about 36" wide), heavy, and prevent patients from traveling very far regardless of whether they are in lying or sitting positions. The obvious advantage is the patient can be transported without needing to first be transferred to separate mobile device. However such beds do not help patients who need to be moved to other patient support platforms (such as examining or radiology tables).
Stretcher Chairs and Transfer Chairs
Rotating Belt Systems
The disadvantage of these systems besides their expense is that they are currently only used as gurneys and not as chairs. They are thus good for supine patients and moving them onto operating room tables and similar support surfaces.
As mentioned earlier, the greatest limitation of many of these devices is cost. With the exception of moderately priced lifts or simpler sliding sheet systems, many hospitals, skilled nursing facilities, and private households simply cannot afford to buy or rent, and store and maintain these transfer devices.
All of the above devices are useful and important and contribute to improving the quality of patient care. They all have a role to play in the medical arena. All of them are also being continually improved. But if the fundamental concept of the device has inherent limitations, no amount of improvement will be likely to erase those limitations.
Given the many drawbacks of the above mentioned devices, it seems necessary to find a better way to transfer and transport patients. The NoLiftingTM Patient Transfer System satisfies this need.
1. Pasero C., McCaffery M. (2002). "Pain in the Critically Ill" American Journal of Nursing, 102(1):59-60
2. J Li, L Wolf, and B Evanoff. Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers Inj. Prev., August 1, 2004; 10(4): 212 - 216. Full Online Article
3. Collins JW, Wolf L, Bell J, et al. An evaluation of a "best practices" musculoskeletal injury prevention program in nursing homes. Inj Prev 2004; Full Online Article
4. Lloyd, J., & Baptiste, A. (2004). "Biomechanical evaluation of friction-reducing devices for lateral patient transfers". Research Rehabilitation & Development Journal.