Why is it important to sit with a client at the edge of the bed prior to transfer

Transferring is the client’s movement from one surface to another. The process involves the pre-transfer, transfer, and post-transfer. As the client has some physical or cognitive limitations, they require the physical assistance, cues, or supervision of the OT, caregiver, or staff. As each client, OT, their strengths/weaknesses, environment, and situation are different, each transfer must be adapted to fit the client’s needs.

Whether you have done a type of transfer 1000x, 10x, 1x, or never, you should always ensure the safety of yourself, your co-workers, and the client. Proper lifting technique is crucial because you need to protect your most important asset to your career – yourself. You might be able to get away with an improper lifting technique once, but compounded over the many times you perform it incorrectly over your career may result in injury. Rushing to do a transfer without necessary precautions may also result in an injury or fall to the client.

My facility started requiring staff members to enroll in safe patient handling courses. This is a great asset because many staff, including nurses, have been getting injured on the job transferring patients. I hope that this post provides information for everyone to take away from, whether you are an experienced OT or just starting out as a new grad. Even students should learn proper technique before getting into the workforce. I hope that you learn some new proper and safe skills/techniques or become inspired as you reflect and gain insight into how you are lifting and transfer clients. There is always some room for improvement because new technologies and research are being developed or shared to make the OT, caregiver, and client’s life easier.

Risks to Injury

Vertical – lifting, e.g. dependent transfers

Lateral – between flat surfaces, e.g. bed to gurney

Repositioning – e.g., turning or repositioning in bed

Ambulation – e.g., assisting to walk

Bariatric – more than 200#

Common Transfers Locations

Consider these types of transfers when preparing clients for discharge, especially when training caregivers so that they are comfortable with all these types.

• In and out of bed
• In and out of a wheelchair
• In and out of a chair or sofa
• On and off of toilet or commode
• On and off bath chair or bench
• On and off 4 wheeled walker
• In and out of a car
• Off the ground (floor recovery) vs. calling EMS

Safety Tips

• ALWAYS keep in mind your safety and the safety of your client when lifting.
• Address the client’s fear of falling.
• Consider your client’s weight and ask for assistance when needed.
• Consider your client’s level of alertness and physical ability for the type of transfer you are attempting.
• Consider the client’s orthostatic hypotension when changing positions quickly.
• Reduce environmental risks (e.g., slick floors, inappropriate footwear, poor lighting)
• Use proper body mechanics.
• Position yourself so that you are not awkward, e.g. hunched over, arms with elbows extended instead of elbows by your side.
• Keep a wide base of support.
• Push rather than pull, if possible.
• Bend at the knees, not at the waist.
• Lift in a smooth motion, not a jerky motion.
• Take advantage of gravity (e.g., positioning the bed in Trendelenburg to facilitate with sliding client to head of bed instead of bed flat) and momentum.
• Ask for assistance when necessary.
• Use a mechanical device/lift when necessary (some facilities require the use based on certain criteria).
• Communicate before the move if collaborating with others.
• Complete the move in small steps if needed instead of one giant one – which could result in an awkward position.
• Do not over-help, allow the client to exert effort, if they will not break any precautions, e.g. weight-bearing
• Never let your client hold onto your neck for support.
• If your client is a “pusher”, give their pushing hand a job to do such as holding an object.

Body Mechanics

Principles

The OT must understand the biomechanics of movement prior to transferring their client to maximize the success and facilitate movement while preventing injury or a fall.

• Pelvic Tilt
• Trunk alignment
• Hip alignment
• Center of gravity (static and during the transfer)
• Posture
• Extremity positioning
• Muscle tone (hyper-, hypo-, clonus, etc.)
• Weight shifting

“APPLAUSE”

Approach – get close to the client.

Plan – plan ahead with your client how you will perform the transfer.

Pivot – pivot your legs, do NOT twist or rotate your spine or back.

Legs – use your legs, not your back, arms, or shoulders

Apart – keep your feet shoulder-width apart for increased back support.

Up – keep your head up to ensure correct spinal curve

Stomach (suck it in) – increase your inner abdominal pressure to serve as a splint to your spine

Easy – take your time, do not rush

Falls/Loss of balance during transfer

• If a significant loss of balance is occurring, do not attempt to hold the client up, as this may injure you and the client.
• Assist the client in a safe descent to the floor.
• Use a wall or firm surface to assist in “sliding down” if nearby.

The Setup & Transfer

I like to say that my transfer is “90% set up and 10% transfer”. The set up is very important and can reduce the amount of effort and problems that can arise. This list is very comprehensive and while each step does not apply to every transfer, they are important to consider depending on your situation.

1. Consider how much time the transfer will need. The client may become fatigued. They will also need to transfer back to a safe surface such as back to bed for activities such as taking a shower.
2. Plan the move in your head and visualize it. Leave enough room for both you and your client (and helpers) to move between the origin and destination.
3. Plan the move back to the surface the client came if necessary (either at the end of your session or later on with other staff). Caregivers coming back to the original surface with slide board transfers because they are faced with going “uphill” and at this point, the client is often very fatigued to assist.
4. Gather appropriate equipment for the transfer. Some things that are often forgotten are gait belts, footwear (grippy socks), wheelchair leg rests, and chair alarms.
5. Know the weight limits of the device you will use to transfer, and the weight limits of the surface the client will be transferred onto.
6. Consider the type of transfer you will do, and whether it is the most appropriate for your current client presentation.
7. If requiring additional assistance, alert staff when to come in when you are ready to transfer. “We will be ready to transfer in 5 minutes, please bring X, Y, and Z.”
8. Remove environmental clutter and hazards – trash, food on the ground, phone charging cables, power cords from SCD pumps, etc.
9. Remove DME hazards or barriers, e.g. leg rests, armrests if appropriate.
10. Ensure proper lighting and reduce glare if possible.
11. Can the client see well as well? Do they need glasses? Do they have diplopia? Left neglect?
12. Manage medical lines – IV, NG, nasal cannula, catheters/foley, SCDs, etc. I like to remove the client’s covers & blankets completely to see everything that may be connected.
13. Ensure lines are long enough and have enough slack to allow for the final position of the transfer. If you pull out an IV or NG tube, you will have a bad day.
14. Move surfaces as close as possible and minimize the gaps.
15. Adjust the height of the surface (e.g., bed) to your benefit (match the height to the body mechanics of the shorter person participating in the transfer).
16. Flatten the surface if beneficial (e.g., bed – lower the foot of the bed so that it is flat and the patient is not in a “hump” after they come to sit up at the edge of the bed).
17. Lock the brakes! Test the brakes – including the ones on the bed – you never know what the last staff member may have forgotten. Even when locked, some beds with worn-out brakes may still slide a little.
18. Turn off the alarms – you’ll forget these enough times to maybe learn to do this step. I still forget to turn off the bed or chair alarms. Don’t stress over this one, it’s just not fun having the unit nurse run into the room during a transfer.
19. Put on a gait belt (depending on your facility culture or policy).
20. Double-check weight-bearing precautions and mobility orders (bed rest vs. ambulate).
21. Provide instructions to the client, having them teach-back the sequence out loud and/or demonstrate the transfer beforehand. “Noes over toes.” Have them move towards their strong side if possible.
22. Position of client’s hands and feet, e.g. one hand pushing off the bed and one hand reaching to support front-wheeled walker; feet with a wide base of support.
23. Provide clear, concise, short directions. Can the client understand your instructions? Are they hard of hearing? Are they aphasic?
24. Agree on the timing of the transfer, e.g. “On 3.”
25. Perform the transfer – without rushing.
26. Remember the transfer details for documentation. Can another person reading the chart understand how to replicate the transfer?
    • Transfer type
    • Transfer origin and destination
    • Assistance provided/needed (I, supervised, SBA, CGA, min, mod, max, dependent, 2 person, mechanical)

Equipment for Transfers

Bed

The best beds are ones that can elevate and lower electrically. Manual crank-style beds are also common. Some hospital beds are not considered “low beds” and cannot lower enough to match the height of other surfaces such as wheelchairs or commodes, making various transfers more difficult. Another consideration is the type of bed that the client will actually have at home.

If a hospital bed will not be available at home, the client should be trained to simulate their bed height at home or resources should be provided to them to modify their bed or overcome this barrier. To make getting into higher beds easier, a flat wooden platform can be installed or a commercial bed rail can be purchased.

Wheelchairs

• Wheelchair brakes should be functional so that the wheelchair does not slide during transfers.
• Anti-tippers for are also encouraged for clients starting out with the wheelchair.
• Legrests should be swiveled away or removed.
• Armrests that can be removed or folded-up are more versatile.
• The type of cushion including its firmness and thickness can also make a transfer easier or more difficult.
• Manual vs. electric – manual will be easier for the OT or caregiver to move because they are generally lighter. They can be folded away to save space. Electric wheelchairs will need to be “driven” into place, often requiring more skill or be put into manual drive mode and pushed. However, this still requires a significant amount of physical effort due to the weight of the components.
• Space available – the physical environment may prevent a wheelchair from fitting in certain places, or even through spaces such as narrow doorways. Narrow doorways can be the major barrier to wheelchair transfers because a wheelchair cannot be negotiated between rooms.

Walkers

Front wheeled, Platform, Four Wheeled

• Generally more stable than 4 wheeled walkers.
• Should be adjusted accordingly for the height of the client – walker handles at hand grip level when the elbow is about 15 degrees flexion.
• Can be easily folded up and stored against the wall to save space.

Slide Board

See above for transfer sequence.

Beasy Board

Slide Sheets

SLIPP

• Do not leave the SLIPP under the patient after use.
• Do not share SLIPPs between patients before cleaning.
• If the client is over 250lbs, use a minimum of 3 caregivers to transfer.

Sit to Stand Devices

• Sara Stedy – a great transfer device to use if your facility has one, easy to train to use, has no batteries or electrical components. Be sure the platform “flaps” have enough space to up and out (especially against walls).
• Vanderlift
• Vera Lift

Hover Mattress

• Single patient use.
• Reduces friction via blown up air connected via an electronic pump.
• Useful for repositioning in bed and for lateral transfers – sliding between flat surfaces, e.g. bed <-> gurney.
• Comes in 34″ and 39″.
• Remove from under patient after use.

HoverJack

• Series of mattresses that are inflated by a pump.
• May be useful for fall recovery to lift from floor to bed.
• Caregivers can perform CPR on mattress.
• Must be wiped down with germicidal wipes (re-usable).
• Dimensions 32″x72″30″.

Backboards

• Less commonly used in OT compared to EMS.
• Require training and familiarity for placement of straps.
• Require a team lift of at least 2 people.

Grab bars

• Should be installed properly.
• Suction-cup style grab bars are not recommended.
• Towel racks and toilet paper dispensers are also, not recommended.
• Alternatively, countertops may act as a grab bar if they are close enough.

Trapeze bar

• Beware of lifting precautions, some clients end up with trapezes with sternal precautions, for example, when they should not be lifting with their upper extremities in this manner.
• May be useful for clients getting out of bed.
• Should be “weened” off as soon as possible.
• Simulate their home environment, clients will likely not have a trapeze bar when they go home.

Gait Belt

• Use a gait belt and/or pants during transfer when possible.
• Connect 2 gait belt together if 1 is not long enough.
• Be careful not to put a gait belt on colostomy bag, PEG tube, or breasts.
• Do not use belt loops for support – they can rip or break.

Canes

• Large or small base quad canes
• Single-point canes (more hazardous to use to transfer with, recommend transferring with both hands from origin surface such as armrests, then reaching for the cane once in standing)

Hand Hold Assist

• Educate caregivers to not pull from arms during transfers.

Types of Transfers

Bed Mobility

Rolling

• Avoid having the client rolling away from you, especially without bed rails as they may put in too much effort and roll off the bed.
• Adjust the bed height if too low or high in order to have your arms at a biomechanically advantageous position.
• Adjust the head of the bed and/or foot of the bed to supine or semi-fowler’s (depending on precautions and medical risks).

1. Prepare opposite arm for rolling – protract client’s scapula if hemiparetic to prevent injury. If the client is passively moving, have them clasp the hemiparetic arm with the strong arm. If the client is actively moving, have the hemiparetic arm placed across their torso towards the side they will be rolling on so that it does not get “left behind”.
2. Have the client or assist them in flexing their knees.
3. Assist the client (have them put in most of the effort) in rolling to their side, starting with arms, then the legs. If log rolling, the OT supports the arms and the legs or torso.

Side-lying to sit

1. Assist or have the client bring their feet off the edge of the bed.
2. Stabilize the client’s lower extremities with your knees.
3. Place one supporting hand on the lateral shoulder (between shoulder and bed) and other at hip or back of knees while you assist them in an upright sitting position.
4. The client will usually support their hands on the bed or bedrail for support.
5. Scoot to the edge of the bed if necessary.

Scooting to the edge

1. Have or assist the client in shifting weight to one side.
2. Position your hand behind the opposite hip/buttock and assist them forward. Tip: use the sheet or pad the client is sitting on to assist in sliding them forward, one hip at a time.
3. Repeat with weight shifting to the other side to assist them forward.
4. Repeat steps 2 & 3 as necessary to assist the client all the way to the edge with their feet flat on the floor.
5. Lower the bed for shorter clients.

Sliding / Boosting to Head of Bed (2 Person Assist)

• You will probably do this type of transfer several times even on your shift. It is very common. I am talking about the “boost” to head of bed when the client gets back to bed but is too low from the headboard. Most commonly, 2 caregivers (one on each side of the bed) will grab onto either a chux pad the client is on or the bedsheet and simultaneously slide them to the head of bed. There is nothing wrong with this type of transfer itself. In fact, the chux pads used in hospitals have several hundred-pound weight limits and are very hard to rip during transfers.
• Client’s weight – the heavier they are, the more effort will be needed to move them.
• Friction – without any other equipment, there is a lot of friction between these surfaces because they are not meant to slide. You do not want your client to slip out of bed when they are sleeping.
• Shearing – be cautious of clients with pressure injuries on their bottoms, open wounds, burn patients, etc.
• Bed level – flat vs. Trendelenburg; if not contraindicated and the bed can go into Trendelenburg, do it! Use gravity to your advantage.
• Client’s ability – can the client bridge and kick up with their legs or use their upper extremities to help? Let them assist if they can follow the command appropriately.
• Slide sheets – USE THEM! Known as SLIPP sheet in some facilities, they can help with sliding clients either up in bed or between surfaces. They work by reducing the #1 most contributing factor to slide transfers – friction.
• Hover Matts – reduce friction EVEN MORE! If your facility has them, also USE THEM! Remember to remove them from under the client when finished, as clients have been known to slip off them and onto the floor!

Bridging to the Head of Bed (1 Person Assist)

• If the client is capable, this a more functional method to have the client repositioned closer to the head of the bed.

1. Position the bed flat or in Trendelenburg (if medically cleared – a better method that takes advantage of gravity).
2. Instruct or assist the client in bending their knees.
3. Support the feet so that they do not slide.
4. Instruct the client to bridge their hip (raise it off the bed) while simultaneously kicking up towards the head of bed.
5. The client may use their upper extremities to pull with the side rails on each side. Be careful of client’s shoulders if they attempt to pull with the headboard instead.
6. Repeat these steps as necessary until the client reaches the desired position near the headboard.
7. Reposition bed to flat from Trendelenburg.

Sit to Stand

1. Raise the surface to their advantage, e.g. elevate bed, but too high that their feet won’t touch the floor.
2. Assist in sliding the client to the edge of the surface.
3. Position their feet on the floor with a wide base of support.
4. Stand on the client’s affected or weaker side.
5. Have the client push with their strong hand and support their other hand on the front wheeled walker or another device. Alternatively, have the client push with both hands from their armrests or surface.
6. Stabilize the involved knee with your own knee if hemiparetic.
7. Support the client at the waist or gait belt as they come into a stand.
8. Instruct the client to stand up straight and/or “squeeze their bottom together”.

Stand Pivot

1. Position the two surfaces about 90 degrees.
2. Raise the origin surface to their advantage, e.g. elevate bed, but too high that their feet won’t touch the floor.
3. Assist in sliding the client to the edge of the origin surface.
4. Position their feet on the floor with a wide base of support.
5. Have the client’s heels point (angled, but not perpendicular) toward the surface they will be transferring towards.
6. Instruct the client not to reach for your neck for support.
7. Have the client push with both hands (if no sternal or weight bearing precautions) from their armrests or surface.
8. Cue them with “nose over toes”.
9. The client may reach toward the surface they will be transferring to.
10. Get close to your client. You can have your head on the side of the destination surface, but the client will not be able to see where they are going.
11. Guide the client toward the destination surface while lowering them down into a sitting position.

Stand Step

A stand step pivot is a sit-to-stand combined with sidestepping (instead of feet pivoting at an axis) towards the destination surface, then coming from stand to a sit. The OT assists in the same manner for setup, cues, hand placement, and client hand placement. Consider the client’s cognitive and physical ability as stand step with some clients may be risky, especially the client with a hemiparetic lower extremity which may have difficulty lifting off the ground as opposed to just pivoting.

Squat (Bent) Pivot

• When clients cannot maintain a standing position.
• Sometimes a safer alternative to stand pivot by keeping the client’s lower extremities in equal weight-bearing while maintaining trunk and lower extremity support during transfer.
• Use a gait belt.

1. Position surfaces close together ~90 degrees.
2. Remove armrests from wheelchairs.
3. Assist or instruct the client to scoot to the edge of the origin surface.
4. Angle the client’s heels towards the destination surface.
5. Block the client’s knees with your knees.
6. Instruct the client to push off the surface while shifting their weight “nose over toes”.
7. Support the client at gait belt, waist, or buttocks and assist in guiding the transfer towards the destination surface. Never grasp under the weak arm or the weak arm.
8. Get close to your client. You can have your head on the side of the destination surface, but the client will not be able to see where they are going.
9. Instruct the client to reach for the destination surface.
10. Assist in lower the client onto the destination surface.

Slide Board (between surfaces)

Ideal for when clients cannot bear weight through their lower extremities or with bilateral lower extremity weakness, paralysis. Clients should have safe trunk control and good sitting balance for a safe sliding board transfer, especially onto/off a commode.

• Friction: too much, e.g. skin on slide board may inhibit sliding on the board – consider using a chux pad or a pillowcase over the slide board. Too little can be dangerous, e.g. slide board on top of commode seat (plastic) can shift during a slide board transfer. Consider placing Dycem between the slide board and commode seat.
• Board length – longer slide boards are often beneficial for car transfers.
• Pinch hazard – be sure both you and your client do not have their fingers pinched under the slide board during transfers. One common spot this may occur is if a slide board has a cut out hole about 1/3 of the board where clients like to place their hand.
• Board placement is crucial – it should be adequately under the client’s buttocks.

1. Check the slide board for damage.
2. Position the wheelchair about 90, as close as possible to the other surface.
3. Lower the destination or raise the origin surface so as to have a slight downhill angle.
4. Place the slide board under one leg, midthigh between buttocks and knee angled toward the opposite hip. Slideboard must be firmly under the high and firmly on the destination surface.
5. Block the client’s knees with your knees. Alternatively, block the client’s knees with one of your knees, and use your other leg to stabilize the destination surface, e.g. outside wheelchair wheel to prevent it from sliding.
6. Instruct the client to lean forward (leaning too far back may result in fall – but if they lean too far forward, the OT will be blocking and supporting the client).
7. Instruct the client to use their hands to push (depression push) towards the destination surface.
8. Assist the client with shifting weight and supporting of the trunk while moving. If the slideboard shifts mid transfer, stabilize it with one hand and support the client with your other hand.

Weight Shifting to Slide

The client leans to one side laterally to shift weight onto that side (unweighting the bottom of their opposite side), while the therapist assists in sliding the opposite side (usually the hip) anteriorly or posteriorly. This is much easier if the client is on a pad or sheet than just with pants on a surface, but is often still very physically demanding on the OT. Remember friction is your enemy, but sometimes in small spaces like on a wheelchair, you do not have much room to work. Call for assistance if needed – 1 person to assist with the lower extremities and the 2nd at the torso.

Airplane (Depression Scoot)

• See post on Airplane transfers.

Dependent (One-Person Assist)

• For clients with minimal to no function for transferring.
• Potentially hazardous if performed incorrectly.
• Practice with able-bodied individuals before performing on your client.
• With heavier clients, this is best with 2 persons assisting.

Ground or Fall Recovery

Mechanical Lift

Sit to Stand devices

Hoyer lifts (Electric & Manual)

Vanderlift, Vera Lift

• Have 2 people perform the transfer (depending on the facility or local policy).
• Check the batteries.
• Test the up/down lift briefly before using it.
• Know where the emergency stop button is.
• Remember to lock the brakes.
• Use the correct side sling for your client, orient it correctly.
• Match the hooks symmetrically between left and right hooks.
• Consider wrapping the lower extremities in a “cross pattern” (instead of like a cocoon) beneath the groin so the client will not slip out and down from the sling.
• Ensure the head is properly supported by the sling.
• When lowering the lift, be careful not to lower any parts onto the client’s head.

Overhead lifts

• Similar to hoyer lift.
• Be aware of where the hoyer track can travel from/to.
• Don’t bump your or your client’s head against them.

Further Reading

• Occupational Therapy DME Weight Limits

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