1. Patterson, Miki
  2. Mechan, Patricia
  3. Hughes, Nancy
  4. Nelson, Audrey


Vertical transfers of patients with a cast/brace or sling on an upper or lower extremity from bed to chair pose a high risk for musculoskeletal injury. A task force was formed, including representatives from National Association of Orthopaedic Nurses, American Nurses Association, National Institute for Occupational Safety and Health, Patient Safety Center of inquiry at the James Haley Veterans Administration Medical Center in Tampa, FL, and related clinical experts. This task force developed an ergonomic decision-making tool (algorithm) to determine best practice for safe vertical transfer of a patient with an upper or lower extremity injury in a sling cast or brace. This tool was designed with current literature review, ergonomic safety concepts, and technology available.


Article Content

National Association of Orthopaedic Nurses (NAON) published a guidance statement to identify patient-handling tasks performed in the orthopaedic setting that present high risk for work-related musculoskeletal disorders (MSDs) to caregivers and to develop evidence-based solutions for each task aimed at reducing that risk. The development process for this guidance statement has been described previously (Sedlak, Doheny, & Nelson, 2009). This is the third article characterizing specific high-risk orthopaedic tasks and delineating ergonomic solutions. Specifically, the high-risk task is vertical transfer of a patient with an extremity cast or splint. An algorithm has been developed to outline ergonomic solutions likely to improve safety for the patient and the caregiver.


Nurses and other caregivers in orthopaedic settings are at high risk for musculoskeletal injury associated with the need for mobility assistance. Among the challenges is care of the patient with upper and/or lower extremity immobility due to postoperative conditions, injuries, or disease impairments.


When the use of one or multiple extremities is compromised, patients are unable to utilize their usual motor patterns to accomplish activities of daily living, including bed repositioning, sitting at the edge of bed in preparation for transfer, standing, or completing a transfer to a chair or commode, to name a few. Orthopaedic nurses will frequently compensate for mobility deficits, placing themselves in postures and positions that are unsafe and posing serious risk for musculoskeletal injury (Sedlak & Doheny, 2006). For example, a caregiver might bend forward and reach across a bed or chair to help "hoist" the patient up. This position is ergonomically unsafe to the nurse, putting excessive stress and pressure on the spine (Marras, Davis, Kirking, & Bertsche, 1999).



On the basis of input from a panel of experts in ergonomics and orthopaedic nursing, it was determined that transferring orthopaedic patients with casted or splinted upper or lower extremities out of bed was identified as a potential high-risk task for work-related MSDs, such as low back or shoulder injuries. In the orthopaedic setting, vertical transfers of patients with a compromised extremity from bed to chair are performed many times during a typical work shift. Several factors contributing to increased risk include the weight of the patient or extremity, functional mobility status, location of the patient at the time of the task relative to the caregiver (how close the caregiver can get to the person's body or the extremity), and required frequency and duration of task.


According to the literature, the back can be equated to a mechanical lever system, with the L5/S1 spinal disc being the fulcrum of the lever system. When a caregiver performs a lifting task, the lever system in the back must be balanced at all times. Therefore, the muscles must exert large internal forces to create the lifting motion or to hold the spine in a fixed position during a lift (Nelson, Waters, Spratt, Peterson, & Hughes, 2007). In fact, depending upon the caregiver's posture during the lift, these muscle forces can be more than 20 times greater than the weight being lifted (Marras et al., 1999). It is these large muscle forces that create tremendous pressure on the spinal discs that are thought to cause damage to the soft tissues of the spine and result in low back pain. It has been established that the pressure on the spine exceeds the acceptable thresholds, when trying to perform bed-to-chair transfers with one or two persons, for patients who are unable to assist and support their body weight, balance, weight shift, and transfer to another surface (Marras et al., 1999).


The acceptable weight threshold for a caregiver's spine to bear has been established by Waters (2007). When patients are able to follow directions and the caregiver expects no sudden movement, up to 35 lb of weight or force is acceptable (Waters, 2007).


Upper or Lower Extremity Impairments With Vertical Transfers

In orthopaedic inpatient settings, typical extremity injuries are fractures, dislocations, and crush injuries that require internal or external reduction/fixation. Admission and overnight stay can occur when the extremity requires monitoring, follow-up imaging, or when there are associated medical or surgical complications related with the primary extremity injury. Such medical or surgical complication(s), other sequelae from the injury or surgery, and associated discomfort and immobility can compromise the patient's ability to independently perform a bed-to-chair transfer.


A common postinjury or postoperative guideline for patients with an extremity injury is to limit the weight patients can place or bear on the affected extremity, such as nonweight bearing or partial weight bearing. In addition, the patient may have a splint, cast, brace, or sling on the affected extremity to protect the reduction and support the fixation. Assessing patient mobility and ensuring ability to safely get out of bed, move to a chair, and walk are all activities that orthopaedic nurses perform frequently.


An algorithm or decision-making tool has been developed to assist caregivers in performing such assessments, so they consider key information about the patient's status in order to decide what method of assistance to provide, number of caregivers needed to provide assistance, and what equipment and/or devices are recommended to safely accomplish a vertical transfer of the patient with upper or lower extremity cast/brace or injury.


Ergonomic Tool 3: Vertical Transfer of Patient With Cast/Splint on Upper or Lower Extremity

As shown in Figure 1, there is a start position. The start position to accomplish a vertical transfer without caregiver assistance would require a patient to move from supine to sitting at the edge of the bed. If the patient cannot perform this activity with an impaired upper or lower extremity and the amount of assistance from the caregiver exceeds 35 lb, then follow the related footnote steps for the start position.

Figure 1 - Click to enlarge in new windowFIGURE 1. Orthopaedic Algorithm 3: Vertical transfer of a patient with an extremity cast/splint.

From the start position, consider whether the patient is cooperative and able to follow directions. If unable, then the recommended strategy is to use a mechanical lift with minimum of two caregivers. However, if the patient is cooperative/able to follow directions, then consider whether the patient is able to bear weight with the lower extremities. The recommended medical-surgical weight-bearing guidelines for the patient's extremity will guide the selection of the next steps. If a patient is unable to bear weight through the lower extremities at all, then a mechanical lift with two caregivers is preferred.


If the patient is partially able to bear weight with the lower extremities, then follow the recommendations described in algorithm for partial weight bearing. For patients who can partially weight bear through a lower extremity, there are three possible choices:


* Manual stand and pivot technique, with or without use of a gait belt and one caregiver


* Stand and pivot technique, using a pivot disk style of device with one caregiver (see Figure 2)

Figure 2 - Click to enlarge in new windowFIGURE 2. Standing disk pivot transfer.

* Powered standing assist lift with one caregiver



Assessment of the patient's ability to weight shift in standing while correctly maintaining his or her weight-bearing precautions will assist in determining which of the three options is most appropriate for the patient. Remember, if a caregiver would be required to exert more than 35 lb of force to provide the amount of assistance needed to safely execute the transfer task, then it exceeds the recommended threshold of force, and a more dependent method of transfer is recommended, such as using a mechanical lift.


When the patient is able to fully weight bear with the lower extremities, then as noted in Figure 1, caregiver assistance is not needed. Caregivers should act as standby assistance for safety. The team will determine which mobility aids to utilize, such as a walker or cane.


Some basics of how the patient can get to a sitting position at the edge of bed are explained in the footnote section of the algorithm. The actions include using the bed controls to assist the patient to a sitting position, encouraging the patient to pull on side rails to turn and pull up to sitting (if safely able to perform with an injured arm or leg).


Antifriction sheets or pads (see Figure 3) and seated discs (see Figure 4) can assist a patient into a sitting position at edge of bed. However, if a patient is not able to do this, a mechanical lift will be necessary. Sling accessories in conjunction with a mechanical lift (see Figures 5 and 6) can be used to support a limb if the weight of the impaired limb (including cast/splint) exceeds 35 lb (Waters, Sedlak, Howe, Gonzalez, & Doheny, 2009).

Figure 3 - Click to enlarge in new windowFIGURE 3. Antifriction pad.
Figure 4 - Click to enlarge in new windowFIGURE 4. Seated disk.
Figure 5 - Click to enlarge in new windowFIGURE 5. Casted leg sling-hoist.
Figure 6 - Click to enlarge in new windowFIGURE 6. Transfer casted leg.

Selection of the appropriate sling accessory for movement/lift/transfer must include the following considerations:


* Decision to transfer the patient in sitting versus supine position-choose correct functionality of the sling.


* Select appropriate size sling.


* Maintain alignment of the affected body part(s) according to preoperative/postoperative guidelines.


* Consider the patient's body size, shape, and physical characteristics (e.g., a very large abdominal girth can limit degree of hip flexion).


* Features of sling.Consider where material covers patient.The length of material for thigh supports in seated slings can often be modified by selecting differing loop attachment points of the sling onto the hanger bar (e.g., providing more material length will allow lower extremity [i.e., hip] to be in less flexed position).Seated slings' back height can vary from supporting the whole trunk and head to covering the pelvis/waist only. When upper extremities are involved, consider the height of the sling-high back slings will wrap around and enclose an upper extremity, whereas a low back sling will allow upper extremity to be free.


* If alignment/positioning guidelines cannot be met with the sling accessory available, transfer the patient in a supine position with a sheet style sling or antifriction methods, then sit the patient upright.



Rationale for the Tool

In 2006, via membership survey, NAON identified common tasks in orthopaedic nursing as high risk for caregiver injury. Transferring an orthopaedic patient out of bed to chair with an impaired upper or lower extremity was identified as a high-volume, high-risk task. A key responsibility of the orthopaedic nurse is to provide safe patient care by protecting the patient from further injury, while facilitating mobility improvement. The number of caregivers required to safely transfer a patient should always be adequate to maintain the patient's alignment and weight-bearing guidelines as well as to protect caregivers from injury. When transferring a patient, there are multiple patient safety factors that must be considered in conjunction with the safety of the caregiver. Outlining these factors in the steps of the algorithm provides a decision-making structure for caregivers to follow when faced with a high-risk patient-handling task.


Clinical Considerations

Clinical considerations for moving and vertical transfer of a patient with a cast/splint/brace or sling on an extremity include the patient's medical and surgical condition, comorbidities, maintaining alignment of the extremity, and maintaining the ordered weight-bearing limitations.


Medical complications can include such impairments as dysrhythmias, unstable hemodynamics, dehydration or other volume depletion, and abnormal glycemic function, to name a few (Hendricks & Counselman, 2004; Powers & Boenau, 2005). The presence of such factors can cause fatigue for patients and impair their ability to participate fully and/or maintain weight-bearing/alignment precautions.


Comorbidities, such as severe osteoporosis that affects bone integrity can impact the alignment and weight-bearing precautions for a patient. A postinjury or postoperative status for persons with compromised bone integrity can often be more limited than for a person with normal bone integrity. The status of the repaired bone might be fragile, calling for restrictive guidelines for movement and positioning, in which patients are limited from certain positions and/or the amount of force and pressure they may exert on the affected extremity.


The differences between caring for patients with upper versus lower extremity injuries can be significant. Those with upper-extremity injuries typically have their injured arm in a sling or supportive device. Most will have no lower extremity restrictions so that ambulating may be fairly independent. The biggest problem is actually getting upright and getting up from the bed. According to the recommended weight chart by Waters et al. (2009), the caregiver may lift/support one upper extremity, independently, with both hands if the overall body weight is 440 lb or less (Waters et al., 2009). It may be difficult for a patient with an injured upper extremity to pull to the side of the bed, push off the bed, or grasp a handle on a mechanical stander. Many times the nurse needs to keep the upper extremity in alignment throughout the vertical transfer process. This results in a position for the nurse that is out or around the side of a patient, which can put the caregiver at risk for injury to neck and shoulders.


On the other hand, those orthopaedic patients with lower-extremity injuries typically have weight-bearing restrictions and/or abnormal mobility limitations from surgery, casts, external fixators, or braces. Lifting or supporting a lower extremity is frequently done to aid an orthopaedic patient in getting to the edge of the bed, by reaching across the bed, or reaching up from the end of the bed. Both of these positions put the caregiver at risk for injury. Caregivers may also aid the orthopaedic patient in lowering the injured extremity to the floor. A lower extremity weighs up to 37.7 lb in a 190- to 240-lb person, so caregivers must carefully consider the overall weight of the person, consult the extremity weight chart, and, if established safe thresholds are exceeded, should not lift an extremity alone (Waters et al., 2009). Mechanical lifting devices for the lower extremity are available.


Summary and Conclusions

On the basis of the assessment by NAON, vertical transfer of a patient with an impaired extremity presents a high risk of developing MSDs, particularly low back and shoulder injuries for the caregiver. Extended reaching postures and high-lifting loads require large muscle forces that can create excessive loads on the soft tissues of the spine and shoulder joint. These forces are large enough to cause damage to musculoskeletal tissues that could result in severe low back or shoulder pain and could lead to permanent disability. Therefore, it is important to determine which tasks may be safe to perform manually versus those that should be performed with the use of technology, such as patient transfer devices or other ergonomic equipment. The ergonomic tool presented in this article focuses on vertical transfer of a patient with cast/splint on an extremity. The algorithm presented provides a user-friendly guideline for making such a determination. As with all ergonomic tools, however, users should continue to rely on professional judgment when making decisions such as these.




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