Module 6: Client Moving Techniques * Terms marked by an asterisk are defined in the Glossary

Transcription

1 Module 6: Client Moving Techniques * Terms marked by an asterisk are defined in the Glossary 6.1 Introduction Module 1 introduced the moving task as a consistent set of steps used to move a client. At this point in the task, the worker has completed the first three steps and obtained the following results: by clarifying the nature of the moving task, the worker has determined whether the moving task is a reposition (a move on the same surface, or between two surfaces of equal height in which the client does not bear any weight) or a transfer or lift (a move from one surface/location to another surface/location) by identifying the moving technique if previously documented, the worker has determined the minimum level of assistance (which includes the moving technique, assistance, assistive devices and/or mechanical equipment) required when transferring, lifting or repositioning the client by conducting an assessment, the worker has identified: personal risk factors, as well as risk factors in the client and environment that have the potential to jeopardize the safety of the worker(s) and/or client at the time the moving task is performed which, if any, of these risk factors can be eliminated and/or managed which, if any, of these risk factors cannot be eliminated or managed Risk factors that cannot be eliminated or managed have the potential to jeopardize the safety of the worker and/or client during the moving task. If all risks cannot be eliminated or managed, the worker should not proceed with the moving task until alternate solutions can be agreed upon. The purpose of Module 6 is to describe the remaining steps in the client moving task by building upon these initial results April 2011

2 To fulfill this purpose, Module 6 achieves 10 goals. It: describes the process for selecting the appropriate moving technique outlines the preparatory steps for moving a client identifies and describes transferring techniques identifies and describes mechanical lifting techniques identifies and describes repositioning techniques identifies and describes a technique for moving a non-weight-bearing client and a total lift client without a mechanical lifting device identifies and describes bed rest identifies and describes emergency lifts describes the process for evaluating the assessment and moving technique describes the process for communicating the selected moving technique Understanding these goals enables you to safely move a client. 6.2 Selecting the Appropriate Moving Technique An appropriate moving technique: reduces the probability of injury to the worker(s) and client, and is considered to be the safest manner possible to perform the moving task at this time is appropriate for the worker, environment and client at the time the moving task is performed is comfortable for the worker(s) and client enables the client to be as independent as possible moves the client in a consistent manner, enabling the client to: become familiar and confident with the moving task perfect their role in the moving task become less anxious and confused during the moving task allows the worker(s) to gain confidence in their ability to move the client safely and responsibly April 2011

3 The worker uses the results of the first three steps in the moving task to select the appropriate moving technique: if no risk factors were identified or if all risk factors can be eliminated, the worker selects the moving technique that ensures the minimum level of assistance at the time the moving task is performed. This technique will be identified in the client s care plan and logo if the client has been assessed per a General Client Mobility Assessment. Refer to Section 470(2) of Saskatchewan's Occupational Health and Safety Regulations, if all risk factors cannot be eliminated, the worker selects the moving technique that manages the risk factors and enables the worker to perform the moving task in the safest manner possible. The worker begins with the moving technique that ensures the minimum level of assistance and increases the level of assistance until the moving technique that manages all risk factors is selected, as indicated by the criteria for each logo. If the moving technique documented in the client s care plan and logo is not appropriate for the worker and/or environment and/or client at the time the moving task is performed, the worker selects the safest technique for moving the client. The worker is never allowed to use less assistance than documented (exception: see in-transition logos below) unless the client s level of assistance has been re-assessed through a General Client Mobility Assessment (see Section 5.5A) and/or a Specialized Client Mobility Assessment (see Section 5.5C), and only after it has been documented appropriately in the care plan and logo. In-transition Logos: designed primarily for acute care settings where the client s mobility status changes rapidly throughout the day. The in-transition logos can be changed following each ongoing assessment. Logo assignment can reflect not only changes that require a higher level of assistance but also a lower level of assistance. Once the client s status stabilizes, the standard TLR logos should be used. Refer to the In-transition Guidelines, Appendix B. Note: A client needs to be re-assessed according to an agency s policy and guidelines when more than the documented level of assistance was used consistently to move the client. This situation is different than increasing the level of assistance occasionally, such as when the client has flu symptoms or when the client is temporarily tired because they just completed therapy. Such conditions may indicate the need for two logos that are clearly labelled with the time frames and the reasons for the different logos documented April 2011

4 6.3 Preparing for Moving the Client The worker uses the results of the assessment and the criteria of the selected moving technique (as indicated by the logo) to prepare for moving the client. Essential elements of preparation are: Eliminating Risks Obtaining Assistance Communicating the Plan with Client and Co-worker(s) Eliminating Risks When conducting the assessment, the worker identified all risk factors that could be eliminated. The worker now eliminates all personal risk factors, as well as risk factors in the environment (including equipment) and the client that can be eliminated. Personal Risk Factors To eliminate personal risk factors (see Module 5, Section 5.3), for example, the worker: warms up and stretches determines how to apply the principles of good body mechanics and ergonomics to the moving task wears clothing that allows unrestricted movement, and closed-in shoes that are secured to the foot (not a slip-on type, but ones that are laced or strapped on) and have reasonable non-slip soles. Refer to Section 96(1) of Saskatchewan's Occupational Health and Safety Regulations, Environment (including equipment) Risk Factors To eliminate risk factors in the environment (see Module 5, Section 5.4), for example, the worker: plans the pathway by rearranging items such as furniture, carts or equipment that could impede the moving task clears spills and clutter from the floor adjusts lighting so that it is comfortable, and reduces glare and shadows limits noise minimizes distractions April 2011

5 To eliminate risk factors with equipment (see Module 5, Section 5.4), for example, the worker: considers and uses only equipment designed for the intended purpose ensures that all required equipment is available checks equipment for safety removes faulty equipment from service and reports it places equipment in accessible and convenient locations removes armrests, footrests and leg rests, if possible and when appropriate locks all wheels and brakes as applicable sets the working surface to the optimal height that promotes good body mechanics Client Risk Factors To eliminate risk factors in the client (see Module 5, Section 5.5), for example, the worker: ensures that attachments such as IVs, urine drainage bags and safety belts do not interfere with the moving task applies or removes splints or braces as necessary ensures that the client s clothing and footwear are appropriate ensures that the client is wearing sensory assistive devices (e.g., glasses, hearing aids) if required Obtaining Assistance The primary worker obtains assistance as indicated by the selected moving technique (logo). The need for assistance may also be indicated by the pre-moving assessment of risk factors in the worker, environment and client for the specific move. Communicating the Plan with Client and Co-worker(s) The primary worker communicates with the client and assistant/co-worker(s) before the moving task begins. The worker provides clear instructions as to: their own role in the moving task the assistant/co-workers roles in the moving task the procedure, or steps, for the moving technique the count that will be used for the moving technique. The count consists of followed by an appropriate command. It is important that all workers and the client understand that the move occurs when the command is used after the count. The count ensures that the movements of the worker, client and assistant/co-worker(s) are coordinated. Now that the primary worker has eliminated the risk factors, obtained assistance and communicated the plan with the client and co-worker(s), they are prepared to move the client using the appropriate moving technique April 2011

6 6.4 Moving the Client Using the Appropriate Moving Technique Essential elements of moving the client are: Communicating with Client and Co-worker(s) During the Move Taking Precautions Proceeding with Preparatory Steps Positioning of the Worker Proceeding with the Moving Technique Procedure for an Assisted/Guided Fall* Communicating with Client and Co-worker(s) During the Move The primary worker communicates with the client and assistant/coworker(s) during the moving technique by: giving short, clear commands one at a time throughout the moving technique signalling the count in the moving technique (e.g., Stand or Sit ) Taking Precautions During the moving technique, the worker takes precautions to: never apply pressure under the client s armpits during any type of move. This will help avoid shoulder injury to the client. A transfer belt must be used when indicated. not allow the client to grasp them around the neck, their clothing or any part of their body during any type of move. This will help avoid neck or back injury to the worker and will help to maintain the worker s balance. apply the principles of good body mechanics and ergonomics during any type of move to help avoid injury to themselves. For example, the worker: moves their body in the direction of the move without rotating or twisting the spine. keeps their trunk upright (maintaining the three natural curves of the spine), tightening the abdominal muscles, bending at the hips and knees, and using the legs instead of the back. assumes the stance that provides a safe, flexible base, ensuring that the body is balanced and the centre of gravity is over the feet. This stance prepares the worker for any unexpected movement. works with gravity, always April 2011

7 Proceeding With Preparatory Steps Lying to Sitting Many TLR techniques, and some mechanical lifting equipment, require the client in a sitting position prior to the move. Workers may provide the client with verbal guidance or minimal assistance, including use of assistive devices, in order to achieve a sitting position. A total lift may be required in some situations. A sit/stand lift is not an appropriate device for lying to sitting. Depending upon the assessment, the following may be used to achieve lying to sitting. Using verbal guidance, the worker: instructs the client to move to a sitting position considers assistive devices (e.g., raise head of bed, trapeze, Sask-a-pole, repositioning cushions/wedges, use of bed rail, etc.) that may be required in order for the client to achieve a sitting position instructs the client, when appropriate, to begin with lowering their legs over the side of the bed. This allows momentum to assist them with getting their upper body into an upright position Using verbal guidance and minimal assistance, the worker: uses minimal manual effort ensures that the brakes on the bed are working properly and locked in position adjusts the height of the bed to ensure the use of good body mechanics when assisting the client and adjusts the head of the bed to meet the client s needs lowers the bed rail(s) or positions the rail to allow the client to use the rail during the move instructs and/or assists the client to roll on to their side and then instructs them to push into the mattress with their upper arms considers assistive devices (e.g., raise head of bed, trapeze, Sask-a-pole, repositioning cushions/wedges, use of bed rail) that may be required in order for the client to achieve a sitting position instructs and/or assists the client, when appropriate, to begin with lowering their legs over the side of the bed. This allows momentum to assist them with getting their upper body into an upright position adjusts the height of the bed so that the client s feet rest flat on the floor when seated on the edge of the bed if the client cannot be left unattended, calls a second worker to assist if hands-on assistance is needed, appropriately applies a transfer belt to the client once they are in a sitting position If the client requires additional assistance, two workers may be required and the use of a total lift may be considered to ensure a safe move. The workers would follow the procedure listed above with one worker assisting with the client s trunk and the second worker assisting with the legs April 2011

8 Sitting to Lying Workers may provide the client with verbal guidance or minimal assistance, including use of assistive devices, in order to achieve a lying position. A total lift may be required in some situations. A sit/stand lift is not an appropriate device for sitting to lying. Depending upon the assessment, the following may be used to achieve sitting to lying. Consideration must be given to: adjusting the bed to safe and suitable (low) position prior to the client achieving the sitting positioning on the edge of the bed adjusting the height of the bed when workers need to provide hands-on assistance removing the footboard and headboard to eliminate the risk of injury Using verbal guidance, the worker: ensures that the brakes on the bed are working properly and locked in position instructs the client to sit on the edge of the bed, with the buttocks on the mattress and their feet in a stride stance. The client should be seated near the middle of the bed or slightly toward the head of the bed considers assistive devices (e.g., raise head of bed, trapeze, Sask-a-pole, repositioning cushions/wedges, use of bed rail, etc.) that may be required in order for the client to move from sitting to lying instructs the client, when appropriate, to begin with pushing themselves back onto the mattress while swinging their legs up and onto the mattress and turning their upper body to be in alignment with their legs. instructs the client to lay back, using their arms or assistive devices to achieve a lying position Using verbal guidance and minimal assistance, the worker: uses minimal manual effort ensures that the brakes on the bed are working properly and locked in position using proper body mechanics and a transfer belt, assists the client to sit on the edge of the bed, with the buttocks on the mattress and their feet in a stride stance. The client should be seated near the middle of the bed or slightly toward the head of the bed considers assistive devices (e.g., raise head of bed, trapeze, Sask-a-pole, repositioning cushions/wedges, use of bed rail, etc.) that may be required in order for the client to move from sitting to lying instructs and/or assists the client, when appropriate, to begin with raising their legs over the side of the bed and turning their upper body to be in alignment with their legs instructs and/or assists the client to lay back, using their arms or assistive devices to achieve a lying position if the client cannot assist, calls a second worker to assist If the client requires additional assistance, two workers may be required and the use of a total lift may be considered to ensure a safe move. The workers would follow the procedure listed above with one worker assisting with the client s trunk and the second worker assisting with the legs April 2011

9 Following completion of the move, evaluated what went well: Did the workers feel that the move compromised their body mechanics? At any time did the workers feel they were lifting the client? If the response to either question is yes, use of a total lift should be considered to ensure a safe move. Increased worker communication and observation skills may be necessary as the client may be stiff, sore, dizzy, etc., once they are sitting. Consideration must be given to removing any repositioning sheet from under the client in order to manage/eliminate the risk associated with slipping off the bed. Using a transfer belt Indications for use The worker applies a transfer belt when the client requires physical, hands-on assistance with standing. The exception is the client for whom the use of a transfer belt would either compromise their safety and/or the safety of the worker (e.g., the psychiatric client or the abdominal surgery client). During the moving task, the worker grasps the transfer belt instead of the client s arm, waist or clothing. The TLR program recommends that each worker have a transfer belt available at all times. Transfer belts may be worn by the worker for ease of accessibility when it is required to assist with a client move. A transfer belt may also be readily available in the client s room. It is further recommended that the worker be responsible for ensuring that the belt is in good repair. The belt should be inspected for fraying of the fabric, cracks or breaks in the buckle, strength when fastened, and slipping due to an incorrectly threaded buckle. Defective belts must be removed from service until repaired (if possible) or appropriately disposed of. Proper replacement belts should then be available. Criteria The transfer belt is appropriate for the client who: is cooperative is not aggressive or abusive may be slightly weak or unsteady can bear their body weight through part(s) of their body meets the criteria for the one-person or two-person transfers with belt Alert: No manual lifting of the client is to occur. The client must be able to bear their own body weight through part(s) of their body April 2011

10 Procedure To use a transfer belt, the worker, using good body mechanics: applies the transfer belt in a manner that respects a client's personal space and does not frighten them (no "lassoing" over the client's head) fastens the transfer belt around the client s waist or around the client s rib cage, below the level of the bust adjusts the transfer belt so that the worker is able to grasp the transfer belt comfortably and firmly without causing the client discomfort grasps the transfer belt using an effective and safe grip (see Module 3 for principles of good body mechanics) grasps the transfer belt (not the client) during the transfer removes the transfer belt immediately following the transfer Precautions The worker: should only use the transfer belt for its intended use. It is not intended to be used as a wheelchair/chair safety device or as a client restraint device. should not manually lift the client with the transfer belt. If the client indicates that they are experiencing discomfort and/or the belt is sliding up, the worker should determine whether they are lifting the client. Transferring in and out of a bed When transferring the client in and out of a bed, the primary worker: ensures that the brakes on all equipment (e.g., wheelchair, bed, commode) are working properly, and locked in position adjusts the height of the bed to ensure the use of good body mechanics when assisting the client in or out of bed adjusts the head of the bed to meet the client s needs lowers the bed rail(s). The worker should never work over a bed rail, as this does not allow the use of good body mechanics instructs and/or assists the client to sit on the edge of the bed, if transferring out of bed instructs and/or assists the client to roll on to their side instructs the client to push into the mattress with the upper arms instructs and/or assists the client to swing the legs over the edge of the bed once the client is sitting, adjusts the height of the bed so that the client s feet rest flat on the floor when seated on the edge of the bed if the client cannot be left unattended, calls a second worker to assist if hands-on assistance is needed, applies a transfer belt to the client once they are in a sitting position April 2011

11 Transferring in and out of a chair/wheelchair When transferring the client in and out of a chair/wheelchair, the primary worker: ensures that the chair/wheelchair brakes are working properly, and locked in position prepares the wheelchair by: undoing the seatbelt, removing or swinging the footrests out of the way, and removing the armrest(s), if appropriate. These simple attachments can cause major injuries if they impede the move in any way applies a transfer belt to the client appropriately instructs and/or assists the client to move forward in the chair to prepare for the transfer of their body weight instructs and/or assists the client to place their hands on the armrest, if this ability is present Positioning of the Worker The primary worker finds a position close to the client with a stance that provides strength and balance during the moving technique. This position permits the worker to: maintain good control use good body mechanics make the client feel safe reduce the probability of injury have increased flexibility and control ensure body weight is distributed over their centre of gravity Proceeding with the Moving Technique The worker then proceeds with the selected moving technique (see Section 6.5 for transferring techniques, Section 6.6 for mechanical lifting techniques and Section 6.7 for repositioning techniques). Procedure for an Assisted/Guided Fall A client may fall unexpectedly for any number of reasons. If the client starts to fall, the worker: will guide the fall only if within a distance that permits assistance does not try to stop the fall. The worker must not work against gravity by: holding the client up stopping the client from sliding off a chair attempting to drag the client back to the client s original position moves in as close as possible to the client grasps the client (if safely possible) and guides/slides the client gently to the floor by quickly bending at the hips and knees while keeping the trunk upright (maintaining the three natural curves of the spine) April 2011

12 if the client is unable to get up on their own, ensures that the client is made comfortable on the floor until: the client is assessed by appropriate professionals for injuries the necessary equipment and/or assistance is obtained to move the client from the floor if the client is able to get up on their own, gives the client time to regain composure and get up from the floor Never attempt to manually lift a client from the floor unless it is a lifethreatening situation always follows agency guidelines for the handling and reporting of client falls 6.5 Transferring Techniques A transfer is a moving technique: used to assist the client in moving from one surface/location (e.g., from a bed to a wheelchair) to another surface/location (e.g., from a wheelchair to the toilet), ensuring the safety of the client and/or worker and using a minimal amount of manual effort that is a dynamic and cooperative (physically and mentally) action between the client and worker in which the client is bearing their own body weight through part or parts of the body. The worker does not bear any of the client s body weight no manual lifting is used The following moving techniques can be used to transfer a client: Independent Transfer Modification of Independent Transfer: Independent Sliding Board* Transfer Supervised Transfer Minimum Assistance Transfer One-Person Transfer with Belt Modification A: One-Person Transfer with Belt - with a Client Handling Sling* from Bed to Wheelchair Modification B: One-Person Sliding Board Transfer with Belt One-Person Transfer with Belt and Assistant Two-Person Transfer with Belt Model Procedure: Two-Person Transfer with Belt (Side by Side) Modification A: Two-Person Transfer with Belt (Front Only) Modification B: Two-Person Transfer with Belt (Front and Back) from Bed to Wheelchair Modification C: Two-Person Sliding Board Transfer with Belt April 2011

13 Independent Transfer Indications for use (nature of the moving task) An independent transfer is used by the client to move from one surface/location to another surface/location with or without the use of assistive devices such as a cane or walker (e.g., from a bed to wheelchair, or from a wheelchair to the bathroom/toilet). Criteria for independent transfer At the time of the move the client: displays sound judgement (is cognitive) When sound judgement is not consistently present, the client needs to be assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. can bear their body weight through part(s) of their body is cooperative is predictable and reliable in performance and behaviour to the extent required for the move (e.g., is steady on the feet and can safely and confidently relocate themselves) requires no physical hands-on assistance requires no verbal assistance requires no assistance with equipment Workers should always consider the risk of abusive/violent behaviour. Consider Modification of Independent Transfer: Independent Sliding Board Transfer (on following pages) Model procedure for independent transfer There is no formal procedure for an independent transfer because the client is able to move independently without any assistance. The client prepares for the move. The worker ensures that the client s environment is safe, pathway is clear, and that all equipment is well maintained and appropriate (e.g., equipment such as canes, crutches, walkers, braces/splints or wheelchairs must be specifically fitted for the client by a specialist or therapist). Any concerns with the client s equipment should be directed back to the specialist or therapist for evaluation. The specialist or therapist would also train the client and worker in proper and safe usage of the equipment April 2011

14 Modification of independent transfer: independent sliding board transfer Indications for use (nature of the moving task) An independent sliding board transfer is used to move the client between two surfaces of equal height. A sliding board transfer has the potential to enhance the client s independence with all transfers once an appropriate specialist or therapist has assessed and evaluated the client, and taught safe usage of the sliding board to the client and worker. Criteria for independent sliding board transfer An independent sliding board transfer is appropriate for the client who: has good trunk control, and is able to lift the buttocks off the surface by using the arms and upper chest muscles, without assistance is able to shift along the board to the new surface and reposition the lower limbs without assistance is able to bear their body weight through their arms, and has minimal or no ability to bear weight on the lower limbs (e.g., leg amputee(s), paraplegics and clients with limited or decreased range of motion of their joints) displays sound judgement (understands what is expected) is cooperative is predictable and reliable in performance and behaviour to the extent required for the move Model procedure for independent sliding board transfer from bed to wheelchair 1. The client prepares for the move. The worker ensures that the client has all necessary equipment near at all times, and that the sliding board is appropriate for the client s size, weight and needs. Any concerns in this area are referred to an appropriate therapist for evaluation. Note: If a client is transferring from a wheelchair to another surface, or vice versa, they will remove any footrests and/or armrests, as these attachments can impede the move. This ability is necessary to being designated an independent sliding board transfer. 2. The wheelchair is parallel to the bed, and the armrest nearest to the bed is removed. Rationale: The armrest presents a barrier to the move. Removing the barrier allows the board to be used correctly and safely. An alternate position for the client with double lower limb amputations is to line the wheelchair up perpendicular to the bed; the client is taught to manage the transfer independently. 3. The client executes the independent transfer from the bed to the wheelchair. The worker, if present, evaluates the client s safety throughout the move. 4. The client repositions themselves in the wheelchair to a comfortable, safe, supported and dignified position April 2011

15 Supervised Transfer Indications for use (nature of the moving task) A supervised transfer is used to move the client from one surface/location to another surface/location with or without the use of assistive devices such as a cane or walker. Criteria for Supervised Transfer At the time of the move the client: displays reasonable judgement. This client may have some difficulty with decisionmaking, but can still physically mobilize on their own (e.g., the client with Alzheimer s/dementia). can bear their body weight through part(s) of their body is cooperative is predictable and reliable in performance and behaviour to the extent required for the move requires no physical hands-on assistance may require verbal guidance (such as reminders and cueing), and/or minimal physical assistance with setting up equipment (e.g., with positioning the wheelchair) may be supervised from a distance Workers should always consider the risk of abusive/violent behaviour. If closer supervision is required or if the client requires some physical hands-on assistance (e.g., if the worker needs to take the client s hand, or if the client takes the worker s hand or arm to move in the intended direction), the client needs to be assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. Model procedure for supervised transfer from bed to wheelchair 1. The client prepares for the move. 2. The worker adjusts the height of the bed so that the client s feet will rest flat on the floor when seated on the edge of the bed. Note: The bed should be left and/or returned to this position at all times to ensure safety for the client. 3. The worker ensures that the client has all necessary equipment nearby April 2011

16 4. The client and/or worker ensure all brakes (e.g., on the bed and wheelchair) are locked. 5. The worker remains close enough to help but not hinder the client s movements, and is prepared to assist if necessary. The worker must be prepared for the unexpected. 6. The worker ensures that the client adjusts the footrests, and instructs the client to place their feet on them, if applicable. 7. The worker ensures that the client applies and positions the wheelchair safety belt, if necessary. 8. The worker ensures that the client is left in a comfortable, safe, supported and dignified position, with the assurance that additional help is available should it be needed April 2011

17 Minimum Assistance Transfer Indications for use (nature of the moving task) A minimum assistance transfer is used to move the client from one surface/location to another surface/location with or without the use of assistive devices such as a cane or walker. Criteria for Minimum Assistance Transfer At the time of the move the client: can bear their body weight through part(s) of their body is cooperative is predictable and reliable in performance and behaviour to the extent required for the move reasonably understands what is expected to the extent required for the move. The client may respond more appropriately to non-verbal cues (e.g., the physically-able dementia client who holds the worker s hand as the worker leads or guides them to the dining room). may require minimal assistance such as help with putting on shoes or appliances may require assistance with setting up or placing equipment Workers should always consider the risk of abusive/violent behaviour. If any of these criteria are not met, the client is assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. Model procedure for minimum assistance transfer from bed to wheelchair Tip: Hand-to-hand contact often provides the directive the client needs to gain the confidence and motivation to proceed with the move. 1. The worker and client prepare the equipment by: adjusting the height of the bed to the wheelchair, if possible positioning the wheelchair so the client moves to their stronger side whenever possible, and so the wheelchair is parallel to or at a 45 degree angle to the bed locking the brakes on all equipment (e.g., on the bed and chair) removing the armrests/footrests on the wheelchair, if applicable April 2011

18 2 The worker instructs the client to: sit on the edge of the bed move forward to the edge of the bed place feet flat on the floor 3. The worker stands directly in front and facing the client, and/or: stands on the client s weaker side facing the client from in front or the side, if applicable stabilizes the client s weaker foot with their foot, if necessary stabilizes the client s weaker knee with their knee, if necessary 4. The worker instructs the client to lean forward by bending at the hips, and to push up from the bed by placing the hands on the bed, on the knees, or on the thighs. Rationale: This action transfers the client s weight from the buttocks/thighs to the feet. If necessary, the worker instructs the client to rock back and forth to gain the momentum required to lift the buttocks off the surface. If this ability is not present, the client needs to be assessed per a General Client Mobility Assessment (see Section 5.5A) using two workers and/or a Specialized Client Mobility Assessment (see Section 5.5C) to determine the minimum level of assistance. 5. The client rises to the appropriate safe height (tall or crouch) as the worker continuously assesses and evaluates the client s abilities. The worker is always prepared for the unexpected, ensuring personal safety and safety for the client. 6. The worker instructs the client to turn, and take small steps back until the client s legs touch the wheelchair. 7. The worker instructs the client to bend at the hips and knees and lean forward slightly (to ensure that the centre of gravity is over the thighs and feet). As the client reaches for the armrest(s), the worker observes and reminds the client to sit well back in the wheelchair. 8. The client and/or worker replaces/adjusts the armrests/footrests if applicable, and encourages or assists the client to place the feet properly. 9. Once the client is seated, the worker assesses the client s alignment for comfort, safety, support and dignity, and assists with repositioning as necessary. If a significant amount of assistance is needed for the client, the client needs to be assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. No manual lifting should take place. If a manual lift occurs, it must be documented as an unusual incident to ensure that follow-up problem solving can be done to prevent future problems April 2011

19 One-Person Transfer with Belt Indications for use (nature of the moving task) A one-person transfer with belt is used to move the client from one surface/location to another surface/location with or without the use of assistive devices such as a cane or walker. Criteria for one-person transfer with belt At the time of the move the client: can bear their body weight through part(s) of their body is cooperative is predictable and reliable in performance and behaviour to the extent required for the move understands what is expected to the extent required for the move is able to transfer with assistance from one worker (no manual lifting) Workers should always consider the risk of abusive/violent behaviour. If any of these criteria is consistently not met, the client is assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. Model procedure for one-person transfer with belt from bed to wheelchair 1. When preparing for this technique, the worker applies a transfer belt appropriately. 2. The worker stands in front of the client and prepares to transfer the client towards the client s stronger side, if applicable. A Specialized Client Mobility Assessment (see Section 5.5C) should be considered and requested for the client who demonstrates special considerations, such as kyphosis or hemiplegia, and who may need a Sask-apole*, transfer disc*, etc. 3. The worker places their feet in front of the client s feet to help prevent them from slipping, and/or their legs against the client s legs to help prevent the client s knees from buckling. Note: When the client has a weaker side, the worker provides support on the weaker side and transfers the client towards the stronger side if possible. 4. The worker assumes a stable yet flexible stance, and bends at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine). Rationale: This stance allows the worker to respond to and absorb most sudden stressors April 2011

20 5. The worker grasps the transfer belt correctly (or the client handling sling if using Modification A on the next pages), and applies slight pressure to alert the client as to the direction of the move. Rationale: This action encourages safe use of the hands and a secure hold of the client, as well as provides a form of non-verbal communication. Tip: The worker can assist the client to the front of the chair by hip walking if necessary. Hip walking is a technique by which the worker places one hand on the client s hip and pulls forward. The other hand is on the client s opposite knee and pushes backward at the same time. This action walks the buttocks to the edge of the seating surface, or backwards to the back of the seating surface with minimal effort. 6. The worker instructs the client to lean forward at the hips, push down on the bed, and stand up on the count Stand.. 7. If momentum is needed to get the client up, the worker rocks the client forward with each count. This action also prepares the client s lower limbs to accept their body weight. Rationale: The rocking motion brings the client s centre of gravity forward and facilitates transfer of weight from the buttocks to the thighs and then to the feet. 8. On the count Stand, the worker and client partially straighten both legs and stand while keeping the trunk upright (maintaining the three natural curves of the spine). 9. When appropriate, the worker and client pause for a moment in the standing position (see modifications on next pages for alternate steps if standing upright causes difficulties or poses a risk to the client and/or worker) to allow adjustment to the new position. 10. The worker and client pivot by shifting their weight and turning and/or shuffling their feet while stepping in the direction of the intended move. The worker continues to maintain control of both the client s feet and knees. Rationale: Controlling the client s legs ensures that they do not buckle. Note: A client with only one leg needs to be able to put their weight on to the ball of the foot to pivot and then hop in the direction of the move, or be taught how to use a Sask-apole or transfer disc by an appropriate specialist or therapist. 11. The worker instructs the client to place both hands on the arms of the wheelchair or on the bed, with or without the arms extended, if able. The client then bends forward at the hips, as the worker bends at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine). The worker assists the client to safely and smoothly lower themselves into the wheelchair on the count Sit. 12. The worker: replaces the footrests ensures the client is positioned properly for comfort, safety, support and dignity ensures the placement of the seatbelt on the client removes the transfer belt and/or handling sling April 2011

21 Modification A: One-Person Transfer with Belt with a Client Handling Sling from Bed to Wheelchair Criteria for one-person transfer with belt with a client handling sling from bed to wheelchair In addition to the criteria for a one-person transfer with belt, Modification A is appropriate for the client who has trouble standing due to having heavy hips and/or heavy buttocks. Model procedure for one-person transfer with belt with a client handling sling from bed to wheelchair 1. When preparing for this technique, the worker applies a transfer belt and client handling sling appropriately. 2. The worker stands in front of the client and prepares to transfer the client towards the client s stronger side, if applicable. 3. The worker places their feet in front of the client s feet to help prevent them from slipping, and/or their legs against the client s legs to help prevent the client s knees from buckling. Note: When the client has a weaker side, the worker provides support on the weaker side and transfers the client towards the stronger side if possible. 4. The worker assumes a stable yet flexible stance, and bends at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine). Rationale: This stance allows the worker to respond to and absorb most sudden stressors. 5. The worker grasps the client-handling sling, which has been placed at the base of the client s spine. Using minimal manual effort, the worker applies a forward directional pressure to the client s hips, and pulls not lifts on the sling. 6. The worker encourages the client to lean forward at the hips, push down on the bed, and stand up on the count Stand. 7. If momentum is needed to get the client up, the worker rocks the client forward with each count. This action also prepares the client s lower limbs to accept their body weight. Rationale: The rocking motion brings the client s centre of gravity forward and facilitates transfer of weight from the buttocks to the thighs and then to the feet April 2011

22 8. On the count Stand, the worker and client partially straighten both legs and stand while keeping the trunk upright (maintaining the three natural curves of the spine). When the client is in the standing position, the worker grasps the transfer belt to provide handles and ensure standing stability. Rationale: The action with the client handling sling assists the client in straightening their hips. The transfer of the hands to the belt encourages safe use of the hands and a secure hold of the client. 9. If appropriate, the worker and client pause for a moment in the standing position to allow adjustment to the new position. 10. The worker and client pivot by shifting their weight and turning and/or shuffling their feet while stepping in the direction of the intended move. The worker continues to maintain control of both the client s feet and knees. Rationale: Controlling the client s legs ensures that they do not buckle. Note: A client with only one leg needs to be able to put their weight on to the ball of the foot to pivot and then hop in the direction of the move, or be taught how to use a Sask-apole or transfer disc by an appropriate specialist. 11. The worker instructs the client to place both hands on the arms of the wheelchair or on the bed, with or without the arms extended, if able. The client then bends forward at the hips, as the worker bends at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine). The worker assists the client to safely and smoothly lower themselves into the wheelchair on the count Sit. 12. The worker: replaces the footrests ensures the client is positioned properly for comfort, safety, support and dignity ensures the placement of the seatbelt on the client removes the transfer belt and handling sling April 2011

23 Modification B: One-Person Sliding Board Transfer with Belt Criteria for one-person sliding board transfer with belt A one-person sliding board transfer with belt is appropriate for the client who needs to be transferred from one seating surface to another seating surface of equal height, and who: has good trunk control is able to lift the buttocks off the surface by using the arms and upper chest muscles, with assistance from one person is able to shift along the board to the new surface and reposition the lower limbs with assistance from one person is able to bear their own body weight through the arms has minimal or no ability to bear weight on the lower limbs (e.g., paraplegics, leg amputee(s) and clients with limited or decreased range of motion in their lower limb joints) wants to be as independent as possible for as long as possible without resorting to mechanical lifting devices displays sound judgement (is cognitive) is cooperative is predictable and reliable in physical performance and behaviour to the extent required for the move is not aggressive or abusive If any of these criteria are not met, the client is assessed per a General Client Mobility Assessment (see Module 5, Section 5.5A) and/or a Specialized Client Mobility Assessment (see Module 5, Section 5.5C) to determine the minimum level of assistance. Training on specific equipment must be provided to workers to ensure they are knowledgeable on the operating procedures of the equipment April 2011

24 Model procedure for one-person sliding board transfer with belt from bed to wheelchair 1. The worker prepares the client and equipment by: applying the transfer belt appropriately ensuring that the client has the appropriate sliding board for their weight and size (previously assessed by an appropriate therapist) placing the wheelchair parallel to the bed on the client s stronger side locking all brakes on the bed and wheelchair removing the footrests, if applicable and possible, or adjusting them so that they do not pose a risk to the client and/or worker removing the armrest closest to the bed Rationale: As the armrest poses a barrier to the move, this action allows the sliding board to be used correctly and safely. 2. The worker instructs and/or assists the client to sit on the edge of the bed, pauses to allow the client to adjust to the change in position, and checks that the client s legs are appropriately aligned and the knees are at a 90 degree angle, if possible (the arthritic client or the client with limited range of motion may not be able to flex the knees to this angle). 3. The worker encourages the client to tip to one side away from the chair (and lean on their hand for stability) to enable the placement of the sliding board under the client s buttocks. The other end of the sliding board is placed on the wheelchair to bridge the gap between the two surfaces. The client should be encouraged to do as much of this as possible. 4. Once the sliding board is in place, the worker blocks the client s knees with their knees to give the client the feeling of safety. 5. The worker instructs and/or assists the client to put one hand on the sliding board and move the buttocks onto the board by weight-bearing through the arms. 6. The worker continues to block the client s knees with their knees, and while grasping the transfer belt, slides the client along the board in small moves until the client can reach the remaining armrest of the wheelchair. 7. The worker continues to grasp the transfer belt and holds the client firmly and as close as possible. The client s and worker s chins are on the other s shoulders, if possible. Rationale: This action adds stability to the trunk, keeps the client flexed at the hips and gives the client confidence and security that they will not slide off the board April 2011

25 8. The worker instructs and/or assists the client to continue to slide across the board on to the surface of the wheelchair by using the count Slide as often as it takes to get the client from one surface to the next. The worker replaces the armrest if the client is unable. 9. The worker instructs and/or assists the client to move back into the wheelchair by placing both hands on the armrests, if possible. The worker can help the client with hip walking, if necessary. Tip: The worker can assist the client to the back of the chair by hip walking if necessary. Hip walking is a technique by which the worker places one hand on the client s hip and pulls forward. The other hand is on the client s opposite knee and pushes backward at the same time. This action walks the buttocks to the edge of the seating surface, or backwards to the back of the seating surface with minimal effort. 10. The worker replaces the footrests, assesses the client s alignment for comfort, safety, support and dignity, and assists with repositioning as necessary April 2011

26 One-Person Transfer with Belt and Assistant Indications for use (nature of the moving task) A one-person transfer with belt and assistant is used to move the client from one surface/location to another surface/location with or without the use of assistive devices such as a cane or walker. Criteria for one-person transfer with belt and assistant At the time of the move the client: can bear their body weight through part(s) of their body is cooperative is predictable and reliable in performance and behaviour to the extent required for the move understands what is expected to the extent required for the move is able to transfer with physical assistance from one worker requires assistance from a second worker to manage equipment/attachments such as catheters or IVs that could interfere with the safe progression of the transfer may need additional verbal guidance or reassurance to place the buttocks on to the second surface Workers should always consider the risk of abusive/violent behaviour. Model procedure for one-person transfer with belt and assistant from bed to wheelchair The primary worker is the worker responsible for the client and/or the moving task. The primary worker is also responsible for coordinating equipment and ensuring the safety of all those involved in the moving task. The assistant is the worker called in to manage the equipment/attachments. The assistant does not provide physical hands-on assistance to the client. The assistant is not present to lift or bear any of the client s weight, or catch the client if they are demonstrating unpredictable physical abilities during this moving technique. This worker is not required to have their hands on the transfer belt. 1. The primary worker removes the armrest nearest to the bed, if applicable. 2. The primary worker stands in front of the client and prepares to transfer the client towards the client s stronger side, if applicable. The primary worker applies a transfer belt appropriately April 2011

27 Rationale: This position provides support where it is most needed. 3. The primary worker places their feet in front of the client s feet to help prevent them from slipping, and/or their legs against the client s legs to help prevent the client s knees from buckling. Note: When the client has a weaker side, the worker provides support on the weaker side and transfers the client towards the stronger side if possible. 4. The primary worker assumes a stable yet flexible stance, and bends at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine). Rationale: This stance allows the worker to respond to and absorb most sudden stressors. 5. The primary worker grasps the transfer belt correctly, ensuring that the wrists are in a safe position. 6. The primary worker instructs and/or assists the client to lean forward at the hips, push down on the bed, and stand up on the count of Stand. Rationale: This action brings the centre of gravity forward to facilitate the transfer of weight from the buttocks to the thigh muscles to the feet. 7. The primary worker instructs and/or assists the client to turn their feet, and move backwards until the edge of the wheelchair is touching the client s legs. Rationale: This action ensures that the client does not attempt to sit down until positioned over the wheelchair properly. 8. The primary worker instructs the client to reach back for the armrests. Rationale: Verbally guiding the client helps to ensure that this action occurs correctly and not prematurely. 9. The assistant controls any equipment/attachments such as tubings, urine drainage bags and IVs. This assistant may also be asked, by the primary worker, to move the wheelchair to the client if necessary. 10. The primary worker instructs and/or assists the client to bend at the knees and hips, lean forward at the hips, and sit down in the wheelchair by counting Sit. The primary worker bends at the hips and knees, and while keeping the trunk upright (maintaining the three natural curves of the spine), assists the client to sit down gently and smoothly. 11. The primary worker assesses the client s alignment for comfort, safety, support and dignity, and assists with repositioning (using minimal manual effort) as necessary April 2011

28 Two-Person Transfer with Belt Indications for use (nature of the moving task) A two-person transfer with belt is used to move the client from one surface/location to another surface/location with or without the use of assistive devices such as a cane or walker. Criteria for two-person transfer with belt The technique selected is typically determined by the personal preferences of the workers and/or client, and/or environmental risk factors. At the time of the move the client: can bear their body weight through part(s) of their body is cooperative is predictable and reliable in performance and behaviour to the extent required for the move understands what is expected to the extent required for the move may have difficulty pivoting or shuffling the feet may need assistance with trunk stabilization or to physically guide the buttocks or limbs to the second surface/location may need assistance to help in sitting up or staying sitting Workers should always consider the risk of abusive/violent behaviour. If the client cannot shuffle, pivot or take meaningful steps, the worker should consider: using a sit/stand lift; having the client assessed per a General Client Mobility Assessment and/or requesting a Specialized Client Mobility Assessment (see Module 5) for the addition of a Sask-a-pole and/or transfer disc. Model procedure for two-person transfer with belt (side by side) from bed to wheelchair The second worker does not lift or bear any of the client s weight, or catch the client if they are demonstrating unpredictable physical abilities during this moving technique. 1. The primary worker applies a transfer belt properly. 2. The primary worker adjusts the height of the bed so that the client s feet rest flat on the floor when seated on the edge of the bed April 2011

29 3. The primary worker instructs and/or assists the client to sit on the edge of the bed with feet flat on the floor and knees at approximately a 90 degree angle (if this ability is present). 4. The primary worker places the wheelchair on the client s strong side, if indicated, far enough away from the bed to allow both workers to maneuver safely. The distance should be just far enough to ensure that the wheelchair does not interfere with the smoothness of the move. Wheelchair foot/leg rests should be removed, or swung back and out of the way. 5. The primary worker ensures that brakes on the bed and wheelchair are locked. 6. The workers position themselves facing each other, one on either side of the client, in a stride stance position to prepare for a weight transfer. The worker s one leg can be near the side of the bed and the other foot flat on the floor, bracing the client s knees and feet, if possible. Rationale: This action ensures that the client s feet are prevented from slipping during the move. 7. The workers grasp the transfer belt, using proper wrist alignment, as they cradle the client s shoulders between them. Rationale: This action prevents the client s torso from tipping from side to side. 8. The client is instructed to assist, if possible, by using their arms to push up off the bed or by pressing on their thighs. The client may hold on to their walker/cane or other assistive device. 9. The workers arms can be linked in a criss-crossed fashion across either the client s back or chest, or both if possible. If the client is quite tall with trunk instability or if the client is unable to take meaningful steps during the transfer, the client needs to be assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. This client is a good candidate for the sit/stand lift. The client with trunk instability is not a candidate for the sliding board transfer. However, if the support needed is only across the client s back, the workers front hands can be offered to the client to grasp as they stand in unison. The workers may also want to hold the client s hands palm to palm to keep the client s hands occupied and controlled. Tip: This moving technique can be used for the client who is prone to pinching or grabbing staff or bed rails, as long as this behaviour is controllable (e.g., by applying mitts or giving the client something to hold such as a towel). 10. The workers bend at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine) and use a weight transfer on the command word Stand to assist the client into a standing position April 2011

30 11. The primary worker instructs the client to lean forward while bending at the knees and hips, and rock back and forth with the workers to the count of stand to gain the necessary momentum for the move, if needed. It is important for the client and workers to move in unison. Communication at this point is critical. 12. The primary worker encourages the client to stand to the point of control and safety for all those involved in the move. The workers and client pause for a moment to allow the client time to adjust to this new position. 13. The primary worker instructs and the workers assist the client as needed to pivot and/or shuffle by moving their feet, controlling the client s knees until the back of the client s legs are centred in front of the wheelchair. The worker on the side closest to the wheelchair will have moved past the front of the wheelchair to the opposite side, and the other worker will now be on the side of the wheelchair closest to the bed. 14. The workers help the client take small steps backwards until the backs of the client s legs touch the front of the wheelchair s seat. 15. The primary worker instructs and/or assists the client to place both hands on the armrests, if possible, or place their hands on their own thighs, and lean forward by bending at the hips and knees. Rationale: This action brings the client s weight over their centre of gravity. Alert: Clients with conditions such as arthritis do not always have the necessary mobility of their shoulders or the necessary strength in their arms to use the armrests effectively. 16. On the count Sit, the primary worker instructs and/or assists the client to sit down slowly with the buttocks pointed to the back of the chair. Rationale: This action helps to ensure that the client is seated correctly when the move is completed, and reduces the need for repositioning. 17. The primary worker encourages and/or assists the client in positioning themselves comfortably, if necessary. 18. The primary worker replaces and secures the wheelchair safety belt, and removes the transfer belt. 19. The workers replace all parts to the wheelchair, and adjust the chair to fit the client. 20. The workers assess the client's alignment for comfort, safety, support and dignity, and assist with repositioning (using minimal manual effort) as necessary April 2011

31 Modification A: Two-Person Transfer with Belt (Front Only) Criteria for two-person transfer with belt (front only) In addition to the criteria for a two-person transfer with belt, Modification A is appropriate in situations where both workers need to stand in front of the client during the transfer due to factors such as limited or decreased range of motion in their lower limb joints, or forward trunk instability, and/or environmental space issues. Model procedure for two-person transfer with belt (front only) 1. The primary worker applies a transfer belt properly. 2. The primary worker adjusts the height of the bed so that the client s feet rest flat on the floor when seated on the edge of the bed. 3. The primary worker instructs and/or assists the client to sit on the edge of the bed with feet flat on the floor and knees at approximately a 90 degree angle (if this ability is present). 4. The primary worker places the wheelchair on the client s strong side, if indicated, far enough away from the bed to allow both workers to maneuver safely. The distance should be just far enough to ensure that the wheelchair does not interfere with the smoothness of the move. Wheelchair leg rests should be removed, or swung back and out of the way (if possible). 5. The primary worker ensures that brakes on the bed and wheelchair are locked and working properly. 6. Both workers stand in front of and facing the client. 7. Each worker grasps the transfer belt with their inside hand (hand closest to the client) maintaining a neutral wrist position. The client's arms can be on the outside of the worker's arms so that they are free to grasp a cane, walker, wheelchair arms, etc., for further stability. The worker's outside hand can then be positioned either on the transfer belt at the client's side (slightly toward the back of the client) or on the client's shoulder blade area, whichever position will allow the maintenance of good body mechanics for the worker and provide stability and safety during the move for both the client and the worker. If the client cannot take meaningful steps during the transfer, the client needs to be assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. This client may be a good candidate for the sit/stand lift, providing all criteria are met. 8. The client is instructed to assist, if possible, by using their arms to push up off the bed or by pressing on their thighs. The client may hold on to their walker/cane or other assistive device. If the client is quite tall with trunk instability or if the client is unable to take meaningful steps during the transfer, the client needs to be assessed per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. This client is a good candidate for the sit/stand lift. The client with trunk instability is not a candidate for the sliding board transfer April 2011

32 9. The workers bend at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine) and use a weight transfer on the command word Stand to assist the client into a standing position. 10. The primary worker instructs the client to lean forward while bending at the knees and hips, and rock back and forth with the workers to the count of stand to gain the necessary momentum for the move, if needed. It is important for the client and workers to move in unison. Communication at this point is critical. 11. The primary worker encourages the client to stand to the point of control and safety for all those involved in the move. The workers and client pause for a moment to allow the client time to adjust to this new position. 12. The primary worker instructs and the workers assist the client as needed to pivot and/or shuffle by moving their feet, controlling the client s knees until the back of the client s legs are centred in front of the wheelchair. The worker on the side closest to the wheelchair will have moved past the front of the wheelchair to the opposite side, and the other worker will now be on the side of the wheelchair closest to the bed. 13. The workers help the client take small steps backwards until the backs of the client s legs touch the front of the wheelchair s seat. 14. The primary worker instructs and/or assists the client to place both hands on the armrests, if possible, or the client may place their hands on their own thighs, and lean forward by bending at the hips and knees. Rationale: This action brings the client s weight over their centre of gravity. Alert: Clients with conditions such as arthritis do not always have the necessary mobility of their shoulders or the necessary strength in their arms to use the armrests effectively. 15. On the count Sit, the primary worker instructs and/or assists the client to sit down slowly with the buttocks pointed to the back of the chair. Rationale: This action helps to ensure that the client is seated correctly when the move is completed, and reduces the need for repositioning. 16. The primary worker encourages and/or assists the client in positioning themselves comfortably, if necessary. 17. The primary worker replaces and secures the wheelchair safety belt and removes the transfer belt. 18. The primary worker replaces all parts to the wheelchair, and adjusts the chair to fit the client. 19. The primary worker assesses the client s alignment for comfort, safety, support and dignity, and assists with repositioning (using minimal manual effort) as necessary April 2011

33 Modification B: Two-person Transfer with Belt (Front and Back) Criteria for two-person transfer with belt (front and back) The criteria for this moving technique are the same as that for a two-person transfer with belt (front only). The technique selected is typically determined by the personal preferences of the workers, client assessment and environmental risk factors. 1. The primary worker applies a transfer belt appropriately. 2. The primary worker adjusts the height of the bed so that the client s feet will rest flat on the floor when seated on the edge of the bed. 3. The primary worker instructs and/or assists the client to sit on the edge of the bed with feet flat on the floor and knees at approximately a 90 degree angle (if this ability is present). 4. The primary worker positions the wheelchair on the client s strong side, if indicated. The distance should be far enough to ensure that the wheelchair does not interfere with the smoothness of the move. Wheelchair leg rests should be removed, or swung back and out of the way. Tip: The client should be transferred to their stronger side whenever possible. 5. The primary worker ensures that all brakes on the bed and wheelchair are locked. 6. Both workers stand in front of and facing the client. 7. Both workers position their feet and legs in front of the client s knees and feet to prevent the client s feet from slipping. 8. Each worker grasps the transfer belt with their inside hand (as indicated in the Twoperson Transfer with Belt (Front Only) technique on the previous pages). Both workers' outside hand can then be positioned either on the transfer belt at the client's side or on the client's shoulder-blade area. Tip: Workers should avoid blocking the client s line of view to the second surface whenever possible April 2011

34 9. The client is instructed to assist, if possible, by using their arms to push up off the bed or by pressing on their thighs. The client may hold onto their walker/cane or other assistive device. Tip: If the client is quite tall with trunk instability, or if the client is unable to take meaningful steps during the transfer, the client needs to be re-assessed as per a General Client Mobility Assessment and/or a Specialized Client Mobility Assessment (see Module 5) to determine the minimum level of assistance. This client is a good candidate for the sit/stand lift. 10. Both workers bend at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine) and use a weight transfer on the command word stand to assist the client into a standing position. 11. The primary worker instructs the client to lean forward while bending at the knees and hips, and rock back and forth (as tolerated by the client) with the workers to the count of "1-2-3-Stand" to gain the necessary momentum for the move, if needed. It is important for the client and workers to move in unison. Communication at this point is critical. 12. As the client rises off the bed, the primary worker encourages the client to stand to the point of control and safety for all those involved in the move. As the client rises to stand, the effort required by the workers to maintain good balance will increase. 13. Both workers support the client in a standing position, the client is then directed by the primary worker to turn, pivot/shuffle around to the chair. 14. The second worker removes their grasp from the transfer belt, moves behind the wheelchair and slowly moves it toward the client until the client can feel the wheelchair behind their knees. 15. The primary worker maintains their grasp on the transfer belt while positioning their hands on either side of the client, and instructs the client to lean forward (if possible) by bending at the hips and knees, and then slowly lowers themselves onto the seating surface of the wheelchair, while the primary workers uses the count "1-2-3-Sit". Rationale: This action ensures that the client's buttocks are pointed toward the back of the chair, enabling the client to sit well back in the chair, and reduces the need for repositioning once the client is seated. 16. Using good body mechanics, the second worker positions their hands below the client's waist and guides the client's buttocks into the wheelchair seat. 17. The primary worker replaces all parts to the wheelchair and removes the transfer belt, assessing the client's alignment for comfort, safety, support and dignity April 2011

35 Modification C: Two-Person Sliding Board Transfer with Belt Criteria for two-person sliding board transfer with belt Modification C is appropriate for the client who: has good trunk control may be having difficulty elevating the buttocks, or shifting the buttocks along the surface of the sliding board without assistance is able to bear weight through the arms understands all safety factors related to the moving task is awkward to move (e.g., due to limited or decreased range of motion in their joints) is slow in movement (e.g., due to Parkinson s) can only move in small stages due to excessive weakness or shortness of breath on exertion Model procedure for two-person sliding board transfer with belt 1. The primary worker stands in front of the client and towards the client s weaker side, if applicable. The primary worker applies a transfer belt appropriately. Rationale: This position provides support where it is most needed. 2. The primary worker places their knees/legs against the client s legs to help prevent the client s weight from slipping or shifting forwards. 3. The primary worker assumes a stable yet flexible stance, and bends at the knees and hips while keeping the trunk upright (maintaining the three natural curves of the spine). Rationale: This stance allows the worker to respond to and absorb most sudden stressors. 4. The primary worker places the wheelchair at a slight angle to the bed, which allows the second worker to have one knee on the bed and the other foot flat on the floor between the wheelchair and the bed. Alternatively, the second worker can get right up onto the bed behind the client, and walks on their knees as the client is slid across the sliding board until this worker is able to step down behind the wheelchair. It is very important to do this in small, calculated moves and in unison, to ensure the safety of all those involved. 5. Both workers firmly grasp the transfer belt using correct wrist action and alignment. 6. The primary worker counts Slide, and gives clear and concise directions. The move takes place in several small shifts along the board until the client is on the second surface. 7. The primary worker assesses the client s alignment for comfort, safety, support and dignity, and assists with repositioning (using minimal manual effort) as necessary April 2011

36 6.6 Mechanical Lifting Techniques A sit/stand lift is used: to move the entire weight of the client from one surface to another surface (e.g., from a bed to chair, or stretcher to bed) to move the client who can only partially bear their own body weight, and who is physically able to assist with the move to move the client who is mentally cooperative when the client is consistently resistive to the efforts of staff to assist with transfers A total lift is used: to move the entire weight of the client from one surface to another surface (e.g., from a bed to chair, or stretcher to bed) to move the client who is unable to bear their own body weight to move the client who may be mentally incapable of assisting and cooperating enough to perform a safe move using a sit/stand lift when the client is consistently resistive to the efforts of staff to assist with transfers It is critical that the worker considers the following when selecting the lift: the weight of the client the lifting capacity of the equipment being considered for the lift (weight limit determined by manufacturer) the mechanisms (e.g., electric versus manual in relationship to client size) of the lift the appropriateness of the sling TLR recommends two workers operate a mechanical lift; one to manage the client and one to manage the equipment. The operation of a mechanical lift begins with the application of the sling. The following moving techniques can be used to mechanically lift a client: Sit/stand Lift Total Lift (includes ceiling track, gantry and portable models) Refer to Appendix C - Guidelines for the Use of Mechanical Lifts with Post-operative Knee Replacement Surgery and Post-operative Hip Replacement Surgery. When using mechanical equipment, workers must ensure all attachments remain secure throughout the move April 2011

37 Sit/Stand Lift Indications for use (nature of the moving task) A sit/stand lift is used to move the client: from one seating surface to another seated surface (e.g., from a bed to a wheelchair) to a bathroom adjacent to the client s room on the same seating surface (e.g., in a chair) if repositioning techniques or devices are inappropriate for the client Proper use of the sit/stand lift requires the client to be in a sitting position, either on the edge of a bed or in a seated surface. The sit/stand lift is not intended to get a client into a sitting position. It is recommended that a sit/stand lift not be used for transportation. When considering the use of a lift for transportation, a Specialized Client Mobility Assessment would be requested to determine the safety of the procedure (see Module 5). If an exception to the rule is deemed necessary, the results of the assessment must be documented in writing, with clear rationale, and communicated to all staff. When using mechanical equipment, workers must ensure all attachments remain secure throughout the move. To ensure client and worker safety at all times, a minimum of two workers is recommended: one worker manages the client while the other operates the equipment. Criteria for sit/stand lift At the time of the move the client: can achieve and maintain a sitting position, either independently or with minimal assistance is cooperative, understands and responds appropriately to simple instructions to the extent necessary for this move may be unpredictable and/or unreliable in their physical and/or mental performance during a move has limited or partial weight bearing ability; demonstrates the ability to bear some body weight through part(s) of the body has limited abilities due to pain and/or stiffness (e.g., due to arthritis) is able to keep at least one arm outside the harness* (if required by equipment) may be demonstrating the inability to take meaningful (purposeful) steps and/or cannot pivot or shuffle the feet when standing may be demonstrating the tendency to hold on to the worker and pull the worker into awkward positions, whether from fear of being dropped, or a perceived or actual inability to maintain support of their body weight through the legs/lower extremities may be aggressive and/or abusive when physically touched may be disproportionate in size and/or weight to the worker s size and/or weight is disproportionate to the worker s abilities as indicated by the worker self assessment weighs less than the sit/stand lift s rated capacity for lifting can be moved in a sitting position, if necessary Workers should always consider the risk of abusive/violent behaviour April 2011

38 Model procedure for sit/stand lift The following model procedure describes steps that are common to all makes and models of sit/stand lifts. It is essential that all workers are trained to use the lifts available in their agency, and have read the manufacturers information regarding the safe usage of the lifts and laundering of the harnesses. It is important for workers to practice using these lifts on their colleagues, and for the workers to experience a lift as a client would. This enables workers to experience the sensations the client feels, such as comfort/discomfort, swaying, pressure on various parts of the body and security. 1. The primary worker compares the lifting capacity of the lift and harness to the client s weight and needs. 2. The primary worker checks the lift to ensure that it is in good working order and safe, including checking the wheels for lint. 3. The primary worker checks all attachments, including the sling and harness, to ensure that they are in good working order, safe and appropriate for the client. 4. With the client in a sitting position, the primary worker applies the appropriate harness to the client by: placing the widest part of the torso portion of the harness across the client s back. When placed correctly, the upper border of the harness should be below the armpit (on women, under the breasts), and the lower border should be at or near the sacral area. tightening the inner belt (if applicable) so that it is comfortable for the client. The workers should expect this belt to loosen as the client is being raised off the surface this is not a concern at this point. applying leg safety straps, if applicable 5. The worker positions and widens the base of the lift centrally around the chair or wheelchair, or under the bed with the client facing the mast of the lift. Do not apply the brakes at this time. Rationale: This allows the lift to maintain its centre of gravity as the client is being raised and limits the client s tendency to move laterally outside the base. The client should never be left unattended in any mechanical lift April 2011

39 6. The primary worker instructs and/or assists the client to place their feet on the foot plate, and adjusts the knee pads to fit the client. While in the sitting position, ideally, the top of the knee pad should be aligned with the top of the client s thigh (i.e. it is at the front of the client s knee but does not extend above the knee), and the pad should be up against the shin with the knee at a 90 degree angle. Rationale: With this alignment, the client s knee should not slip over the top of the knee pad once the client is being elevated. 7. The workers position the lift so that the harness loops can be safely attached without the workers needing to tug or strain. Rationale: This action decreases the stressors placed on the wrists of the workers. The workers attach the harness to the lift ensuring proper wrist alignment. Tip: The workers must ensure proper use of body mechanics, paying special attention to body posture and joint positions when hooking up and using a mechanical lift. 8. The worker uses the hand controls as follows: the electric component allows the operator to raise or lower the client without physical effort the remote hand control allows the worker to move into a position that enables contact with the client an emergency manual release and an emergency stop button should always be easily accessible in case electrical components fail 9. The primary worker instructs and/or assists the client to grasp the handle(s) on the boom. If the client is able to grasp with only one hand, the worker should be prepared to balance the client s other side. 10. The primary worker instructs and/or assists the client to lean back until the harness is snug around the client s back. If the client is unable to do this effectively, the second worker can stand behind the client, hold the harness in its correct position or gently guide the client s shoulders back as the primary worker mechanically raises the client from the surface. Rationale: This action prevents the harness from slipping up, and causing problems under the client s armpits due to premature hip flexion. Alert: A client with orthopedic hip problems may require a Specialized Client Mobility Assessment (see Module 5, Section 5.5) to determine whether this lift is appropriate. 11. The client needs to be raised only a bit off the surface. The higher the client is raised, the more weight bearing and balance are required, and the more inclined they are to step off the footplate April 2011

40 If the client is well enough to be predictable with balance, weight bearing and gait, and does not need to hold on to someone, the client may need to be assessed per a General Client Mobility Assessment (see Module 5, Section 5.5A) to become a transfer. Remember that the client s abilities can improve! 12. For clients who attempt to step off the footplate and are known to be at risk for injury, the primary worker could try using a padded transfer belt across the calves and around the knee pads to encase the lower limbs. The primary worker provides the explanation and assurance to the client that the strap is needed for safety and will be removed as soon as the lift is completed. Certain sit/stand lifts have a total harness for those clients who may be unpredictable, and who may: step off the lift once they are elevated release their grip on the handles A total harness is a safety feature that changes this lift into a semi-total lift. The availability of a total harness is an important consideration when assessing some clients for a sit/stand lift because this harness allows the client to be lowered back on to a surface quickly and safely. This feature needs to be thoroughly demonstrated by the manufacturer and practised by the staff on each other before using it on any client. A total harness cannot take the place of a total lift. Raising the client too high can place abnormal pressure on the femurs causing pain and possible fractures. 13. The primary worker checks the security of all attachment points and continues to monitor them while the lift is in progress. Because some clients may attempt to unhook the sling, both workers need to closely monitor the client throughout the entire procedure. 14. The workers move the client to the second surface, which in the case of repositioning in a chair, may be the same surface. If the surface the client is moving to is a movable and lighter device (such as a wheelchair or commode), the second worker will bring the device to the client, whenever possible. 15. The client is lowered onto the second surface. 16. The primary worker positions the client in a comfortable and safe posture. 17. The workers unhook the harness from the sit/stand lift. 18. The primary worker pulls the lift away from the client. 19. The workers remove the harness from the client, assess the client s alignment for comfort, safety, support and dignity, and assist with repositioning (using minimal manual effort) as necessary. 20. The lift, with all attachments, is returned to its designated storage space to be ready for the next moving task April 2011

41 Total Lift Indications for use (nature of the moving task) A total lift is used to move the client: from one surface to another surface (e.g., from a bed to a wheeled chair, from a wheeled chair to a bed, or from a bed to a stretcher) to a bathroom adjacent to the client s room in and out of high-backed chairs such as a geriatric chair or lounge chair in and out of bathtubs using bathing mesh slings, if the lift base is compatible with the tub base/supports in bed, if repositioning devices are inaccessible and/or inappropriate for the client It is recommended that a total lift not be used for transportation. When considering the use of a lift for transportation, a Specialized Client Mobility Assessment would be requested to determine the safety of the procedure (see Module 5). If an exception to the rule is deemed necessary, the results of the assessment must be documented in writing, with clear rationale, and communicated to all staff. When using mechanical equipment, workers must ensure all attachments remain secure throughout the move. To ensure client and worker safety at all times, a minimum of two workers is recommended: one worker manages the client while the other operates the equipment. Criteria for total lift At the time of the move the client: cannot weight bear as per the definition of weight bearing in this program may be unpredictable and/or unreliable with weight bearing during a transfer, thereby increasing the risk of injury to themselves and/or the worker may not be able to follow instructions during assisted transfers due to cognitive and/or physical disabilities. The exceptions are clients with diagnoses such as Alzheimer s or other forms of dementia who cannot follow instructions, but can get up and walk away. These clients are not placed into total lifts until their physical condition warrants this level of assistance. weighs less than the total lift s rated capacity for lifting may be uncooperative, aggressive and/or abusive during moves may need to be moved in a supine* position Workers should always consider the risk of abusive/violent behaviour. To ensure client and worker safety at all times, a minimum of two workers is recommended to operate a total lift safely. One worker manages the client while the other operates the equipment April 2011

42 Model procedure for total lift (portable) The following model procedure describes steps that are common to all makes and models of portable total lifts. Other types of total lifts are available, such as ceiling and wall mounted lifts and free-standing lifts with frames. It is essential that all workers are trained to use the lifts available in their agency, and have read the manufacturers information regarding the safe usage of the lifts and laundering of the slings. It is important for workers to practice using these lifts on their colleagues, and for the workers to experience a lift as a client would. This enables workers to experience the sensations the client feels, such as comfort/discomfort, swaying, pressure on various parts of the body and security. 1. The primary worker compares the lifting capacity of the lift and sling to the client s weight and needs. 2. The primary worker checks the lift to ensure that it is in good working order and safe, including checking the wheels for lint. 3. The primary worker checks all attachments, including the sling, to ensure that they are in good working order, safe and appropriate for the client. 4. The primary worker ensures the bed is adjusted appropriately to ensure good body mechanics for those involved. If the client s trunk needs to be elevated, the workers mechanically raise the head of the bed. 5. The primary worker instructs and/or assists the client to bend the knees, and encourages the client to fold their arms across the chest, if applicable. 6. The workers position the client on the appropriate sling, keeping in mind that different slings are used for different clients and for different purposes. It is the primary worker s responsibility to ensure that the correct sling is used for the client at the time the moving task is being performed. 7. The primary worker ensures the bed is adjusted, if necessary, so that the lift can be rolled under the bed, midway between the client s shoulders and pelvis. 8. The primary worker broadens/widens the base of the lift for stability. 9. Brakes are applied until the client is ready to be moved from the first surface to the second surface. 10. The primary worker lowers the boom of the lift so that the sling can be attached without being forcefully tugged on and without the client being lifted to be attached. It may be necessary to raise the entire bed and/or adjust the base of the lift to its widest point to accommodate this maneuver April 2011

43 11. The primary worker lowers the boom slowly, being careful not to frighten or accidentally hit or injure the client. The workers attach the sling to the lift. The workers ensure that any hooks on the equipment face away from the client to avoid potential tears to the skin or other injury. The client should never be left unattended in any mechanical lift. 12. The primary worker ensures security of all attachment points, unlocks the brakes and continues to monitor the attachments and equipment while the lift is in progress. Because some clients may attempt to unhook the sling, both workers need to monitor the client throughout the entire procedure. 13. The primary worker verbally prepares the client for the move, and slowly raises the client off the first surface while avoiding any fast or jerking motions that may be frightening and uncomfortable for the client. The second worker then turns the client s legs towards the mast of the lift, if applicable, which provides a sense of security and brings the client s weight to the centre of the lift s base. Rationale: This action brings the weight closer to the fulcrum of the lift and improves stability by ensuring that the client s weight is over the lift s centre of gravity. 14. The workers move the client to the second surface. The workers ensure that the client is positioned in the upper middle of the bed or towards the back of the chair so that a minimal amount of repositioning is necessary once the sling is removed. 15. The client is lowered gently to the second surface. 16. The workers unhook the sling from the total lift. 17. The primary worker pulls the lift away from the client. 18. The workers remove the sling from the client, if applicable. The primary worker assesses the client for comfort, safety, support and dignity. The workers assist with repositioning (using minimal manual effort) as necessary. 19. The mechanical lift, with all attachments, is returned to its designated storage space to be ready for the next moving task April 2011

44 6.7 Repositioning Techniques Prior to the move, the workers encourage the client to reposition themselves as much as possible, if applicable. The workers may need to provide cueing and or minimal assistance during the move, depending upon the client s abilities determined through the assessment (see Module 5). A reposition is a moving technique: that is most often performed with a minimum of two workers that involves shifting, moving and/or adjusting the client s entire body weight from one position to another position on the same surface (e.g., moving the client up or down in a bed or a chair, or moving the client across the surface of a bed) that involves moving the client between two bed-like surfaces of equal height when the client is unconscious and/or unable to assist in transferring from the first surface to the second surface (e.g., the post-operative client). The client s body is in constant contact with the surface in which the client is physically unable to move their body weight, or may be mentally unable to follow instructions, or recognize when their body needs to be repositioned A reposition in bed is appropriate for the client who, at the time: is unable to move in bed, or is only able to minimally assist with moving in bed requires frequent repositioning which increases the risk of injury to the client and/or worker(s) due to the repetitive nature of the task experiences an increased level of pain/discomfort with physical activity/exertion when not assisted with repositioning or the use of a repositioning device With new equipment being developed to assist with safe client handling, checking with equipment vendors may prove beneficial in the area of repositioning. A review, evaluation or testing of equipment prior to purchase is recommended. Equipment may be available to assist with repositioning a client in bed or from one surface to another of equal/lesser height. The logo for repositioning should be used when repositioning the client in bed. Indicating the assistive device, along with the required number of workers, will assist in ensuring a safe move that is appropriate for the client based on the assessment. The following general steps and moving techniques can be used to reposition a client: General Steps for Any Repositioning Task Repositioning with Turning/Repositioning Sheets Repositioning with Long Tubular Rollers* Repositioning with Short Tubular Rollers Repositioning with Full-length Glider Boards Repositioning in Chairs April 2011

45 General Steps for Any Repositioning Task 1. The primary worker is responsible for selecting the equipment/assistive devices and ensuring the safety of the moving task. If a repositioning device is left on the bed when the client goes from lying to sitting, ensure that the client is not sitting on the device. This will ensure that the client does not accidentally slip off the edge of the bed. 2. All equipment/assistive devices are inspected for flaws, wear and tear, and cleanliness before each procedure by the primary worker. Equipment/assistive devices that do not meet standards must be removed from use until repaired or replaced. 3. The primary worker explains to the client what will be happening and what the client can do to assist, if possible. 4. The primary worker ensures the equipment and bed are adjusted, as necessary throughout the procedure, to allow the use of good body mechanics. 5. The workers place the appropriate assistive (low friction) device under the client in the same way that a sling or other sheet is placed (as per manufacturer/vendor guidelines), and an occupied bed is made. The primary worker ensures the client s comfort and involvement as much as possible. 6. The primary worker eliminates and/or manages all risk factors that could put the workers into awkward positions. The workers should not over-extend themselves by reaching or by attempting to perform the move in one slide. Several small moves should be used whenever possible. 7. The workers use hand-grasps that allow correct wrist, elbow and shoulder alignment (i.e., the palms-up grip; elbows in). 8. The client should be supine to start the procedure. If the client is on their side to one side of the bed, the workers log roll the client on to their back, if practical (e.g., if the bed is wide enough). Otherwise, the client can be slid to the centre of the bed, and then log rolled on to their back. 9. The primary worker instructs and/or assists the client to bend the knees and cross their arms over the chest, if applicable. Rationale: Raising the knees prevents dragging the client s legs, which increases the weight/load. 10. The workers proceed with the moving task. 11. The primary worker assesses and positions the client for comfort, safety, support and dignity at the end of the moving task. The additional worker(s) may assist with positioning the client as needed. 12. The repositioning device is removed or left under the client as per the assessment of the client s needs, manufacturer s instructions and/or the agency s policy April 2011

46 Repositioning with Turning/Repositioning Sheets Indications for use (nature of the moving task) A turning/repositioning sheet is used to move the client: from side to side in a bed up in a bed Criteria for repositioning with turning/repositioning sheets A reposition with a turning/repositioning sheet is appropriate for the client who: experiences an increased level of pain/discomfort with physical activity/exertion (e.g., the palliative care or burn client) may need frequent repositioning due to tendencies towards such factors as skin breakdown or contractures are incapable of assisting in repositioning due to physical or mental conditions (e.g., the comatose or neurologically-compromised client) Precautions for repositioning with turning/repositioning sheets 1. Certain sheets should not be directly in contact with the client, and should not be left under the client for any prolonged period of time. Rationale: Rubberized or heavy nylon sheets can cause skin problems due to sweating. These sheets should have a draw sheet and/or soaker pad placed on top of them when they are being used. In this situation, the worker pulls on the draw sheet and not on the turning/repositioning sheet when performing the move. 2. The primary worker needs to be aware of the client s skin condition even when using turning/repositioning sheets that can be left under the client. 3. To prevent the client from sliding back down the bed when the turning/repositioning sheet is left under the client, the worker needs to be able to tuck in the sheet to secure its position. Sheets that cannot be tucked in should be removed after each move as they defeat their purpose if the client must be turned and repositioned simply to facilitate use of the repositioning device. Slightly raising the lower part of the bed (knee-gatch) also inhibits the client from sliding back down in the bed. 4. The client s shoulders and hips both need to be placed on the turning/repositioning sheet as these are the heaviest portions of the body. 5. The primary worker must pay special attention to the position of the client s head and neck to prevent injury during repositioning April 2011

47 6. When moving the client up in bed, the primary worker should place a pillow against the headboard to protect the client s head during the move. Anti-friction devices can make this type of move happen very quickly, especially for workers who are accustomed to lifting the client up in bed. 7. The client should have either the knees bent or the legs elevated on pillows. Rationale: This prevents the legs from being dragged during the move. 8. The primary worker must ensure safe and proper usage of such items as side rails, trapeze* bars and rope ladders before, during and after the moving task. Turning/repositioning sheets should be cleaned according to manufacturer s instructions April 2011

48 Model procedures for moving the client up in bed using turning/repositioning sheets (opposite sides of the bed) 1. The primary worker explains the procedure to the client, and how the client can help, if possible. For example, the primary worker can instruct and/or assist the client to: bend the knees; press down with the soles of the feet when the workers begin the sliding action; keep the head elevated (tuck the chin in on the chest) and arms crossed over the chest; by grabbing the trapeze bar. Note: The primary worker may need to instruct the client throughout the procedure to avoid giving the client too much information at once. 2. The primary worker prepares the bed (e.g., by lowering the side rail/s, adjusting the bed height). The primary worker ensures that the bed is at the proper height for both workers to be able to use good body mechanics. The primary worker also takes care to choose the appropriate repositioning device that eliminates and/or manages all risk factors (e.g., for the client who requires frequent repositioning, the ideal repositioning device is one which can be left under the client at all times). The workers appropriately place the device underneath the client. 3. When two turning/repositioning sheets are used and each has a slippery side and a slip-proof side, the workers place the slippery sides facing each other with the upper sheet taking the place of the draw sheet and the bottom sheet tucked in securely under the mattress, if possible, to prevent it from moving during the move. In situations where the turning/repositioning sheet has only one slippery side, the workers may place this side facing up with an additional draw sheet placed on top, or refer to the manufacturers directions for use. 4. The primary worker removes any obstacles, such as pillows, extra wraps or blankets, from the bed. One pillow must be placed against the headboard in case the client is unintentionally moved too far and too quickly. 5. The bed must be flat or in the Trendelenburg position. The Trendelenburg position (in which the head of the bed is lower than the foot of the bed) can help to make the move easier if medically tolerated by the client, and especially if the client is very large. Rationale: The Trendelenburg position promotes working with gravity. 6. The two workers stand on opposite sides of the bed in a stride stance (feet shoulder-width apart with knees slightly flexed). The foot closest to the head of the bed is pointed in the direction of movement. 7. The workers grasp the sheet using a palms-up grip with both hands as close to the client as possible, and pull the sheet tight. It is important to keep the wrists properly aligned and elbows tucked in. 8. The primary worker instructs the client to push with the heels, if possible, below the level of the sheet being pulled April 2011

49 9. The workers move in unison on the count of Slide, shifting their weight on to the foot closest to the head of the bed, and sliding the client up in bed. This step is repeated as many times as necessary to ensure the safety of the workers and client while moving the client up in the bed. 10. The workers straighten the turning/repositioning sheet and flat sheet under the client, or remove the sheets. 11. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) may assist with positioning the client as needed. Tip: If the client is positioned with the head of the bed elevated, stabilize the turning/repositioning sheet by tucking the side panels under the mattress. If the client will be sitting on the edge of the bed, consider removing the slider sheets/devices to prevent the client from slipping off the bed. To help prevent the client from sliding down when in the Semi- Fowler s* position, raise the knee-gatch to bend the knees slightly (if appropriate) April 2011

50 Alternate model procedure for moving the client up in bed using a turning/repositioning sheet (top of bed with bed moved away from the wall and headboard removed) The following alternate model procedure describes steps that are common to all types of turning/repositioning sheets. It is essential that all workers are trained to use the sheets available in their agency, and have read the manufacturer s information regarding the safe usage and laundering of the sheets. 1. The primary worker explains the procedure to the client, and how the client can help, if possible. For example, the primary worker can instruct and/or assist the client to: bend the knees; press down with the soles of the feet when the workers begin the sliding action; keep the head elevated (tuck the chin in on the chest) and arms crossed over the chest; or assist by grabbing the trapeze bar. Note: The primary worker may need to instruct the client throughout the procedure to avoid giving the client too much information at once. 2. The primary worker prepares the bed (e.g., by lowering the side rail(s), adjusting the bed height). The primary worker ensures that the bed is at the proper height for both workers to be able to use good body mechanics. The primary worker also takes care to choose the appropriate repositioning device that eliminates and/or manages all risk factors (e.g., for the client who requires frequent repositioning, the ideal repositioning device is one which can be left under the client at all times). The workers appropriately place the device underneath the client. 3. When two turning/repositioning sheets are used and each has a slippery side and a slip-proof side, the workers place the slippery sides facing each other with the upper sheet taking the place of the draw sheet and the bottom sheet tucked in securely under the mattress, if possible, to prevent it from moving during the move. In situations where the turning/repositioning sheet has only one slippery side, the workers may place this side facing up with an additional draw sheet placed on top, or refer to the manufacturers directions for use. 4. The primary worker moves the bed away from the wall (with the assistance of the assistant), removes any obstacles, such as pillows, extra wraps or blankets, from the bed. The headboard may also be removed (if possible) to facilitate use of good body mechanics. 5. The bed must be flat or in the Trendelenburg position. The Trendelenburg position (in which the head of the bed is lower than the foot of the bed) can help to make the move easier if medically tolerated by the client, and especially if the client is very large. Rationale: The Trendelenburg position promotes working with gravity. 6. The two workers position themselves at the top of the bed using a stride stance. The workers must ensure that they are using good body mechanics throughout the moving task April 2011

51 7. Both workers grasp the sheet using a palms-up grip with both hands as close to the client as possible, and pull the sheet tight. It is important to keep the wrists properly aligned (one hand gripping near the shoulder of the client and the other hand gripping near the client's elbow/waist). Ensure worker's elbows are tucked in and their arms are within a comfort zone reach. No lifting is to occur during this procedure this is a sliding action. 8. The primary worker instructs the client to push with the heels, if possible, as the primary worker counts Slide. The workers pull on the sheet in unison while performing a front to back weight transfer. This step is repeated as many times as necessary to ensure the safety of the worker(s) and the client while moving the client up in the bed. 9. The workers remove the repositioning device, reposition the headboard (if applicable), and/or raise the side rails. 10. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) may assist with positioning the client as needed. The workers put the headboard back on and return the bed to its original position. Tip: If the client is positioned with the head of the bed elevated, stabilize the turning/repositioning sheet by tucking the side panels under the mattress. If the client will be sitting on the edge of the bed, consider removing the slider sheets/devices to prevent the client from slipping off the bed. To help prevent the client from sliding down when in the Semi-Fowler s* position, raise the knee-gatch to bend the knees slightly (if appropriate) April 2011

52 Alternate model procedure for moving the client up in bed using a turning/repositioning sheet (top of bed when bed cannot be moved away from the wall and/or the headboard cannot be removed) The following alternate model procedure describes steps that are common to all types of turning/repositioning sheets. It is essential that all workers are trained to use the sheets available in their agency, and have read the manufacturer s information regarding the safe usage and laundering of the sheets. 1. The primary worker explains the procedure to the client, and how the client can help, if possible. For example, the primary worker can instruct and/or assist the client to: bend the knees; press down with the soles of the feet when the workers begin the sliding action; keep the head elevated (tuck the chin in on the chest) and arms crossed over the chest; or assist by grabbing the trapeze bar. Note: The primary worker may need to instruct the client throughout the procedure to avoid giving the client too much information at once. 2. The primary worker prepares the bed (e.g., by lowering the side rail(s), adjusting the bed height). The primary worker ensures that the bed is at the proper height for both workers to be able to use good body mechanics. The primary worker also takes care to choose the appropriate repositioning device that eliminates and/or manages all risk factors (e.g., for the client who requires frequent repositioning, the ideal repositioning device is one which can be left under the client at all times). The workers appropriately place the device underneath the client. 3. When two turning/repositioning sheets are used and each has a slippery side and a slip-proof side, the workers place the slippery sides facing each other with the upper sheet taking the place of the draw sheet and the bottom sheet tucked in securely under the mattress, if possible, to prevent it from moving during the move. In situations where the turning/repositioning sheet has only one slippery side, the workers may place this side facing up with an additional draw sheet placed on top - or refer to the manufacturers directions for use. 4. The primary worker moves the bed away from the wall (with the assistance of the assistant), removes any obstacles, such as pillows, extra wraps or blankets, from the bed. The headboard may also be removed (if possible) to facilitate use of good body mechanics. 5. The bed must be flat or in the Trendelenburg position. The Trendelenburg position (in which the head of the bed is lower than the foot of the bed) can help to make the move easier if medically tolerated by the client, and especially if the client is very large. Rationale: The Trendelenburg position promotes working with gravity. 6. The two workers position themselves on opposite sides of the bed, with the side rails lowered. Each worker places the inner knee (i.e. the knee closest to the bed when standing parallel to the bed) on the bed, with their backs facing the head of the bed (i.e., their backs facing the direction of the move). The workers must ensure that they are using good body mechanics throughout the moving task April 2011

53 7. Both workers grasp the sheet using a palms-up grip with both hands as close to the client as possible, and pull the sheet tight. It is important to keep the wrists properly aligned (one hand gripping near the shoulder of the client and the other hand gripping near the client's elbow/waist). Ensure worker's elbows are tucked in and their arms are within a comfort zone reach. No lifting is to occur during this procedure this is a sliding action. 8. The primary worker instructs the client to push with the heels, if possible, as the primary worker counts Slide. The workers pull on the sheet in unison until they are sitting back on the heel of the leg that is on the bed. This step is repeated as many times as necessary to ensure the safety of the worker(s) and the client while moving the client up in the bed. 9. The workers remove the repositioning device, reposition the headboard (if applicable), and/or raise the side rails. 10. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) may assist with positioning the client as needed. Tip: If the client is positioned with the head of the bed elevated, stabilize the turning/repositioning sheet by tucking the side panels under the mattress. If the client will be sitting on the edge of the bed, consider removing the slider sheets/devices to prevent the client from slipping off the bed. To help prevent the client from sliding down when in the Semi-Fowler s* position, raise the knee-gatch to bend the knees slightly (if appropriate) April 2011

54 Model procedure for turning the client or moving the client side to side in bed using turning/repositioning sheets (opposite sides of bed) The following model procedure describes steps that are common to all types of turning/repositioning sheets. It is essential that all workers are trained to use the sheets available in their agency, and have read the manufacturer s information regarding the safe usage and laundering of the sheets. 1. The steps for preparing the client and bed are the same as those for moving the client up in bed. 2. The workers position the client s arms and legs in preparation for turning, and should place pillows for the client s support and comfort at this time. Rationale: Placing the pillows saves time and is comfortable for the client. 3. The workers position themselves on opposite sides of the bed. The primary worker is positioned to pull on the sheets, using a front to back weight transfer technique (one foot on the floor near the bedside and the other foot extended behind them on the floor in preparation for the transfer of their weight). 4. The second worker positions their hands (open palms) on the client s arms and thighs (being very careful not to hurt the client by exerting too much force on the client's body). 5. The primary worker grasps the sheet with the palms-up grip, elbows in, to ensure proper use of their upper extremities. 6. When the primary worker counts Slide, this worker carefully slides the client towards him/herself (by using a front to back weight transfer technique and pulling the repositioning sheet toward themselves) while the second worker gently pushes the client (using a back to front weight transfer technique) until the client is on their back in the middle of the bed. Both workers ensure that they are using good body mechanics. 7. This technique may require several small moves until the client is in the desired position. Note: Working in unison is crucial to the safe and effective performance of the move. 8. When the client is being moved across the bed, and at the same time, on to their side, the workers must use a blended pull/glide and turn motion. The client faces away from the primary worker upon completion of the move. 9. The workers assess and position the client for comfort, safety, support and dignity. 10. The workers tuck in or remove the repositioning device, and raise the side rail, if applicable April 2011

55 Model procedure for turning the client or moving the client side to side in bed using turning/repositioning sheets (same side) The following model procedure describes steps that are common to all types of turning/repositioning sheets. It is essential that all workers are trained to use the sheets available in their agency, and have read the manufacturer s information regarding the safe usage and laundering of the sheets. 1. The steps for preparing the client and bed are the same as those for moving the client up in bed with the following exceptions: workers are on the same side of the bed with only the near side rail lowered. The side rail furthest from the workers is left up for safety. the bed is positioned, if possible, to ensure both workers are able to use good body mechanics during the moving task 2. The workers position the client s arms and legs in preparation for turning, and should place pillows for the client s support and comfort at this time. Rationale: Placing the pillows saves time and is comfortable for the client. 3. The workers face the client and assume a stride stance for a front to back weight transfer movement. 4. One worker is positioned to move the client s shoulders and hips, and the other worker to move the client s hips and thighs. 5. Both workers grasp the sheet with the palms-up grip to ensure proper use of their upper extremities. 6. When the primary worker counts Slide, the workers carefully slide the client towards them until the client is on their back in the middle of the bed by pulling and sliding the repositioning sheet. Both workers ensure that they are using good body mechanics and an effective weight transfer technique. Note: Working in unison is crucial to the safe and effective performance of the move. 7. The workers may need to use several small moves until the client is in the desired position. 8. When the client is being moved across the bed, and at the same time, on to their side, the workers must use a blended pull, glide and turn motion. The client faces away from the workers upon completion of the move. 9. Both workers assess and position the client for comfort, safety, support and dignity. 10. The workers tuck in or remove the repositioning device, and raise the side rail, if applicable April 2011

56 Model procedure for repositioning from one bed surface to another bed surface of equal height using turning/repositioning sheets 1. The primary worker is responsible for preparing the client and coordinating the moving task to ensure safety for all those involved. 2. The primary worker explains to the client what is going to happen, what the workers will be doing, and how the client can assist (if possible). 3. The primary worker stands beside the new bed surface and grasps the top/draw/flannel sheet (which is on top of the low friction surface). This worker is constantly aware of good body mechanics by maintaining the three natural curves of the spine, not over-reaching, using the palmar grip, keeping elbows tucked in, and standing in a stride stance. 4. The second worker is beside the old bed surface in a stride stance with both hands placed on the client one on the shoulder and one on the hip prepared to push the client with the palms of their hands. While pushing in a sideways direction, it is important that the client s body alignment is maintained to prevent twisting of the client s body and/or repositioning device. The pushing is a gentle action on the client s upper arm and thigh with the worker ensuring that they are not over-reaching or getting their hands caught under the client. 5. On the count Slide by the primary worker, the workers move the client smoothly with coordinated push and pull movements. Option: For the heavier/taller client, additional workers may be positioned on the opposite side of the bed to push with an open hand on the client s upper arm and thigh. 6. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) may assist with positioning the client as needed April 2011

57 Repositioning with Long Tubular Rollers Indications for use (nature of the moving task) A reposition with a long tubular roller is used to move the client from side to side in bed. A long tubular roller can also be used to move the client from one bed-like surface to another bedlike surface of equal height by adapting the model procedure for full-length glider boards in Section 6.7. It is recommended that a minimum of two workers use the roller. The primary worker (the worker who is assigned to the client) is the leader for the moving task and is responsible for the safety of all those involved in the move. Criteria for repositioning with long tubular rollers A reposition with a long tubular roller is appropriate for the client who: may be physically and/or mentally unable to assist with repositioning (e.g., the client who is in a body cast, the paralyzed client or the client who may be mentally incapacitated and unable to understand or know when and why the repositioning is needed, such as the client who has suffered brain-damage or is comatose) needs to be repositioned in a supine or prone position experiences increased pain/fatigue with physical exertion (e.g., the palliative client with bone cancer) is on bed rest and requires frequent side to side repositioning to prevent skin breakdown and limited or decreased range of motion in their joints, and to provide adequate postural drainage April 2011

58 Model procedure for repositioning with long tubular rollers The following model procedure describes steps that are common to all types of long tubular rollers. It is essential that all workers are trained to use the rollers available in their agency, and have read the manufacturer s information regarding the safe usage and laundering of the rollers. 1. The workers place the roller under the client by rolling the client from side to side in the same manner that is used when placing a draw sheet/flannel sheet or sling under the client. The client should be positioned on their back, if possible, with arms and legs prepared for turning. 2. The workers place a draw sheet/flannel sheet on top of the roller if one is not already in place. 3. The workers position the roller under the full length of the client. The roller only needs to be onethird of the width under the client s head and shoulders if it is used in combination with a turning/repositioning sheet. Some rollers can be left under the client for frequent turnings, as long as the draw sheet/flannel sheet and/or soaker pad are next to the client s skin. The open ends of the roller are at the head and foot of the bed. 4. It is helpful for the client to bend the knees to prevent the dragging of the legs across the bed. If the client is unable to, it is advisable to cross the client s ankles so that the ankle that will be the lower one after the turn is completed is the lower one at this time. 5. The workers should consider placing the comfort pillows on the client s chest and between the knees before the turn. Rationale: Placing the pillows lessens the need to manipulate the limbs after the move is completed. It is more comfortable for the client, and saves time and energy for the worker. 6. The workers ensure proper and safe use of the side rails and all other safety mechanisms before, during and after the moving task. 7. The primary worker stands so that their hands are at the shoulder and hip of the client. The second worker places one hand at the hip and the other hand at approximately mid-thigh. 8. The workers stand facing the bed on the same side of the bed and place their feet in a stride stance to prepare for a weight transfer. With both hands, the workers grasp the edge of the appropriate sheet as close to the client as possible, keeping the wrists properly aligned. Option: For the heavier/taller client, additional workers may be positioned on the opposite side of the bed to push with an open hand on the client s hip and shoulder. 9. Using a weight transfer, the workers move in unison to the count Slide, and pull the client to the desired position, ensuring the use of good body mechanics. 10. The workers continue to gently pull on the sheet to roll the client on to their side, facing away from the workers. 11. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) can assist with positioning the client as needed April 2011

59 Repositioning with Short Tubular Rollers Indications for use (nature of the moving task) A reposition with a short tubular roller is used to move the client who has slipped down in bed and needs to be repositioned back up onto the pillows at the head of the bed. Repositioning with a short tubular roller is not recommended for moving the client side to side in bed unless the client is relatively small. It is recommended that a minimum of two workers use the roller. The primary worker (the worker who is assigned to the client) is the leader for the moving task, and is responsible for the safety of all those involved in the move. Criterion for repositioning with short tubular rollers A reposition with a short tubular roller is particularly appropriate for the client who may be unable to mentally or physically assist in repositioning themself up in bed. Model procedure for repositioning with short tubular rollers The following model procedure describes steps that are common to most types of short tubular rollers. Many agencies use different sizes of rollers for various reasons. This procedure refers to the short tubular roller that is approximately 30 inches square and covers the average client s trunk only. It is essential that all workers are trained to use the rollers available in their agency, and have read the manufacturer s information regarding the safe usage and laundering of the rollers. 1. The primary worker is responsible for preparing the client and coordinating the moving task to ensure safety for all those involved. 2. The bed must be flat or in the Trendelenburg position. The Trendelenburg position (in which the head of the bed is lower than the foot of the bed) can help to make the move easier if medically tolerated by the client, and especially if the client is very large. The primary worker also takes care to choose the appropriate repositioning device that eliminates and/or manages all risk factors (e.g., for the client who requires frequent repositioning, the ideal repositioning device is one which can be left under the client at all times). Rationale: The Trendelenburg position promotes working with gravity. 3. The workers put a draw sheet/flannel sheet on top of the roller, and under the client in the same manner used to make an occupied bed (e.g., by log rolling the client). The client s shoulders and hips need to be on the roller. The open ends of the roller should face the sides of the bed April 2011

60 4. The primary worker instructs and/or assists the client to bend the knees and/or raises the client s legs on pillows. Rationale: Bending the knees or raising the legs prevents dragging of the legs during the move. 5. The primary worker ensures that the client s head and neck are supported during the move if needed. 6. The primary worker places a pillow at the head of the bed to prevent injury to the client as this slide can happen quickly, and lowers the bed to an appropriate level. 7. The workers stand at either side of the bed, with their backs facing the head of the bed. Each worker s inner knee (i.e., the knee closest to the bed) is on the bed, with the other foot flat on the floor. 8. Using good body mechanics (e.g., the draw sheet/flannel sheet is grasped by the workers with their hands in the palmar grip to ensure correct wrist alignment), the workers slide the client in unison to the count Slide given by the primary worker. 9. The workers gently pull backwards until they are in a sitting position on their heels on the bed. 10. The workers should use several small moves until the client is in the desired position. 11. The workers remove the roller and replace the side rails, if appropriate. This roller should not be left under the client, as the client tends to slide back down very quickly, defeating the purpose of the move. 12. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) may assist with positioning the client as needed. Tip: To help prevent the client from sliding down when in the Semi-Fowler s position, raise the knee-gatch to bend the knees slightly (if appropriate) April 2011

61 Repositioning with Full-length Glider Boards Indications for use (nature of the moving task) A reposition with a full-length glider board is used to move the client from one surface to another surface of the same height. For example: from an operating room table to a stretcher from a bed to a stretcher from a stretcher to an x-ray table from an ambulance stretcher to an emergency room bed This device has a variety of names such as the smooth mover and cookie sheet. Alert: Most of these boards are not rigid enough to be used as a spine board or back board. Criteria for repositioning with full-length glider boards A reposition with a full-length glider board is appropriate for the client who: has difficulty moving safely from one bed surface to another surface due to physical and/or mental inabilities may have pain or experience injury when moving themselves (e.g., the palliative client with irretractable/uncontrolled pain levels) needs to be moved in a supine position from one surface to another surface of the same height April 2011

62 Model procedure for repositioning with full-length glider boards The following model procedure describes steps that are common to most types of semi-rigid and rigid body boards. It is essential that all workers are trained to use the boards available in their agency, and have read the manufacturer s information regarding the safe usage and cleaning of the boards. 1. The workers place the glider board under the client in the same manner used to make an occupied bed (e.g., by log rolling the client). A draw sheet/flannel sheet should be placed on top of the board and under the client for the workers to grasp during the move. Rationale: The draw sheet/flannel sheet ensures that the workers do not over-reach. Overreaching across the bed surface does not allow good body mechanics. 2. The workers prepare the two surfaces by placing them parallel to one another with all brakes locked. The workers ensure that the two surfaces stay in this position by continually pushing them against each other. 3. The glider board is placed as a bridge between the two surfaces. As many workers as necessary are called to assist in performing the moving task safely. 4. Using the draw sheet/flannel sheet, the workers pull the client across the glider board between the two bed surfaces, and reposition on the second surface. The workers remove the glider board and replace the side rails. Note: The primary worker ensures that the client is safely positioned on the second surface before the two surfaces are separated. The glider board is always removed after the moving task is completed. Option: For the taller/heavier client, some workers may stand on the opposite side of the bed in a stride stance. Using a weight transfer, they can help by pushing with the palms of their hands at the level of the client s shoulder and hip as the primary and second workers pull on the sheet. The primary worker uses the count of Slide to ensure the move is smooth, coordinated and safe. 5. The primary worker assesses and positions the client for comfort, safety, support and dignity. The additional worker(s) may assist with positioning the client as needed. 6. The workers return all equipment to its designated storage area in preparation for the next moving task April 2011

63 Repositioning in Chairs Indications for use (nature of the moving task) A reposition in a chair is used to move the client: up in a reclining chair vertical in a chair (e.g., a wheelchair with an upright back) to correctly align their body Criteria for repositioning in chairs A reposition in a chair is appropriate for the client who: can assist by cooperating is not abusive or aggressive is able to bear their weight through part(s) of their body experiences increased pain, discomfort or fatigue if repositioning themselves frequently slips down in a chair, and needs assistance to readjust frequently tips to one side, and needs supportive pillows to keep the trunk upright TLR promotes minimal manual effort with the maximum use of equipment. In consideration of reducing risk of injury to workers as well as the client, use of mechanical lifts may need to be considered to assist with repositioning techniques. Encouraging the client to reposition themselves and/or to assist with a reposition should also be considered and dependent upon the client assessment. Use of equipment and/or assistive devices is not intended to limit mobility of the client or interfere with rehabilitation; however, if used correctly it will assist with reducing/eliminating risks associated with the moving task. Prior to the move, the workers can encourage the client to reposition themselves as much as possible. The workers may need to provide cueing and/or minimal assistance during the move, depending upon the client s abilities determined through the assessment (see Module 5, Section 5.5) Model procedure for minimum assistance reposition in a chair - one worker 1. The worker ensures the client has appropriate footwear. 2. The worker ensures wheelchair brakes are on. Note: Both front wheels should not be turned forward except to facilitate the completion of this technique. 3. The worker assists the client to place both feet flat on the floor, with ankles flexed and positioned slightly under the front of the chair. 4. The worker instructs the client to lean forward, place their hands on the armrests, to slide their buttocks back into the seat of the chair while pushing themselves back into the chair with their feet. Note: If a cushion is under the client s buttocks, they may have to lift a bit to stop the cushion from bunching up. Consider inserting a sliding device between the chair seat and the client s buttocks to decrease friction. 5. The worker realigns the front wheels on the wheelchair for stability and safety April 2011

64 Model procedure for minimal assistance reposition in a chair - two workers 1. The primary worker ensures the client has appropriate footwear. 2. The primary worker ensures wheelchair brakes are on. Note: Both front wheels should not be turned forward except to facilitate the completion of this technique. 3. The primary worker assists the client to place both feet flat on the floor, with ankles flexed and positioned slightly under the front of the chair. 4. The primary worker stands in a stride stance in front of the client as a precaution in the event the client comes forward too far. 5. The assistant stands behind the chair in a stride stance. 6. The assistant places their hands on the client s shoulders; and using a forward weight transfer, gently pushes the client forward into an upright seated position. 7. The primary worker instructs the client to lean forward, place their hands on the armrests to assist with sliding their buttocks back into the chair while pushing themselves back into the chair with their feet. Note: If a cushion is under the client s buttocks, they may have to lift a bit to stop the cushion from bunching up. Consider inserting a sliding device between the chair seat and the client s buttocks to decrease friction. 8. The worker realigns the front wheels on the wheelchair for stability and safety. Alternate model procedure for reposition in a chair - two workers (front and back) There may be increased risks to the workers when this reposition is performed. The role of the second worker/assistant is to move the chair. When this reposition requires maximum effort or manual lifting from the workers, a mechanical lift (sit/stand, total lift) should be considered. For model procedures for use of a mechanical lift, see Sit/stand Lift and/or Total Lift (Section 6.6). 1. The primary worker ensures the client has appropriate footwear. 2. The primary worker applies the transfer belt to the client. Rationale: The transfer belt provides firm handles for the worker to grasp. 3. The primary worker instructs and/or assists the client to place both feet flat on the floor and as far under the seat as safely possible. Rationale: This position allows the client s trunk to be easily tipped forward April 2011

65 4. The primary worker stands facing the client in a stride stance that provides strength and balance for both the worker and the client during the moving technique. The primary worker's feet and knees are in a position that both support and brace the client's knees, legs and feet (ensuring placement of the worker's feet will not interfere with the movement of the wheelchair). Rationale: This prevents the client s feet from slipping forward, their knees buckling, and their legs interfering with the move. 5. The assistant ensures the wheelchair brakes are on and the front wheels are aligned properly in order to facilitate the forward movement of the wheelchair. The assistant then stands behind the chair, holding the back of the chair securely. Note: The front wheels on the wheelchair will need to be realigned for stability and safety once the move is complete. Both front wheels should not be turned forward except to facilitate the completion of this technique. 6. The primary worker instructs and/or assists the client to lean forward at the hips and instructs the client to cross their hands on their lap (the assistant can help with this movement by supporting the shoulders of the client as they lean forward). 7. The primary worker bends at the hips and knees (maintaining the three natural curves of the spine) and grasps the transfer belt (one hand on either side of the client) using a safe, effective grip (keeping elbows tucked in). The primary worker instructs the client to move in close to the worker so that the client is physically leaning their head sideways on the worker's shoulder. Rationale: This position provides a safe, flexible base for both the worker and the client, ensuring the worker's body is balanced and the centre of gravity is over their feet. The worker is prepared for any unexpected movement. 8. The primary worker counts Slide, and on the word command "slide" the primary worker lowers their centre of gravity using a front to back weight transfer (the worker s buttocks will drop down as the worker shifts their weight to their back leg). 9. On the "Slide" command, the client's buttocks should be slightly off the chair, at which time the second worker will lift the back wheels of the wheelchair (using the wheelchair handles to raise the wheelchair slightly) and slide the chair forward, underneath the client's buttocks. 10. The primary worker assesses and positions the client for comfort, safety, support and dignity. The second worker realigns the wheelchair's front wheels for stability and safety. For some clients, a rocking motion may be used if the client's individual assessment indicates it is tolerated and safe. The primary worker counts "1-2-3" and on each count the worker shifts/rocks the client forward a fraction higher than the previous shifting/rocking motion. On the command "slide", the assistant pushes the chair forward under the client. The wheelchair brakes should be in the locked position and the front wheels properly aligned to facilitate the smooth forward movement of the wheelchair until it is firmly underneath the client's buttocks April 2011

66 6.8 Bed Rest Criterion for bed rest Bed rest is appropriate for the client who has been confined to bed by their physician or by the nature of their medical condition (e.g., the client with a back injury or fracture, or the palliative client). Alert: The client needs close observation per agency protocol for complications of total bed rest such as skin breakdown and pneumonia. To prevent complications of bed rest, the client may require additional range of motion exercises, per agency protocol. The client should also be encouraged to perform deep breathing and coughing exercises, if practical, and will require additional skin care treatment. Model procedure for bed rest The client remains in bed at all times until assessed per a General Client Mobility Assessment (see Module 5, Section 5.5A) and/or a Specialized Client Mobility Assessment (see Module 5, Section 5.5C) to determine the minimum level of assistance. This assessment should be a team effort including the health care providers who are part of the specialized client mobility assessment. The client is repositioned per agency protocol to prevent the complications of total bed rest April 2011

67 6.9 Emergency Lifts In the TLR program, manual lifting is only used with a client in an emergent situation, or with a pediatric client for whom a lift is not available. An emergency lift is a moving technique used to move the client in an emergency (e.g., lifethreatening situation) in which there is an urgent need to change the client s position and/or location, and when the use of mechanical equipment is impractical, unavailable and/or too time-consuming due to the urgency of the move. For example, an emergency manual lift is appropriate: for the client whose medical treatment or quality of life is being compromised due to their position on a particular surface in an evacuation situation (e.g., due to a fire or chemical spill) in an emergency situation where a clear airway is vital to the client s survival in a disaster situation where several victims are involved, and decisions are being made as to transportation and delivery of clients to specific areas and/or treatment surfaces/centres The following moving techniques can be used to emergency lift the client: Emergency Manual Lift Log Lift For additional information on emergency evacuation procedures, refer to your employer s policies and procedures. Emergency Manual Lift Criteria for emergency manual lift An emergency manual lift is appropriate: for the client who is unresponsive or unable to assist in any way (i.e., the client who is unstable and needs to be transported to a treatment centre) if emergency treatment or evacuation is required when a mechanical lift is unavailable, impractical (e.g., a lift cannot be used to get a large client out of a small car) or too time-consuming in an emergency situation A transfer sheet, lift sheet, back board or spine board should be used if available and if time permits during an emergency manual lift. Alert: A minimum of four workers is recommended to lift a person weighing more than 70 kilograms (or 150 pounds) off the floor April 2011

68 Model procedure for emergency manual lift, supine, from floor to stretcher It is important for workers to use good body mechanics during an emergency manual lift. 1. While kneeling on the floor, the workers log roll the client on to a secure lift sheet, emergency evacuation blanket, canvas stretcher or rigid full-length glider board with grip handles. Alert: Most full-length glider boards are not rigid enough to be used as a spine board or back board. 2. The four workers position themselves two on each side and near the corners of the client s body. The tallest two workers should be near the head of the client so that the client s head remains elevated throughout the lift. 3. Kneeling on one knee, each worker grasps the sheet using a palms-up grip with wrists properly aligned and rolls it as closely as possible to the client and/or grasps the board appropriately. 4. The primary worker counts Lift, and everyone stands on the Lift command. 5. The workers move in unison to position the client over the stretcher. On the primary worker s count of Down, the team lowers the client onto the stretcher. 6. As time allows, and as appropriate, the assistive device is removed from under the client by log rolling the client from side to side April 2011

69 Model procedure for emergency manual lift, sitting, from one seated position to another seated position (front and back) It is important for workers to use good body mechanics during an emergency manual lift. 1. This technique requires two workers, with the primary worker taking the lead and the other assuming the role of the second worker. 2. The taller worker steps behind the client, laces the arms under the client s arms, grasps the client s forearms, and places them against the client s chest in a criss-cross fashion. The worker leans the client slightly forward. 3. The second worker steps to the side of the client (facing the client s legs) and, in a squat position, wraps one arm under the client s thighs and the other arm under the client s lower legs to support the legs. The client s legs are now close to the worker s body. 4. On the primary worker s count of Lift, both workers lift the client off the first surface and carry them to the second surface/location. 5. Once the client is over the second surface, on the primary worker s count of Down, both workers lower the client onto the second surface by using proper body mechanics such as bending at the hips and knees and keeping the trunk upright (maintaining the three natural curves of the spine). 6. The client is left in a comfortable, safe, supported and dignified position. Model procedure for emergency manual lift, sitting, from one seated position to another seated position (side by side) 1. This technique requires two workers, with the primary worker taking the lead and the other assuming the role of the second worker. 2. The workers place themselves on either side of the client. 3. If moving from a bed, the inside leg of each worker is bent and on the bed. The workers bend at the hips and knees, and keeping the trunk upright (maintaining the three natural curves of the spine), they criss-cross their arms over the client s back by grasping the other worker s forearm. 4. The workers grasp each other s forearms under the client s thighs, creating a chair effect. Note: If a client handling sling or towel is available, the workers can use it under the client s thighs instead of their arms. This facilitates the use of good body mechanics by the workers. 5. The client is cradled between the workers arms and tipped slightly back as the primary worker counts Lift and the workers stand in unison. 6. The workers carry the client to the second surface/location using good body mechanics. 7. Once the client is over the second surface, the primary worker counts Down, and the workers lower the client in unison to the surface. 8. The client is left in a comfortable, safe, supported and dignified position April 2011

70 Log Lift Criteria for log lift A log lift is appropriate for the client who: is unable to bear weight weighs less than 88 kilograms (or 195 pounds) must be moved in a supine position may be tall Alert: Depending on the weight of the client, this may be a two-, three- or fourperson log lift. The assistance of additional workers is required when the client is exceptionally tall or has an appliance (e.g., halo traction). Model procedure for three-person log lift from bed to stretcher It is important for workers to use good body mechanics during an emergency manual lift. 1. The primary worker explains to the client what will be happening, what the workers will be doing, and how the client can assist, if possible. 2. The primary worker adjusts the height of the bed to the highest comfortable height for all workers involved, if possible. Waist height is preferred. 3. The workers position the stretcher/recliner at a 90 degree angle to the bed. The head of the stretcher/recliner chair must be positioned near the foot of the bed. 4. The primary worker ensures that all brakes are locked (bed and stretcher). 5. All workers stand on the same side of the bed. 6. The primary worker assigns the tallest person to stand at the client s shoulder level. Rationale: The tallest worker lifts the upper torso of the client, keeping the client s head higher than the client s lower body. 7. The second worker stands at the client s hip level. 8. The third worker stands at the client s knee level. 9. The primary worker instructs and/or assists the client to tuck the chin in to the chest (as appropriate), and cross the arms over the chest (as appropriate) April 2011

71 10. All workers stand facing the bed with the same foot forward, and hips and knees bent. 11. The tallest worker slides their arms well under the client s head, neck and shoulders. 12. The next worker slides their arms well under the client s trunk, waist and hips, supporting the client s arms if necessary. 13. The last worker slides their arms well under the client s thighs and legs. 14. The primary worker counts Slide and all three workers move the client in unison to the side of the bed on the count Slide. 15. The primary worker counts Roll and all three workers move in unison to bend their elbows to slightly roll the client onto their side facing the workers. This allows the client to be supported against all the workers shoulders and chests. 16. The primary worker counts Lift-and Turn and all three workers: stand to lift the client shift their weight from the front to the back legs, stepping back one step pivot and walk in step towards the stretcher/recliner chair 17. The primary worker counts Down as all three workers bend their knees and hips to lower the client to the stretcher/recliner chair. 18. The workers adjust the side rails/seatbelts/safety belts, as appropriate. 19. The client is left in a comfortable, safe, supported and dignified position April 2011

72 6.10 Evaluating the Assessment and Moving Technique To evaluate the assessment and moving technique upon completion of the moving task, the worker asks questions such as: Did I properly identify all risk factors involved in the task? Did I effectively and appropriately eliminate or manage all identified risk factors? If I did not identify all risk factors, what steps can I take to ensure they are identified next time? Are there changes I could make to improve the safety and comfort of this task for all involved? Is there equipment available that, if accessible, could decrease injury rates by managing the risk factors in this moving task? Am I constantly using good body mechanics at work and at home? Am I physically fit enough to perform my job safely, and if I am not, how can I eliminate or manage this risk factor? Do I need to upgrade or develop my transferring and repositioning techniques so that I am using minimal manual effort and maximizing the use of equipment when appropriate? Have I taken every opportunity to become involved in the problem-solving process and to practice using available equipment so that I am able to care for my co-workers and clients in a responsible manner? Have I taken the responsibility to ensure that the problemsolving process proceeds through all appropriate levels and that all necessary documentation is in place before performing the moving task? Am I continually and consistently conducting ongoing client mobility assessments so that I have the information I need to ensure the safety of all involved in the client moving task? April 2011

73 6.11 Communicating the Selected Moving Technique The process for communicating the selected moving technique is specific to each agency. For example, in long term care, workers are expected to chart in the client s main file. Other agencies may require charting in several different areas. Regardless of these specific charting needs, agencies adopting TLR will be able to use the TLR Mobility Record (see Appendix B) to document and communicate information about the client s ability to mobilize. This document is located at or near the location of the client (refer to Section 470 of Saskatchewan's Occupational Health and Safety Regulations, 1996), and is used by all workers as a guide for moving the client. The designated worker who has completed a general client mobility assessment/re-assessment indicates the client s identification, logo, repositioning devices, slings, assistive devices and assistive appliances on the chart. Upon completion of a moving task, the worker indicates any changes in the client s information on the chart. These notes may indicate the need for a General Client Mobility Assessment (see Module 5, Section 5.5A) and/or a Specialized Client Mobility Assessment (see Module 5, Section 5.5C). The logo near the client s location and the client s care plan must be accurate, consistent and appropriate to ensure the safety of the client and/or worker April 2011