Definition/Introduction

Patient care transfer can be defined as moving a patient from one flat surface to another. The most common patient transfers are from a bed to a stretcher and from a bed to a wheelchair. While seemingly intuitive, successful patient transfers rely on understanding each patient’s specific needs while simultaneously adhering to evidence-based guidelines. Patient care transfer can also be defined as transferring patients within the same facility and between facilities.[1][2] 

Patient care transfers are an essential yet often neglected aspect of patient care. Patient care transfers are an indispensable aspect of patient care, requiring rigorous adherence to clinical guidelines.[2] Proper transfers are based on the concept that focuses on maintaining continuity of care both during and after the transfer.

Depending on the complexity, patients often receive care in multiple settings during and after hospitalization. While some aspects of patient transport vary depending on the patient’s status, intrahospital transports are inevitable, particularly in critically ill patients. Poorly organized patient transfers can result in increased morbidity and mortality and should be performed with careful attention.

Issues of Concern

While each hospital will likely have its policy, several safety concerns should precede patient transfers.[2] These include: 

• Perform proper hand hygiene 
• Check the patient’s chart/room for any additional precautions
• Introduce the team to the patient
• Confirm the patient’s identification
• Ensure patient privacy
• Assess ABCDs (airway, breathing, circulation, and disability)
• Airway: if airway compromise is possible, electively intubate the patient with an endotracheal tube. Some patients require a nasogastric tube placement to prevent gastric contents' aspiration during the transfer, while other patients may require cervical spine stabilization. 
• Breathing: control ventilation with optimized arterial blood gas levels. Ensure adequate oxygenation at all times.
• Circulation: critically ill patients typically have two large-bore IV cannulas in place before transfer in the event of shock or bleeding.
• Disability: Patients with altered mental status or head injury should have their Glasgow Coma Scale monitored before, during, and after the transfer. 
• Ensure that all tubes, attachments, monitors, attached machines, patient wristbands, and lines are placed properly
• Obtain necessary equipment (slider board, full-size sheet/reducing sheet, etc.) 
• Special considerations:
• Providers should avoid using their weight to lift patients. Instead, patients should use their strength during transfers when possible.
• Providers should stay close to patients at all times during the transfer to keep the patient’s weight close to the provider’s center of gravity.
• Be careful not to let patients wrap their arms around the provider’s head.
• If there is a communication barrier, the best resource is demonstrating the transfer using another person. Afterward, the patient is given hand signals to start the transfer.

Clinical Significance

Transfers from a Bed to a Stretcher[3][4][5]

After the pre-transfer checklist is complete, the transfer from a bed to a stretcher may be performed according to the following steps:

1.  Identify the number of staff required for the transfer (typically 3-4 providers for a bed-to-stretcher transfer)
2. Explain what the patient can do to help the procedure (hands crossed over the chest, chin tucked, etc.) and obtain necessary supplies
3. Raise/lower the bed to a safe working height, lock the brakes, lower guard rails, and position the patient closest to the side of the bed where the transfer will take place
4. Place a sheet on top of the slider board; this is used to transfer the patient onto the stretcher and decrease friction.
5. Roll the patient over to the side opposite to the stretcher and place the slider board underneath the patient, such that the board is between the patient and the bed
6. Roll the patient back into the supine position, make sure the patient is centered on the slider board and that the feet are in a straight position
7. Bring the stretcher to the side of the bed near the patient and position the stretcher slightly lower than the bed. Lock the brakes of the stretcher.
8. Position the healthcare team such that the patient’s weight is distributed evenly
• Two on the side of the stretcher, grasping the sheet placed over the slide board
• One at the head of the bed, grasping the pillow and the sheet.
• One at the far side of the patient, between the chest and the hips
• An additional one can be at the foot of the bed.
9. The leader of the healthcare team will initiate the transfer, counting 1, 2, 3
• The provider on the far side of the bed will push the patient.
• The two providers on the side of the stretcher will shift their weight from front to back, bringing the patient with them by pulling the sheet.
• Meanwhile, the providers at the head and foot of the bed will ensure that the patient is secured, lifting the head/shoulders and feet, respectively.
10. Continue to slide the patient until the patient is on the stretcher’s center.
11. Remove the slide board from underneath the patient by rolling the patient over to the side opposite the bed. Make sure the patient is comfortable and covered with sheets. 
12. Raise the guard rails and adjust the stretcher height.

Transfer from a Bed to a Wheelchair[6][7][8][9]

Transferring patients from a bed to a wheelchair requires understanding the needs of the patient. Always communicate with the person being transferred so that assistance is being given at the appropriate time, allowing for coordination of efforts between the assistant and the patient. If the patient can bear weight on both lower extremities and predictably take small steps, a one-person assist may be performed. If these criteria are not met, a two-person transfer or a mechanical lift may be necessary to safely transfer the patient. If transferring a patient from a bed to a wheelchair, first complete the pre-transfer checklist and proceed according to the following steps:

1. Apply the patient’s footwear before ambulation.
2. Raise/lower the bed to a safe working height, lower guard rails, place wheelchair next to the bed at a 45-degree angle and ensure the brakes are applied. If one side of the patient is weaker, place the wheelchair on the healthier side.
3. Sit patient on the side of the bed with the legs off of the bed and the feet squarely on the floor. If necessary, attach a gait belt/walking belt around the patient’s waist.
4. Place hands on the patient’s waist. 
5. The provider positions his/her legs on the outsides of the patient’s legs. As the patient leans forward, bending at the waist, the provider grasps the gait belt (or the patient’s waist).
6. Help the patient shift weight in a rocking motion (front foot to back foot, and so on) until reaching a standing position.  
7. Once the patient is standing, have them walk a few small steps backward until feeling the wheelchair’s back against the legs. Ask the patient to grasp the wheelchair.
8. The provider will shift their weight from back to front as the patient sits in the wheelchair slowly, using the wheelchair’s arms for support. 
9. Ensure that the patient is adequately draped and sitting comfortably in the wheelchair.
10. Patients may use slide boards for more effortless transfer.
11. When the patient transfers back to the bed from the wheelchair, the safest sequence of actions is positioning the chair at a 45-degree angle to the bed, locking the brakes, raising the footplates, and rotating the leg rests outward. Only after the correct sequence is performed can the patients scoot to the front of the wheelchair. When the patient scoots forward, the body is positioned over the feet. This will allow the patient to stand more easily. Leaning forward or grasping the edge of the bed is likely to cause the wheelchair to tip forward. Assistance can be given to block the person's knees to provide additional support.

Slide Boards Transfer[9][10]

Clinicians and patients most preferred the slide board technique for comfort and safety after becoming familiar with it. A sliding transfer board can benefit patients with paraplegia, lower-extremity amputation, and decreased balance or strength at the lower extremities. A patient with quadriplegia would not have the postural support or upper extremity strength to use a slide transfer board. A patient who can do a stand pivot transfer would not need a slide transfer board. A patient that cannot follow commands will not benefit from a slide transfer board.

1. A transfer belt is placed around the patient’s hips/buttocks.
2. The wheelchair is placed as close to the bed, and brakes are applied. The armrest is removed, and the footrests must be swung away. The patient of the assistant places the sliding transfer board under the patient's buttock/leg.  Placing the sliding transfer board under the patient's buttock/leg will prevent the patient from falling off the board. Fingers should not be under the board to avoid pinching the fingers.
3. The slide board should extend the distance between the bed and the wheelchair.
4. The assistant places one knee between the patient’s knees and the other knee near the wheelchair's front, close to the other surface.
5. The assistant holds the transfer belt and slowly slides the patient across the board.
6. If a patient moves from a wheelchair into a car seat or a bed and the patient's clothing sticks to the surface fabric, place a plastic garbage bag over the surface to decrease friction when sliding.

Log-rolling Procedure[11][12]

1. The purpose of the log-rolling procedure is to move a patient without flexing the spinal column. The entire body is transferred as a single object.
2. If a neck injury is a concern, a firm neck support should be in place, and in-line traction should be maintained with multiple assistants while performing the procedure.
3. The patient should not ambulate until proper examination and radiographs are obtained.
4. Keep the patient's arms on the side of the body at all times. Some recommend that the patient's arms be crossed over the chest.
5. A pillow can be placed between the legs for support while turning.
6. For thoracolumbar trauma and some cervical trauma, the log-rolling procedure has more spinal motion than using a scoop stretcher, a straddle lift-and-slide maneuver, or the 6 + lift and slide maneuver.[11][13]
7. Many authors do not recommend the use of log-rolling for traumatic spinal cord injured patients.[11][14][15][16][17][18][19]
8. Kinetic therapy bed use also reduces the motion at an unstable cervical spine compared to the log-rolling procedure.[20]

Nursing, Allied Health, and Interprofessional Team Interventions

Providers who assist in patient transfers should be trained, competent, and experienced. Patient transfers induce many physiologic changes that may be associated with increased risk to the patient. Adverse events that should be considered include: losing the patient wristband/identification, disconnected/obstructed lines, decreased/increased systolic blood pressure, loosened/kinked tubes, fractures, and change in mental status. Many guidelines exist to help providers transfer patients with the utmost care, and specific training is often recommended. As mentioned, pre-transport checklists help decrease the risk of adverse events that may arise, and proper technique will improve the transfer’s safety.[21][22][23] 

Unexpected events during transfers of critically ill intensive care unit patients can be reduced when an intensivist or medically qualified personnel accompanies the patient.[24][25] The use of standardization of procedures, checklists, and good team training reduces the risk of unexpected events, improving the patient’s safety, and lowering the complications.[25][26][27][28] A nurse with post-registration qualification in critical care is recommended to accompany the transfer of critically ill intensive care unit patients.[29]

Depending on the setting, nurses are frequently involved in patient transfers. Transferring a patient may be considered a high-risk maneuver because of the potential harm posed to the patient and the provider. While there is no consistent method used to teach proper transfer techniques, simulation-based or hands-on training is encouraged in teaching these advanced patient handling methods.[30] Patient-handling tasks such as transfers, lifting, and repositioning patients are physically demanding and often require strenuous movements and awkward positioning for the provider. Using assistive devices such as gait belts, walking belts, and multi-person teams may reduce the burden placed on providers who routinely perform patient transfers. Attention to proper ergonomics may reduce the risk of musculoskeletal injuries to healthcare personnel.[3][31][32]

Paraplegic patients are taught how to improve the upper extremities' strength and upper back muscles to improve transfers. A realistic goal for paraplegic patients is to become independent with transfers using a slide transfer board. While at a nursing home or a rehabilitation center, the occupational therapy the patient receives should include practicing transfers under various conditions. This will help the patient to adjust to different situations outside the nursing home.