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Queensland Spinal Cord Injuries Service

Key principles of transfers

What are the principles of a good transfer?

Any style of transfer including independent or assisted transfers can impact skin integrity. A transfer where there is adequate clearance of obstacles such as the wheels and bed surface can eliminate any risk of shear and friction. Mastering independent transfers requires a good technique by building skills and lots of practice. For people who require assisted transfers, mastering a good technique is just as important and clinicians should consider training those providing care.

Transfer difficulty increases:

  • with considerable differences in height and increased distance to traverse. Examples are car transfers, toilet transfers and floor/couch-to-chair transfers
  • with reduced surface availability for good hand positionings such as toilet or commode transfers
  • between two mobile objects such as between a wheelchair and a shower commode. Where both surfaces can be unstable. This is extremely high risk and not recommended.

Assisted horizontal transfer considerations

  • Position the wheelchair close to the transfer surface to reduce the transfer gap.
  • Align the front castors to be forward facing, in front of the stem and in line with the back wheel to increase the stability of the wheelchair.
  • A transfer board is to be used as a bridge and not an aid for sliding. Sliding will increase shear and friction.
  • Encourage moving forward to assist with clearing the wheel. Cover the wheel if necessary and sit in front of the person if needed when assisting with the transfer.
  • Encourage hand placement close to the weight/load and close to the final position after the transfer.
  • Make sure weight is transferred forward enabling a good lift and clearance for the transfer.

Hoist considerations

  • Boom height will determine clearance from the bed. Make sure the client’s head does not hit the boom.
  • Mast clearance allows space, so the person’s feet don’t knock the motor/ mast on lifting and lowering.
  • A yoke-style or two-point frame lends itself to a large variety of slings with loops. Shearing from the sling can occur as weight is taken especially during the transition from a lying to a sitting position.
  • Pivot frame design can assist with positioning the person more rearward and upright into the shower commode or wheelchair. Pivot frame hoist slings are hoist specific in design and cannot be interchanged. Pivot frames can also have powered actuators which allow for a controlled transition between lying and sitting.

Sling considerations

  • Ensuring the right fit and size selection is crucial. Measure from the coccyx to the top of the head for slings with head support. Centre the sling over the spine. If the person’s body touches or falls outside the binding, change to a larger and wider sling. This will prevent friction and physical skin trauma as well as minimise the risk of a person falling or rolling out of the side of an undersized sling.
  • Different styles have different levels of contact with the skin. A key-purpose sling has greater coverage than a hygiene or toileting sling.
  • Different fabric options such as mesh, fabric or ‘parachute’ material offer different friction coefficients. Mesh is generally not recommended due to high friction.
  • Support the leg when inserting and removing the sling leg straps to prevent shear and friction.
  • Never tug or pull on the sling to reposition the person in the chair. Hoist the person up again to reposition.
  • Never use a wet sling.

Good techniques for hoisting into a wheelchair/shower commode

Step 1: Hoist transfer into a wheelchair.
  • Before hoisting, check that the cushion is correctly placed on the wheelchair and working.
  • Make sure the person is centred in the sling. Rolling is the best manual handling technique for sling application.
  • Sit the person up in bed after the sling is applied to reduce friction and slide into the sling from a supine position. This is also more comfortable for the person.
  • Clear the bed before pivoting the person around to clear the feet from the bed.
  • Wearing shoes or protective footwear can reduce potential injury to the feet from the hoist motor/mast.
Step 2: Check person is rearward in the wheelchair and commode.
  • If able, use the tilt-in-space on the power drive wheelchair or shower commode. Gravity helps position the pelvis back into the chair.
  • As the person is lowered into the chair, push on the knees or use the powered frame (whilst maintaining the person’s sitting balance). 
  • Check the person’s balance and positioning once the weight is offloaded from the sling. If the positioning isn’t correct, hoist up again and reposition. Never pull the clothing to reposition in the wheelchair as this can cause shear, friction, and inappropriate clothing fit.
  • You can check by leaning the person forward in the wheelchair and feel or see if there is space between the sacrum and the backrest. There should be no gap. If you are satisfied, the sling could be removed after checking.
  • If you need to reposition the person, lean them forward and push them on their knees. This can be done with two people and/or using the tilt function on the power or manual tilt in space wheelchair.
  • If the person is on a commode or the above measure did not work, you will need to re-hoist to reposition.

Poor seated posture can increase risk of shearing if the person slides forward in the wheelchair.

Photo by: AliMed

Good seated posture with pelvis in neutral will promote healthy skin integrity.

Photo by: AliMed

Step 3: Remove the sling.
  • For safety, always stand in front of the person.
  • Once the person is correctly positioned, the sling can be removed. Lean the person forward to remove the sling and pull down and rearrange any clothing as needed to decrease wrinkles and creases. If required a further adjustment can be made by leaning forward in the chair and pushing against the knees to get back into the chair.
  • Remove the sling legs by lifting one leg at a time.
Step 4: Check pelvis is level.

Make sure the pelvis is level in sitting by placing thumbs on the front of the pelvic bones (Anterior Superior Iliac Spine-ASIS) and check:

  • the space down each side of the person is even
  • the ASISs are at the same height
  • that they are not rotated (one forward and one backward)

To make any corrections with an uneven height, you can:

  • slide your hand under the side of the pelvis making sure your hand is supporting the hip and buttock not pulling on the clothing. Gently reposition the pelvis up.
  • have a second colleague to support the person during this process
  • if access is difficult, consider removing armrests or skirt guards

To make any corrections with a rotated pelvis, you can:

  • gently push back on the knee of the side that is forward
  • leaning the person forward at the same time can make this easier to do

Always re-check ASIS after any repositioning.

Step 5: Check the trunk, head and shoulders are centred and level.
  • Assistance with this is required only for people who do not have full control of their trunk or have impaired balance.
  • If someone is independent with their balance and trunk support, they can check their posture in the mirror and readjust as needed.
  • After placing the arms into the arm troughs on the chair, place hands on either side of the rib cage/trunk and reposition as needed by gently pushing on the side to correct.
  • The head needs to be centred on the headrest. If the head and shoulders cannot be centred, then recheck the pelvis (ASIS).
Step 6: Check the feet and leg positioning.

Make sure the feet are centred and flat on the footplates and if the person is not wearing shoes, make sure there is padding under the feet e.g. folded towel.

Step 7: Attach straps and supports.

When these steps are completed, apply straps and supports for safety as required. A chest strap is highly recommended for someone who has impaired sitting balance. A thigh strap may be used to prevent the legs from rolling out. These will be assessed and provided by the clinician as required.