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Proper Sling Selection and Application While Using Patient Lifts (CE)
In response to staff shortages, an aging clinical workforce, and research on safe patient handling, manufacturers have provided an extensive array of patient-lifting technology, including ceiling, floor-based, and sit-to-stand lifts as well as slings that are required for their use. Expanded choice, however, may pose challenges to both healthcare facilities and individual clinicians. These challenges, if not successfully resolved, can preclude the consistent, safe, and efficient use of patient-handling devices. This article provides nurses and other direct patient care providers with a heightened awareness of the challenges to appropriate sling and lift use in rehabilitation and other clinical settings. A new way to categorize slings is introduced, and guidelines for safely evaluating and using slings for different patient-handling tasks are offered.
Clinicians have access to many types of patient- handling equipment to help them lift, transfer, reposition, and move patients, and it is well documented that the use of such safe patient-lifting technology helps reduce the excessive forces in the spine that occur during manual patient handling (Chhokar et al., 2005; Heacock et al., 2004; Keir & MacDonell, 2004; Smith, Weinel, Doloresco, & Lloyd, 2002; Zhuang, Stobbe, Hsiao, Collins, & Hobbs, 1999). In response to staff shortages, safe patient-handling research, and an aging clinical workforce, manufacturers have provided an extensive array of patient-lifting technology, including ceiling, floor-based, and sit-to-stand lifts and the slings that are needed for their use. However, increased choice yields increased complexity, which can be challenging to both healthcare facilities and individual clinicians. If not successfully resolved, these challenges can preclude the consistent, safe, and efficient use of patient-handling devices and reduce the positive impact for both clinicians and patients.
Patient-lifting devices are only as effective as the slings that are used with them. Given the myriad sling designs and application-specific types, it is critical that clinicians become adept at selecting the right sling for the right patient and using it in the correct manner. Any errors in the selection, placement, application, attachment, or removal of a sling can endanger the health and well-being of both the clinician and the patient (Edlund, Harms-Ringdahl, & Ekholm, 1993). Improper sling application is associated with pain and suffering, dislocated joints, damaged nerves, soft tissue damage, pressure ulcer development, and broken bones (Kneafsey, 2000). Insufficient research has been devoted to safe sling use.
The purpose of this article is to make nurses and other direct patient care providers more aware of the challenges to appropriate sling and lift use in rehabilitation and a variety of other clinical settings. A new way to categorize slings is introduced, and guidelines and tips for safely evaluating and using slings in different patient-handling tasks are offered. The sling categories covered in this article are seated, standing, supine, ambulation, support, and repositioning. It should be noted that this discussion does not address support slings such as arm slings. The sling use guidelines described in this article are sling selection, sling application and placement, sling attachment, sling use and lift operation, and sling removal.
Sling Use Guidelines
Table 1a. Guidelines for Sling Selection
The first task is to select the appropriate sling based on the particular patient-handling activity to be performed and the specific characteristics of the patient. For example, slings are designed to transfer the patient from the bed to a chair, to assist the patient with standing or toileting, or to provide assistance with patient showering. Table 1 provides sling type recommendations based on the activity to be performed and the patient’s ability and tolerance and lists circumstances in which each sling type is contraindicated. As outlined in Table 1, sling designs can be grouped into the following categories:
Proper sling selection also involves choosing a sling that is compatible with the lift to be used and is appropriate for the size of patient to be moved. Edlund and colleagues (1993) found that sling sizes varied greatly across manufacturers, increasing the difficulty of sling selection. They noted that the same size of sling from different manufacturers created different sitting positions for the same person. Given that sling sizing is not standardized across vendors, it is essential that the nurse be familiar with the weight capacity of the particular sling to be used. Moody, McGuire, Hanson, and Tigar (1996) found that 57% of surveyed nurses did not know the maximum weight capacity of the lift, let alone that of the sling. However, nurses must be aware that specified weight limits alone do not predict proper sling fit because the patient’s body weight distribution is a significant consideration.
Sling design has been found to be vital to patient comfort, safety, and dignity (Edlund et al., 1993; McGuire, Moody, & Hanson, 1996). In an evaluation of 10 different lift devices (McGuire, Moody, & Hanson) participants reported that slings providing head and neck support were more comfortable and felt safer than those that did not. Furthermore, slings that did not offer sufficient leg support allowed participants to slip through the sling. Moreover, slings that did not provide adequate support in general and forced participants to sit with their legs widely abducted were reported to be the least comfortable and least dignified. Similarly, Edlund, Harms-Ringdahl, and Ekholm (1998) found that a larger one-piece sling with divided leg supports provided better patient support than a smaller divided sling. However, the authors noted that a larger sling may increase the difficulty of patient handling and may prevent the patient from visualizing the transfer process. They added that a divided sling was preferable for toileting and dressing the patient. Also, Edlund and colleagues (1998) found that the effect of different lengths of lift spreader bars (i.e., the link between the sling and the lift motor) depends on the choice of sling. These authors reported that various combinations of sling type and spreader bar design resulted in different sitting inclination angles.
After the correct sling is selected, and before placement under the patient, the sling should be inspected to ensure sufficient integrity. If the sling is frayed or torn or has holes, broken clips, or failing components, it is unsafe to use. Inspection of attachment points, seams, and other fragile areas is critical before every use to ensure safety.
Sling Application and Placement
Proper sling application and placement depend on the sling type and the patient’s tolerance, functional ability, and medical condition. Priorities for proper application and placement include preventing patient discomfort, minimizing shear forces, maintaining patient dignity, and ensuring nurse safety. The application method used depends on the position and condition of the patient and the type of sling in use. A friction-reducing device (FRD) may be used to make sling application easier for staff and more comfortable for patients. An FRD is a slippery sheet that allows an easier, smoother move.
There are multiple techniques for applying a sling; however, many nurses are unaware of them. Moody and colleagues (1996) found that 22% of the nurses surveyed reported that they had received no lift and sling use training, and another 61% reported that they had received only informal on-the-job training by their colleagues. Moody and colleagues noted that it was apparent during the lift evaluation trials that this training was not adequate.
To better understand sling attachments, we will briefly review the common elements of a sling and the variety of spreader bars available. A multitude of sling types and designs exist, but the common elements are shown in Figure 7.
Similar to the variety in sling choices is the variety in spreader bars, which differ in length, height, and the number of suspension points. There are two-, four-, six-, and eight-point spreader bars, and manufacturing companies are constantly working on improvements to increase the variety of spreader bars that attach to the slings (Figure 8).
The method of attaching the sling to the lift’s spreader bar may also vary, as seen in Figure 9. For example, some slings are attached to the lift spreader bar by hooks or clips, whereas other slings are designed with loops. An evaluation of sling attachments revealed that sling designs that allow the sling to be attached directly to the spreader bar frame by plastic clips minimized the magnitude of swing of the patient in the sling (McGuire, Moody, & Hanson, 1996). If the sling is not attached properly, as may occur if a nurse pulls on the sling hook, clip, or loop to meet the spreader bar attachment or if the hook, loop, or clip is attached to the wrong point on the spreader bar frame, the sling may become uneven. This will result in an unstable, and thus unsafe, situation for the patient and the nurse.
To achieve effective and safe lift operation, adequate training is essential (McGuire, Moody, & Hanson, 1996). McGuire and colleagues found that lift operators needed direction and guidance for correct sling attachment (McGuire, Moody, & Hanson). Moody and colleagues (1996) also found that sling attachment often is taken for granted and not identified as a safety issue for the patient or the nurse. Difficulty attaching the sling to the lift was identified by 57% of the nurses surveyed as a situation that would prevent the use of a mechanical assist device (Moody et al.).
Edlund and colleagues (1998) observed that excess backward trunk inclination in a seated sling poses significant problems with sitting-to-sitting transfers because the patient cannot be placed sufficiently far back in the chair. Consequently, the patient is placed on the edge of the chair and must be repositioned manually. Conversely, too little backward inclination requires the patient to have good upper body control to avoid falling forward. Moreover, the combination of a large flexion angle (more than 30 degrees) and a large opening in the sling (e.g., a divided sling) increases the risk of jack-knifing during patient transfer.
The authors’ study (Edlund, Harms-Ringdahl, & Ekholm, 1998) revealed that the desired position of the patient in the sling for both safety and comfort is a thigh position of 7 degrees forward and upward from the horizontal plane, providing a trunk–thigh angle greater than 83 degrees and a backrest backward inclination of 20–25 degrees, resulting in a hip flexion of 103–108 degrees. Figure 10 shows the proper alignment of a patient in a seated sling. (Medical conditions may not allow this alignment for some patients.)
Sling Use and Lift Operation
During lift operation, it is essential that nurses consistently assess pressure points and comfort. Participants have reported discomfort of the upper and lower back, buttocks, thighs, and lower legs when in seated slings (McGuire, Moody, Hanson, & Tigar, 1996). Additionally, underarm pain and upper and lower back discomfort associated with the use of standing slings were documented. Be alert for pinch points, undue pressure over bony prominences, and equipment or devices inadvertently caught in the sling. Also, be aware that some new areas of discomfort may indicate the need for further medical assessment, such as pain due to a possible acute pathological fracture. Staff should respond immediately to any patient complaints of discomfort by checking sling placement. Patient comfort can also be assessed through nonverbal cues, such as grimacing or signs of discomfort for patients who are unable to express themselves verbally. In addition to assessing a transfer for freedom from pain, staff should ensure that the affected limbs of patients with stroke or paralysis are adequately supported before and during the transfer. Patient dignity should be maintained by covering private areas and completing the task in an efficient manner.
When the patient has been placed in the desired position after the transfer, the final step in the process of sling use is removing the sling from under the patient. Priorities for sling removal include preventing patient discomfort, minimizing shear forces, maintaining patient dignity, and ensuring nurse safety. The sling removal method used depends on the position and condition of the patient and the type of sling in use. As during sling insertion, an FRD may be used to assist in removing a sling for both staff ease and patient comfort. It is important that skin be assessed for irritation after every transfer.
Anecdotally, the practice of leaving slings under patients for an extended period of time in preparation for the next lift or transfer has been reported and observed. Most manufacturers do not recommend leaving a transfer sling under a patient beyond the actual transfer, but documentation of patient outcomes in this regard is lacking. An important consideration before the implementation of a protocol that allows a sling to remain in place should include assessment for compromised skin integrity and the effects of a specialty surface used to protect the patient’s skin.
Barriers to Safe and Efficient Sling Use
Research has revealed that 94% of staff do not consistently use recommended patient-handling techniques (Swain, Pufahl, & Williamson, 2003). This is despite the fact that approximately this same percentage of staff have reported that mechanical lift devices are safer and more comfortable for both nurses and patients (Moody et al., 1996). Obviously, some barriers must be overcome to promote the proper use of slings. As noted previously, lack of knowledge about sling selection and use is the primary barrier to use, but system obstacles also affect use.
Knowledge Gaps and Training Needs
A confident and highly skilled nurse operating a lift device promotes the perception of safety and the patient’s willingness to use the lift (Edlund et al., 1993). Lack of staff knowledge regarding slings and sling application must be addressed to promote proper sling selection and use. Sling training materials can be found at the Department of Veterans Affairs Web site (www.visn8.med.va.gov/patientsafe tycenter). A facility sling training program should include the following topics:
Appropriate training sessions may be tailored to particular units, but regardless of the format chosen, the goal of these sessions should be to educate all staff on sling types, selection, inspection, placement, use, and removal; infection control, hygiene, and laundering procedures; and maintenance and tracking of slings. Hands-on training in how to safely and properly attach a sling to a lift, insert a sling, and remove a sling may be very beneficial to staff. A discussion of sling selection based on medical conditions and of alternative transfer methods should be included. (For example, for a lateral transfer, are friction-reducing devices or slide boards available in the event that the unit lacks the right sling?)
Availability of Appropriate Sling Types
As can be seen in Table 1, a variety of slings is necessary for the various patient care tasks, but sling need depends on patient characteristics. Consequently, availability of specific sling types on a unit is critical. The use of disposable or patient-specific slings may be a bit more costly but advantageous if slings are often lost or lifts unused because of the unavailability of slings.
Sling Sharing and Assignment
When slings must be shared, it is recommended that a standard procedure be instituted that identifies specific locations for sling storage, assignment to patients, and laundering. For units with slings assigned to each patient, a successful storage strategy may be to store the sling on a hook near the door of every patient room for easy access. Moody and colleagues (1996) noted that sharing lifts between units was an obstacle to consistent use because of the inconvenience and time needed to locate lifts and slings. Furthermore, although 63% of respondents reported that slings were usually available, typically only two slings were shared between two units: a large- and a medium-size sling.
Bewick and Gardner (2000) contended that the lack of adequate numbers and types of slings promotes the sharing of slings between patients and raises the risk of infection. Use of disposable slings addresses this concern, but for those who must share, at a minimum, slings should be laundered regularly, when soiled, and after assignment to a patient. Use of disinfectants and other biocides may break down the sling fabric, so before use, read the manufacturer’s instructions for laundering.
Maintenance of Slings
Stories abound regarding slings disappearing during laundering off the unit, so launder slings on the unit if possible. Moody and colleagues (1996) found that 59% of nursing staff did not know who was responsible for laundering slings. This contributed to the lack of availability of slings in the facility (Moody et al., 1996; Swain et al., 2003). Attachment points, seams, and other fragile areas should be inspected before every use to ensure safety.
Sling Use Recommendations
Attention to the following areas will promote safe, efficient, and effective sling use.
Desired clinical outcomes are achieved through the seamless integration of the best technology and the best processes. If either is not realized, both patient safety and nurse well-being are compromised. Given the recent advancements in mechanical lifting device design and varied sling types, it is incumbent on healthcare facilities to ensure availability, adequate training, and consistent use of equipment and companion slings. This article was intended to begin the discussion of guidelines for proper sling selection and use. Further exploration of sling use and related issues is encouraged.
The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, through the Rehabilitation Research and Development Research Enhancement Award Program and the Patient Safety Center of Inquiry. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
About the Authors
Andrea Baptiste, MA OT CIE, is a biomechanist and certified ergonomist at James A. Haley Veterans Administration Medical Center. Address correspondence to her at Patient Safety Center of Inquiry, James A. Haley Veterans Administration Medical Center, 11605 North Nebraska Avenue, Tampa, FL 33612, or firstname.lastname@example.org.
Michelle Mc Cleerey, PhD MA RN MEd, is a director of clinical marketing at Hill-Rom IT Solutions, Cary, NC.
Mary Matz, MSPH, is the Veterans Health Administration patient care ergonomics consultant and an industrial hygienist at the Patient Safety Center of Inquiry, James A. Haley Veterans Administration Medical Center, Tampa, FL.
Celinda P. Evitt, PhD PT GCS, is a physical therapist consultant and educator on the topics of wound care, geriatric rehabilitation, and patient safety in Tampa, FL.
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