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section 3
Contents
Whyriskassessmentisimportant
Risksrelatedtomovingandhandling
Identifyinghazardsinworkplaces
Workplacehazardmanagementandriskcontrols
Theriskassessmentprocess
Riskassessmenttools
Monitoringriskassessment
Referencesandresources
Appendices:Resourcesforriskassessment.
Risk assessment
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3. 1 Why risk
assessment is
importantAriskreferstothepossibilityof
somethinghappening.Inmoving
andhandling,thetermrisk
isusuallyusedtorefertothe
possibilityofaninjuryorother
negativeoutcomeoccurring.A
lowriskmeansalowlikelihoodof
anegativeoutcome.Ahazardis
afeatureofataskorenvironmentthatmayleadtoinjuryorharmto
acarerortoaclient.Thepurpose
ofriskassessmentistoidentify
andmanagehazardstoreducethe
likelihoodofincidentsoccurringthatcouldcauseharmorinjuryforcarersandclients.
Riskassessmentisakeypreliminaryprocedureforalltypesofmovingandhandling.
Itneedstobeundertakenpriortomovingandhandlingpeopletoensurehazardsare
eliminated,isolatedorcontrolled.
Inmanycountries(e.g.Australia,Canada,theUnitedKingdomandtheUnitedStates)local,regionalandnationalhealthauthoritiesnowhaveguidelinesandcodes
ofpracticethatincludeconductingriskassessmentsbeforemovingandhandling
people.1Aprimaryfocusinclientmovingandhandlingguidelinesisthathazards
relatedtomovingandhandlingclientsshouldbeclearlyidentifiedandeliminated,
minimisedorcontrolledwherefeasible.
InNew Zealand,bestpracticeformovingandhandlinginworkplacescomesunderthe
jurisdictionoftheDepartmentofLabourandtheAccident Compensation Corporation
(ACC).The Health and Safety in Employment Act (1992) requiresemployerstoprovidesafe
placesofwork.Employersareexpectedtosetupsystemsandprocedurestoidentifyhazardsintheworkenvironment,assesstheirsignificance,providecontrolsand
evaluatetheeffectivenessofthecontrols.
1. Forexample,RoyalCollegeofNursing,2003;Johnson,2011.
Box 3.1
New Zealand legislation and
risk assessmentThe use of the term hazard in these
Guidelines is consistent with its use in the
Health and Safety in Employment Amendment
Act (1992), and the procedures recommended
for reducing risks are consistent with those
required of employers by that legislation.
We regard the lack of systems for
identifying and/or not regularly reassessing
hazards in places of work as being serious
noncompliance with the health andsafety legislation.
(Department of Labour, 2009a, p. 13)
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3.2 Risks related to moving and handling
Severalresearchstudieshaveidentifiedthatclientmovingandhandlingtasks
areassociatedwithanincreasedriskofinjuries(Box3.2),includinganextensive
studybasedonACCclaimsin
New Zealand(Box3.3).The
identificationandcontrolof
hazardsrelatedtothesemoving
andhandlingtasksneedto
considerthefollowingfactors:
Workplaceorganisation,
suchaspoliciesand
procedures,shiftpatterns,
staffavailabletoassist,
workplacecultureand
trainingforstaff
Physicalworkenvironment,
suchasworkspaces,
layout offurnitureand
equipmentavailable
Clientcharacteristicssuchassizeandweight,theabilityandwillingnessofthe
clienttounderstandandcooperate,andanymedicalconditionsthatinfluencethechoiceofmethodfortransferringorrepositioningtheclient
Carersandthephysicaldemandsofatask,suchastheforcerequired,
awkwardposturesandthefrequencyanddurationofthetask.
Box 3.3
Moving and handling tasks associated with higher risks of injury for carers in
New Zealand residential care
A taxonomic study of ACC entitlement claims that involved 60 days or more off work betweenJuly 2007 and May 2009 reported that lifting patients was the most frequently reported task
leading to longterm claims. Lifting patients involved 74% (129) of the 176 claims for injuries
that occurred while moving and handling patients within the New Zealand residential care
(or retirement village) sector. Of the 129 claims involving patient lifting incidents, 61 had
information about the types of transfer during which the carers were lifting the patients.
Among these 61 claim incidents, 33 (54%) involved transferring patients to or from equipment
(e.g. bed, chair, wheelchair, toilet, commode), 15 (25%) involved catching falling patients, and
seven (11%) involved picking patients up from the floor.
Source: Ludke & Kahler, 2009, pp. 2728
Box 3.2
Client handling tasks associated with
injuries to carers
Transfers between bed and chair
Transfers between chair and toilet
Lateral transfers between bed
and stretcher
Repositioning in bed
Repositioning in a chair
Sitting to standing.
Sources: Nelson et al, 2003; Royal College of
Nursing, 2003; Waters et al, 2007
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3.3 Identifying hazards in workplaces
Forcontrollingrisksinworkplaces,thePrevention and Management of Discomfort, Pain
and Injury Programme(DPIProgramme),establishedbyACCin2006,describesseven
generalfactorsrelatedtoworkplacehazards(seeSection2).Thesesevenfactors
provideageneralcontextforidentifyinghazardsandcontrollingrisksrelatedto
peoplemovingandhandling.Hazardidentificationshouldbepartofriskassessment.
Fourspecificgroupsofhazardareoutlinedthatmakepeoplemovingandhandling
activitiespotentiallyhazardous.Thesehazardsneedassessmenttoreducetheriskof
injurytocarers.Itisimportanttobecomefamiliarwiththesehazardssothattherisks
canbemanagedbyeliminating,isolatingorcontrollingthem.
(i) Hazards related to workplace organisation and practices
Examplesofworkplacefeaturesthatarepotentiallyhazardousinclude:
Administrativepoliciesandprocedures.Alackof,orinadequate,policiesand
procedures,orpoliciesandproceduresthatarenotfollowed,canincreasethe
levelofriskassociatedwithperformingapeoplemovingandhandlingtask
Equipmentnotprovidedornotmaintainedadequately,forexamplewhena
hoistmaintenanceprogrammeisnotfollowed,fundingisnotprovidedfor
thereplacementofobsoleteequipment,sometypesofequipmentarenot
availablesuchasholdupsonslidesheetsorslingssenttolaundry,ornot
enoughequipmentisallocatedtospecificunits
Staffinglevels.Toofewstaffforthenumberofclientsandforpeoplemoving
andhandlingtaskscanresultinincreasedworkdemandsbeingplacedonthe
existingstaff,forexamplethroughmoretransfertasks(repetition)oneach
shiftandlongdurationsonmovingandhandlingtasks.Thiscanleadtofatigue
andreducedworkcapacity,andtostafftakingshortcutsandunsafepractices.
Understaffingiscommonduringpeaktimes,forexampleduringactivitiesfor
dailylivingsuchasbathinganddressing
Extendedworkdays.Longworkhours(morethaneighthours)canleadto
increasedexposuretotheriskofinjury,forexamplewhenovertimebecomesnecessarybecausestaffonthenextshiftaresuddenlyunavailable,orpeople
areworkingin12hourshiftscateringfordependentpeople(seeBox3.4)
Workinginisolation.Forexample,whencaringforadependentpersonintheir
home,acarergenerallydoesnothavetheopportunitytocallforassistance.
Theavailabilityofassistancetoacarerwillaffectthelevelofriskassociated
withperformingpeoplemovingandhandling actions
Lackofvariability.Thiscanincreasetheloadonbodytissuesowingtoalack
ofchangesinpostureandthereducedchanceofrecovery,forexampleby
performingoneactionrepeatedly,suchasholdingalimb
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Inadequaterestbreaks.Notallowingenoughtimebetweenpeoplemoving
andhandlingtaskscancontributetofatigueandoverexertion.Anexampleis
busyworkschedulesleadingtomissedworkbreaks
Lackofconsultationwithworkerswhenpurchasingnewequipment
Inadequatetraining
Workplaceattitudesandpracticesthatdonotsupportacultureofsafety.
Box 3.4
Long working hours reduce quality of care
A case brought before the New Zealand Health and Disability Commissioner involved a
person being cared for in her home by nursing agency staff. She had developed pressure
sores and foot ulcers as a result of inadequate care. The notes for this decision reportedthat: The records indicate that in the several months prior to Mrs As death, it was not
uncommon for one caregiver in particular to work in excess of 100 hours per week. There are
instances of staff working 24hour shifts with relief for only several hours in the morning or
early evening.
Source: Health and Disability Commissioner, Decision 02HDC08905, retrieved 19 August
2010 from www.hdc.org.nz/2010
(ii) Hazards in the physical work environment
Slip,tripandfallhazardssuchaswiresandwetfloors
Unevenworksurfaces
Spacelimitations(smallrooms,lotsofequipment,clutter)
Inadequatespacearoundbedsandtoilets
Facilitydesigninadequatefortransfertasksinthetransferareaandforthe
equipmentrequired
Inadequatelighting.
(iii) Hazards related to clients
Poormobility
Peoplewhoaredifficulttomovebecauseoftheirsizeorcondition
Variationinclientcooperation
Aclientsabilitytohear,seeandunderstand,whichmayaffecttheirmobility
andabilitytocooperate
Cognitiveissuessuchasconfusionanddementia
Languageandculturaldifferences
Unpredictabilityofclientwhenbeingmoved
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Clientanxietyandfearofmoving,whichcanlimitcooperation
Medicalattachmentstoclient,whichmaylimittheirabilitytohelp
Pain,whichcanaffectaclientsabilitytocooperate.
(iv) Hazards for carers and use of moving and handling techniques
Forcetheamountofphysicaleffortrequiredtoperformatask(suchaslifting,
pushingandpulling)andtomaintaincontrolofequipment
Repetitionperformingthesamemovementorseriesofmovements
frequentlyduringtheworkingday
Awkwardpositionsassumingpositionsthatplacestressonthebody,such
asleaningoverabed,kneelingortwistingthetrunkwhilemovingaclient,
reachingawayfromthebodyorovershoulderheightforlongperiodsand
whileexertingforce
Carerlacksknowledgeortraining
Carermaybewearinginappropriatefootwearandclothing
Insufficientnumberofcarersformovingandhandlingtasks
Carerworkinglonghoursorisfatigued
Nosuitableequipmentavailable
Unsupportiveworkplaceculture.
Uncooperative and aggressive clients
Whenaclientiscombativeoraggressive,thecarershouldnotattempttohoist,
transferorrepositiontheclientifthereisarisktothecarerspersonalsafety.Ifthere
isanactualorpotentialrisktotheclientifatransferisnotcarriedout,restraintmay
benecessary.Inthiscasethefactorsinfluencingthedecisionrelatingtorestraint
shouldbedocumentedandallcarersshouldbemadeawareofthesefactors.
HealthcarestandardsinNew Zealandrequirethatanyrestraintusedmustbethe
leastrestrictivefortheleastamountoftime,andusedonlyafteralllessrestrictive
interventionshavebeenattemptedandfoundtobeinadequate.Restraintisaserious
interventionthatrequiresclinicaljustificationandoversightandshouldbeusedonly
inthecontextofensuring,maintainingandenhancingsafety,whilemaintainingthe
clientsdignity.Ifaclientisbeingphysicallyrestrained,thecarermustbetrainedand
certifiedinrestraintpractice.Forcarersworkingaloneinthecommunity,thereshould
beanagreedprocedureforseekingassistance.Thisisessentialtopreventundue
distressandseriousharmtotheclientsbeingrestrained,andtomaintainthesafety
of carers.
Anuncooperativeoraggressiveclientwhoneedstobemovedandhandledfor
personalcaremayneedtobeassessedundertheMental Health (Compulsory Assessment
and Treatment) Act (1992).Insuchacase,acareplaninvolvingallmembersofthecare
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teamshouldbeinplace.Arestraintregister,orequivalentprocess,islegallyrequired
toprovidearecordofrestraintuseforauditpurposes,asdescribedintheStandards
New Zealanddocument:Health and Disability Services (Restraint Minimisation and Safe
Practice) Standards.2
Organisationsneedtodeveloptheirownpoliciesandproceduresoncalming
andrestraintthatcomplementtheirmovingandhandlingpolicies.Policies
shouldbebasedontheHealth and Disability Services (Restraint Minimisation and Safe
Practice) Standards.2
2. SeeStandardsNew Zealand,2008
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3.4 Workplace hazard management and risk controls
Workplacehealthandsafetypoliciesshouldincorporatemovingandhandlingand
aretheresponsibilityofmanagement.Theyshouldincluderiskassessmentandrisk
controlprocesses.
Typicalriskcontrolfeaturesinclude:
Writteninformationandprotocols(e.g.hazardregisterwithriskorhazard
controlplan,workplaceprofile)
Equipmentprovidedformovingandhandlingclients
Trainingprogrammeforclientmovingandhandling
Incidentandinjuryreportingsystems.
Carersshouldbefamiliarwiththeirworkplacehazardregistersandriskcontrol
policiesandprocedures.Thesubsequentstepsinworkplaceriskassessment
processesshouldbeconsistentwithriskcontrolandhazardmanagementpolicies.
Workplace profile
Furtherinformationondevelopingaworkplaceprofileinwhichworkplacerisk
controlsformovingandhandlingcanbeincluded,aredescribedlaterinthissection
(3.6Riskassessmenttools)andadetailedexampleisshowninAppendix3.2.For
somelocations,suchasresidentialcarefacilitiesandcommunitysettings,theworkplaceriskassessmentprocessmayneedtobeadaptedtocontrolrisksforcarers
andclients(seeBox3.5andAppendix3.5).
Client risk assessment (load)
Clientcharacteristicsthatcanaffectmovingandhandlingrisksinclude(butarenot
limitedto)sizeandweight,levelofdependencyandmobilityandextentofclient
compliance.Somespecificpointstonotearethat:
Aclientsphysicalcharacteristicsmustbeknownandpreparedforinplanning
Clientsmayhavespecificphysicalconstraintssuchastheirfragility,tiredness,
havingcontractures,beingunabletolieflat,intravenouslines,drainagebags,
intubationandframes
Clientscansometimesberesistive,unpredictable,confusedanduncooperative.
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Carer risk assessment (individual)
Thecapabilitiesofcarersinvolvedinmovingandhandlingclientsincludetheir
physicalability,trainingrelatedtomovingandhandling,levelofstressandfatigue
andthenumberofothercarersinvolved.Examplesofspecificrisksforcarersare:
Staffwhoareinexperienced,inadequatelytrainedorunfamiliarwithclients
andmovingandhandlingequipment
Continualmovingandhandlingofclientsforlongperiods
Inadequatestaffnumbersforsafemovingandhandling.
Box 3.5
Example of a community risk assessmentTask caring for a client in a low bed and on a double bed, including:
Clinical procedures carried out on the client in bed
Turning in bed
Moving up and down the bed
Sitting client to lying and vice versa
Bedbathing
Getting client in/out of bed.
People involved carers, including public health nurses, family members
and physiotherapists.
Identified risks
Prolonged stooped postures when attending to client
Awkward posture when moving client in bed.
Control measures the level of risk depends on the client and the environment and should
be assessed locally. For medium to high risks, consider using these options when working
with a client:
Place knee(s) on bed or floor to reduce stooping when attending to the client (considerinfectioncontrol issues)
Provide electric profiling bed
Provide hoists and sliding boards for transfers to and from bed
Keep the client in bed until equipment is available
Provide extra staff as required
Provide low stool for carers and staff.
An assessment may result in a recommendation to move furniture or provide equipment.
This would need to be discussed with the client and their family. The environment should
be managed appropriately, and if the client and family refuse assistive equipment, care may
need to be scaled down to avoid risks to carers.
Adapted from: Royal College of Nursing, 2003
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Task risk assessment
Ataskriskassessmentincludesidentifyingthespecifictypeofmovingandhandling
task,matchingthemovingandhandlingprocedurewiththeloadandtask,and
ensuringthattheequipmentneededforthetaskisavailable.Notethatthefollowing
arehigherrisktasks:
Repositioninginabed
Repositioninginachair
Transfersbetweenbedand chair
Transfersbetweenchairandtoilet
Lateraltransfersbetweenbedandstretcher
Sittostand
Prolongedorsustainedholds,suchasholdingalimbwhilechangingadressing
orchanging clothing.
Thetaskwillneedreplanningifcarersneedtodoanyofthe following:
Awkwardpostures,suchasprolongedorrepeatedbendingforwardor
sideways,twisting,andworkingatorbelowkneelevel
Exertinghighforce,suchaswhenholding,restrainingorpushingorwithloads
notequalforbothsidesofthebody
Reachingawayfromthebodyorovershoulderheightforlongperiodsorwhile
exertingforce(seeBox3.6).
Box 3.6
One carer or more than one carer needed?
A common question, particularly for clients receiving care in their homes, is whether
one carer or two or more carers is needed to transfer a client. Best practice is that, for
all new clients and clients whose status has changed, there must be a rigorous onsite
risk assessment carried out by a person who is experienced in moving and handlingassessments. The risk assessment should then be used to determine how many carers are
needed for specific types of client transfers. Where there is a significant change to a clients
mobility or following an incident, a risk assessment should take place as soon as possible.
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Environmental risk assessment
Anenvironmentalriskassessmentincludesthephysicalspace,equipmentavailable,
floorsurfaces,clutter,lighting,noiseandtemperature.Foracomprehensive
environmentalassessmentforaclient,somespecificenvironmentalfeaturesto
assessare:
Inappropriatefurnitureandfittings,suchaswindupandmanualadjustbeds,
lowbathsandlowclientchairs
Nograbrailsinbathrooms,toiletsorcorridors
Limitedspaceandaccesstoworkingareas
Equipmentnoteasilymoveable
Slipperyfloors Carpetsthatmakepushingequipmentdifficult
Narrowdoorwaysorramps
Changesoflevelatlifts.
Anexampleofaspecificsystemorapproachforclientriskassessment,knownas
theLITENUPapproach,isshowninAppendix3.1.LITENUPhasbeenusedin
somefacilitiesinNew Zealandsince2003andissuitableforusewhereahealthcare
providerwishestouseaspecificclientriskassessmentsystem.
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3.5 The risk assessment process
Beforeanymovingandhandlingofaclient,thereshouldbeasystematicrisk
assessmenttoidentifyrisksandorganisecontrols.Figure3.1providesanoverviewof
theprocessofriskassessment.
Figure 3.1 Overview of the risk assessment process
yesno
Do not move client
Considerotheroptions
Is moving the client necessary?
Workplace risk controls
Stafftraining,equipment,clientmovingprotocolsanddocumentation
5. Client ready to move
1. Client risk assessment
Capabilities,mobilitystatus,size,compliance.Consultclientprofile
2. Carer risk assessment
Carertraining,physicalcapacity,stress,tiredness,numberofcarersinvolved
3. Task risk assessment
Whatisthetask(e.g.chairtobed)?
Whathandlingtechniqueisappropriate?
Whatequipmentisneeded?
4. Environmental risk assessment
Floorcondition,spaceavailable,equipment accessible
Whenadecisionhasbeenmadethataclientshouldbemoved,thecarerneedsto
carryoutthespecificriskassessmentproceduresrelatingtotheclient,thecarer
(orcarers),thetaskandtheenvironmentinwhichthetaskwilltakeplace.The
componentsforthespecificriskassessmentsaredescribedinmoredetailbelow.
Theriskassessmentssetoutinthissectionareprimarilyrelevantforinpatients
orclientsreceivingongoingcare.Carerswhohaveonlybriefcontactwithclients
(e.g. ambulanceandfireservicestaff)shouldusebrieferchecklistsorassessments,
whichcanbeadaptedfromtheexamplesshowninthissection.
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3.6 Risk assessment tools
Thissectionoutlinesfiveassessmentproceduresthatcontributetotheoverallclient
assessment.Theassessmentproceduresincludetheworkplaceprofile,clientprofile
andclientmobility,fallsandpremovementriskassessments.Examplesofspecific
assessmenttoolsareincludedinthesectionappendices.Thesetoolsandexamples
illustratepossiblewaysforconductingriskassessments.Eachorganisationshould
adapttheexistingtoolsandformstosuititsspecificneeds,ordevelopitsowntools.
Developing a workplace profile
Theworkplaceprofileisaspecificmovingandhandlingauditoftheenvironmentin
whichcarerswork.Itcanincludebothpeoplehandlingandobjecthandling.Fromthe
workplaceprofile,controlsaredevelopedtomaximisestaffandclientsafetywithintheworkplace.Aworkplaceprofileandriskcontrolplanhelporganisationsmeettheir
legalresponsibilities.Itsetsoutwhattherisksare,whatwillbedoneaboutthem,
andwhenchangesshouldbemadeandbywhom.Theycanalsobeusedtorecord
andcontrolrisksandothersafetyissuesidentifiedduringclientmovingandhandling.
Theinformationgatheredshouldbeintegratedintotheorganisationalmovingand
handlingprogrammeandincludedintrainingprogrammes.
Theworkplaceprofilecanbeusedto:
Identifyandprioritisetheareasthatarepotentialrisksorneedimprovementtoreducemovingandhandlingrisks
Establishabaselinefromwhichtomeasureimprovements
Giveasnapshotoftheworkplace,includingaclientshomewhererelevant
informationthatcouldbeusefulwhendealingwithconsultants,designers,
suppliersandtechnicalexperts
Developinformationthatcanbecomparedwithotherworkunits
or organisations
Provideinformationneededtoprepareariskcontrolplan Provideinformationneededaspartoftheorganisationalmovingand
handling programme.
Who does the workplace profile?
Thewardorunitmanagerisresponsibleforcompletingordelegatingthetaskof
completingtheworkplaceprofileanddevelopingacontrolplantoaddresstherisks
identified.Theyshouldworkwiththeclientmovingandhandlingadviserorthehealth
andsafetycoordinatorandarrangefordiscussionsatstaffmeetingstogetfeedback
fromstaff.Theworkplaceprofileshouldbecompletedatleasteveryyear,and
updatedearlierwheneverthereisasignificantchangeintheworkplace.
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What does the workplace profile involve?
Theworkplaceprofileisintwoparts:
Workplace detailsthiscoversclientpopulations,staffnumbers,equipment
andfacilities
Workplace risk assessmentthisusesascoringsystemtoidentifyrisksand
prioritiseactionstobuildaneffectiveclientmovingandhandlingprogramme.
Risksyouwillneedtothinkaboutinclude:
EquipmentDoyouhavetherightequipmentforthetasksyoucarryout,
doyouhaveenoughequipment,whatsortofconditionisitinandisitreadily
accessibleforstafftouse?Arethereanequipmentmaintenancescheduleand
replacementplan?
StaffDoyouhaveenoughstaff,dotheyknowwhatisexpectedofthem,has
everyonedonethebasictrainingrequired,anddoyouhaveclearpoliciesand
procedurestoguidethem?Istheworkplaceculturesupportive?
EnvironmentIsthereenoughspaceformovingandhandlingoperations,can
youimprovethelayoutandremovecluttertoimproveconditions,andcanyou
providemobilityaidstohelpclientsbemoreindependent?
Incident reporting Doyouhaveacultureofreportingnearmissesand
accidentsrelatingtomovingandhandling?
Appendix3.2attheendofthissectionprovidesanexampleofaworkplaceprofile.
The client profile
Theclientprofilesummarisesaclientsdetails,capabilitiesandactionplan.Theclient
profileincludesinformationonindividualclientcharacteristicsandfactorsthatcould
affectclientmovingandhandling.Itprovidesinformationneededtomakedecisions
aboutthetechniquesandequipmentrequired,andothercontrolsforclientmoving
andhandling.Whererelevant,itcanincludeclinicalreasoningrelevanttospecific
recommendationsregardingequipmentandtechniques(seeBox3.7).
Theclientprofileshouldbesignedoffbyanauthorisedperson.Inhealthcarefacilities,
thiswillusuallybearegisterednurse,physiotherapistoroccupationaltherapist.The
profileprovidesaguideforallcarerswhoworkwiththeclient.Appendix3.3provides
anexampleofthesummarydetailsthatcanbeincludedinaclientprofile.Each
organisationneedstoensurethat,whatevertypeofclientprofileisused,itcontains
informationrelevanttomovingandhandling.
Who does the profile and when?
Foradmissionstohealthfacilities,usuallyaregisterednurse,occupationaltherapistorphysiotherapistcompletestheclientprofilewhenaclientisadmitted.Staffwho
arerequiredtocompleteorreviewtheclientprofileshouldbeidentifiedbythe
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organisationorunitmanagerandtrainedappropriately.Theprofileshouldbe
reviewedperiodicallyorascircumstanceschange,suchas:
Whentheclientscondition
ortreatmentchanges
Atagreedperiodsasper
policy(e.g.insomeDistrict
HealthBoardsitisevery
threedays)
Whenconditionsinthe
wardorunitchange
(forinstanceiflayoutor
procedureschange)
Whentheclientmovestoa
differentwardorservice
Whentherehasbeenan
incidentorinjuryinvolving
theclient.
Forresidentialcarefacilities,there
shouldbeaninitialriskassessment
atthetimeofadmissionofa
clientandatregularintervals
followingadmission.Theinitial
riskassessmentshouldbe
completedbyastaffmemberwho
hashadtraininginmovingand
handlingriskassessmentsandis
deemedqualifiedtodosobythe
organisation.Priortoanytransfer,theriskassessmentshouldalsobecheckedbythe
carerwhowillbemovingtheclient.
Forclientsinhomecare,aninitialonsiteriskassessmentshouldbecarriedoutbya
carerdeemedqualifiedbytheorganisation.Itshouldinvolvetheclient,theclients
familywhereappropriateandifapplicablethefunder.Theriskassessmentshould
notewhatmovingandhandlingequipmentwillberequired,whatchanges(ifany)
areneededinroomorbuildinglayout,andwhethertheclientwillrequireassistance
fromoneortwocarersforspecifictransfers(seeAppendix3.3).Thecarerassignedto
theclientwillberesponsibleforcarryingoutthecarespecifiedbytheriskassessment
priortoeachclienttransfer.Solecarersshouldbeabletorequestspecialistrisk
assessmentsfollowinganysignificantchangesinclientsmobility,profileor
environment,orfollowinganyindicationthatmorethanonecarerordifferentequipmentmayberequiredtotransferclients.
Box 3.7
Clinical reasoning in client
profile information
Including clinical reasoning for a technique
or equipment choice helps where staff may
later question a decision, or do not understand
why a specific choice was made. For example,
a carer has tried a simple turning device to
assist a standing turn from wheelchair to
bed, but the client feels unsteady because
they prefer to hold on to something duringthe turn. Instead, a turning device with a
handle is used. A new supervisor makes an
independent assessment and decides the
more expensive device is not necessary, failing
to consider the previous decision outcome
that the ordinary turn disc was unsuccessful.
The new supervisor restarts the process,
potentially leading to distress for the client
and frustration for other staff. Documented
clinical reasoning, especially in complex
situations, enables future assessors or
practitioners to understand the decisions
taken and review these appropriately.
Source: Carole Johnson, moving and handling
consultant, UK
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What information is included in the client profile?
Theclientprofilesummarisestheclientsdetails,capabilitiesandneedsandprovides
amovingandhandlingplanwhenneeded(seeAppendix3.3).Itconsistsoftwoparts:
1. The client risk assessmentcoversfactorsthatcanaffectclienthandlingand
increasemovingandhandlingrisks,suchaspain,medication,orthoticsand
compliance.Iftheassessmentshowsthereareanyriskfactors,thesecond
part,themovingandhandlingplan,mustbecompleted
2. The moving and handling planrecordsthetechniques,theequipment
consideredappropriateforeachmovingandhandlingtaskandthenumber
ofcarersrequired.Itshouldbefollowedbyeveryonecarryingoutthetasks,
unlesstheclientsconditionhaschanged.Forinstance,achangeinaclients
conditionormedicationmayhavealteredtheirbalanceorabilitytofollow
instructions.Noteveryclientwillneedamovingandhandlingplan,butthe
assessmentpartoftheprofileshouldbedoneforeveryclientandregularly
reviewedincasethingschange.
Theclientprofileprovidescarerswiththeinformationtheyneedinaclearand
consistentway.Itprovidesaquickoverviewoftheclientsconditionandanymoving
andhandlingneeds.Itsetsoutthetechniquesandequipmentmostsuitableforeach
movingandhandlingtask,andprovidesaquickchecklistofthefactorsthatcarers
needtoconsiderbeforetheycarryoutthetask.
Theclientprofileshouldbe:
Availabletoeveryonewhoworkswiththeclient
Considered,andifnecessaryreviewed,beforeeachmovingandhandlingtask
iscarriedout
Keptwiththeclientsmedicationandtreatmentcareplan(atthebedside)
Sentwiththeclientiftheymovetoanotherwardorservice.
Involvetheclientwherepossibleinthedevelopmentoftheclientprofile.Thiswill
assistwithintroducinganyspecialistequipmentrequired.Itisessentialtoexplainto
theclienthowtheequipmentworksandwhatthebenefitsare.Itisalsoimportant
thattheclientunderstandsthattheassessmentisreducingtheriskofinjurytocarers
andthemselves.
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Client moving and handling plan
Theclientmovingandhandlingplanincludes:
Clientmobilityassessment Fallsriskassessment
Equipment
Techniques
Staffrequired.
Aclientmobilityassessmentiscarriedoutwheneveranewclientisadmitted.It
assessestheclientsneedforassistance.Thereareseveralsystemsusedtoassess
clientmobilityordependency.Theserangefromsimpletoquitecomplicatedsystems.
Inmostcases,itisbettertohaveasimplesystemthatallowsforadditionalcommentswhenneeded.Theclientmobilityinformationshouldbeincorporatedinto
theclientprofileandshouldbeaccessibletoallstaffresponsibleforcaringforthe
client.Clientmobilityinformationshouldbeupdatedregularly.Thefrequencyof
updatingdependsontheclientsconditionandprogress.
Box3.8describessomecommonly
usedcategoriesofclientmobility
thatcanbeusedtoassessaclient
priortomovingthem.Theclients
mobilitystatuswilldeterminetheselectionofaspecifictechnique
forthemovingandhandlingtask.
Forclientscategorisedasassisted
movement,theassistance
requiredmayrangefrommoderate
tosubstantial.Thisisreflectedin
havingmorethanonetechnique
forsometransferswhereclients
needassistance.Thesevariationsshouldberecordedontheclient
profileform.
Eachfacilityneedstodevelop
itsownsystemthatcanbe
easilyconductedandclearly
communicatedtoallstaffinvolved
inmovingandhandlingclients.Examplesoftwosystemsforcategorisingclient
mobilityareshowninTable3.1.
Box 3.8
Assessment of client mobility
Independent: Client does not requireassistance, able to move on own
without supervision.
Supervised movement: Client can move on
own provided they are supervised. May need
oral instruction and some physical assistance
(such as lowering the bed or positioning a
chair) with preparation for a move.
Assisted movement: Client requires some
or considerable physical assistance. Client is
cooperative, willing to assist movement andhas weightbearing capacity.
Dependent: Client is completely dependent on
help from carers to move. Client is unable or
unwilling to assist.
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AnexampleofamorecomplexmobilityscaleisthePhysicalMobilityScale,developed
toassessmobilityinfrailolderpeople.3Inthisscale,eightmovementsarecovered
(Box3.9)andeachmovementisscoredonasixpointscale(0=unabletodounaided;
5=independent,noassistancerequired).
Box 3.9
Movements covered in Physical Mobility Scale
1. Rolling
2. Lying to sitting
3. Sitting balance
4. Sitting to standing
5. Standing to sitting
6. Standing balance
7. Transferring from bed to chair
8. Ambulation ability.
Source: Nitz et al, 2006
Table 3.1 Examples of mobility assessment tools
Example 1Hoist, Assist, Supervise, Independent(HASI)*
Example 2Patient Movement Classifications**
Hoistmovingandtransfersrequiretheuseof
ahoist
Total assist/max assistpatientperformsless
than50%oftaskanddemonstratesanyofthe
following:poorsafetyawareness,seriousgaitimpairment,poorsittingbalanceand/orweight
bearingrestriction(Redcolourcode)
Assistsomeassistanceisneededfromthe
carerand/oruseofequipment
Mod/min assistpatientperforms5075%of
taskbutmaybeunsteady,unpredictable,have
amotorplanningdeficitand/oraweightbearing
restriction(Orange colour code)
Superviseclientcanmovebyselfbutneeds
supervisionbyacarerduring movement
Supervision/mod independentpatient
performs100%oftaskbutrequiresassistance
settinguporusingequipment
(Greencolourcode)Independentclientcanmovewithout
assistanceorsupervision
*WaitemataDistrictHealthBoardprovidedthe
informationaboutHASI.
**SwedishMedicalCentre,2007,SafePatient
HandlingRiskAssessment.
3. Nitzetal,2006.
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Section 3: risk assessment
Falls risk assessment
Whenaclientisassessedasbeingatriskoffalling,thisriskstatusshouldbe
communicatedtoallstaff,theclientandtheclientsfamily.Thisshouldberecorded
intheclientprofileandmentionedduringhandovercommunication,onsignage,and
inlinewithanylocalfallspreventionstrategy,policyordocumentation.Iftheclients
mobilityislikelytochangeoveraday,theclientprofileshouldreflectthesechanges
sothatinformationontheclientsmobilityisuptodate.Theriskratingshould
reflecttheclientsleastabletimes.Forexample,someonewhocanwalkwithanaid
andlotsofassistancemaystillneedhoistingat3amforatoiletvisit,sobothshould
be recorded.
Premovement risk assessment
Apremovementriskassessmentiscarriedoutimmediatelybeforemovinga
client.Staffandcarersshouldbefamiliarwiththeworkplaceprofileandtheclient
profile,andusetheinformationfromthesesourcesaspartofthepremovement
riskassessment.Thepurposesofthepremovementriskassessmentaretoidentify
specificriskspriortomovingaclientandtoplanthemovesothattherisksare
controlledorreduced.Thismayinvolveconsultationamongcarersorbetweenacarer
andunitmanager,especiallywhereseveralpremoveriskfactorsareidentified.An
exampleofapremovementriskassessmentformisshowninAppendix3.4.
Apremovementriskassessmentneedstobedonepriortoeverymove.Anychangesintheclientsconditionneedtobedocumentedintheclientsnotes.Ifacarerisin
doubtregardingtheclientscondition,theyshouldseekadvicefromtheirclinicalor
professionalsupervisor.
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3.7 Monitoring risk assessment
Thefinalstepintheprocessofmanagingexposuretotherisksassociatedwithpeople
movingandhandlingistomonitorandreviewtheeffectivenessofmeasures.Thisis
necessarytomakesurethesystemsareworkingasintended.Monitoringassesses
theextenttowhichorganisationalsystemsandcontrolmeasuresareworking
andensurestheyareimplementedsystematicallythroughouttheworkplace.Itis
importanttoconsultarangeofstaff,particularlythosewhohaveworkedwiththe
controlmeasures.
Aspecificpartofmonitoringandreviewistoconductauditsofriskassessment
procedures.Anauditreferstoaperformancereviewintendedtoensurethatwhat
shouldbedoneisbeingdone.Wheretherearegaps,anauditshouldprovide
informationthatenablesimprovementstobemade.Instructionsonhowtoconducta
riskassessmentauditaredescribedinSection13Audits.
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Section 3: risk assessment
References and resources
ACC.(2008).Health Care Workers: Preventing and managing discomfort, pain and injury to
healthcare workers.Wellington:ACC.
DepartmentofLabour.(2009a).Keeping Work Safe: The Department of Labours policy
on enforcing the Health and Safety in Employment Act 1992 .Wellington:Department
of Labour.
DepartmentofLabour.(2009b).Managing the Risk of Workplace Violence to Healthcare
and Community Service Providers: Good practice guide.Wellington:Department
of Labour.
EuropeanAgencyforSafetyandHealthatWork.(2007).Risk Assessment in Health Care
(EFacts18).Retrieved9August2010fromhttp://osha.europa.eu.
EuropeanAgencyforSafetyandHealthatWork.(2008).Patient Handling Techniques to
Prevent MSDs in Health Care (EFacts 28).Retrieved31July2009from
http://osha.europa.eu.
Johnson,C.(2011).Manualhandlingriskassessment.InJ.Smith,(Ed.).The Guide to
the Handling of People: A systems approach(6thed.)(pp.1738).Middlesex,United
Kingdom:BackCare.
Ludcke,J.,&Kahler,R.(2009).Taxonomy of Injuries in Residential Care. Brisbane:The
InterSafeGroupPtyLtd.
Nelson,A.,Lloyd,J.D.,Menzel,N.,&Gross,C.(2003).Preventingnursingback
injuries:redesigningpatienthandlingtasks.AAOHN Journal,51(3),126134.
Nelson,A.,Matz,M.,Chen,F.,Siddharthan,K.,Lloyd,J.,&Fragala,G.(2006).
Developmentandevaluationofamultifacetedergonomicsprogramtoprevent
injuriesassociatedwithpatienthandlingtasks.International Journal of Nursing
Studies,43(6),717733.
Nitz,J.C.,Hourigan,S.R.,&Brown,A.(2006).Measuringmobilityinfrailolder
people:reliabilityandvalidityofthePhysicalMobilityScale.Australasian Journal on
Ageing,25(1),3135.(IncludesthePhysicalMobilityAssessmentScale.)RoyalCollegeofNursing.(2003).Manual Handling Assessments in Hospitals and the
Community.London:RoyalCollegeofNursing.
StandardsNew Zealand.(2008).Health and Disability Services (Restraint Minimisation and
Safe Practice) Standards.NZS8134.2:2008.Retrieved29April2011from
www.moh.govt.nz/moh.nsf/pagesmh/8656/$File/813422008nzsreadonly.pdf.
Waters,T.,Collins,J.,Galinsky,T.,&Caruso,C.(2006).NIOSHresearcheffortsto
preventmusculoskeletaldisordersinthehealthcareindustry.Orthopaedic Nursing,
25(6),380389.
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Waters,T.R.,Nelson,A.,&Proctor,C.(2007).Patienthandlingtaskswithhighrisk
formusculoskeletaldisordersincriticalcare.Critical Care Nursing Clinics of North
America,19(2),131143.
WelshAssemblyGovernment.(2009).All Wales Manual Handling Training Passport andInformation Scheme.Retrieved11August2010fromwww.wlga.gov.uk.
WorkplaceHealthandSafetyQueensland.(2001).Manual Tasks Involving the Handling of
People Code of Practice 2001.Brisbane:WorkplaceHealthandSafetyQueensland.
WorkSafeVictoria.(2009).Transferring People Safely: A guide to handling patients,
residents and clients in health, aged care, rehabilitation and disability services (3rded.).
Melbourne:VictorianWorkCoverAuthority.(Formoreinformationandupdates,
checktheWorkSafeVictoriawebsiteatwww.worksafe.vic.gov.au.)
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Section 3: risk assessment
Appendices: Resources for risk assessment
Theseappendicesincluderesourcesrelatingtoriskassessment.Itisrecommended
thateachorganisationadaptexistingtoolsandformstosuititsspecificneeds,or
developitsowntools.ExamplesofothertoolsareinthereportslistedinReferences
andresources.
Appendix 3.1Exampleofariskassessmentsystem:TheLITENUPapproach
Appendix 3.2Exampleofaworkplaceprofile
Appendix 3.3Exampleofinformationincludedinaclientprofile
Appendix 3.4Exampleofpremovementriskassessmentform
Appendix 3.5Exampleofaclientassessmentprofileforhomecaregivers
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Appendix 3.1 Example of a risk assessment system:
The LITENUP approach
Thisappendixdescribesanexampleofaspecificsystemorapproachforclientriskassessment,knownastheLITENUPapproach.LITENUPhasbeenusedinsome
facilitiesinNew Zealandsince2003.Itissuitableforusewhereahealthcareprovider
wishestouseaspecificclientriskassessmentsystem.
ThepurposeofLITENUPistoensurethatclienthandlingissafeforbothcarersand
clients.RiskcanbeassessedusingtheLITEprinciplesoutlinedbelowinconjunction
withsuitableassessmentsofclientdependency.TheLITEprinciples,combinedwith
clientprofileinformation,providetheinformationneededtomakedecisionsabout
safeclienthandling.
The LITE principles
LITEisawaytorememberthekeyriskfactorsthatshouldbeconsideredwhen
preparingasafeclienthandlingstrategy.TheLITEprinciplesaredescribedinthe
tablebelow.
LITE principles
Load Loadreferstotheclientcharacteristicsthatcanaffectthehandlingrisk,such
asage,gender,diagnosis,comprehensionoforallanguage,dependency,
neurologicalstatus,size,weight,ability,extentofclientcooperation,client
disabilities,cultureandfallrisk.
Individual Individualreferstocarerswhoaremovingtheclient.Itincludesthecarers
knowledge,training,generalhealthandfatiguethatcanaffectonesabilityto
dothejob.
Task Taskreferstothenatureofthemovingandhandlingtasktobedone,howand
when.Differenttaskshavedifferentchallenges.Eachmovingandhandling
taskneedsassessmentandaspecificstrategy.
Environment Environmentmeanstheworkingenvironment,andcoversfactorssuchas
space,equipmentavailability,staffinglevels,workcultureandresources,whichallimpactonhowthetaskcanbedone.
IntheLITENUPapproach,riskfactorsarenotnecessarilyassessedintheorder
shown,andnotallriskfactorsneedtobecompletelyreassessedineverysituation.
InmostwardsorunitstheEnvironmentandIndividualfactorscanbeassessedby
staff(orotherpeoplewhoaretrainedinriskassessment)andappliedtomostclient
handlingsituations.Generally,carersmustconsiderallfourLITEprinciplesbefore
selectingahandlingtechniqueandorganisinganyequipmentrequired.Checkthe
informationintheclientprofile,relatedtoriskassessment,priortomovingtheclient
toensureappropriatehandlingproceduresareused.
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Section 3: risk assessment
Appendix 3.2 Example of a workplace profile
Workplace profile (Part A)
Organisation
Lastreviewdate Nextreviewdate
Wardorunit Profilecompletedby Date
Profile of clients
Numberofbedsorplaces
(inunit)
Typesofclientadmitted(e.g.agerange,medicalconditions,shorttermorlongterm)
Profile of staff
Seniorstaff Permanentstaff
Newgraduates Casualandagencystaff
Nursingassistants Otherstaff
Numberofstaffinvolvedinmovingclients Proportionofstaffwhohaveattendedmanual
handlingtraining(onedayormore)
Person(orpeople)responsibleforpolicy,advice,training,practicesandequipmentmaintenance
relatingtomovingandhandlinginthisunit(listnames,jobtitlesand responsibilities)
Name Title Responsibility
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6
Workplace profile (Part A) Continued
Equipment inventory (list types of equipment available for use in unit)
Equipment item
(notenumberinunit)
Location
(noteifsharedwith
another unit) Maintenance
Ceilinghoists Performanceverification
stickermustbeindate
Mobilehoists Performanceverification
stickermustbeindate
Hoistslings(mobileand
ceiling hoists)
Disposableslingsareone
client,multipleuseperclient,
thendiscarded
Multipleuseslingsareoneclient,multipleuseperclient,
thenlaundered(greenbag)
Slidesheets(twoper
occupied bed)
Oneclient,multipleuseper
client.Launder(whitebags)
afterdischargeorsoiling
Patslides
Transferbelts
Electricbeds
Add other equipment items as needed
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Section 3: risk assessment
Workplace profile (Part B)
Profile of facilities
Numberofbeds Numberoftoilets
Numberofelectricbeds Numberofbath/showerrooms
Equipmentstorageareas
Add other facility details as needed
Moving and handling activities
(training, communication, maintenance and upgrading)
Activity or event Describe arrangements Person responsible
Inductionbriefingfornewstaff
onmovingand handling
Ongoingmovingandhandling
trainingforstaff
Recordofstaff
training completed
Communicationofmovingand
handlingpoliciesandpractices
tostaffandclients
Clientmobilityassessments
Routineequipmentchecks
Equipmentrepair
and replacement
Riskcontrolplan
Incidentreporting
Injuryreporting
Riskassessmentaudits
Identificationandreportingof
facilityfeatures(e.g. buildings,
space,flooring)that
need upgrading
Add other activities as needed
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8
Appendix 3.3 Example of information included in a
client profile
Client profile
Organisation
Lastreviewdate Nextreviewdate
Wardorunit Profilecompletedby Date
Client details
Name Preferredname
Height Weight Dateofbirth
Relevantmedicalconditions
Clientmobilitystatus
Independent Supervise Assist Hoist
Noteanyspecificconditionsthataffectmovingtheclient
Fallingrisk Skinatrisk Medicalequipment
Inpain Incontinence Surgeryrisks
Impairedmovement Visionproblems Footwearneeds
Lossofsensation Hearingproblems Complianceissues
Othercommunicationissues Otherissues(e.g.cognitive
state).Describehere
Handling plan required? No____ Yes____ complete details below
Task (add tasks as needed)
Technique to be used,
number of carers,
equipment needed Comments*
Sittingandstanding
Walking
Movinginbed
*Forexampleclientcapabilities,clinicalreasoning
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Section 3: risk assessment
Appendix 3.4 Example of a premovement risk
assessment form
Circle one Circle one
Client assessment Carer (staff) capability
Largeorverylarge(bariatric)
client
No Yes Staffnotadequatelytrained
fororconfidentaboutplanned
move
No Yes
Clientunabletoassist No Yes Continualhandlingofclients
formorethan30minuteson
shift
No Yes
Clientphysicalconstraints
(e.g.medicalequipmentinplace,spinalorotherinjury)
No Yes Insufficientstaffnumbersfor
move
No Yes
Clientmaybe
resistive, unpredictable
or uncooperative
No Yes
Task assessment Environmental assessment
Highriskmove* No Yes Limitedspaceoraccessto
workingareas
No Yes
Moverequiresawkward
postures,bending,twisting
No Yes Slipperyfloors,
uneven surfaces
No Yes
Moverequireshighforce,
holding,restraining
No Yes Inappropriatefurniture,such
aswindupbeds,nograbrails
inbathrooms
No Yes
Moverequiresreaching
awayfrombodyorover
shoulder height
No Yes Equipmentnot
easily moveable
No Yes
Total column score (Yes selected) Total column score (Yes selected)
*Highriskmovesinclude:repositioninginbed,
repositioninginachair,transferbetweenbed
andchair,transferbetweenchairandtoilet,
lateraltransferbedto stretcher.
Total risk score =
(outof15)
Scoresover6indicateneedtoreplan
movetocontrolorreduce risk
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Appendix 3.5 Example of a client assessment profile for
home caregivers
Client Assessment Profile
Thefollowingcriteriaaredesignedtoassistahomecaregiverwhoisintheprocess
ofmakingadecisionregardingaccesstoanappropriatehoist.Onceyouhave
consideredthesecriteria,werecommendyouconsultDistrictHealthBoardstaff,ACC
orstaffinotherorganisationswhoarefamiliarwithmovingandhandlingequipment
togetadviceonrecommendedmodelsofhoists,slings,bedsandaccessoriesto
meetyourspecificneeds.Occupationaltherapistsandphysiotherapistsmayalso
beabletoadviseonaccesstoMinistryofHealthandACCfundedmovingand
handling equipment.
Client dependencetheclientsrequiredlevelofassistanceisoneofthemost
importantcriteriawhendetermininghoisttypesandaccessories.Whenconsideringa
hoist,assesswhethertheclientisfullydependentorpartiallydependentonthecarer
forassistanceingettingintoandusingthehoist.
Client clinical conditiontheclientsclinicalandmentalconditioncanalsoaffect
hoistselection.Makeanoteofpainlevels,fracturesorjointlimitations,medication,
recentsurgery,musclespasms,sensitiveskin,abilitytocommunicate,agitation
and cooperativeness.Client strength and staminaboththeclientsupperandlowerbodystrength
mustbetakenintoconsiderationbeforemakingahoistrecommendation.Thismay
determinewhetherastandinghoist,ceilinghoist,gantryhoistoramobilefloorhoist
wouldbestsuityourneeds.
Weight bearinganotherimportantconsiderationistheclientsabilitytobeartheir
ownweightforaperiodoftimeandtoretaintheirbalance.
Physical characteristicsmakeanoteoftheclientssize,heightandweight.Weight
willhelptodeterminethetypeandmodelofhoist,whilesize/shapewillhelpto
determineslingsizeandtype.Ensureyouhavethecorrectsafeworkingloadhoistto
fityourclient.
Special circumstancesmakeanoteofanyotherfactors,suchasgeneral
practitionerortherapyrecommendations,surgicaldressings,attachedmedical
equipmentandanticipatedlengthofrecovery.NOTE:Iftheclientsconditionis
permanentorlongterm,youmaywishtoconsidergettingahoist.Contactan
occupationaltherapistorphysiotherapistforadviceortoaccessMinistryofHealthor
ACCfundedmovingandhandlingequipment.
Adaptedfrom:www.safeliftingportal.com/homecare/patientlift/assessmentinformation.php.