Further Development of the Nocturnal Home Hemodialysis Interactive Reviewing Tool

Transcription

1 Further Development of the Nocturnal Home Hemodialysis Interactive Reviewing Tool Anthony Dai Wing Kung A thesis submitted in partial fulfillment of the requirements for the degree of BACHELOR OF APPLIED SCIENCE Supervisor: Professor Paul Milgram Department of Mechanical and Industrial Engineering University of Toronto March 2007

2 Abstract An Interactive Reviewing Tool has been proposed by Allison M. Lamsdale in accordance to alternative training materials requested by the patients at the Nocturnal Home Hemodialysis (NHD) Clinic at the University Health Network (UHN). The review tool is composed of procedural information and video clips of a patient performing each step, and is intended to reinforce knowledge for patients to administer treatment, thus improving patient safety, confidence and anxiety levels. The objective of this thesis was to further develop Allison s prototype on Establishing Vascular Access, in hopes to contribute to the progress of coming up with a final design. The design of the prototype consisted of performing a user needs analysis, a task analysis of establishing vascular access, creation of paper prototypes, and a nurse evaluation of the paper prototypes. The final prototype was created in Microsoft FrontPage. I

3 Acknowledgements I would like to thank the following people for their contribution to my thesis project: Professor Paul Milgram for the valuable insight, guidance, and support provided throughout the supervision of this project Doctor Christopher Chan for providing me with the opportunity to work on a project in an area of interest to me Nocturnal Home Hemodialysis Staff (Rose Faratro, Stella Fung, Celine D Gama, and Elizabeth Wong) for their patience, helpful explanations of the treatment process, and coordination of the patients filmed Allison M. Lamsdale for proposing this Interactive Reviewing Tool and also for providing a solid prototype as a starting point Family and Friends for the endless encouragement, motivation, and support provided from beginning to end II

4 Table of Contents 1. Introduction Patient Experiences in Training for Nocturnal Home Hemodialysis Interactive Reviewing Tool Proposed by Allison M. Lamsdale Final State of Allison s Prototype Summary of Nurse Evaluation of Allison s Prototype Thesis Objective Dialysis Treatment Background Functions of the Kidney End Stage Renal Disease (ESRD) Hemodialysis (HD) Nocturnal Home Hemodialysis (NHD) Establishing Vascular Access Dialysis Access Arteriovenous (AV) Fistula Arteriovenous (AV) Graft Central Venous Catheter (CVC) /Permanent Catheter (Permcath) Type of Technique used to Establish Access Rope Ladder Technique Buttonhole Technique Type of Needle used to Establish Access AV Fistula Needle Supercath Needle Problems Associated with Establishing Access Design of New Prototype User Needs Analysis Task Analysis of Establishing Vascular Access Creation of Paper Prototypes Table of Contents/Main Menu Procedural Information and Video Footage for Slides III

5 3.4 Nurse Evaluation of Paper Prototypes Final Prototype Table of Contents Buttons and Hyperlinks Size of Slides and Resolution Font Size of Procedural Content Instructions on Running the Review Tool Limitations of the Final Prototype Suboptimal Video Footage Candidates Level of Detail and Completeness Lack of Browser Compatibility Future Work Comprehensive User Testing Introduction of Review Tool into Training Program Analysis of Infection Rates and Patient Anxiety Post Implementation of Review Tool Creation of More Modules Creation of Browser Independent Application Conclusion References Appendix A: Cannulation Procedure from Training Manual Rope Ladder Cannulation Procedure (AV Fistula/AV Graft) Buttonhole Cannulation Procedure (AV Fistula Only) Appendix B: Slides of the Final Prototype Fistula Needle and Rope Ladder Technique Version Supercath Needle and Buttonhole Technique Version IV

6 List of Figures Figure 1.1: Table of Contents of Allison s Prototype (Lamsdale, 2007)... 3 Figure 1.2: Generic Slide of Allison s Prototype (Lamsdale, 2007)... 3 Figure 2.1: Hemodialysis Diagram (National Kidney Foundation)... 7 Figure 2.2: Rope Ladder Technique Figure 2.3: Buttonhole Technique Figure 2.4: The Features and Benefits of the Gambro Plume Safety AVF needle (Gambro) Figure 2.5: Suru AV Fistula Needle (Suru International Pvt. Ltd., 2007) Figure 2.6: Supercath CLS Needle (Medikit Co. Ltd.) Figure 3.3: Main Menu (Arterial Cannulation) of Fistula Needle and Rope Ladder Technique version Figure 3.4: Main Menu (Venous Cannulation) of Fistula Needle and Rope Ladder Technique version Figure 3.5: PowerPoint slide for Cleanse cannulation site for the Fistula Needle and Rope Ladder Technique V

7 1. Introduction There has been a shift from nurse administered hospital treatment only, to treatments done at home by the patients themselves (Lamsdale, 2007). One of the more complex treatments being performed at home is Nocturnal Home Hemodialysis (NHD). NHD is one of the treatments used by patients with kidney failure. The main advantage of selfadministered treatment at home is more patient freedom and schedule flexibility (Lamsdale, 2007). The main disadvantage to this change in treatment delivery is the fact that patients, who are not healthcare professionals, must administer the treatment themselves (Lamsdale, 2007). Although the patients are not experts, the risk of harm should be minimized with adequate training, support, and practice. For the NHD patients at University Health Network (UHN), the clinic staff provides a six to eight week training program combined with home visits, to ensure that the patients are capable of performing the treatment on their own. This shift towards self-administered treatment also marks a change in the duties of nurses, not only do they need to be experts in providing care, they also need to acquire the skills of good teaching and training practices (Lamsdale, 2007). There are many issues surrounding these changes in the healthcare system, but this thesis will be covering the design of an interactive reviewing tool prototype used to enhance the training of NHD patients only. 1.1 Patient Experiences in Training for Nocturnal Home Hemodialysis The patient training experiences at the UHN NHD clinic have been researched and explored by Jennifer Wong, a University of Toronto M.A.Sc. student. A qualitative analysis was carried out on a group of 23 NHD patients and caregivers with the use of interviews and focus groups. The findings included a high level of patient anxiety pertaining to learning the procedure and the shift of responsibilities of administration, fear pertaining to needles and the unexpected, the importance of peer support and empathy and understanding from the clinicians, and finally the compatibility of patient learning preferences with the current training practices (Wong, 2007). It would be very difficult to enforce peer support or empathy and understanding from clinicians, but fitting 1

8 the training materials to patient learning preferences would be an area that could be improved. In fact, many of the patients in Jennifer s study identified themselves as visual learners, and therefore requested training material in the form of a video (Wong, 2007). With improved training materials, the patients should gain more confidence in performing the procedure, especially in comparison to reading a complicated and intimidating training manual. 1.2 Interactive Reviewing Tool Proposed by Allison M. Lamsdale The need for alternative training materials for NHD patients has led to Allison M. Lamsdale, a University of Toronto M.A.Sc. student, developing a procedurally based interactive reviewing tool. The tool is intended to enhance patient training by reinforcing the knowledge and skills necessary for patients to administer treatment, thus improving patient safety, confidence, and anxiety levels (Lamsdale, 2007). The tool incorporates both procedural information and video clips of a patient performing the steps. The prototype was created on how to establish vascular access. The vascular access is where the patient s blood will be accessed for treatment. This procedure was selected because it was identified to be an essential step for the dialysis treatment, because if unable to do so, the patient will not be able to administer the treatment at all (Lamsdale, 2007). This step is also associated with a high level of anxiety and fear towards needles (Wong, 2007). In fact, NHD patients have reason to be afraid, because according to the Center of Disease Control and Prevention, bacterial infections are the second most common cause of death in hemodialysis (HD) patients (Center of Disease Control and Prevention (CDC), 2001). Furthermore, in a study of 27 French HD centers, the vascular access site was the most common site for infection, accounting for 33 percent of the 230 infections (CDC, 2001) Final State of Allison s Prototype Allison s prototype was developed using Flash Macromedia. The table of contents was represented in a flow chart with decision diamonds and action boxes, also known as a Decision-Action Diagram (See Figure 1.1 below). Each slide was designed to include a title describing the step, the procedural details of the step, a video clip demonstrating the 2

9 Site Selection Arterial Cannulation Venous Cannulation Further Development of the Nocturnal Home Hemodialysis Interactive Reviewing Tool step, and buttons linked to the menu (i.e. table of contents), the previous slide in the procedure and the next slide in the procedure (See Figure 1.2 below). AV Access : Establish access for cannulation Wash hands Attach 2 syringes with saline to needles Prime air out of needles Unclamp needles Do you have a fistula or graft access? Fistula AV Fistula : Tourniquet warm compress Wait 5 min Graft Cleanse cannulation area Select arterial cannulation site Begin cannulating the arterial needle Evaluate needle placement Advance needle Re-evaluate needle placement Is the needle properly placed? No Reposition needle Yes Flush line, attach tubing, clamp access No Is there pain or swelling? Yes Is repositioning the needle successful? No Recannulate the needle Yes Select venous cannulation site Begin cannulating the venous needle Evaluate needle placement Advance needle Re-evaluate needle placement Is the needle properly placed? No Reposition needle Yes AV Access Established Remove tourniquet Flush line, attach tubing, clamp access No Is there pain or swelling? Yes Is repositioning the needle succesful? No Recannulate the needle Yes Figure 1.1: Table of Contents of Allison s Prototype (Lamsdale, 2007) Figure 1.2: Generic Slide of Allison s Prototype (Lamsdale, 2007) 3

10 1.2.2 Summary of Nurse Evaluation of Allison s Prototype The suggested improvements for Allison s prototype from her nurse interviews are listed below (Lamsdale, 2007): 1. Troubleshooting of Procedures The patient faces the most anxiety and fear when a problem is encountered; therefore troubleshooting should be provided to guide the user. 2. Equipment Specification The type of needle (i.e. Fistula or Supercath) used for establishing access should be specified, because it determines the technique used for repositioning and stopping. 3. Video Clips and Information The level of clarity and detail of the video clips for each step should be improved. The perspective of the video footage should be filmed in either the view of the patient or person who is administering the treatment. Auditory narration was also suggested. 1.3 Thesis Objective In recognition of the potential for improvement in the training material provided by the NHD clinic, the objective of this thesis is to further develop the interactive reviewing tool proposed by Allison, and more specifically to refine the prototype she created on establishing vascular access. This will be achieved by building on Allison s prototype and suggested improvements from the initial nurse evaluation she carried out. The ultimate goal is for this tool to eventually be used by nurses to improve training at the clinic, and by patients to review at home (Lamsdale, 2007). By reinforcing the procedure of establishing vascular access, it is hoped that the level of anxiety, number of access infections, and overall quality of patient life is improved. 4

11 2. Dialysis Treatment Background To get a better understanding of the dialysis treatment, background information is provided on Functions of the Kidney, End Stage Renal Disease (ESRD), Hemodialysis (HD), Nocturnal Home Hemodialysis (NHD), and Establishing Vascular Access. 2.1 Functions of the Kidney The kidneys excrete natural waste products, including urea and creatinine, as well as foreign substances like alcohol and drugs, from the body (Faratro et al., 2004). The kidneys also regulate the water and electrolyte (dissolved salts) balance and the acid-base balance (Faratro et al., 2004). The kidneys also produce and secrete important hormones, including renin, erythropoietin (EPO), and vitamin D. Renin is involved in regulating blood pressure, EPO is used to stimulate the bone marrow to produce red blood cells, and vitamin D is needed to absorb the calcium from food in the intestine (Faratro et al., 2004). 2.2 End Stage Renal Disease (ESRD) End stage renal disease (ESRD) occurs once 90 percent of the kidney function is lost (National Kidney Foundation). Acute renal failure occurs when the kidney fails suddenly, but this may be a temporary problem, and after a short period of treatment the patient may recover (Faratro et al., 2004). If acute renal failure persists, it is referred to as chronic renal failure, where damage to the kidney function will never recover (Faratro et al., 2004). Patients with ESRD must either perform medical treatments, like hemodialysis, that substitute the function of the kidneys, or they must have a kidney transplant (Faratro et al., 2004). 2.3 Hemodialysis (HD) Hemodialysis (HD) is the most common treatment option for ESRD patients. This treatment involves blood being taken from the body and circulated through a machine with an artificial kidney called a dialyzer, which performs ultrafiltration and diffusion 5

12 through a semipermeable membrane (The Kidney Foundation of Canada, 2004). The blood flows on one side of the membrane and the dialysis fluid passes on the other side in a counter flow (The Kidney Foundation of Canada, 2004). The excess water and waste products pass from the blood into the dialysis fluid, which is then discarded, and the cleaned blood is returned to the body (The Kidney Foundation of Canada, 2004). The blood tubing that carries the blood from the patient to the dialyzer is called the arterial segment, and the tubing that carries the cleaned blood back to the patient is called the venous segment (Faratro et al., 2004). See Figure 2.1 for a simplified HD diagram. Conventional HD involves patients coming to the hospital three times a week, for three to four hour sessions, where a nurse administers and monitors the patient s treatment (Lamsdale, 2007). After receiving treatment, many patients feel exhausted and not well due to the large fluctuations in blood volume and solute clearance, putting stress on the bodily functions (Lamsdale, 2007). 6

13 Figure 2.1: Hemodialysis Diagram (National Kidney Foundation) 2.4 Nocturnal Home Hemodialysis (NHD) Nocturnal Home Hemodialysis (NHD) is a special type of HD. The main differences are the treatment is administered by the patient, normally four to six sessions are performed each week, and each session lasts for approximately six to eight hours (The Kidney Foundation of Canada, 2004). Patients and family members are trained by healthcare professionals on how to administer their own treatment. NHD improves the removal of waste products because of the longer sessions and more frequent treatments. It also improves quality of life because patients should have more energy and freedom during 7

14 the day, reliance on medications should be reduced, and there should be fewer restrictions on diet (The Kidney Foundation of Canada, 2004). After treatment, patients feel better with NHD because there are fewer fluctuations in blood volume and solute clearance, thus alleviating some of the stress on the bodily functions (Lamsdale, 2007). 2.5 Establishing Vascular Access Establishing vascular access, also known as cannulation, involves inserting two needles into the access site. The arterial cannulation is used to carry the blood to the dialysis machine, and the venous cannulation is used to return the cleaned blood to the body. See Appendix A for the detailed procedure for cannulation. Further detail on the dialysis access, technique used to establish access, and type of needle used to establish access is provided below Dialysis Access The dialysis access is a long-term method of accessing the patient s blood for treatment (Faratro et al., 2004). There are three types of access: Arteriovenous (AV) Fistula, Arteriovenous (AV) Graft, and Central Venous Catheter (CVC) or Permanent Catheter (Permcath). The AV fistula is considered to be the first choice, because they generally last longer and there are fewer complications with infection and blood clotting since no foreign materials are involved (National Kidney Foundation). The suitability of the access is dependent on each individual patient Arteriovenous (AV) Fistula The AV fistula is a surgical connection between an artery and a vein usually in the arm (Faratro et al., 2004). This means patients who have weak blood vessels would not be good candidates for this type of access. The AV fistula should not be used for at least two months after the surgery in order to allow the venous walls to mature and strengthen (Faratro et al., 2004). For treatment, the AV Fistula involves connecting two needles into the access site, which are connected to the dialysis tubes of the machine. 8

15 Arteriovenous (AV) Graft The AV graft is similar to the AV fistula, but the artery and vein are indirectly connected with a soft synthetic tube, either straight or looped, and grafted under the skin (Faratro et al., 2004). For treatment, the AV Graft also involves connecting two needles into the access site, which are connected to the dialysis tubes of the machine Central Venous Catheter (CVC) /Permanent Catheter (Permcath) The CVC/Permcath is implanted surgically into the right atrium of the heart through the internal jugular vein (Faratro et al., 2004). For treatment, the CVC is directly connected to the dialysis tubes without cannulation. Since the prototype deals with the procedure of establishing access through cannulation, this access will not be covered in the prototype Type of Technique used to Establish Access Similar to determining a suitable access for each patient, the type of technique used would be recommended by the attending training nurse. The two techniques used are Rope Ladder and Buttonhole Rope Ladder Technique The UHN nurses described the Rope Ladder technique as follows: The arterial cannulation starts from the bottom of the access site and the venous cannulation starts from the midpoint of the access site. With each dialysis treatment, the patient will cannulate above the previous sites, like climbing up a ladder. This process is continued until the top of the access is reached for either segment, and the technique is started at the bottom again. See Figure 2.2 below for sample cannulation sites of the first 5 treatments for the rope ladder technique along a forearm access (Note: The technique is not limited to 4 sites for either segment). 9

16 Figure 2.2: Rope Ladder Technique Buttonhole Technique The UHN nurses described the Buttonhole technique as follows: Sets of buttonholes will develop from repetitive cannulation in the same sites. Patients usually have either two or three sets of buttonhole sites. With each dialysis treatment, the buttonhole sites are rotated. See Figure 2.3 below for sample cannulation sites of the first 5 treatments for the buttonhole technique along a forearm access (Note: There are two sets of buttonholes). Figure 2.3: Buttonhole Technique Type of Needle used to Establish Access The type of needle used is also recommended by the attending training nurse. The two needles are AV Fistula and Supercath. 10

17 AV Fistula Needle The current AV Fistula needles used at the NHD clinic are the Gambro Plume Safety AVF needles. See Figure 2.4 for the features and benefits of the Gambro Plume Safety AVF needle and Figure 2.5 for a full view of a typical AV fistula needle. Figure 2.4: The Features and Benefits of the Gambro Plume Safety AVF needle (Gambro) 11

18 Figure 2.5: Suru AV Fistula Needle (Suru International Pvt. Ltd., 2007) Supercath Needle The current Supercath needles used at the NHD clinic are the Medikit Supercath CLS needles. See Figure 2.6 for the features and benefits of the Medikit Supercath CLS needle. Thanks to its extremely fine finish, the catheter tip causes almost no damage to the vessel wall and thus ensures smooth insertion into the vessel. Fast contact of the inner needle and catheter ensures smooth puncture. The CLS is a jointless Teflon catheter of onepiece molded construction that prevents blood clots, thereby ensuring smooth flow and ample flux. (Utility Model Number: ) 12

19 Grasp the tube with forceps after removing the inner needle. Because the CLS is equipped with a stop valve, blood does not leak out even after the inner needle has been removed. The transmission of infectious diseases by blood contagion is therefore prevented. (Patent No: ) The connector and the stop valve can be removed easily by turning the connector anticlockwise. Figure 2.6: Supercath CLS Needle (Medikit Co. Ltd.) Problems Associated with Establishing Access Some problems associated with establishing access are (Faratro et al., 2004): Bacterial infections caused by poor hygiene or use of non-sterilized equipment. Infiltration, collection of blood confined within the tissues surrounding the access, caused by poor needle insertion. 13

20 3. Design of New Prototype 3.1 User Needs Analysis Before creating the second iteration based on Allison s prototype and interview evaluation, it was decided that the suggested improvements would be clarified, and the scope of the user needs should be redefined. To achieve this, a discussion group was held with all the nurses from the NHD clinic. Allison s prototype was first reviewed to refresh their memories, followed by a discussion on overall suggestions for improving the prototype. The feedback is summarized below: The nurses had a general consensus that the current prototype is wonderful and great for the training phase at the hospital. They feel that the videos are worth a 1000 words and make the steps for establishing access more clear than any user manual or verbal explanation would. The nurses thought that improving the details of the current troubleshooting for an improperly placed needle (i.e. to reposition needle: remove needle, stop bleeding, etc.) would be beneficial. It was later decided that the only way to represent this step would be to purposely improperly place a needle, but this would not be ethically correct. The nurses suggested adding more problem scenarios with solutions, in order for patients to improve their problem identification and recovery. It was later decided that this would be outside the scope of refining the module on establishing access. 3.2 Task Analysis of Establishing Vascular Access Task analyses for the two combinations of technique and needle to be captured in the prototype were created in the form of flow charts. See Figure 3.1 for the task analysis of Fistula Needle and Rope Ladder Technique and Figure 3.2 for the task analysis of Supercath Needle and Buttonhole Technique. The task analyses were developed from interviews with nurses and reading the detailed cannulation procedures in the training manual (See Appendix A for cannulation procedures provided in training manual). Each large step in the procedure was broken down into smaller steps so that each step would be 14

21 simple and not too overwhelming for the patient (Lamsdale, 2007). This should increase patient confidence and reduce their level of anxiety. Wash hands Fill syringes with saline Attach syringes to needles Apply tourniquet Cleanse cannulation sites Select arterial cannulation site Establish needle placement Advance needle Pain/Swelling Tape needle securely in place Check if needle is properly placed No Resistance Reposition needle and check if successful No Recannulate the needle Yes Yes Flush needle and clamp access Select venous cannulation site Establish needle placement Advance needle Pain/Swelling Tape needle securely in place Check if needle is properly placed No Resistance Reposition needle and check if successful No Recannulate the needle Yes Yes Flush needle and clamp access Remove Tourniquet Figure 3.1: Task Analysis of Fistula Needle with Rope Ladder Technique 15

22 Wash hands Fill syringes with saline Apply tourniquet Cleanse cannulation sites Select arterial cannulation site Break supercath vacuum seal Establish needle placement Advance needle Secure needle Withdraw inner needle Clamp supercath Attach syringe to supercath Check if needle is properly placed No Recannulate the needle Yes Flush needle and clamp access Select venous cannulation site Break supercath vacuum seal Establish needle placement Advance needle Secure needle Withdraw inner needle Clamp supercath Attach syringe to supercath Check if needle is properly placed No Recannulate the needle Yes Flush needle and clamp access Remove Tourniquet Figure 3.2: Task Analysis of Supercath Needle with Buttonhole Technique 16

23 3.3 Creation of Paper Prototypes The structure and layout of the prototype created by Allison was followed as a guideline. The Table of Contents/Main Menu was designed to be a hyperlinked flow chart of the procedure, which would give the user freedom to either go through the steps sequentially, or to access a particular step when desired (Lamsdale, 2007). Furthermore, the flow chart would provide the user with a full representation of the options at each step (Lamsdale, 2007). The general composition of each slide was designed with the step name along the top, the procedural content on the left side, the video clip on the right side, and a Main Menu, Previous, and Next button along the bottom Table of Contents/Main Menu Each Table of Contents was created from the task analyses performed, and paper prototypes were designed in Microsoft Visio. Allison s Table of Contents was simplified from a Decision-Action Diagram to a regular flow chart. This was achieved by rephrasing the decision nodes from questions to statements. For example, Is the needle properly placed? was changed to Check if needle is properly placed. From Allison s evaluation, the nurses recommended to increase the size of the font in the Table of Contents. To address this issue, the Table of Contents for each version of the procedure was broken down into two parts, arterial and venous cannulation. See Figures 3.3 and 3.4 for the Table of Contents of the Fistula Needle and Rope Ladder Technique version. 17

24 Supplies Checklist Wash hands Fill syringes with saline Attach syringes to needles Apply tourniquet Cleanse cannulation sites Select arterial cannulation site Establish needle placement Pain/Swelling Advance needle Tape needle securely in place Check if needle is properly placed No Resistance Reposition needle and check if successful Recannulate the needle Yes Yes Flush needle and clamp access Main Menu (Venous Cannulation) Figure 3.3: Main Menu (Arterial Cannulation) of Fistula Needle and Rope Ladder Technique version Main Menu (Arterial Cannulation) Supplies Checklist Select venous cannulation site Establish needle placement Pain/Swelling Advance needle Tape needle securely in place Check if needle is properly placed Yes Resistance Reposition needle and check if successful Recannulate the needle Yes Yes Flush needle and clamp access Remove tourniquet Exit Figure 3.4: Main Menu (Venous Cannulation) of Fistula Needle and Rope Ladder Technique version 18

25 3.3.2 Procedural Information and Video Footage for Slides For each slide, the procedural information and brief video clip description was designed in Microsoft PowerPoint. The procedural information was written to be clear and concise, while the video clips were intended to demonstrate each step with proper technique. See Figure 3.5 for a sample PowePoint slide. Figure 3.5: PowerPoint slide for Cleanse cannulation site for the Fistula Needle and Rope Ladder Technique 3.4 Nurse Evaluation of Paper Prototypes Once satisfied with the preliminary designs, the paper prototypes were brought to the NHD clinic to be evaluated by the nurses. The nurses were chosen to evaluate the prototype because they are the experts in dialysis treatment. The desired feedback included verification on the sequence of steps, accuracy of the procedural content, and overall suggestions for improvement. The feedback received was minor changes to phrasing and wording, and one change to the sequence order. The nurses had no further suggested improvements and felt that the procedure was captured well. It must also be stated that by requesting feedback on the paper prototypes by the nurses, it essentially 19

26 made them a part of the design team. This may be problematic since their suggestions would be implemented into the next iteration, and their feedback on the final prototype may now be biased. 3.5 Final Prototype The software used to create the final prototype was Microsoft FrontPage. The prototype was initially going to be created in Microsoft PowerPoint, but in hopes to increase universal use, html was chosen since all that would be required to run the tool would be a web browser. Another reason why FrontPage was chosen over PowerPoint, was the fact that there would be no controls for the video clips in PowerPoint. It was agreed upon with Professor Paul Milgram that the users may want to either freeze a certain part of a video, or to view a certain section of a video, and therefore the video controls would be necessary. See back cover for the DVD of the final prototype. The features of the Final Prototype are described below: Table of Contents Although the size of the font for the Table of Contents was only increased to size 10, this is still an improvement from Allison s prototype. The colour of the boxes for arterial cannulation steps is red, and the colour of the boxes for the venous cannulation steps is blue. The reason for this was to add redundancy for the colour of the tubing attached to the dialysis machine. Red is associated with the arterial segment, and blue with the venous segment Buttons and Hyperlinks The main menu button links the user to the respective cannulation main menu. The next button links the user to the next step of the procedure in sequential order. The previous button causes a problem since some steps have multiple entry points. It was decided that the previous button would link to the entry point in the base line cannulation procedure where no complications occur. For example, for the Fistula Needle and Rope Ladder Technique version, the Flush needle and clamp access slide can be accessed by either the Check if needle is properly placed slide or Reposition 20

27 needle and check if successful slide. In this case, the previous button would link back to the Check if needle is properly placed slide since this would be the entry point if no complications occurred. For the Table of Contents, the hyperlinks link the user to the respective slides Size of Slides and Resolution It was decided to design the size of the slides to be 800 x 525 pixels. Again the aim was to accommodate as many people as possible as well as to avoid any scrolling. Although the current resolution standard used by friends and family polled is 1024 x 768 or higher, older computers with 15 inch monitors mostly use 800 x 600. While creating the prototype in FrontPage, with a resolution of 1024 x 768, the 800 x 525 pixel slides just barely fit on the page. The reason why these slides just barely fit was because of the space occupied by the browser task bar Font Size of Procedural Content The font size used for the procedural content of each step was size 18. This was decided by finding the largest font size that would fit in the given area for the slide with the most content. To maintain consistency, all the procedural content was size Instructions on Running the Review Tool Once the Review Tool DVD is placed in the DVD drive, there is a built in function that will run the Review Tool automatically in your default browser. If Internet Explorer is not your default browser, the index.htm in the address line should be copied and pasted into Internet Explorer for best results. Most browsers have a security feature which will prompt the user that there is active content (i.e buttons and the video clips) on the page. The user should then allow the blocked content in order to view the buttons and video clips. To access the control of the buttons and video clips, they must be clicked once to first activate the control, and a second click to use the control. For example, the buttons must be double clicked to see results. 21

28 4. Limitations of the Final Prototype 4.1 Suboptimal Video Footage Candidates When contacting potential candidates, many patients of the NHD clinic were unavailable. Some felt uncomfortable performing the procedure while being observed and recorded; while others were busy working full-time jobs from 9am to 5pm. The candidates filmed for this module of the review tool were suboptimal. The aim of the video clips was to demonstrate the steps of establishing vascular access using good technique and the baseline procedure taught by the nursing staff. The ideal candidates should have good cannulation technique, and an access site that a majority of patients would be able to relate to (i.e. an access site that is an average difficulty level to cannulate). With this being said, one patient filmed had an uncommon fistula access, which was not straight, but actually slightly curved. This patient was also only half way through her training and was not very confident in performing the procedure. 4.2 Level of Detail and Completeness Only two combinations of technique and needle were filmed, but in order to provide effective demonstration of establishing vascular access, it would be most beneficial if there was video footage that directly related to the same technique and needle type for all the combinations. Another limitation is associated with the level of detail of the review tool, and the fact that it is difficult to capture certain steps. For example, for the troubleshooting portion, it would be unethical to make a patient stage an incident in order to show the procedure on how to recover. There is currently no video clip for the Reposition needle and check if successful slide and the Recannulate the needle slide. The suggestion to improve this troubleshooting portion from Allison s nurse evaluation could not be achieved, but in the future, maybe a dummy arm could be utilized to demonstrate this step. Furthermore, the quality of the video clips for some steps was poor. For example, when attempting to demonstrate which site to cannulate next in the rope ladder technique, the previous site needs to be seen, but this could not be captured by the zoom. 22

29 4.3 Lack of Browser Compatibility The review tool was tested on a Personal Computer in Microsoft Internet Explorer (IE) and Mozilla Firefox. The review tool displayed correctly in IE, but in Mozilla Firefox, the buttons and Main Menu hyperlinks were misaligned and worst of all, the video clips would not display. Most browsers have security features and the html file created in FrontPage may not be accommodated. Further testing on different browsers for both Personal Computers and Macintosh Computers are required. 23

30 5. Future Work 5.1 Comprehensive User Testing Before running a beta test on the NHD patients, the NHD staff should evaluate the new prototype and verify the accuracy of the information and video clips provided. If needed, changes would be made, and the prototype would be reevaluated. This iterative process would continue until all discrepancies have been fixed. When UHN proceeds with the beta test, the sample of the test subjects should include patients with varying age, gender, access sites, technique, needle, and level of experience with establishing access. Qualitative feedback could be gathered through a questionnaire. Some sample questions may include: How helpful is the review tool? Did any slides confuse you? Do you have any suggestions for improvement? The main goal is to determine if the review tool is helpful, and if so, more usability testing on the interface may be pursued. Results would be analyzed and the suitable changes would be made accordingly. 5.2 Introduction of Review Tool into Training Program First, a meeting should be held with the NHD staff in order to discuss the potential utilization of the interactive reviewing tool. If the review tool is decided to be implemented, the NHD staff would then need to decide on an effective way to add the review tool into the current training program. Before the review tool is actually introduced to the patients, the NHD nurses would have to be trained on how it works, since they would be required to answer any questions the patients may have. 5.3 Analysis of Infection Rates and Patient Anxiety Post Implementation of Review Tool A statistical analysis of infection rates should be performed. First the historical data on infection rates for NHD patients should be gathered. Next, each cannulation related infection should be recorded. All the past cases should then be compared with the new data tracked once the Interactive Reviewing Tool was introduced to the training program. The main goal would be to see if the review tool had a positive effect on reducing 24

31 cannulation infections and admissions to the hospital. Qualitative questionnaires or interviews could be used to analyze the level of anxiety of new patients in training who now have access to the review tool. 5.4 Creation of More Modules If good results or feedback is received from either the qualitative or quantitative analyses, UHN should continue to create more modules for the Interactive Reviewing Tool. The next module developed should be created on the next most important procedure in the NHD treatment. From the discussion group, the nurses had a general consensus that troubleshooting and setting up the dialysis machine are both very important things to review. 5.5 Creation of Browser Independent Application To improve the universal use of the final prototype, an application that would be independent of a web browser should be pursued. One recommendation would be to use Flash Macromedia. 25

32 6. Conclusion In order to enjoy the luxury of increased freedom with home treatment, patients must be trained properly in the correct procedures to administer effective treatment. Many patients at UHN NHD clinic identified themselves as visual learners and therefore requested additional training materials in the form of a video (Wong, 2007). In response to this request, Allison M. Lamsdale proposed the development of an Interactive Reviewing Tool which would combine procedural information as well as video clips demonstrating the correct procedure. The goal of the review tool is to reinforce knowledge of procedures in order to improve patient safety, confidence, and anxiety levels. By further developing Allison s prototype on establishing vascular access, it is hoped that the progress made would contribute to a final design, provided UHN decides to pursue this project. On completion of the final prototype in Microsoft FrontPage, it was realized that the functionality of html is very limited. When the final prototype was tested in the web browser Mozilla Firefox on a Personal Computer, it was discovered that many features were misaligned and the video clips did not work at all. Although more web browsers and different makes of computers remain to be tested, the lack of compatibility demonstrated in Mozilla Firefox was a large disappointment. Therefore, when creating the final design of the Interactive Reviewing Tool, it is recommended to use an independent browser application like Flash Macromedia. 26

33 References Centers for Disease Control and Prevention (2001). Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. Retrieved November 11, Webpage: Faratro, R., D Gama, C., Fung, S., and Tantalo, R. (2004). Nocturnal Home Hemodialysis Clinic: Home Hemodialysis Manual, Toronto, Ontario. Gambro. Gambro Plume Safety AVF Needle. Retrieved March 20, Webpage: Lamsdale, A. (2007). Development of an Interactive Reviewing Tool for Enhancing training of Nocturnal Home Hemodialysis Patients, Unpublished M.A.Sc. Thesis, University of Toronto, Toronto, Ontario. Medikit Co. Ltd. Product Information: Supercath CLS. Retrieved March 20, Webpage: National Kidney Foundation. Hemodialysis Access. Retrieved November 8, Webpage: SURU International Pvt. Ltd. (2007). Arterial Venous Fistula Needle. Retrieved March 20, Webpage: The Kidney Foundation of Canada (2004). Hemodialysis. Retrieved November 8, Webpage: Wong, J. (2007). An Exploration of Patient Experiences in Training for Nocturnal Home Hemodialysis, Unpublished M.A.Sc. Thesis, University of Toronto, Toronto, Ontario. 27

34 Appendix A: Cannulation Procedure from Training Manual Rope Ladder Cannulation Procedure (AV Fistula/AV Graft) Supplies: 1 Clean towel 2 Fistula needles 2 10ml syringes prepared with normal saline 2 18 gauge needles 1 Chlorhexidine Gluconate swabstick 1 Package 4x4 gauze 1 Tape of choice 1 Tourniquet if required 1 Warm compress if required Procedure: 1. Scrub hands and access extremity with soap and warm running water for 15 seconds. Dry with clean towel. 2. Attach 10ml syringes prepared with normal saline to fistula needles. Prime air out of the fistula needles. Leave fistula needle unclamped. 3. Patients with AV fistulas apply tourniquet and +/- warm compress for 5 minutes. (Patients with AV grafts need not apply tourniquet or warm compress.) 4. Cleanse cannulation sites with chlorhexidine gluconate swabstick. 5. Cannulate the arterial needle bevel up at 45 degree angle. 6. Advance needle carefully. If blood seeps around the puncture site, wipe it away with gauze. 7. Pull back on the plunger of the syringe to assess the placement of the needle. If able to withdraw blood with no resistance, inject the normal saline into access. 8. If unable to withdraw blood when assessing the placement, reposition the needle. If this is unsuccessful, remove the needle. Recannulate. 9. If pain and swelling occurs, remove needle, ice the access. Attempt to recannulate above the hematoma. 10. Tape the fistula needle securely in place with tape of choice. 11. Cannulate the venous needle, repeat steps 5 to Continue with dialysis initiation protocol. 28

35 Buttonhole Cannulation Procedure (AV Fistula Only) Note: Due to the ability of the native vein to heal, buttonhole cannulation technique is used exclusively with AV fistula access. Arterial and venous buttonhole cannulation sites are rotated with each dialysis treatment. The scab on the buttonhole is removed before cannulation thus allowing visibility of the needle entry port. Supplies: 1 Clean towel 2 Supercath needles 3 18 gauge needles 1 Pkg 4x4 gauze 1 Chlorhexidine Gluconate swabstick 2 IV 3000 dressing 2 Clamps 3 10ml syringes prepared with normal saline 1 Tourniquet 1 Warm compress if required Procedure: 1. Scrub hands and access extremity with soap and warm running water for 15 seconds. Dry with clean towel. 2. Select two buttonhole sites to cannulate. 3. Clean area with chlorhexidine gluconate swabstick. 4. Apply tourniquet. Apply warm compress (5 minutes), if desired. 5. Remove scabs on selected cannulation sites with 18 gauge needle. Use a new needle for each site. 6. Rotate the inner needle of the supercath to break the seal between the needle and the catheter. 7. Insert a supercath needle into arterial buttonhole bevel up at a 45 degree angle. Blood will flashback into the hub of the needle. Thread the needle into the fistula. 8. Release the tourniquet. 9. Secure the needle with IV 3000 dressing. 10. Withdraw the inner needle. 11. Clamp the supercath. 12. Remove the cap from the supercath. 13. Attach 10ml syringe prepared with normal saline to supercath. 14. Remove the forceps clamp and pull back on plunger. (Trap air from supercath into 10ml syringe.) If able to withdraw blood easily, flush the supercath with normal saline and clamp. 15. If unable to withdraw blood when assessing the position of the supercath within the blood vessel, remove the needle and attempt to recannulate. 16. If pain and swelling occurs at any time during the cannulation procedure remove the supercath, ice the access, select a new site, recannulate. 17. Apply tourniquet. 18. Cannulate venous needle. Repeat steps 6 to Continue with dialysis initiation protocol. 29

36 Appendix B: Slides of the Final Prototype 30

37 Fistula Needle and Rope Ladder Technique Version 31

38 32

39 33

40 34

41 35

42 36

43 37

44 38

45 39

46 40

47 41

48 42

49 43

50 44

51 Supercath Needle and Buttonhole Technique Version 45

52 46

53 47

54 48

55 49

56 50

57 51

58 52

59 53

60 54

61 55

62 56

63 57

64 58

65 59

66 60