CQI Project: Cannulation of AVF using Buttonhole technique CHOW Yuen Ha (APN) Renal Unit Department of Medicine & Geriatrics Princess Margaret Hospital
Background Vascular access (VA) is the lifeline of haemodialysis patients Arterio-venous fistula (AVF) is the recommended type of VA in NKF K/DOQI Guidelines Needle cannulation is essential (Arterial & Venous sites) 2 needling techniques: o Rope-ladder (traditional) o Buttonhole (newer in HK)
Rope-ladder (RL) technique Rotate puncture sites V V V A A A Use sharp needles in every haemodialysis session Use the whole length of AVF http://www.nwrenalnetwork.org/fist1st/ cannu/buttonholecannulation.pdf
Buttonhole (BH) technique Constant needling site Firstly used by Dr. Twardowski to a very short AVF in 1977 V A Sharp needle puncture at same spot, angle and depth for ~8-12 haemodialysis sessions to create a BH tunnel Blunt needle for subsequent cannulations BH tunnel Ultrasound photo taken by Tony Goovaerts http://www.nwrenalnetwork.org/fist1st/ cannu/buttonholecannulation.pdf BH Vessel lumen of AVF
AVF Cannulation Needles Sharp needle Blunt needle
Sharp needle cannulation Pain: ~300 punctures/year/patient Aneurysm Trauma: Scaring Vessel wall weakening Vascular dilatation Aneurysm Difficult AVF: Vessel infiltration Haematoma Stress to patient & nurse Haematoma
Summary of literature review Advantages: Buttonhole method: Cannulation pain Patient satisfaction Aneurysm Bleeding Ease of cannulation Cosmetic effect Haemostasis time No significant stenosis Disadvantage: Risk of infection Key to success: Designated BH creator Skin disinfection protocol Staff training
AVF and Buttonhole Appearance 6-month BHs 1-year BHs 2-year BHs 4-year BHs
CQI Project Change AVF cannulation from RL to BH method Feb Oct 2011 Objectives: To reduce cannulation pain To train nurses in BH technique To implement BH technique in our HD unit
Method Form a Team Renal Nurses Advanced Practice Nurses CQI Team Renal Nurse Consultant Department Managers Renal Physicians
Method - Roles of Nurses (1) Nurse trainer Train nurses to be BH creators & cannulators (2) BH creator Designated nurse to designated patient until BH tunnel is well-created One creator skin Blood vessel A well-created BH tunnel Multiple creators Difficult to create a BH tunnel (3) BH cannulators Follow creator s track Use blunt needle to cannulate well-created BHs
Method Pamphlet to Patient
Method Action Plan (Feb-Oct 2011) Month Procedures to patients Training to nurses Data collection Feb RL Lecture Pain score Mar BH tunnel creation On-site-coaching Apr 1 st month BH On-site-coaching Pain score May-Sep BH method continued Oct Pain score 7 th month BH Feedback from patients and nurses
Method Protocol (1) BH Creation Create by designated BH creator Yes Is BH tunnel created? No BH creator starts using blunt needle & shows BH cannulators the cannulation angle BH cannulators perform subsequent blunt needle cannulations Yes Sharp needle puncture for 2-4 more times Is BH tunnel created? No Choose a new site
Method Protocol (2) Skin Disinfection Double-disinfection for BH Cannulation 1 Wash access arm with Hibiscrub and dry with paper towel. 2 Moisten and then loosen the BH scab with sterile gauze and normal saline. 3 Before scab removal, disinfect >5 cm skin area at cannulation site with 2% Chlorhexidine Gluconate in 70% Alcohol (30 sec). 4 Gently remove scab with sterile normal saline gauze. Don t scratch the scab with fingernail or bare finger. 5 After scab removal, repeat step 3 to disinfect the site again before cannulation. 6 Cannulate BH aseptically. Strap needles and cover with sterile gauzes.
Method - Data Collection Form(1) Buttonhole Cannulation Record Patient: ChanTM BH creator: WongML *Pain Score Date No. of Cannulation Needle cannulation angle Blunt/Sharp needle A V A V A V *Pain score (VAS 0-10) #Complications (Specify if any) 26/3 12th 12th 30 30 SN SN 4 nil 28/3 13th 13th 30 30 BN BN 1 nil 30/3 14th 14th 30 30 BN BN 1 nil *Pain score (visual analogue scale, 0-10): 0 1 2 3 4 5 6 7 8 9 10 #Cannulation related complications No Pain Very mild pain Mild pain Moderate pain Severe pain Excruciating pain #Complications: 1 Vessel infiltration 2 Haematoma 3 Thrombosis 4 Bleeding 5 Infection 6 Aneurysm 7 Others
Method - Data Collection Form(2) Nurse s comments on BH method (Self-administered questionnaire) I have confidence in educating patients on BH care. Agree Disagree I have confidence in BH cannulation. Agree Disagree I have confidence in BH tunnel creation. Agree Disagree What is/are your perception(s) of BH method?
Results (1) 14 patients had BHs created Median cannulation pain score (SIQR) RL sharp needle BH 1 blunt needle 1 st month BH 2 blunt needle 7 th month 2.50 (0.86) 0.38 (0.39) Z=-3.30, p=0.001 0.13 (0.19) Z=-2.66, p=0.008 Wilcoxon sign-ranks test, level of significance: p <0.05 No episode of cannulation related complications
Results (2) Patients feedback: All preferred BH to RL method: Cannulation pain Comfort during HD Fear of vessel infiltration Range of AVF limb movement Easier to stop bleeding after needle removal 2 of 7 patients: shrinkage of old aneurysm Cosmetic effect
Results (3) Nurses comments: (35 nurses participated in training) Self-administered questionnaire: RR 100% All had confidence in educating patients on BH care 29 (83%) had confidence in BH cannulation 11 (31%) had confidence in BH creation Perceptions of BH method: Patients cannulation pain Risk of vessel infiltration Nurse s confidence in cannulating difficult AVFs
Conclusion BH method improves AVF cannulation quality by reducing pain and promoting comfort in our HD patients. BH method is becoming the preferred cannulation method for our patients and nurses. The structured training programme enhanced nurses knowledge & skills in BH method and facilitated its implementation in our HD unit.
Discussion Matching of nurse s roster with patient s HD schedule is essential for the success of BH tunnel creation. Frequent evaluation of staff s needling technique is paramount in keeping the cannulation standard. BH method can be a solution for difficult AVF cannulation. BH technique reduces cannulation pain and may solve patient s problem of needle phobia, thus it may further promote self-help & home HD programmes. RCTs with larger sample size and longer study period are recommended.
Acknowledgment The CQI team would like to acknowledge the commitment and cooperation of the participating nurses and patients. Special thanks go to Ms. LAM Siu Ying, the nurse trainer of the project, for her dedication in teaching.
Thank you We all strive for excellence in Renal Services & High Quality Patient Care!