CHOW Yuen Ha (APN) Renal Unit Department of Medicine & Geriatrics Princess Margaret Hospital

CQI Project: Cannulation of AVF using Buttonhole technique

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:

oRope-ladder (traditional)

oButtonhole (newer in HK)

Rope-ladder (RL) technique

• Rotate puncture sites

• Use sharp needles in every haemodialysis session

• Use the whole length of AVF

http://www.nwrenalnetwork.org/fist1st/

cannu/buttonholecannulation.pdf

A A A V V V

Buttonhole (BH) technique ◦ Constant needling site

Ultrasound photo taken by Tony Goovaerts

http://www.nwrenalnetwork.org/fist1st/

cannu/buttonholecannulation.pdf

BH tunnel

Vessel lumen of AVF

BH

◦ Sharp needle puncture at same spot, angle and depth for ~8-12 haemodialysis

sessions to create a BH tunnel

◦ Blunt needle for subsequent cannulations

A V ◦ Firstly used by

Dr. Twardowski

to a very short AVF in 1977

AVF Cannulation Needles

Sharp needle Blunt needle

Sharp needle cannulation

Pain: ◦ ~300 punctures/year/patient

Aneurysm

Haematoma

Trauma: Scaring

Vessel wall weakening

Vascular dilatation

Aneurysm

Difficult AVF: ◦ Vessel infiltration

◦ Haematoma

◦ Stress to patient & nurse

Summary of literature review

Buttonhole method:

Advantages:

Cannulation pain Patient satisfaction

Aneurysm Ease of cannulation

Bleeding 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

4-year BHs

6-month BHs

1-year BHs

2-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

Renal Nurse Consultant

Department Managers

Renal Physicians

CQI Team

Method - Roles of Nurses

(2) BH creator Designated

nurse to designated patient until BH tunnel is well-created

(3) BH cannulators Follow creator’s track

Use blunt needle to cannulate well-created BHs

(1) Nurse trainer Train nurses to be BH creators & cannulators

Difficult to create a BH tunnel A well-created

BH tunnel

One creator

Multiple creators

skin Blood vessel

Method – Pamphlet to Patient

Method – Action Plan (Feb-Oct 2011)

Month Procedures to patients

Training to nurses

Data collection

BH tunnel creation

May-Sep

BH method continued

Oct

Feb

Mar

Apr

On-site-coaching

Lecture

On-site-coaching

Pain score

Pain score

Pain score

RL

1st month BH

7th month BH Feedback from patients and nurses

Method – Protocol (1)

Create by designated BH creator

Is BH tunnel created?

BH creator starts using blunt needle &

shows BH cannulators the cannulation angle

Sharp needle puncture for 2-4 more times

Choose a new site BH cannulators

perform subsequent blunt needle cannulations

Is BH tunnel created?

Yes

No Yes

No

BH Creation

Method – Protocol (2)

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.

Skin Disinfection

Method - Data Collection Form(1)

Buttonhole Cannulation Record Patient: ChanTM BH creator: WongML

Date

No. of Cannulation

Needle cannulation

angle

Blunt/Sharp needle

A V A V A V

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

0 1 2 3 4 5 6 7 8 9 10

No Pain

Very mild pain

Mild pain Moderate pain Severe pain

Excruciating pain

*Pain Score

#Cannulation related

complications

#Complications: 1 Vessel infiltration 2 Haematoma 3 Thrombosis

4 Bleeding 5 Infection 6 Aneurysm 7 Others

*Pain score (visual analogue scale, 0-10):

*Pain score

(VAS 0-10)

#Complications

(Specify if any)

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)

No episode of cannulation related complications

RL

sharp

needle

BH 1

blunt needle

1st month

BH 2

blunt needle

7th 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

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 !