Buttonhole Cannulation Technique for Vascular Access
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The document discusses the buttonhole cannulation technique for vascular access in dialysis patients. It provides background on dialysis patients and costs in the US. The buttonhole technique creates fixed puncture sites in an arteriovenous fistula to reduce complications from cannulation. The literature review found the technique reduces pain and complications compared to the rope-ladder technique and has been used successfully in Europe for over 30 years. The document proposes evaluating the buttonhole technique for reducing cannulation pain, anxiety, and complications compared to the rope-ladder technique in outpatient dialysis clinics.
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Buttonhole Cannulation Technique for Vascular Access
- 1. Buttonhole Cannulation Technique Kelley D. Stanley Grand Canyon University February 1, 2011
- 2. * 572,569 patients with ESRD Introduction * 354,754 patients receiving dialysis * 33 billion dollars spent in 2010 on ESRD costs
- 4. Complications due to problems with vascular access is the number one reason for hospitalization of dialysis patients
- 5. Over 57% of dialysis patients receive their treatment through an av fistula, Fistula First Initiative has a goal to increase this number to over 65%
- 6. An AV fistula is the preferred access for dialysis treatment stated by KDOQI.Problem:
- 7. Purpose A vascular access is the dialysis patient’s Life Line!
- 8. Question
- 9. Literature Review Buttonhole Technique successfully used in Europe for over 30 years internet search of the literature provided 32 references on the technique; research studies, and journal articles
- 12. 10,000 dialysis patients participated
- 13. The buttonhole technique was implemented
- 15. Home Dialysis- self cannulation Cannulation of an AV Fistula KDOQI recognizes the Buttonhole technique the Preferred cannulation method For home dialysis Home dialysis patient Self-cannulating his Av fistula
- 16. IncreaseRisk ofInfection Picture is of an av fistula in a patients right upper arm that has become infected. This was the only complication noted in only two of the studies, an increased risk of infection with buttonhole technique. (Doss, et al., 2008; Birchenough, et al., 2010).
- 17. Aneurysm Left Forearm Aneurysm of a patients AV Fistula
- 18. Buttonhole Rope-Ladder VS Positives Negatives
- 19. Lewin’s Change Theory Unfreeze Change Refreeze
- 25. Vascular AccessCharting Form This form was created by the National Kidney Foundation to track and monitor vascular access functioning and complications Key: S/B (sharp/blunt), GA (gauge), QB (Blood Flow Rate), AP (arterial pressure), URR (),Pain scale, Comments/Complications, Nurse Initials
- 27. conclusion Buttonhole Cannulation Technique
- 28. References American Nephrology Nurse's Association (2011). Nephrology Nursing Journal Author Guidelines. Retrieved January 16, 2011 from http://www.annanurse.org/cgi- bin/WebObjects/ANNANurse.woa/1/wa/viewSectionss_id=536873789&s_id=1073744615&wosid=MTJo31Vyq3zf29F2CME4HJ 17gT9 Ball, L.K. (2004). Using the buttonhole technique for your AV fistula. Retrieved May 8, 2006, from www.nwrenal network.org/fist1st/ButtonholeBrochureForPatients1.pdf Ball, L. K. (2005). Improving arteriovenous fistula cannulation skills. Nephrology Nursing Journal, 32(6), 611-618. Ball, L.K. (2005). The buttonhole technique power point presentation. Retrieved from http://www.nwrenalnetwork.org/fist1st/cannu/buttonholecannulation.pdf. Ball, L.K. (2006). The buttonhole technique for arteriovenous fistula cannulation. Nephrology Nursing Journal, 33(3), 299-305. Ball, L.K. (2010). The Buttonhole Technique: Strategies to Reduce Infections. Nephrology Nursing Journal, 37(5), 473-477. Ball, L.K. & Mott, S. (2010). How do you prevent indented buttonhole sites? Nephrology Nursing Journal, 37(4), 427-428, 431. Ball, L. K., Treat, L. & Riffle, V. (2007). A multi-center perspective of the Buttonhole Technique in the Pacific Northwest. In Nephrology Nursing,34(2). Retrieved January 1, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/17486957 Bronwyn, R. (2006). Lewin’s change management model: understanding the three stages of change . Retrieved fromhttp://www.consultpivotal.com/lewin%27s.htm Birchenough, E., Moore, C., Stevens, K., and Stewart, S. (2010). Buttonhole Cannulationin Adult Patients on Hemodialysis: An Increased Risk of Infection? NephrologyNursing Journal, 37(5), 491-498, 555. Biscoe, B. (2006). Writing measurable goals and objectives. Retrieved March 14, 2006, from http://www.helpforschools.com/ELLKBase/forms/WritingGoalsandObjectives.shtml Buttonhole cannulation: should this become the default technique for dialysis patients with native fistulas? Summary of the EDTNA/ERCA Journal Club discussion autumn 2007. (2008). Journal of Renal Care,34(2), 101-108. Retrieved from EBSCOhost Centers for Medicare & Medicaid Services. Fistula First Breakthrough Initiative Special Project, Annual Report, 2009.
- 29. References Figueiredo, A., Viegas, A., Monteiro, M., & Poli-de-Figueiredo, C. (2008). Research into painperception with arteriovenous fistula (AVF) cannulation. Journal of Renal Care, 34(4), 169-172. Retrieved from EBSCOhost. Goovaerts, T. (2005). Long-term experience with buttonhole technique of fistula cannulation. Paper presented March 1,2005 at the Annual Dialysis Conference, Tampa, FL. Harper, G. (1997). The buttonhole technique of fistula access: a personal experience. Home Hemodialysis International., Vol. 1, 41-42. Hartig, V. & Smyth, W. (2009). “Everyone should buttonhole”: A novel technique for a regional Australian renal service. Journal of Renal Care, 35(3), 114-119. K-DOQI. Clinical practice guidelines for vascular access. American Journal of Kidney Disease 2006; 48:S177-S276 Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010. King J. (2009). Implementing the Buttonhole method using the Biohole peg in a busy dialysis unit: a report of the development of current practice. Journal of Renal Care 35(4), 192-200. Kritsonis A. Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity; 8:1, 2004-2005. Kronung, G. (1984). Plastic deformation of cimino fistula by repeated puncture. Dialysis& Transplantation, 13(10), 635-638. Ludlow, V. (2010). Buttonhole cannulation in hemodialysis: improved outcomes and increased expense--Is it worth it?. CANNT Journal, 20(1), 29-37. Retrieved from EBSCOhost Marticorena, R.M., Hunter, J., Macleod, S., Petershoffer, R., Dacouris, N., Donnelly, S.,and Goldstein, M. B. (2006). The salvage of aneurismal fistulae utilizing a modifiedbuttonhole cannulation technique and multiple cannulators. Hemodialysis International, 10, 193-100. Marticorena, R.M., Hunter, J., Cook, R., Kashani, M., Delacruz, J., Petershoffer, S.,Macleod, S., Dacouris, N., McFarlane, P.A., Donnelly, S., and Goldstein, M. B.(2009). A simple method to create buttonhole cannulation tracks in a busy hemodialysis unit. Hemodialysis International, 1-6. Northwest Renal Network. Using the buttonhole technique for your AV fistula. Retrieved from www.nwrenalnetwork.org/fist1st/ButtonholeBrochureForPatients1.pdf. Peterson, P. (2002). Fistula cannulation - the buttonhole technique. Nephrology NursingJournal, 28(2), 195. Robert,K. (2001). Installing Change an executive guide for implementing and maintaining organizational change, Winnipeg: Pragma Press, Inc., 2nd edition. Retrieved from:http://www.mansis.com/freeze.htm Sales, J., Smith, J. & Curran, G. (2006). Models, Strategies, and Tools: Theory in Implementing Evidence-Based Findings into Health Care Practice. In General Internal Medicine,21(s2). Retrieved January 3, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557135/ Showers, M., Chan, C., & Glickman, J. D. (2008). Buttonhole Use in HHD: The Procedure and Why. Nephrology Nursing Journal, 35(2), 179. Retrieved from EBSCOhost
- 30. References The Buttonhole Technique for Arteriovenous Fistula Cannulation from the American Nephrology Nurses' Association, Nephrology Nursing Journal, June 2006, Volume 33/Number 3, pages 299-305 The National Kidney Foundation Kidney Disease Outcomes Quality Initiative Vascular Access Guidelines 2006 update Guideline 7. Retrieved from: www.kidney.org/Professionals/kdoqi/guideline_upHD_PD_VA/index.htm. Toma, S.T. (2005). A timesaving technique (polypropylene peg) to create a fixed puncture route for the buttonhole technique. Paper presented March 1, 2005 at the Annual Dialysis Conference, Tampa, FL. Tordoir, J.H.M. (2009). Buttonhole needling of hemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique. Nephrology Dialysis Transplant, 1-6. Twardowski, Z.J. (1995). Constant site (buttonhole) method of needle insertion for hemodialysis. Dialysis & Transplantation, 24(10), 559- 576. Twardowski, Z., & Kubara, H. (1979). Different sites versus constant site of needle insertion into arteriovenous fistulas for treatment by repeated dialysis. Dialysis & Transplantation, 8, 978-980. Vazquez, M. (2009). Study of Pain, Anxiety and Complications Related to Cannulation of Arteriovenous (AV) Fistula in Chronic Hemodialysis Patients. In Current Opinion in Nephrology & Hypertension,18(2). Retrieved January 1, 2011 from http://www.ClinicalConnection.com/exp/ExpandedPatientViewStudy187639.aspx Verhallen, A.M, Kooistra, M.P., and van Jaarsveld, B.C. (2007). Cannulating in hemodialysis: rope-ladder or buttonhole technique? Nephrology Dialysis Transplant, 1-4. Ward, J., Shaw, K. & Davenport, A. (2010). Patients' perspectives of constant-site (buttonhole) cannulation for hemodialysis access. In Nephron Clinical Practice,116(2). Retrieved January 1, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/ USRDS 2010 Annual Data Report. United States Renal Data System Web site. www.usrds.org/adr.htm. Accessed December 31, 2010.
- 31. Classification of Evidence Levels Ia Ib IIa IIb III IV Table of Studies
- 32. Table of Studies
- 33. Table of Studies
Editor's Notes
- Kelley D. Stanley- Capstone Project- Buttonhole Cannulation Technique- Grand Canyon UniversityAbstract The standard technique of rope-ladder cannulation of AV (Arteriovenous) Fistulas for hemodialysis treatments has proven to cause multiple complications with the treatment process. Over 56% of patients receive hemodialysis treatments through a surgically placed AV Fistula (CMMS, 2010), and the number is expected to increase as this method has been identified as the preferred method by KDOQI (Kidney Dialysis Outcome Quality Initiative). A technique used in Europe for over 25 years called the buttonhole technique has shown promising results when being used in alternative to the rope-ladder technique. A review of the literature was performed to study the available material to determine whether or not the buttonhole technique provides more benefits and less complications than those using the rope-ladder technique. A theory called Lewin’s change theory was then utilized to create an implementation plan to initiate the buttonhole technique in a United States outpatient hemodialysis setting. After reviewing the literature there is a considerable amount of data that supports the use of the buttonhole technique over the rope-ladder technique. Studies showed that initiating the buttonhole technique resulted in decreased pain and anxiety with cannulation and a decreased incidence of complications typically experienced with the rope-ladder technique. The results validated the need for increased research and study in the area to determine the best possible technique of cannulation for those patients with AV Fistulas receiving hemodialysis treatments. The buttonhole technique should be considered a viable alternative to the rope-ladder technique when cannulating AV Fistulas. Through future research and dissemination of the evidence the nephrology community can discover the best possible method for each individual patient and put that technique into practice.
- The field of nephrology/dialysis is a specialty in nursing with its own particular set of problems and issues. There are currently approximately 572,569 people diagnosed with end stage renal disease (ESRD) in the U.S., and 354,754 people receiving renal replacement therapy (Centers for Medicare & Medicaid Services (CMMS), 2011). Medicare spent over 33 billion in 2010 on ESRD costs (CMMS, 2011), and the amount increases every year. Patients are cared for by a multidisciplinary team of healthcare professionals, with nurses being the main caregiver. This is why we nurses need to lead the way in ESRD research to better care for our renal patients using evidenced-based practice.
- Problem One of the main concerns of patients on hemodialysis is the function of their vascular access that they receive hemodialysis treatment through. This is defined as their life line, and is vital to the survival and quality of life for all hemodialysis patients. The main access used and identified as the preferred access by the Institute of Medicine and the National Kidney Foundation (NKF) is the AV Fistula. This access uses the patient’s own tissue and has been shown to provide for a more efficient dialysis treatment with fewer complications. Currently 57.1% (as of October 2010) of all hemodialysis patients receive their treatments through an AV Fistula, with goals by the Fistula First Breakthrough Initiative (FFBI) to increase that to over 65% of patients (CMMC, 2009). The AV Fistula does have its complications such as pain with needle insertion, aneurism, infiltration, immature development, stenos is, hematoma formation, infection, narrowing/poor blood flow, and clotting. Complications with a patient’s vascular access are one of the most important causes of excessive morbidity and mortality in the dialysis population (Vasquez, 2009). “Access complications are also the leading cause of hospitalizations, with the annual cost for these hospitalizations approaching 1 billion a year in the U.S.” (Dinwiddie, 2010, p1). Most patients express that complications with their vascular access are a major source of pain and stress (Vasquez, 2009).
- PurposeThe most commonly used technique to cannulate the AV Fistula in the U.S. is called the rope-ladder technique. However, there is another technique that has been utilized in Europe for over 25 years; it is called the buttonhole technique. This technique has yet to gain wide-spread popularity in the U.S., but there are dialysis facilities that use it and research is being done to compare the two techniques. The original research that studied the buttonhole technique was done in 1979 by KubaraZwardowski. The results showed a decrease in complications, decreased pain with cannulation, less re-insertions / re-sticks, decreased hematoma formation, quicker access, and fewer infiltrations (Zwardiwski, 1979). It is proposed that by implementing the buttonhole technique for appropriate patients the incidence of AV Fistula complications will decrease. This will help maintain quality of life for patients, decrease stress of both nurses and patients, and decrease the cost of hospitalizations related to these complications. Once dialysis nurses are educated to the benefits of the buttonhole technique they will be willing to not only use the new technique but it may also spark more interest and research in this area; further gathering data as to the best cannulation technique for each patient. This would create an alternative, not just using the rope-ladder technique because it’s what we’ve always done and will create an environment of practice using information obtained by evidence-based research.
- QuestionP- Does adult dialysis patients who receive dialysis through an AV Fistula usingI- the buttonhole cannulation technique compared toC- adult patients who receive dialysis through an AV Fistula using the rope-ladder cannulation technique experienceO- less incidence of AV Fistula complications (pain, re-sticks, hematoma, formation, aneurysm, infection, infiltrations, during and post treatment bleeding and patient anxiety)? Do dialysis patients using the buttonhole technique compared to the rope-ladder technique experience fewer incidences of AV Fistula complications?
- Literature Review The buttonhole technique for accessing AV Fistulas for dialysis is a fairly new technique in America, but has been utilized in Europe for over 25 years (Ball, 2010). I conducted an internet search for articles and research papers related to the topic of buttonhole technique. The literature was further separated by articles comparing the buttonhole technique to the most used technique in America, the rope-ladder technique. The results of the reviewed literature are that the buttonhole technique does result in fewer complications than the rope-ladder technique, and has promising applications in both home, inpatient, and outpatient settings. Patients who are diagnosed with ESRD require some type of dialysis to sustain life, and must continue to receive treatment until either kidney transplant or death. The two types of dialysis are hemodialysis and peritoneal dialysis. This review concentrates on those ESRD patients receiving hemodialysis through a surgically placed AV Fistula, further by accessing the site using the buttonhole technique instead of the rope-ladder technique. An internet search was conducted resulting in approximately 32 references addressing the buttonhole technique, the complications, the positives, the history, and research studies. Seventeen of these articles were based on a research study done by the author pertaining to the topic and published in a reputable nursing or medical journal in both America and worldwide.Key words used were; buttonhole technique, AV Fistula, dialysis, rope-ladder, complications, and nursing.
- Nurses have a “pivotal role as vascular access advocates through preservation of existing access, patient/staff education, promoting expert cannulation, and encouraging self cannulation” (Dinwiddie, 2010, p. 1). FFBI is a program created considering the Institute of Medicine’s recommendations report (Kidney Failure and the Federal Government, 1991) whose goal it is to increase patients who have AV Fistulas from 57.1% to over 65%. This makes the issues of maintaining an AV Fistula a priority for dialysis nurses and most patients. Each hemodialysis patient has only 10 sites on their body where an AV Fistula can be placed and once they are used the only option is dialysis through a central line (which is much less efficient and decreases their quality of life).
- The initial study performed was done in Poland in 1977 by Dr. Zbylut Twadowski. The study included almost 10,000 dialysis patients whose treatment was received through an AV Fistula using the buttonhole technique. The first patient to use this technique had a very short access and out of necessity needed to have their access cannulated in the same spot every treatment. It was noticed that, “insertion became less painful, cannulation was accomplished quickly, and no complications were noted” (Twadowski, 1977, p.1). Since the initial study few published research studies exist studying the positives and negatives of using this technique, however those that do exist found that the benefits for the patient included less painful cannulation, fewer missed needle sticks, fewer infiltrations, fewer aneurysms, and quicker cannulation of the AV Fistula.
- In one research study titled: A Multi-Center Perspective of the Buttonhole Technique in the Pacific Northwest (2007), a sample of 61 patients were surveyed as to the pain and complications experienced with buttonhole technique. The study showed that the patients felt they had fewer missed sticks and infiltrations as compared to using the rope-ladder technique. Out of all the patients 70% felt that the buttonhole technique caused less pain, 20% felt the pain was the same, and only 10% stated that this technique was more painful. Needle placement was also found to be quicker with buttonhole technique in 63% of patients. Twardowski repeated a study of the buttonhole technique in 1995 that also resulted with similar results of reported less pain, quicker cannulation, and fewer complications.
- The majority of patients who already use the buttonhole technique in the United States are patients who receive hemodialysis at home and self cannulate (Ball, 2006). The Kidney Disease Outcome Quality Initiative was created by the NKF and is nationally accepted as clinical practice guidelines in nephrology for America. KDOQI has recognized the AV Fistula as the preferred access for hemodialysis treatments and the buttonhole technique is the preferred method for patients who self cannulate. One could theorize that since the buttonhole technique is so successfully used in the home setting, why wouldn’t there be similar results in an outpatient setting?
- One issue that has developed in more recent studies of the buttonhole technique is an increased risk of infection. As reported in a study performed by Doss, Schiller, and Moran in 2008; and Birchenough, Moore, Stevens and Stewart in 2010; there were reports of increased localized and systemic infections of the AV Fistulas. It should be noted that in both studies the subjects were self-cannulating home dialysis patients, the cannulation technique was not implemented by educated professional nurses or CDTs (certified dialysis technicians). The studies do recognize the fact that this is likely the result of patients not cleansing the site appropriately or washing their hands before cannulation. Both studies recommended cleansing the site with soap and water then twice with alcohol pads while also washing hands prior to cannulation.
- Another concern for hemodialysis patients is the “development of aneurysms on their AV Fistula due to repeated sticks” (Marticorena, etal., 2006, p.2). A study conducted in 2006 titled: The Salvage of Aneurismal Fistulae Utilizing a Modified Buttonhole Cannulation Technique and Multiple Cannulators; discusses the benefits and results of using this technique to prevent the development of an aneurysm. It was long thought that using multiple sites as in the rope-ladder technique would prevent deterioration of certain sections of the AV Fistula preventing aneurysm. However, in this studyit reported a decreased incidence of this complication in those patients using the buttonhole technique as compared to those using the rope-ladder technique (Marticorena, et al., 2006). Cosmetic results were also more desirable among those receiving the buttonhole cannulation method. The rope-ladder technique resulted in more unsightly aneurysms of the AV Fistulas, and multiple scars and puncture marks along the length(King, 2009). The buttonhole technique proved to cause less bulging aneurysms and had only 2-3 puncture sites along the AV Fistula. In fact patients who already had aneurysms of their access reported that the “existing deformations became less bulging and made for an improved appearance after initiation of the buttonhole technique”.
- There is only a handful of articles or studies available that mention the problems or down sides of using the buttonhole technique. It appears that the only complication noted was an increased risk of infection (Doss, et al., 2008) (Birchenough, et al., 2010) and one article questioning whether the increased cost of performing the buttonhole procedure is worth it (Ludlow, 2010). The increased risk of infection is likely due to cannulator error of not cleansing the site appropriately and not washing hands prior to cannulation rather than a functional fault of the technique. Even though there is an increased expense using the buttonhole technique (due to higher supply costs comparatively) one could argue that this cost would be off-set by the cost of complications that occur using the rope-ladder technique. Providing the highest quality of care to our hemodialysis patients and ensuring safe effective treatment should always be considered ‘worth the cost’. With all studies and literature considered the buttonhole technique is a viable and perhaps preferable alternative to the rope-ladder technique. Especially for those who experience difficult cannulation, suffer from severe stress due to cannulation, or those who have a limited cannulation area making the rope-ladder technique inappropriate (Verhallen, 2007). Though the technique has been used in Europe for over 25 years there is little evidence-based research on the topic and the results of the existing literature certainly warrant more research on the topic before conclusive results can be made as to which technique results in better outcomes for those on chronic hemodialysis with AV Fistulas. Nurses are primary caregivers, cannulators and educators for those on hemodialysis. There is no other profession more suitable to perform the research needed to substantiate, validate and expand the information already collected on buttonhole technique. Considering that maintaining a functional and efficient access for dialysis is a large indicator of morbidity and mortality among this population, further study on the most favorable technique for extending the life of these AV Fistulas is in the best interest of both patients and hemodialysis nurses.
- Lewin’s Change Theory There are many theories and models that nurses can follow to implement change in their practice. Nurses must select the right theories or models to support their particular wanted change, since they are not one size fits all. One theory that has been “widely used in nursing” (Brownwyn, 2006, p. 1) is Kurt Lewin’s Change Theory. Lewin’s change theory includes three stages; unfreezing, moving/change, and refreezing (see appendix C). All three stages must occur for change to be implemented effectively. The unfreezing stage describes a period of time where the problem and reason for change is recognized. The moving or changing stage consists of actually implementing the change. Lastly the refreezing stage involves adopting the new change as permanent and adapting to any complications or concerns. The theory basically depends on a driving force and a resistant force. For change to occur the driving force must be more dominant than the resistant force. The “driving forces are the change agents who push employees in the direction of change” (Bronwyn, 2006, pg2), such as research supporting the change or a member of management implementing the change. Resistant forces are the agents that do not support the change; examples would be staff or management who do not want the change. This theory would help the implementation of buttonhole technique in hemodialysis patients receiving their treatment through AV Fistulas by providing a guide to follow. This theory will be incorporated by applying the three stages to the implementation of the new technique. During the unfreezing stage data supporting the problem and change will be gathered and presented to the target audience of the change (staff and patients), and support from management will be established. The moving stage will involve preparation of all resources needed to apply the change (education of staff/patients and gathering necessary supplies) and actual implementation of the buttonhole technique on appropriate willing patients. In the refreezing stage the results and effectiveness of the change will be evaluated, based on the outcomes the new technique will be made a permanent alternative to the rope-ladder technique. With the application of this change theory implementing the buttonhole technique can successfully transition staff, management, and patients to the new change. As quoted by Charles Darwin: “It is not the strongest of the species that survive, nor the most intelligent, but the ones most responsive to change”.
- Proposed Solution The proposed solution to the complications experienced with the rope-ladder technique when cannulating AV Fistulas is implementing the buttonhole technique to an outpatient unit. The rope-ladder technique is a style of cannulation that involves multiple puncture sites along the length of the AV Fistula. Buttonhole technique involves cannulating the AV Fistula in the same two to three puncture sites for each dialysis treatment, forming a permanent tunnel that can be re-accessed again and again. “It takes approximately six cannulations using a sharp needle to create a scar tissue tunnel track in a given site. Once a scar tissue tunnel track is well formed, the Medisystems Buttonhole Needle Set with anti-stick dull bevel may be used” (NKF website, 2006). The buttonhole technique in America is mostly used by home dialysis self-cannulating patients. This technique has been accepted by as the preferred method for home dialysis, the benefits for patients being decreased pain, easier cannulation, less bad sticks, less infiltrations, less aneurysms and decreased incidence of hematomas. The technique however has not been widely used in the outpatient dialysis setting, although the benefits experienced by the home hemodialysis patients could reasonably be applied to outpatient dialysis patients in the clinical setting. This would include the nursing and CDT (certified dialysis technician) staff of the facility acquiring the skills necessary to implement the buttonhole technique for their patients and multiple additional actions outlined below.Implementation Plan Applying Kurt Lewin’s change theory to the implementation of the buttonhole technique in the outpatient clinical setting requires three stages. These are unfreeze, change, and refreeze. Each stage will involve multiple actions working towards the goal of successfully implementing this new technique. The outline will include all resources needed including education, supplies, staff, appropriate patients, and facility/management support. The outline below was created following the suggested steps using information in an article titled: Lewin’s Change Theory in Installing Change: an Executive Guide for Implementing and Maintaining Organizational Change (Roberts, 2001).Inclusion Criteria:18 years and olderChronic hemodialysis patient AV Fistula for vascular accessAV Fistula placed more than 3 months prior (no new AV Fistulas-must be mature)Exclusion Criteria:Lack of informed consent(Criteria modeled after the study titled: Study of Pain, Anxiety and Complications Related to Cannulation of AV Fistula in Chronic Hemodialysis Patients authored by Vazquez in 2009)
- Unfreeze1.Gather evidence-based research and reputable articles to support the problem, purpose and solution.2. Communicate with colleagues, staff, management, and experts as to what the problems are and how this solution can help those problems.3. Collect data on complications involving using the rope-ladder technique currently in the facility as to the number of complications and the patients’ and staffs’ opinions of complications.a. Create a survey to present to patients receiving hemodialysis through an AV Fistula and clinical staff (RNs, LPNs, CDTs, Management) to collect baseline data on present complications, opinions, and pain of the participating patients. Use the survey in the study by Vazquez in 2009.b. Give surveys to patients and staff, once complete retrieve surveys and evaluate data.c. Initiate NKF vascular access charting form retrieved from NKF website 2010; to track pain/complications/and concerns from rope-ladder technique 3 months prior to initiating new technique- for baseline/comparative data.4. Create an educational presentation covering the buttonhole techniquea. Create educational pamphlet to provide to appropriate patients on the buttonhole technique (emailed to instructor-too big to fit).b. Create an educational presentation for staff on the same topics above for staff, also include information on how to apply the new technique, training, and expectations of staff’s role. Possibly use a power point created by Lynda K. Ball in 2008 titled: The Buttonhole Technique for Cannulating AV Fistulae.5. Ensure support for solution from upper/lower management, floor staff and other key people in the facility.a. Address questions and concerns. Additional education as needed.6. Gather necessary supplies to implement new technique. Facility already has majority of supplies, only additional would be ordering beveled (dull) Medisystems’s needle set- (Beldico 1425 mf cath blunt).7.Create policy and procedure guidelines for buttonhole technique.8. Speak with billing/financial staff to ensure no billing complications would arise using new technique and new Medisystem needles.
- Change1.Identify appropriate willing patients (decision after reading educational pamphlet provided) to implement buttonhole technique.2. Select trained staff to implement creating buttonhole tunnel (using sharp needles for approximately 6-10 cannulations then switching to the dull needles).3. Implement Buttonhole Charting form to be used to track complications and concerns for patients receiving buttonhole technique.
- Refreeze1. Adapt to any complications or concerns due to new technique2. Provide additional education and training to staff and patients as needed3. Evaluate and track complications and results of new techniquea. Create and implement survey to assess patient’s and staff’s opinions of problems, and concerns of new technique (see next slide). Respond to and address problems and concerns. Encourage staff and patients to ask questions.b. Compare results of NKF charting form at 3, 6, 9, and 12 months to original data collected to determine whether new technique is resulting in theorized beneficial results.4. Solidify to staff and patients that the buttonhole technique is a permanent acceptable facility supported change, and will continue to be offered.a. Share results of evaluation (positives and negatives) to management, staff and patients. b. Write an article presenting the new technique and results of the study on the buttonhole technique to give to involved parties and possibly to a reputable nursing/Nephrology journal to continue to proved evidence and data on the topic to hopefully benefit the practice and profession as a whole.c.Stay abreast of new studies and information available on the new technique. Apply evidence-based interventions and implications as needed.
- Evaluation PlanTarget populations who would be affected by this change are floor staff (nurses, CDTs) and patients with AV Fistulas who elected the buttonhole technique. Patients will have to adjust to a new style of cannulation and agree to fill out pre and post survey forms. Floor staff will have to be educated to provide the new technique, fill pre and post surveys, apply the new technique, and track complications using the NKF vascular access charting form. The surveyswill provide qualitative data as to how the patients and staff feel about the old and new technique, and perceived positives and negatives. The NKF charting form (see next slide charting form) will provide quantitative data to evaluate measurable outcomes on the pain and complication differences between the two techniques. Expected outcomes are that the implementation of the new technique will result in less complications and that the level of pain and anxiety related to cannulation decreases in these patients. Complications will include: access infection, aneurysm, infiltration, bad sticks, ease of cannulation, altered arterial and venous pressures, lower blood flow rates, clotting, hospitalizations due to access problems, and hematoma formation. Determining these outcomes will include evaluating the pre and post surveys from patients and staff. The participants will rate the buttonhole technique more favorably than the rope-ladder technique. The charting form will also show numerically that there were fewer complications with the use of the buttonhole technique as compared to the rope-ladder technique.
- If the results are positive as expected the new technique will continue to be a permanent alternative and in fact a more favorable alternative than the rope-ladder technique. Pre results will be collected on the participating patients 3 months prior to initiation, both surveys and charting forms. Data for the charting form will span the entire 3 months while the surveys will be given at the end of those three months- but before the new technique is applied. After implementing the new technique the survey results will be measured at 12 months and compared to the pre-surveys. The NKF charting form results will be compared to the forms gathered before initiation of the buttonhole technique at intervals of 3 months (this would be at 3, 6, 9, and 12 months post-initiation). The goal will be that the results gathered during the evaluation process will mirror the results previously studied on the outcomes of various buttonhole technique research projects. A decrease in the number of complications and a favorable view of the new technique by patients and staff will ensure successful transition to the change. With complications from a hemodialysis access being the number one reason for hospitalization of dialysis patients (Dinwiddie, 2010), utilizing the best technique proven to prolong the life of the access is essential. Not only will this improve the patients and staffs opinions of the buttonhole technique, but also go a long way to help decrease the cost of dialysis treatment complications. In the words of Kurt Lewin: "If you want to truly understand something, try to change it”. Change is inevitable and vital in all healthcare fields and professions to ensuring the best evidence-based quality care.
- Disseminate the Evidence The purpose of research is not to just complete it, but to share the results to target audiences, organizations, associations, and colleagues. Through sharing your results others are able to educate themselves, make responsible health decisions, change their practice, teach their students, better care for their patients, or conduct new research building the evidence on the topic. There is limited research available on the buttonhole cannulation technique, and any new information is important to providing more definitive results illustrating which technique is of greater benefit to our dialysis patient population. There are multiple organizations, associations, populations, businesses and publishing journals that would be interested in research performed on the buttonhole technique. The target audience would be any patient, educator, or healthcare provider who is involved with the hemodialysis community. Some organizations of interest would be the National Kidney Foundation, the American Nephrology Nurses Association, the Fistula First Breakthrough Initiative, and Kidney Disease Outcome Quality Initiative to name a few. Some of these organizations also have publications, websites and conferences to discuss new topics and research in the field. Some interested publication journals would be the American Journal of Kidney Disease and the Nephrology Nursing Journal. Also a great way of getting the information to the patient themselves is by providing articles, pamphlets, posters or other informational material on the project to the largest dialysis provider companies such as Fresenius, Davita, and American Renal Associates. The conference I would choose to present the material to is the yearly American Nephrology Nurse’s Association national symposium. Ideally presenting your project at the conference for an audience would be ideal, but you could also submit a research poster, leaving your contact information for others who may be interested in your topic (example poster created to present thebuttonhole technique emailed to instructor- too big to fit).The reason this venue was selected is because the primary target population to be reached would be the nephrology nursing community. Considering that nurses play such a vital primary role in the care of hemodialysis patients, inspiring change and research on this topic through nurses would be hugely beneficial. This would be the best way to initiate interest and support, also networking to possibly encourage future presentation or publication opportunities. This could create feedback from peers to help perhaps better organize, write or present the material in the future. Disseminating the evidence you have collected is an important step in the research project. In nursing it is our responsibility to base our practice on the best evidence available, but it must be available and locatable to be considered. Will every nurse perform research in their field? Of course not. However thankfully there are those that do, the very least the rest can do is stay current of the evidence. This means changing our practice accordingly to better our patient outcomes and the nursing profession as a whole.
- ConclusionThe buttonhole technique has proven to be a successful alternative for patients with an AV Fistula upon reviewing the literature. Research articles in this area are few and more research must be done to validate the information already collected before a definitive decision can be made as to the best technique for AV Fistula cannulation. With the use of the AV Fistula going up, there will be an increased interest in how to prolong the life and functionality of the vascular access. With new research being sparked perhaps soon the answer to the question will be clarified. Until then our patients expect to receive the best care from their dialysis nurses as possible, and this can only be done by staying informed and basing our practice on the best evidence available.
- Classification of Evidence LevelsIa Evidence obtained from meta-analysis of randomized controlled trials.Ib Evidence obtained from at least one randomized controlled trial.IIa Evidence obtained from at least one well-designed controlled study without randomization.IIb Evidence obtained from at least one other type of well-designed quasi-experimental study (a situation in which implementation of an intervention is without the control of the investigators, but an opportunity exists to evaluate its effect).III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.