cqi project - hospital authoritycqi project: cannulation of avf using buttonhole technique ....
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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 !