The Effects of Buttonhole Needling

in a Hemodialysis Unit: The Patient and Staff

Experience

Valerie Ludlow, RN, MN, CNeph[C]

Outline Definition Complications of Needling Buttonhole Needling Research Project

Objectives Research Process Data Collection Results:

Quantitative Qualitative

Suggestions for Future Care

Definition

Hemodialysis (HD) – removing chemical substances and water from the blood by passing it through an artificial kidney (dialyzer)

Complications of Needling Infiltrations Bleeding Pain Aneurysms Loss of function

Radiological procedures Central Venous Catheter [CVC] placement Surgical interventions

Complication - Aneurysms

The Joys of Needling!

© Jazz

Communications Ltd

Cannulation Woes!

© Jazz

Communications Ltd

Buttonhole (BH) Needling

Dr Twardowski, Poland, 25 years ago Buttonhole (BH) needling

same individual same site same angle same depth of penetration

A scar tissue tract for a blunt fistula needle

Objectives of Research Project

Improve Patients’ Quality of Life! Decrease needling complications Increase confidence level of patients

Improve Nurses’ Work life! Increase the confidence level of HD nurses

Objectives of Research Project

Improve on Health Care Expenses! Unit level

Nursing time Supplies

Corporate level Radiology procedures Central Venous Catheter [CVC] placements Surgical repair and/or hospitalization

Objectives of Research Project

MAIN OBJECTIVE

Encourage staff and patients to provide their input and thus become stakeholders

Newfoundland & Labrador

Research Process

Obtained support of management, Eastern and Central Health, NL

Received ethical approval Awarded funding by The Health Care

Foundation and the Association of Registered Nurses of NL (ARNNL)

Research Process

Participation of patients and staff

2 HD units in St. John’s (Eastern Health) 2 HD units in Gander, Grand Falls-Windsor

(Central Health)

MOST IMPORTANT!

Nurses’ Responsibilities

Required no extra time Attend in-service Sign consent form Complete confidential questionnaires (Times 1-

4) Needle assigned patients X 3 months Document findings in chart

Patients’ Responsibilities

Sign consent form Complete confidential questionnaire (Times 1-4) Rate Pain of needle insertion (1-10)

***Nothing personal***

TimelinePre T1

questionnaire Inservice (nurses), Consent form

Start Initial needling (sharp needles)

4 weeks T2 questionnaire

Track developed (blunt needles)

8 weeks T3 questionnaire

Blunt needles X 4 weeks

3 months

T4 questionnaire

Conclusion

Data Collection for Patients and Staff

Questionnaire Development Literature Search Extensive HD experience of Primary Investigator Flesch-Kincaid Grade Level (9.4 Staff/<8

Patients) Appropriate Rating systems

5-point Likert 1-10 pain rating, and 1-10 self-confidence rating

Patient Questionnaire

Part One

Please circle the rating that best describes your feelings:1 – All the time 2 – Often 3 – Sometimes4 – Rarely 5 – Never

In relation to the needling of your fistula in the last month, how often have you had:

Pain in your fistula when the nurses needled you ..…. 1 2 3 4 5

Patient Questionnaire

Part Two

Please circle the number that corresponds to your answer:1 – Not at all confident10 – Very confident

How confident are you that all the nurses in the dialysis unit can/will:

Put a needle into your fistula with no problems .…… 1 2 3 4 5 6 7 8 9

10

Comments____________________________________

Staff QuestionnairePlease circle the rating that corresponds to your response:1 – Not at all confident10 – Very Confident

In relation to needling of patient’s fistulas, how confident are you that you can:

Place a blunt needle in a buttonhole tract without causing pain to the patient ……1 2 3 4 5 6 7 8 9 10

Provide information to your patient and his/her family on the advantages of buttonhole needling

…………1 2 3 4 5 6 7 8 9 10

Comments:___________________________________

Buttonhole Arterial/Venous Needle Log

NOTE: Please complete when Blood Flow is 200 ml/min within first 10 minutes of treatment.

Date S/B Ga A/VP EoI PPR Comments In

S/B – Sharp or Blunt needle Ga – Gauge of needle AP – Arterial Pressure VP – Venous PressureEoI – Ease of Insertion (1-easy 2-some difficulty 3-unable to insert)PPR- Patient Pain Rating (1 [no pain] to 10 [severe pain])

Improve the Needling Experience!

© Jazz

Communications Ltd

Results: Participation

Eastern Health Central HealthStaff 25 9Patients 29 28

Results: Staff Demographics

Eastern Health Central HealthFemale Gender

96% 88.9%

RN experience

20.6 years 19.8 years

HD RN experience

9.5 years 4.1 years

Results: Staff Confidence BH High ≥ 8 (1-10 scale)

EH – 77.5% CH – 85.5%

Questions <8 – nursing skills pertinent to BH should improve with time and experience

CH Staff < 3 years HD experience rated confidence <8 at start

All more confident at end

Results: Patient Demographics

Eastern Health Central HealthFemale Gender

37.9% 42.9%

Position AVF Left arm

85.9% 82.2%

Age Current AVF

2.6 years 2.7 years

Time HD Patient

3.2 years 3.3 years

Results: Patients

HD Treatment Complications

Rating 1 (All the time) to 5 (Never) All 3 (sometimes) to 4 (rarely) Significant improvement - bruising in fistula

when needled (p=.001)

Results: Patients

Confidence in Nurses’ Skills

High ≥ 8 (1-10 scale) EH – 73.9% CH – 78.7%

Note: Rating decreased slightly throughout study but not significantly

Results: Patients

Start (Mean) End (Mean) p

PPR (1-10)

Venous Needle 2.6 1.9 .010

Arterial Needle 2.3 1.7 .002

Pressures (mmHg)

Venous Pressure 72.1 69.7 NS

Arterial Pressure 39.4 39.3 NS

Patient Pain Rating (PPR) and Needle Pressures

Results: Patients

Hemostasis Times

Start End p

Hemostasis Times (minutes) 14.08 13.72 NS

Results: Patients

Cost of Fistula Maintenance

Year before study (Group 1) vs Year at start of study (Group 2)

Retrospective chart review Health Care Procedures HD Treatment Complications

Cost of BH Unit Supplies

Results: Patients

Health Care Procedures (p=NS) HD Treatment Complications (p=NS)

BUT decreases in actual frequencies

Cost of BH Unit Supplies – increase of $358.80/patient/year

Results - Summary Decreased pain - significantly Slight improvement/no change A/V vessel

pressures Reduction treatment complications - bruising

significantly High confidence patients/nurses BH skills Improved confidence level nurses/own BH skills No significant decrease in Health Care/HD

Treatment Procedures Increased expenses unit level - more expensive

BH needles/supplies

Additional Results and Suggestions for Future Care Trampoline effect: 20.7%

Longer time with initial needler Revert to sharps PRN

Infection: Increased from 2.1% to 6.9% Continue to monitor/update protocols Treat with Antibiotics

Staff Scheduling Dedicated staff

Qualitative Findings - Staff

Interesting. Positive feedback from clients. Can see long term benefits. The positives are obvious when viewing a fistula that has a BH!

I think it’s important for the same person to needle at least 3 weeks and maybe a little longer for sharps.

Qualitative Findings - Patients

Time to stop bleeding is getting shorter. I find that it (needling) is not as painful. I have to revert to sharps because blunt needles

and the trampoline effect can be really painful.

Before and After 4 Weeks of BH Needling

Established buttonhole

© Tony Goovaerts

Thank You!

Contact information:

vludlow@nl.rogers.com