Vascular access cannulation for dialysis staff is the most difficult obstacle to overcome during the orientation process and can remain a challenge throughout one''s career in caring for patients with renal disease. Learning the "buttonhole technique" can make venipuncture more comfortable for the patient and can eliminate the fear of failure for the cannulator. Not only does it preserve the timeframe of the patient''s access, but establishes a routine process for the dialysis facility to follow for successful cannulation.
Disclaimer: The analyses upon which this publication is based were performed under Contract #HHS-500-2006-NW17C entitled "End Stage Renal Disease Networks Organization for Northern California," sponsored by the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (DHHS). The content of this publication does not necessarily reflect the views or policies of the DHHS or CMS, nor does it mention trade names, commercial products, or organizations that imply endorsement by the U.S. government. The author assumes full responsibility for the accuracy and completeness of the ideas presented.
Introduction
Learning the dialysis process can be accomplished quickly, and during the orientation period most facilities provide adequate time for staff to absorb the mechanical aspects of the treatment. Vascular access cannulation, however, has an unexplained aura surrounding it. Even seasoned staff can carry an unexplained "fear of failure" with them throughout their careers when it comes to cannulation, and it''s not much different than those who are just beginning their nephrology career.
An old, but new, technique to ease everyone''s anxiety about cannulation has been developed, tested, and has been very successful in Europe and is now slowly gaining momentum in the United States. The buttonhole technique for cannulating a fistula can make both the patient and cannulator more comfortable and venipuncture angst a thing of the past. Believing in the buttonhole technique and creating a positive environment makes the process very easy for cannulators to complete.
The buttonhole technique is used best with an arteriovenous fistulas, which is considered the gold standard for access. The Centers for Medicare & Medicaid Services has set a goal for dialysis clinics in all 18 ESRD Networks to have a prevalent arteriovenous fistula rate of 66% by July 1, 2009. That translates into every facility reaching at least a fistula prevalence rate of approximately 60% or better by next year. Putting aside the reasons that fistulas cannot be placed in certain patients, or when surgical support is an issue, preserving the accesses currently in existence and keeping them viable will help everyone. The buttonhole is one of those access preservation techniques.
Fistulas: not all alike. Vascular access is a multifaceted challenge.
- The patient with the ideal AV fistula rarely presents to any dialysis facility.
- Fistulas come in a variety of shapes and sizes; therefore, placement can sometimes be a complete surprise. Buttonhole technique works very well with fistulas that underdevelop and with patients opting for home therapy.
- The best candidate for the buttonhole technique are those patients with a native AV fistula, when there is limited cannulation sites, or when preservation of the access is of critical concern because it is the patient''s last viable access option. Because one buttonhole is developed for the arterial site and one for the venous site, it eliminates the process of trying to decide where to place the needles for dialysis, and avoiding "one site-it is."
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The other challenge to vascular access is staff turnover and lack of experience. New employees recognize the pressure of performing a successful venipuncture, which creates a stressful situation for both staff and patient. If buttonhole can remove the pressure, it is worth everyone''s effort to develop the procedure and initiate the technique.
Benefits of the buttonhole far outweigh the disadvantages.
Advantages of the buttonhole technique
- Access preservation
- Fewer infections, infiltrations, and missed venipunctures
- Decreased hematoma formatioN
Less pain, eliminating the need for anesthetic
Source: Twardowski Z. Constant site (buttonhole) method of needle insertion for hemodialysis. Dial Transplant 1995; 24:559-60.
Master cannulators
Several years ago, two nurses in Illinois decided to take on the issue of poor cannulation techniques and developed the process called "Master Cannulation." The concept was very simple: design a process where a staff member could decide which group, by definition, best described its cannulation ability. The four groups-trainee, skilled, advanced, and master-allowed each person to decide for themselves which group was the best fit; a premise of mastering the technique of cannulation, and thereby moving into the next group. The technique was self-defining but certainly not self-limiting.
Demonstrating and developing master cannulating skills provides facilities with highly qualified vascular access technicians. It is important to note that even though staff do not reach the "master" level for cannulation, their skills are every bit as valuable to those patients with accesses that are less challenging.
Master cannulation is a premier method to use for buttonhole cannulation. Staff that has accomplished the "advance" and "master" levels of the process can cannulate buttonhole accesses with ease and confidence. Master cannulators can access buttonholes and develop methods that provide patients with a painless and access preserving method, which can be ideal for home patients, travel-focused patients, and center-based patients wishing to self-cannulate. Unless patients have a strong desire not to try buttonhole, patients should be given every opportunity.
Experience counts
I was privileged to have visited a dialysis facility recently that treats with the buttonhole technique as commonly as taking a patient''s temperature. The staff at David Grant Medical Center (60th Medical Group), located within Travis AFB in California, currently has two-thirds of its patient population using buttonhole. Under the medical direction of Robert Woolley, MD, John Baron, MD, Ella Bautista, and the rest of the nephrology staff, all the myths surrounding buttonhole were "busted," making it a model program that other facilities can mirror. They have not experienced infection or any bleeding around the needles, and patients do not complain of the pain associated with the rope-ladder technique of venipuncture.
What''s striking was the ease and comfort by which they approach and accomplish the task. It shows in their high success rate.
One of the first advantages that David Grant''s staff experienced was the arrival of new patients with established AV fistulas. Patients were approached with the option of using the rope-ladder technique or buttonhole. Each procedure is explained to the patient and when patients were asked which technique would be best for the longevity of their fistula, buttonhole became the treatment of choice. The David Grant staff is committed to buttonhole success and one staff member stays with the patient until the track is established, which for them usually occurs in eight to 10 treatments.
The technique
The procedure for vascular access is straightforward. Here are the easy steps:
Prep. The patients'' arm is washed with antibacterial soap and water with the buttonhole site cleansed with a betadine solution, or alcohol if there is iodine sensitivity. Betadine is left on the scab, which softens it and makes it easier to remove.
Scab removal. The scab is removed with sterile disposable forceps exposing the track. Using forceps with a pointed tip allows staff members to remove the scab without nicking the ridge surrounding the buttonhole track. This can reduce the possibility of bleeding during treatment and keeps the buttonhole entry site secure. The use of needles or picks to remove scabs should be discouraged and indication that the scab has not loosened enough for removal. Moisten again with betadine or a sterile 2x2 soaked with sterile normal saline.
There is a new product on the market for site removal. It comes in the form of a small hook; a buttonhole scab can be easily removed if it is given the proper amount of time to soften, thus causing less trauma to the buttonhole itself. Choosing the right forceps is a key factor for scab removal. It is recommended that resterilized metal can create a problem if the edges become worn or rusted. It is very difficult to remove the scab with forceps with ends that are larger than the buttonhole. Small, disposable plastic forceps with more pointed ends work the best.
Insert needle. Lidocaine can be used as an anesthetic, although not recommended, during the initial formation of the buttonhole track and then gradually withdrawn, as patients do not experience any pain during access. As nerve endings at the access site diminish, patients feel less pain during the accessing procedure. All insertions should
happen at the same 25 degree angle of entry of every cannulation, thus the reason only one person should develop the buttonhole track. Their entry angle will be consistent with each venipuncture and having the same person establish the track, prevents the track from becoming irregular or convoluted.
Once the track has been developed and working well, usually within eight to 12 successful attempts, additional staff can cannulate the buttonhole. At this point it will be time to switch over to the dull beveled needles. These needles make it much easier to cannulate virtually eliminating errors or complications. Patients should be well informed about the person establishing the track and the eventual switching to other staff to avoid dependence or fear of someone else using their buttonhole.
Buttonhole vs. rope ladder
Rope Ladder cannulation has always been the technique of choice in the United States because it is what we know, and we know that it works. However, it is not the only access technique and buttonhole can be a better option once you understand the ease in which it can be accomplished. The fistula that is difficult to access can be a thing of the past and prevalent fistula rates will slowly start to rise.
Master and advanced cannulators can access the difficult fistulas; however, most rope ladder fistulas are subject to a variety of cannulators. In general, cannulators do not want access complications so the tendency is to find an area close to the previous cannulation. This usually results in "one site-itis" which brings with it all the problems that occur when this exists. Once again, with buttonhole there is only one arterial site and one venous site that is cannulated.
Conclusion
Believing in the buttonhole technique can make the cannulation process so easy to accomplish. Those facilities that have mastered the technique are usually very eager to share their experiences and successes. Each of the ESRD Networks has access to those facilities to perform buttonhole. The staff at David Grant Medical Center read about the procedure, tried it, and now two thirds of their population uses the buttonhole technique.
It takes total commitment to make the outcome positive for both staff and patients. Work schedules need to be adapted so that the same person is available to cannulate, but the rewards are much greater when you have a successful fistula program and happy patients receiving quality care.
Ms. Kregness is the director of operations for Western Pacific Renal Network 17 and has spent 40 years in the field of nephrology nursing, presenting numerous workshops on cannulation techniques--including the "buttonhole technique."
Creating buttonhole access sites: a case study By Kelley Downes, RN BS
W. S. is a 17-year-old male with end-stage renal disease secondary to focal segmental glomerular nephritis, diagnosed at the age of 4. At the age of 14, his renal transplant began to fail. He underwent surgical creation of a brachial-cephalic fistula and has been utilizing this type of access for chronic hemodialysis since 2005. The patient had successfully completed training for self-cannulation. After reviewing the "buttonhole access site" creation and maintenance, the patient requested to begin training.
To create the sites, it requires the same cannulator inserting the needle at the exact same site for 8 to 10 treatments. We reviewed the buttonhole creation process with the patient:
1. Choose cannulation sites that obtain the maximum blood flow.
2. Cannulate same insertion site for 8 to 10 treatments.
3. Monitor patient technique.
4. Provide instruction on importance of "scab" removal prior to cannulation to avoid infection.
5. Clean and inspect access for signs and symptoms of infection.
6. Transfer to dull needle insertion once track has formed.
7. Rotate needle bevel for incorrect track insertion or difficulty with advancement of needle.
8. Instruct patient to notify health care providers (radiologists, acute care dialysis centers) that the AVF has "buttonhole access" sites so as to not interfere with the track formation.
WS successfully cannulated his own fistula with sharp needles for eight treatments and then transitioned to the "buttonhole" needles with ease.
Ms. Downes is a vascular access coordinator at the University of North Carolina at Chapel Hill/Renal Research Institute
