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Valerie Ludlow, RN, MN, CNeph[C]

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1 Valerie Ludlow, RN, MN, CNeph[C]
The Effects of Buttonhole Needling in a Hemodialysis Unit: The Patient and Staff Experience Valerie Ludlow, RN, MN, CNeph[C]

2 Outline Definition Complications of Needling Buttonhole Needling
Research Project Objectives Research Process Data Collection Results: Quantitative Qualitative Suggestions for Future Care

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

4 Complications of Needling
Infiltrations Bleeding Pain Aneurysms Loss of function Radiological procedures Central Venous Catheter [CVC] placement Surgical interventions

5 Complication - Aneurysms

6 The Joys of Needling! © Jazz Communications Ltd

7 Cannulation Woes! © Jazz Communications Ltd

8 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

9 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

10 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

11 Objectives of Research Project
MAIN OBJECTIVE Encourage staff and patients to provide their input and thus become stakeholders

12 Newfoundland & Labrador

13 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)

14 Participation of patients and staff
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!

15 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

16 Patients’ Responsibilities
Sign consent form Complete confidential questionnaire (Times 1-4) Rate Pain of needle insertion (1-10) ***Nothing personal*** 

17 Timeline Pre 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

18 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

19 Patient Questionnaire
Part One Please circle the rating that best describes your feelings: 1 – All the time 2 – Often 3 – Sometimes 4 – 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 ..…

20 Patient Questionnaire
Part Two Please circle the number that corresponds to your answer: 1 – Not at all confident 10 – 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 .…… Comments____________________________________

21 Staff Questionnaire Please circle the rating that corresponds to your response: 1 – Not at all confident 10 – 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 …… Provide information to your patient and his/her family on the advantages of buttonhole needling ………… Comments:___________________________________

22 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 Pressure EoI – Ease of Insertion (1-easy 2-some difficulty 3-unable to insert) PPR- Patient Pain Rating (1 [no pain] to 10 [severe pain])

23 Improve the Needling Experience!
© Jazz Communications Ltd

24 Results: Participation
Eastern Health Central Health Staff 25 9 Patients 29 28

25 Results: Staff Demographics
Eastern Health Central Health Female Gender 96% 88.9% RN experience 20.6 years 19.8 years HD RN experience 9.5 years 4.1 years

26 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

27 Results: Patient Demographics
Eastern Health Central Health Female 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

28 HD Treatment Complications
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)

29 Confidence in Nurses’ Skills
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

30 Patient Pain Rating (PPR) and
Results: Patients Patient Pain Rating (PPR) and Needle Pressures 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

31 Results: Patients Hemostasis Times Start End p
Hemostasis Times (minutes) 14.08 13.72 NS

32 Cost of Fistula Maintenance
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

33 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

34 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

35 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

36 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.

37 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.

38 Before and After 4 Weeks of BH Needling

39 Established buttonhole
© Tony Goovaerts

40 Thank You! Contact information:

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