8Buttonhole (BH) Needling Dr Twardowski, Poland, 25 years agoButtonhole (BH) needlingsame individualsame sitesame anglesame depth of penetrationA scar tissue tract for a blunt fistula needle
9Objectives of Research Project Improve Patients’ Quality of Life!Decrease needling complicationsIncrease confidence level of patientsImprove Nurses’ Work life!Increase the confidence level of HD nurses
10Objectives of Research Project Improve on Health Care Expenses!Unit levelNursing timeSuppliesCorporate levelRadiology proceduresCentral Venous Catheter [CVC] placementsSurgical repair and/or hospitalization
11Objectives of Research Project MAIN OBJECTIVEEncourage staff and patients to provide their input and thus become stakeholders
13Research ProcessObtained support of management, Eastern and Central Health, NLReceived ethical approvalAwarded funding by The Health Care Foundation and the Association of Registered Nurses of NL (ARNNL)
14Participation of patients and staff Research ProcessParticipation of patients and staff2 HD units in St. John’s (Eastern Health)2 HD units in Gander, Grand Falls-Windsor (Central Health)MOST IMPORTANT!
15Nurses’ Responsibilities Required no extra timeAttend in-serviceSign consent formComplete confidential questionnaires (Times 1-4)Needle assigned patients X 3 monthsDocument findings in chart
18Data Collection for Patients and Staff Questionnaire DevelopmentLiterature SearchExtensive HD experience of Primary InvestigatorFlesch-Kincaid Grade Level (9.4 Staff/<8 Patients)Appropriate Rating systems5-point Likert1-10 pain rating, and1-10 self-confidence rating
19Patient Questionnaire Part OnePlease circle the rating that best describes your feelings:1 – All the time 2 – Often 3 – Sometimes4 – Rarely 5 – NeverIn 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..…
20Patient Questionnaire Part TwoPlease circle the number that corresponds to your answer:1 – Not at all confident10 – Very confidentHow confident are you that all the nurses in the dialysis unit can/will:Put a needle into your fistula with no problems.……Comments____________________________________
21Staff QuestionnairePlease circle the rating that corresponds to your response:1 – Not at all confident10 – Very ConfidentIn 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:___________________________________
22Buttonhole Arterial/Venous Needle Log NOTE: Please complete when Blood Flow is 200 ml/min within first 10 minutes of treatment.DateS/BGaA/VPEoIPPRCommentsInS/B – Sharp or Blunt needle Ga – Gauge of needleAP – 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])
26Results: 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 experienceCH Staff < 3 years HD experience rated confidence <8 at startAll more confident at end
27Results: Patient Demographics Eastern HealthCentral HealthFemale Gender37.9%42.9%Position AVF Left arm85.9%82.2%Age Current AVF2.6 years2.7 yearsTime HD Patient3.2 years3.3 years
28HD Treatment Complications Results: PatientsHD Treatment ComplicationsRating 1 (All the time) to 5 (Never)All 3 (sometimes) to 4 (rarely)Significant improvement - bruising in fistula when needled (p=.001)
29Confidence in Nurses’ Skills Results: PatientsConfidence in Nurses’ SkillsHigh ≥ 8 (1-10 scale)EH – 73.9%CH – 78.7%Note: Rating decreased slightly throughout study but not significantly
31Results: Patients Hemostasis Times Start End p Hemostasis Times (minutes)14.0813.72NS
32Cost of Fistula Maintenance Results: PatientsCost of Fistula MaintenanceYear before study (Group 1) vs Year at start of study (Group 2)Retrospective chart reviewHealth Care ProceduresHD Treatment ComplicationsCost of BH Unit Supplies
33Results: Patients Health Care Procedures (p=NS) HD Treatment Complications (p=NS)BUT decreases in actual frequenciesCost of BH Unit Supplies – increase of $358.80/patient/year
35Additional Results and Suggestions for Future Care Trampoline effect: 20.7%Longer time with initial needlerRevert to sharps PRNInfection: Increased from 2.1% to 6.9%Continue to monitor/update protocolsTreat with AntibioticsStaff SchedulingDedicated staff
36Qualitative 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.
37Qualitative 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.