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!
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