Buttonhole cannulation in hemodialysis: improved outcomes and increased expense--is it worth it?
Article Type: Report
Subject: Cohort analysis (Methods)
Hemodialysis (Methods)
Fistula (Care and treatment)
Author: Ludlow, Valerie
Pub Date: 01/01/2010
Publication: Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136
Issue: Date: Jan-March, 2010 Source Volume: 20 Source Issue: 1
Geographic: Geographic Scope: Canada Geographic Code: 1CANA Canada
Accession Number: 223216275
Full Text: Abstract

Background: Access to an adequate blood flow is a requirement for successful hemodialysis (HD). This often means repeated cannulation of an arteriovenous fistula (AVF), which can lead to damage that needs repair and revision. The Buttonhole (BH) method offers a successful cannulation with minimal damage.

Design: A prospective cohort research study was initiated in two HD units in St. John's, Newfoundland and Labrador, to assess the effects of cannulating AVFs using the BH technique from the patient and nurse perspective.

Methods: Twenty-five nurses and 29 patients completed questionnaires at four times throughout the three-month study period, rating their confidence levels about BH cannulation issues. Patients also provided information on the pain of the cannulation and the frequency of cannulation complications. Nurses documented data on arterial and venous pressures, and hemostasis times. Patient charts were also reviewed for complications requiring extensive interventions such as AVF repair or Central Line Catheter (CVC) placement. The cost of providing the BH cannulation was also examined.

Results: At the end of the study, it was noted that cannulation pain was statistically reduced with both the arterial (p = .002) and venous (p = .010) needles, and vessel pressures and hemostasis times were decreased slightly or stayed the same throughout the study. The frequency of access infections, however, increased, although not significantly. Using a 10-point Likert scale in which a score of [greater than or equal to] 8 indicates a high level of confidence, 77.5% of nurses and 73.9% of patients reported a high level of confidence in the nurses' abilities to use the BH technique effectively. In terms of expense, no significant changes were noted in frequency of procedures required for AVF repair with the BH cannulation, although an increase of approximately $358.80 per patient per year for BH supplies was noted.

Conclusion: BH cannulation did provide significant improvements. However, the increase in infection rate was an issue of concern. The additional cost of the BH procedure should be weighed against the positive outcomes realized

Keywords: buttonhole (BH) cannulation, self-confidence, arteriovenous fistula (AVF), hemodialysis (HD), cannulation pain


An effective hemodialysis (HD) treatment is dependent upon a functioning vascular access. The preferred choice is the arteriovenous fistula (AVF) (Allon & Robbin, 2002; Bay, Van Cleef, & Owens, 1998; Van Waeleghem, Elseviers, & De Vos, 2004). The AVF is a blood vessel developed as a result of surgically connecting an artery to a vein, thereby allowing the increased blood supply and pressure of the artery to cause dilation of the vein. As the AVF develops and matures, this allows visualization and palpation of the vessel for needle placement or cannulation. Two needles are generally inserted into the AVF for HD; one needle removes the blood from the patient's body while the other needle returns the blood from the dialysis machine to the patient. Conventional HD requires three dialysis treatments a week, which amounts to approximately 312 needle insertions per year, if no complications occur.

Although the rope ladder (RL) technique (cannulating along the length of the vessel) is considered the standard method in most HD units, area cannulation is often used due to patient preference and ease of insertion by the nurse (Twardowski & Kubara, 1979; Van Waeleghem et al., 2004). Aneurysms (over-dilation of the access) often develop as a result of repeated cannulation in the same area. Conversely, stenosis in areas adjacent to the aneurysm develops causing additional problems that can lead to failure of the access (Kronung, 1984; Toma et al., 2003). Problems may develop and, if access failure occurs, this could necessitate the use of diagnostic testing, central venous catheter (CVC) placement, surgery, and/or hospitalizations (Lee, Barker, & Allon, 2006).

HD nurses play a vital role in the successful care of the AVF in HD patients. Bay et al. (1998) found that nurses ranked difficult cannulation as their main concern associated with the dialysis treatment. It takes experience and skill development for HD nurses to successfully cannulate AVFs (Robbin et al., 2002).

The study by Bay et al. (1998) also found that 39% of HD patients experienced pain during cannulation. In the same study, 23% of these participants stated that ease of cannulation was important to them. Shayamsunder, Patel, Jain, and Peterson (2005) also found that a significant percentage of patients reported pain on cannulation (78.5%). Additionally, Baldree, Murphy, and Powers (1982), and Welch and Austin (1999) ranked the pain of arterial and venous cannulation as twelveth out of 29 stressors and ninth out of 27 stressors relating to the HD treatment, respectively.

An alternative cannulation technique that is being offered to patients in some HD centres is the buttonhole (BH) or constant-site method that was initiated in 1979 by Dr. Z. Twardowski (Twardowski & Kubara, 1979). This technique requires that the same nurse use a sharp needle to puncture the AVF at the same angle in the same site until a scar track is developed (Ball, 2006). Once the BH track is formed, usually after the insertion of sharp needles for six to nine treatments, then blunt (BH) needles can be threaded into the vessel. This technique is similar to the placement of a pierced earring.

Interestingly, Marticorena et al. (2006, p. 198) found that BH cannulation required a "soft touch" to advance the blunt needle through a scar track, a different skill than the one required to be an experienced cannulator. In fact, the cannulator had to gently advance the blunt BH needle and feel it slide along the track and into the vessel rather than use a sharp needle and advance it in a particular direction, as with RL cannulation.

The BH technique has been especially helpful in home dialysis programs where self-cannulation is promoted, as well as when AVFs have limited available area to cannulate (Verhallen, Kooistra, & van Jaarsveld, 2007) or are difficult to cannulate (Ball, Treat, Riffle, Scherting, & Swift, 2007; Peterson, 2002; Van Waeleghem et al., 2004). However, one disadvantage of this method was an increased risk of infection due to inadequate area cleansing, and/or scab removal (Ball, 2006; Kronung, 1984; Marticorena et al., 2006; Twardowski & Kubara, 1979; Van Waeleghem et al.) and dubious personal hygiene of the patient.

The use of blunt BH needles has been shown to cause less damage to the AVF, reducing problems such as bleeding post-needle removal, pain with cannulation (Verhallen et al., 2007), poor arterial/venous blood flow, and the development of aneurysms (Marticorena et al., 2006). Complications such as infiltration and subsequent hematoma development, which may require re-cannulation of the site, have also been shown to be reduced (Twardowski & Kubara, 1979). In addressing cannulation issues, nephrology nurses require additional time and supplies, which place an added financial burden on the dialysis unit. As well, these complications may add to the personal cost to the patient in terms of access-related pain, which has been shown to be an indicator of health-related quality of life (HRQOL) (Davison, 2003; Skevington, 1998).

One major challenge that has been encountered in HD units trying to initiate BH cannulation is the inability to align the schedules of the nurses with those of the patients. In order for BH sites to be established, this requires that the same nurse cannulate the same patient's access repeatedly for at least six to nine times. Generally, an adjustment in either the patient's or the nurse's schedule is needed. Since patients require a set number of hours of HD treatments based upon a prescribed timetable, the changes often need to be made at the nursing level, which can be very disruptive to work and family life and may lead to dissatisfaction with the procedure (Ball, 2006; Ball et al., 2007). One HD unit (Marticorena et al., 2006) was successful at initiating the BH technique in a busy HD unit using multiple cannulators. However, this involved the designation of two nurses as "tunnel track creators (TTC)" (i.e., initial cannulators) (p. 194).

In terms of financial expense, AVFs are noted to be the most cost-effective access (Lee et al., 2002) and associated with less infection, stenosis, mordibity and mortality, when compared with central venous catheters (CVC) and synthetic grafts (National Kidney Foundation [NKF], 2000). However, the actual cost of maintaining an HD access can be expensive (Lee, Barker, & Allon, 2006). Therefore, considering that all forms of renal replacement therapy (HD, peritoneal dialysis, renal transplant) are life saving, the challenge becomes to balance the cost of providing such treatment against the benefits to the patient (less pain, less bleeding, and ease of cannulation).


In February 2007, the Primary Investigator (PI), with support from the division manager of the HD units of Eastern Health, St. John's, NL, initiated a prospective cohort study reviewing the effects of BH cannulation for patients with AVFs over a three-month period. The complications of AVF use (pain with cannulation, prolonged hemostasis times and hematoma development) were being experienced by many of the patients, as is typical of most HD units. The concerns of nurses, especially with difficult cannulations, were also noted. The purpose of this study was to examine if BH cannulation might affect positive changes for the patients and the nurses.

In order to evaluate the impact of BH cannulation, it was decided to break the study into Phase 1 and 2. Phase 1 occurred during the three months of the study to determine whether or not BH cannulation made a difference between the start and the finish of the study. First of all, patients and nurses were requested to complete questionnaires at four times throughout the study to indicate their confidence in the nurses' abilities to provide BH cannulation care: prior to initiation (Time 1--baseline), at four weeks (Time 2--once the track had been developed and after the blunt BH needle had been attempted), at eight weeks (Time 3--ideally after the blunt BH needle had been used for several weeks) and at the conclusion of the study (Time 4). Second, patients also indicated how many times specific complications (bruising, bleeding, and re-cannulations) occurred during the HD treatment. In addition to completing this questionnaire, nurses used log sheets to chart arterial/venous pressures recorded at a blood flow of 200 ml/min within the first 10 minutes of the treatment. Nurses also recorded the Patient Pain Rating (PPR) of the cannulation, as indicated by the patient. The Visual Analogue Scale (Verhallen et al., 2007) was used for this item: it is a 1 to 10 pain rating scale with 1 indicating 'no pain' and 10 indicating 'severe pain'. Patients were encouraged to rate the pain of the cannulation, not the skill of the nurse. Hemostasis times were charted in the patients' HD record for the treatment.

Phase 2 reviewed whether or not BH cannulation made a financial impact at the unit and corporate level. The actual 'monetary cost' of the procedures required for AVF damage/repair was determined to be outside the scope of this project. Therefore, the frequency of complications and procedures was tabulated for the purpose of comparison. The only actual cost that was estimated was that of the more expensive BH needles and Adson Forceps used for the BH cannulation.

Comparison was made between Group 1--patients who were using an AVF (RL cannulation) in the year prior to the initiation of the BH procedure (starting February 1, 2006) and Group 2--patients who were using BH cannulation in the year after the initiation of the study (starting February 1, 2007). This involved an extensive chart review by the PI. For the unit level expenses, the PI documented the number of specific complications that occurred during the HD treatment that required nursing intervention such as 'blood leak around a needle' or 'infiltration' of the needle. At the corporate level, the number of procedures (venogram and/or angioplasties, central venous catheter [CVC] insertions, emergency room visits, surgery, and hospitalizations) that were required by the patients to correct extensive problems (AVF damage or failure) was recorded. The cost of BH (blunt) needles and Adson Forceps was reviewed on per patient per year basis.

Ethical considerations

Approval was received from the Human Investigation Committee (HIC) of Memorial University in December 2006. The Research Proposal Approval Committee (RPAC) of Eastern Health provided permission to access the patients' medical records within their institutions.

A convenience sample was used for this study. All nurses and any patient with a functioning AVF being used for HD were provided with information on the study and given the opportunity to participate. Appropriate consent forms were signed by all volunteer participants.


The questionnaire that nurses were asked to complete was developed by the PI based upon nursing cannulation issues, as discussed in the literature, combined with the PI's extensive HD experience. The rating system for these questions used a 1 to 10 scale recommended by Bandura (1997) and used by Boardman, Catley, Mayo and Ahluwalia (2005). In this scale, 1 indicated 'not confident at all' and 10 meant 'very confident'. Readability of the questionnaire was acceptable at 9.4 grade level using the Flesch-Kincaid Grade Level instrument, as per HIC guidelines.

The questionnaires completed by the patients were also developed by the PI. These 5-point Likert scale instruments inquired about the frequency of their experiences related to the HD procedure (Part A); Part B encouraged them to rate how confident they were that nurses in the unit could provide specific BH cannulation practices using the 1 to 10 scale, as described above. The readability of this questionnaire was determined to be acceptable for the general population (< Grade 8 using the Flesch-Kincaid Grade Level instrument).

Study participants

Staff population

Staff participants were nurses who were required to have a minimum of six months of HD cannulation experience. Two were familiar with how to cannulate using the BH technique. In total, 25 nurses from two HD units of Eastern Health participated in the study.

Patient population

Patients were required to be at least 19 years of age, English speaking, and an HD outpatient with a functioning AVF by the end of the recruitment phase, which closed on February 1, 2007. As of that date, 29 patient participants in Eastern Health began the study.

Study process

Once they agreed to participate in the study and written consents had been obtained, patients had their AVFs cannulated a minimum of six times with a sharp needle by designated initial cannulators. Once the tracks were established by these nurses, other nurses who had attended the BH in-service were able to cannulate with guidance from the initial cannulator (Ball, 2006; Marticorena et al., 2006; Twardowski & Kubara, 1979). Sharp needles were only used if the blunt needles were not successfully inserted. These were inserted by a nurse who had been an initial cannulator (Ball, 2006). Guidelines were developed and posted to assist the nurses in addressing problems that arose when the initial cannulator was not available.

Chlorohexidine swabs were used to cleanse the cannulation sites pre-and post-scab removal to maintain as aseptic a field as possible. As well, sterile forceps were used to remove the scabs from the access sites prior to insertion of the BH needle (Ball, 2006; Verhallen et al., 2007).

Data analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, version 16.0). The demographic profiles of participants were reviewed using frequencies, means, standard deviations, and medians with 25 to 75 percentiles (interquartile ranges [IQR]) when appropriate.

In reviewing the staff and patient questionnaires, missing items were evaluated and deemed to be of a random pattern. One-way ANOVA was used to review the mean responses of all participants over the four time periods. Paired sample t-tests and Chi-square for independence were also used for analysis when the data deemed it appropriate. A p-value of < .05 was considered statistically significant.


Staff participants


In this study, 96% of the nurses who participated were female. They had a considerable amount of nursing and HD experience, with a mean of 20.6 years and 9.5 years, respectively.

Confidence levels

In reviewing the data (see Table One), confidence levels of eight or greater were noted in more than 77.5% of the nurses' responses. Throughout the course of the study, all confidence levels increased for all items, significantly so for 'place a sharp needle in a BH tract without causing pain to the patient' (p = .011).

Patient participants


Data on patient participants were collected from the self-report information on the patient questionnaire:

* Males comprised 62.1% of the participants,

* The mean age of the current AVF was 2.7 years,

* The duration of time on HD averaged 3.2 years, and

* The most common location of an AVF was in the left arm (85.9%).

HD cannulation issues and confidence levels

Questionnaires were completed by patients at Times 1 to 4 throughout the study (see Table Two). This questionnaire consisted of two sections:

Part A asked patients to rate the frequency of specific occurrences relating to the HD treatment itself. The data indicate that, with the exception of question two, there were no significant changes in these incidences, which only occurred sometimes (3) to rarely (4). Question two (bruising during needling) was the only occurrence that indicated a significant change from 3.3 (less than sometimes) to 4.4 (rarely to never) with a p-value of .001. It is interesting to note that the most frequent complication was experienced sometimes (2.9), indicating that very few complications were being experienced by patients.

Part B reviewed the participants' confidence in the unit nurses' abilities to provide specific aspects of care again using the 1 to 10 confidence rating scale. It was noted that more than 73.9% of patient participants responded with confidence levels [greater than or equal to] 8 throughout the study. Interestingly, the confidence levels dropped from initially high scores to lower levels by the end of the study, although that change was not significant.

Cannulation pain and venous/arterial pressures

Data, collected from patients at the start and at the end of the study, included the Patient Pain Rating (PPR) related to cannulation pain, and the pressure of the blood within the vessel upon cannulating the venous and arterial sites. As shown in Table Three, there was a significant decrease in the pain rating with both the venous (p = .010) and arterial (p = .002) cannulations.

It was found that there were no statistically significant decreases in venous and arterial pressures. However, pressures were noted to decrease slightly or stay the same during the study.

Post-HD hemostasis

There was no statistically significant decrease found in the hemostasis times (see Table Four). However, the values were noted to be the same or slightly less when comparing those from the start to the finish of the study.

Cost of AVF maintenance


In order to evaluate whether or not the BH cannulation technique had a financial impact on providing care to the Eastern Health HD patients, a retrospective chart review was conducted on HD patients who had a functioning AVF, as of February 1, 2006 (group one), as well as on those patients who commenced BH cannulation as of February 1, 2007 (group two). Demographic information indicated that the groups were comparable:

* Group one was slightly older than group two (65.9 years versus 62.9 years),

* Males comprised the majority of both groups (57.9% and 62.1%), and

* The most common location of a participant's AVF was in his/her left arm (76.8% and 85.9%) during both time periods.

Health care procedures

Analysis of the data (see Table Five) collected on these two groups concerning health care procedures found that there were no statistically significant differences between the frequencies of these items whether they were reviewed as a group, or as individual occurrences (p = NS). It should be noted, however, that the actual frequencies of specific items indicate a decrease with group two (BH cannulation) for AVF evaluation/repair (e.g., venogram [14.7% versus 3.4%] and venogram and angioplasty [13.7% versus 3.4%]), as well as for CVC insertions as a result of AVF failure. It can also be seen from Table Five that there is a slight increase in the frequency of emergency room visits, surgery repair and hospitalizations. However, as with the previous information, the difference is not statistically significant.

HD treatment complications

In reviewing the documentation by nurses regarding HD treatment complications (see Table Six), there was a decrease in group two (BH cannulation) in the frequencies of 'blood leaking around the needle', and the presence of 'clots' in the needles. Conversely, increases were observed in frequencies of 'infiltrations' and 'poor flow/unable to advance the needle' in that group.

Infections in AVFs had a previously low rate of occurrence (2.1%) in the units studied. However, with the initiation of the BH procedure, it became an important, although not statistically significant, issue (increased to 6.9%).

Unit Supplies

A review of the supplies required to perform the BH cannulation procedure was completed. In particular, BH (blunt) needles were found to be more expensive than sharp AVF needles that were used to perform RL cannulation ($1.32 each versus $0.85; difference $0.47). As well, Adson Forceps were items that were required to remove the scabs from the BH cannulation sites at a cost of $1.36 each. Therefore, for each treatment, assuming no complications occurred, two BH needles and one Adson Forceps were required increasing the cost per HD treatment by $2.30. Considering that the average patient received three treatments per week, this amounts to an additional cost of $6.90 per week. Over 52 weeks, the total estimated additional cost of using the BH procedure would be $358.80 per patient per year.

Trampoline effect

The trampoline effect (see Table Six) was a complication that frequently occurred with patient participants (20.7% of the patients experienced at least one episode). This happens when the blunt BH needle threads successfully through the scar track, but will not enter the blood vessel: "It just bounced off it--boing, boing, boing, just like a trampoline" (Ball, 2006, p. 303). If excessive force is used to advance the blunt needle, tearing of the track can occur and patients often experience pain in this situation.


Staff confidence levels

High levels of confidence were expressed by nurses in their ability to perform BH skills. However, in reviewing questions that involved BH knowledge, understanding of personal and other nurses' needs, and ability to monitor specific HD outcomes (questions 3, 6, 7 and 8), it was seen that all of these items had high confidence ratings from the start. Questions that rated [Less than] 8 were nursing skills that may improve with time and experience (questions 1, 2, 4 and 5).

Patient HD cannulation issues and confidence levels

The data offered in Part A of the patients' questionnaire (frequency of HD complications) might indicate that, as the nurses became more skilled at performing the BH procedure, fewer complications were experienced by the patients.

Part B suggests that patients had a high level of confidence in nurses' ability to BH cannulate and that there was no significant change throughout the study. It is interesting to note, however, that confidence levels dropped after the start of the study. This might be due to the fact that some complications were being experienced with the BH procedure even though it had been promoted as a means to decrease them. Confidence in the nurses did improve towards the end of the study, once again, possibly, due to increased nursing experience and establishment of the BH sites.

Cannulation pain and arterial/venous pressures

The significant decrease in pain, as experienced by the patients, was similar to results found in other studies (Marticorena et al., 2006; Toma et al., 2003). Pain with cannulation is noted to be an important HRQOL indicator for HD patients. Therefore, this can be considered a positive outcome for these patients.

As in Marticorena et al. (2006), there were no statistically significant changes in the arterial/venous pressures. Since, the actual readings were well within the acceptable limits of "< 150-200 mmHg, 15 gauge needles" for a blood flow of 200 ml/min (Daugirdas, Blake, & Ing, 2007, p. 115), this can be viewed as a positive outcome since the lower the pressure, the less damage caused to the access (Marticorena et al.; Daugirdas et al.).

Post-HD hemostasis

Although there have been significant improvements found in post-HD hemostasis with the use of the BH procedure (Toma et al., 2003), this was not the case in this study. Worthy of note is that at both the start and end of the study, the median times of hemostasis were lower than the means, indicating that there may have been a few patients who had extended bleeding times that increased the mean hemostasis time of the group.

Cost of AVF maintenance

There were no significant changes noted in the frequency of health care procedures and HD treatment complications between RL (group one) and BH (group two) cannulation. However, upon review of the actual frequencies, differences were noted. Emergency room visits, surgery for repair and hospitalizations all indicated a slight increase for the BH group. It should be noted that these were for long-standing aneurysmal damage and infection treatment. Conversely, venograms, venograms and subsequent angioplasties and CVC insertions realized a decrease. The increases in HD treatment items (infiltration, and poor flow/unable to advance needle) may be related to the nurses' inexperience with the new BH skill, underdevelopment of the BH sites, and the need for a soft touch, which is often required for BH cannulation. In contrast, the decreases in frequency of blood leaking around the needle and the presence of blood clots in needles could be as a result of the establishment of the BH track and/or less trauma to the vessels with the use of BH cannulation. With such small numbers in the BH group (29), it may be difficult to draw conclusions as to the causes of these occurrences. However, in a larger study, it would be interesting to compare these same issues for new AVFs with AVFs that already have aneurysm development.

The increase in infections from 2.1 to 6.9% is an issue of concern. In our units, BH cannulation sites are cleansed with chlorhexidine swabs, sterile forceps are used to remove scabs, and sites are then cleaned with fresh chlorhexidine swabs as supported by Ball (2006). As well, nasal swabs are also completed monthly on all BH patients; a positive culture is treated with antibacterial ointment. AVF infections, usually indicated by erythema and/or discharge, are cultured and treated with appropriate antibiotics. These protocols are constantly under review.

In terms of unit supplies, the additional cost of BH cannulation of approximately $358.80 per patient per year above that of RL cannulation is an added expense at a time when health care resources are at a premium. Individual units need to decide if the cost of supplies outweighs beneficial outcomes experienced by the patients.

Trampoline effect

The aim of the BH procedure is, by definition, the development of a track so that a blunt needle can be threaded past the skin and pierces the blood vessel. When a blunt needle cannot puncture the vessel, the trampoline effect is experienced, and gentle manipulation may be required by the cannulator to ensure the appropriate placement of the needle. In fact, BH cannulation needs a "soft touch" (Marticorena et al., 2006, p. 198) that is not necessarily consistent with being an expert cannulator. If insertion with a blunt needle is not successful, a sharp needle can be gently threaded into the track (Ball, 2006) although this is not preferred. This may cause additional cutting of the track, leading to the development of a cone-shaped tunnel, often evidenced by leaking of blood around the needle during dialysis. Further nursing experience with this procedure and an increase in the number of times the AVF is cannulated by the initial cannulator should help decrease the frequency of this complication.


A major challenge that was experienced when implementing the change to the BH cannulation technique in our HD unit was the need to assign the same nurse to needle the same patient for at least six treatments in order to establish the BH track. Once the transition to blunt needles occurred, other nurses could place the BH needles with guidance from the initial cannulator. The assignment of a limited number of nurses to cannulate all of the AVFs would seem to be the ideal situation based on comments from both nurse and patient participants. The alignment of nurse and patient schedules, however, is a challenge in a busy HD unit (Marticorena et al., 2006).

Qualitative data

On both the patient and staff questionnaires, there was space provided for comments, and both groups did provide positive feedback, as well as express their concerns regarding BH cannulation.

Nurses' comments ranged from very positive to having some misgivings about the procedure. Several offered suggestions on how to improve patient outcomes. Some of the comments provided were as follows:

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

* I have noticed that we are having some difficulty inserting blunt needles. This is happening on a few different patients. It happens even to those patients where there were very [few] problems with making a BH tract. It seems like we are going back to sharp needles a fair bit.

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

Patient participants also provided a variety of comments about the whole process. Several wrote page-long letters to express their thoughts. The following are excerpts from the overall comments received.

* I think the blunt BH needles are a great thing. Excellent project.

* I inserted the blunt needle in the lower site. The upper site is more difficult. Maybe I could start a new site if things don't improve. I would like to be able to do both sites myself.

* Time to stop bleeding is getting shorter.

* I find that it (needling) is not as painful.

* As of yet, not much difference in pain level using this new method.

* I have to revert to sharps because blunt needles and the trampoline effect can be really painful.

Although there were concerns expressed by both nurse and patient participants, there were positive comments made for both the initiation of the project and the BH procedure itself. Information provided by both groups supported the recommendation of an increase in the number of treatments that the initial cannulator spends on developing the BH track.


This study was conducted using questionnaires that were specifically created for this project. The researcher's extensive HD experience, combined with a comprehensive review of the literature, enabled the development of questions that were relevant and significant to the BH issue for both nurses and patients. A review by independent researchers would be advisable if these questionnaires were to be considered for future use.

As in all retrospective chart reviews, data collection may not be as comprehensive as hoped, regardless of the tenacity of the researcher. Prospective data collection with dedicated personnel provides more complete data collection and should be considered for similar future projects.

Since participants were recruited on a volunteer basis, the actual numbers were dependent upon nurse/patient agreement and involvement. This may have added to the high ratings by the nurses and patients, as volunteers are often motivated by and interested in the project at hand and may be biased. It has also been documented that dialysis patients like to present themselves in a "socially desirable manner" since nurses who care for them during their HD treatment have a significant impact on their well being (Yanagida & Streltzer, 1979, p. 563). Thus, their answers on psychological tests may be affected by this phenomenon leading to more positive responses.

Due to the small number of participants in this study, the results are not necessarily generalizable to other units. It is important to note, however, that the outcomes were similar to those in other studies.


Our study demonstrated that the use of BH technique for cannulation provided the following outcomes:

* Cannulation pain was decreased significantly

* There was slight improvement or no change in arterial/venous pressures, and hemostasis times

* Treatment complications were reduced, 'bruising' significantly

* Both nurses and patients had high confidence levels in the nurses' BH skills throughout the study

* Nurses became more confident in their own BH skills by the end of the study

* There was no significant decrease in health care or HD treatment procedures as a result of using the BH procedure

* Unit-level expenses increased due to more expensive BH needles and additional supplies (forceps)

The increased cost of BH cannulation should be weighed against the improved outcomes for HD patients when considering this procedure. As well, in order to ensure a successful BH cannulation program, guidelines, as outlined previously, need to be implemented to address issues with the trampoline effect, nurse scheduling issues, and the increase in infections.

By Valerie Ludlow, RN, MN, CNeph(C)

Valerie Ludlow, RN, MN, CNeph(C), Research Assistant with the Patient Research Centre, Memorial University, St. John's, Newfoundland.

Address correspondence to: Valerie Ludlow, RN, MN, CNeph(C), 33 Ortega Drive, Paradise, NL A1L 2L1. E-mail: vludlow@nl.rogers.com

Submitted for publication: October 1, 2009. Accepted for publication in revised form: January 31, 2010.


The author would like to acknowledge the support of the following nurse clinicians during the course of this study: Linda Ivany, Cathy Cake, Valerie Earles and Annette Bennett, all from Eastern Health, as well as Dr. Deborah Gregory, Memorial University, and Patricia Grainger, Centre for Nursing Studies, both in St. John's, Newfoundland, and Koren Snow from Central Health, Gander, Newfoundland. Most of all, the author would like to acknowledge that this project would not have been possible without the help and support of the nursing staff and patients of the hemodialysis units involved in the study.


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Table One: Staff questionnaire--Eastern Health (25)

In relation to needling of        Time 1           Time 2
patients' fistulas, how           (Baseline--      (After 4 weeks)
confident are you that            prior to study)  Mean(SD),
you can:                          Mean(SD),        Median

1. Place sharp needle in a        6.7(2.2),7.0     8.3(1.8),9.0
buttonhole tract without causing
pain to the patient

2. Place blunt needle in          7.4(2.7),8.0     8.7(1.1),9.0
buttonhole tract without causing
pain to the patient

3. Provide information to your
patient and his/her family on:

* the procedure of buttonhole     9.1(0.9),9.0     9.5(0.7),10.0

* the advantages of buttonhole    9.4(0.7),9.5     9.5(0.7),10.0

* the disadvantages of            8.1(2.1),9.0     9.2(0.8),9.0
buttonhole needling

4. Obtain positive comment from   7.6(2.7),9.0     8.6(1.3),9.0
your patient regarding your
buttonhole needling skill

5. Provide guidance to another    7.1(2.7),8.0     8.4(1.3),8.0
staff member on how to place
blunt buttonhole needle

6. Assess your own need for       8.5(1.4),9.0     9.1(1.0),9.0
additional assistance with the
buttonhole needling procedure

7. Request assistance with        8.4(2.6),9.5     9.5(0.8),10.0
placing difficult buttonhole

8. Monitor the outcome measures
relating to buttonhole

* pain intensity                  8.7(1.3),9.0     9.6(0.7),10.0

* hemostasis time                 9.1(1.0),9.0     9.7(0.6),10.0

* venous pressures                9.1(1.0),9.0     9.6(0.7),10.0

* arterial pressures              9.1(1.0),9.0     9.6(0.7),10.0

In relation to needling of   Time 3           Time 4          p
patients' fistulas, how      (After 8 weeks)  (End of study)
confident are you that       Mean(SD),        Mean(SD),
you can:                     Median           Median

1. Place sharp needle in a   8.7(1.5),9.0      8.8(1.6),9.0    .011 *
buttonhole tract without
causing pain to the

2. Place blunt needle in     8.2(1.7),8.0      8.1(2.3),9.0    NS
buttonhole tract without
causing pain to the

3. Provide information to
your patient and his/her
family on:

* the procedure of           9.4(0.8),10.0     9.6(0.6),10.0   NS
buttonhole needling

* the advantages of          9.6(0.7),10.0     9.4(1.1),10.0   NS
buttonhole needling

* the disadvantages of       9.2(1.0),9.5      9.0(1.4),9.5    NS
buttonhole needling

4. Obtain positive comment   8.7(1.1),9.0      8.6(2.2),9.0    NS
from your patient
regarding your buttonhole
needling skill

5. Provide guidance to       8.6(1.2),9.0      8.9(1.4),9.0    NS
another staff member on
how to place blunt
buttonhole needle

6. Assess your own need      9.4(0.7),9.5      9.4(0.8),10.0   NS
for additional assistance
with the buttonhole
needling procedure

7. Request assistance with   9.6(0.6),10.0     9.4(1.0),10.0   NS
placing difficult
buttonhole needle

8. Monitor the outcomess
measures relating to
buttonhole needling:

* pain intensity             9.4(0.9),10.0     9.4(0.9),10.0   NS

* hemostasis time            9.5(0.8),10.0     9.6(0.7),10.0   NS

* venous pressures           9.6(0.7),10.0     9.5(0.9),10.0   NS

* arterial pressures         9.6(0.7),10.0     9.6(0.7),10.0   NS

Rating Scale: 1-Not at all confident to 10-Very confident;

* p<.05; NS-Not significant

Table Two: Patient questionnaire--Eastern Health (N = 29)

Part A: HD treatment complications

In relation to needling of your       Time 1           Time 2
fistula, how often have you had:      (Baseline--      (After 4 weeks)
                                      prior to study)  Mean(SD),
                                      Mean(SD),        Median

1. Pain in your fistula when the      3.0(1.6),3.0     2.9(1.4),3.0
nurses needled you

2. Bruising in your fistula when the  3.3(1.4),4.0     4.1(1.4),5.0
nurses needled you

3. Bleeding after the needles have    3.1(1.5),3.0     3.0(1.7),3.0
been removed

4. To stay longer after dialysis due  3.8(1.2),4.0     4.3(1.1),5.0
to extra bleeding

5. To have more than one needle       4.1(1.3),5.0     3.8(1.5),5.0
placed in each needle site

In relation to needling of     Time 3           Time 4           p
your fistula, how often have   (After 8 weeks)  (End of study)
you had:                       Mean(SD),         Mean(SD),
                               Median            Median

1. Pain in your fistula when   3.6(1.3),4.0     3.4(1.5),3.5    NS
the nurses needled you

2. Bruising in your fistula    4.7(.7),5.0      4.4(.9),5.0    .001 **
when the nurses needled you

3. Bleeding after the needles  3.3(1.4),3.0     3.3(1.6),4.0    NS
have been removed

4. To stay longer after        4.2(1.2),5.0     3.7(1.6),4.5    NS
dialysis due to extra

5. To have more than one       4.4(1.2),5.0  3.8(1.0),4.0       NS
needle placed in each needle

Rating Scale: 1-All the time, 2-Often, 3-Sometimes, 4-Rarely, 5-Never

** p<.01; NS-Not significant

Part B: Confidence in nurses' skills

How confident are you that all   Time 1           Time 2
the nurses in the dialysis unit  (Baseline--      (After weeks)
can/will:                        prior to study)  Mean(SD),
                                 Mean(SD),        Median

1. Put needle into your fistula  8.5(1.9),9.0     6.6(3.4),7.0
with no problems

2. Use only one needle per site  9.1(1.3),10.0    7.9(3.2),10.0
in your fistula

3. Know what to do if there is   9.6(0.8),10.0    9.0(2.5),10.0
trouble with needle

4. Ask another nurse for help    9.6(0.8),10.0    9.2(2.4),10.0
if needed

How confident are you that all   Time 3         Time 4           p
the nurses in the dialysis unit  (After weeks)  (End of study)
can/will:                        Mean(SD),      Mean(SD),
                                 Median         Median

1. Put needle into your fistula  7.1(3.5),9.0   7.7(2.8),8.5     NS
with no problems

2. Use only one needle per site  8.2(3.1),10.0  8.0(2.7),9.0     NS
in your fistula

3. Know what to do if there is   8.5(2.6),10.0  8.6(2.8),10.0    NS
trouble with needle

4. Ask another nurse for help    9.0(2.2),10.0  8.8(2.5),10.0    NS
if needed

Rating Scale: 1-Not at all confident to 10-Very confident;
NS-Not significant

Table Three: Patient pain rating and venous/arterial pressures

Item                       n   Start of Study

                               Mean (SD)       Median (IQR)

Patient Pain Rating (PPR)
* Venous Needle            29  2.6(1.4)        2.5(1.4, 3.8)
* Arterial Needle          29  2.3(1.2)        2.3(1.7, 3.1)

Pressure Readings (mmHg)
* Venous Pressures         29  72.1(17.6)      70.0(58.3, 81.8)
* Arterial Pressures       29  39.4(14.8)      43.3(60.0, 75.0)

Item                        End of Study                       p

Patient Pain Rating (PPR)   Mean (SD)       Median (IQR)

Patient Pain Rating (PPR)
* Venous Needle             1.9(1.1)        1.5(1.0, 2.7)     .010 *
* Arterial Needle           1.7(0.8)        1.5(1.0, 2.3)     .002 **

Pressure Readings (mmHg)
* Venous Pressures          69.7(15.3)      68.3(34.2, 48.3)   NS
* Arterial Pressures        39.3(13.4)      42.0(32.5, 46.7)   NS

Patient Pain Rating (PPR)1-No Pain to 10-Severe Pain

Pressurereadings: Range from to ~150

* p < .05;
** p< .01;

NS-Not significant

Table Four: Hemostasis times

Item                        n   Start of Study

                                Mean (SD)       Median (IQR)

Hemostasis Times (minutes)  29  14.08(3.31)     13.33(11.7, 15.0)

Item                        End of Study                      p

                            Mean (SD)     Median (IQR)

Hemostasis Times (minutes)  13.72(3.99)   12.83(10.8, 16.4)  NS

NS--Not significant

Table Five: Health care procedures

Items                                      Group (N=95)
                                          (Year prior to study)

                                          n          %

Part A
Emergency Room Visits                     3          3.2
Surgery for Repair                        6          6.3
Hospitalizations                          2          2.1

Part B
Venogram                                  14         14.7
Venogram and Angioplasty                  13         13.7
Central Venous Catheter (CVC) Insertions  8          8.4

Items                                     Group (N=29)    p
                                          (Year at start
                                          of study)

                                          n         %

Part A                                                    NS
Emergency Room Visits                     1         3.4   NS
Surgery for Repair                        2         6.9   NS
Hospitalizations                          1         3.4   NS

Part B                                                    NS
Venogram                                  1         3.4   NS
Venogram and Angioplasty                  1         3.4   NS
Central Venous Catheter (CVC) Insertions  2         6.9   NS

Note: values do not add up to 100, since not all participants
experienced complications;

NS-Not significant

Table Six: HD treatment complications

Items                                 Group 1 (N=95)
                                      (Year prior to study)

                                      n           %

* Blood Leak around Needle            17          17.9
* Clot                                16          16.8
* Infiltration                        32          33.7
* Poor Flow/Unable to Advance Needle  20          21.1
* Infection                            2           2.1
* Trampoline Effect                   -           -

Items                                Group 2 (N=29)             p
                                     (Year at start of study)

                                      n              %

* Blood Leak around Needle            2              6.9        NS
* Clot                                4             13.8        NS
* Infiltration                       11             37.9        NS
* Poor Flow/Unable to Advance Needle  8             27.6        NS
* Infection                           2              6.9        NS
* Trampoline Effect                   6             20.7

Note: % values do not add up to 100, since not all participants
Experienced complications;

NS--Not significant
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