A Buttonhole Program for Dialysis Facilities

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A Buttonhole Programfor Dialysis Facilities
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• Lynda K. Ball, RN, BSN, CNN
• Quality Improvement Coordinator
• Northwest Renal Network

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Under contract with the Centers for Medicare
Medicaid Services (CMS), contract 500-03-NW16.
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Myths of the Buttonhole Technique
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• Can only be used on a limited access fistula
• Cannot be used on a mature AV fistula
• Cannot be used if blunt needles are not available
• Will cause aneurysm formation

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Benefits for the patient
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• Less painful elimination of anesthetic
• Fewer infections
• Fewer missed needle sticks
• Fewer infiltrations
• Cannulation of access takes lt 10 seconds

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Twardowski, 1995
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Barriers to success
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• Heavily scarred accesses from
• multiple problematic needle sticks
• a long-lived AV fistula
• lidocaine use
• Large amount of subcutaneous tissue
• Not dedicating one staff person for cannulation
  during the track formation

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Before you startPLAN
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• What are your staffing patterns?
• Who will train the staff?
• How many patients do you plan to start?
• Do you have the necessary supplies for a
  buttonhole program?
• Have you developed a Buttonhole PP?

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Will your patient self-cannulate?
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• Plant the seed from the very first conversation.
• Ask what the patient fears most about the idea of
  self-cannulation.

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Assess the patient
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• Where is the access located?
• Can the patient
• reach their access?

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And assess the access
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• Look at the patients angle of insertion.
• Look at your angle of insertion.
• You will need to readjust your angle.

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Patients angle
Your angle
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Readjusted angle of insertion
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Assessment
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• Do a complete physical assessment on the access -
  inspect, auscultate, and palpate.
• Determine the best two sites on the access - good
  arterial and venous pressures, good blood pump
  speeds, and least likely areas for infiltrates.

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DifferencesRotating sites vs. Buttonhole
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• Adjust as you cannulate.
• Three-point technique used.
• Avoiding the scabs.

• No adjusting - must follow the track.
• Two-point stabilization used.
• Removing the scabs.

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Needles sharp and blunt
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Buttonhole cannulation log
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Dos and Donts of scab removal
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• or
• Soak two 2 x 2s with sterile saline and lay over
  the scabs until moistened, then pinch the scab
  and 2 x 2 between your thumb and forefinger.
• or
• Moisten with alcohol-based gel.

• Dont flip the scab off with the needle you will
  use for cannulation this contaminates the
  needle.
• Dont use a sterile needle you could cut the
  patients skin.
• Do use aseptic tweezers, if available

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Establishing the track
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• For non-diabetic patients It will take
  approximately 8 cannulations to form the
  buttonhole track.
• For diabetic patients It will take approximately
  12 cannulations to form the buttonhole track.
• You need the same staff person doing the
  cannulation until the track is established.

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Importance of good track formation
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• By using the same angle, depth, and insertion
  technique for the 8-12 sticks, a scar track forms
  that is very similar to pierced earring holes.
• You need the hole to stay the same size as the
  bore size of your needle, that is why it is
  imperative that the angle be the same during
  track formation.

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Cannulation
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• Chose a needle size for the blood pump speed
  ordered (e.g., BFR gt350 to 450 ml/min use a 15
  gauge needle)
• Sharp needle and blunt needle sizes must be the
  same
• Initiate a cannulation log sheet for each needle

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Needles sharp and blunt
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Buttonhole cannulation log
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Changing to blunt needles
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• This will be individual to each patient, but you
  want to look for these things
• Can you visualize a round hole?
• Does it look well-healed?
• Has the sharp needle been going in smoothly?
• Do not use excessive force when changing to blunt
  needles.
• You may need to rotate the needle slightly while
  advancing down the track.

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A developing buttonhole
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• A ridge is starting to develop.
• A hole is starting to develop.
• This site is not yet ready for a blunt needle.

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Troubleshooting the buttonhole
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• Bleeding can occur around the needles during
  dialysis if
• You are using sharp needles and have cut
  the track.
• The track has stretched because of trying to
  direct the needle instead of following the track.

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Troubleshooting the buttonhole
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• If, after the weekend you have trouble with blunt
  needles, switch to sharp needles for that day,
  being very careful not to cut the track.
• If a site is not progressing, it is ok to abandon
  that site and find another site.
• Some men have very thick blood vessel walls which
  will require the use of sharp needles all the
  time.

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Troubleshooting the buttonhole
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• If your patient is hospitalized, and the acute
  nurses do not know how to access a buttonhole,
  they can rotate sites as long as they stay one
  inch away from the buttonhole tracks.
• If you have blood flow problems and find you are
  close to a dip or curve, simply find another site.

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Buttonholes do not all look alike
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Why offer the Buttonhole Technique?
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• The Buttonhole Technique can
• Prolong AV fistula life
• Decrease hospitalizations related to access
  infections and complications
• Promote patient self-cannulation
• Decrease pain associated with needle cannulation

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Buttonhole Technique
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• A technique
• whose time
• has come

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For more information
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• Lynda K. Ball, RN, BSN, CNN
• Quality Improvement Coordinator
• 4702 42nd Avenue SW
• Seattle, WA 98116
• 206.923.0714 x 111
• 206.923.0716 (fax)
• lball_at_nw16.esrd.net
• www.nwrenalnetwork.org

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