A Multi-Center Perspective of the Buttonhole Technique in the Pacific Northwest


Lynda K. Ball
Lynne Treat
Virginia Riffle
Dennis Scherting
Liz Swift

The buttonhole technique, a method of needle insertion for native arteriovenous fistulas (AVFs) in which needles are placed in the same two sites each treatment using the same angle, has been utilized for nearly 30 years in Europe and Japan, but has been used only minimally in the United States. The purpose of this article is to share the outcomes of several facilities that are using the buttonhole technique in the Pacific Northwest.

These facilities are part of the Northwest Renal Network #16 (serving Alaska, Idaho, Montana, Oregon, and Washington), which has 59.4% of prevalent patients with AVFs. Currently 38% of facilities are utilizing this technique. Four providers volunteered to share their data on the buttonhole technique as part of the Fistula First project. The data shows that the buttonhole technique is a safe, viable option with less complications and increased patient satisfaction for patients with AVFs.

Development of a Buttonhole AVF Cannulation Program
FMC – Lacey (Formerly RCG of the Northwest)
Lynne Treat, BSN, RN, CNN, Staff Nurse
Effective functioning of an AVF depends on the size and viability of the renal patients’ blood vessels chosen by the surgeon for AVF creation, and on the surgeon’s technical expertise in vascular access surgery. The continued effectiveness of the vascular access, however, depends on the way in which the access is cannulated by hemodialysis staff. There are two main methods for cannulation of the AVF: rotation of puncture sites (rope ladder) or constant-site (buttonhole) cannulation. In our practice area, assessment of the patient’s AVF is carried out by the dialysis access team, which consists of the vascular surgeon, nephrologist, RN, and patient care technicians (PCTs).

First, the dialysis access team comes to consensus about the maturity of the AVF and its readiness for cannulation. Once the AVF is deemed ready to be used for dialysis, the team makes a recommendation regarding a cannulation plan (site rotation vs. buttonhole), and the nephrologist includes this plan in his orders for the dialysis treatment. The first cannulation of an AVF is assigned only to experienced dialysis nurses and/or patient care technicians with superior access cannulation skills, to avoid trauma to the fragile access.

If a site rotation plan is used, the puncture sites are moved sequentially along the length of the AVF, with needles placed at least one inch apart, to avoid blood recirculation during dialysis. The patient is taught about the importance of site rotation, and informed to remind each person doing cannulation about the rotation plan. AVF diagrams in the “access module” of a computerized documentation program assists staff members in “mapping” planned cannulation sites. An alternative option is to draw an access “site map” to be kept on a patient’s clipboard for quick consultation before access cannulation.

If a buttonhole cannulation plan is ordered, additional staffing considerations are necessary. Angles of insertion will vary between staff. To form a consistent, constant site track, the same expert is scheduled for all of the days in which the patient receives dialysis for the first 2 to 3 weeks. The cannulator uses two conventional sharp-beveled fistula needles to form two cannulation tracks or small “tunnels,” not unlike those seen in pierced earlobes. Once the cannulation tracks are formed, then blunt-beveled (buttonhole) needles are used, and any dialysis caregiver can access the buttonhole sites.

Staff members must take care to prevent the incidence of “one-site-itis,” or multiple punctures within the same small area of the AVF. This lapse in technique will cause the development of aneurysms (“ballooned-out” areas) with neighboring areas of stenosis (narrowing), leading to blood recirculation during dialysis and, ultimately, clotting of the access. While it was important to utilize “best cannulators” for new AVFs and to establish buttonhole sites, we find it equally important to mentor newer staff members, pairing them with the expert staff members to observe the cannulation process.

Kandy Collins, a nephrology nurse who has worked primarily in acute hemodialysis, initiated the buttonhole cannulation program in our practice area in 1996. She read the article written by Dr. Zbylut Twardowski (1995) titled “The Constant Site Method of AV Fistula Cannulation” regarding the use of the buttonhole method. She obtained an order from the nephrologists to use this method for AVF access cannulation. When the Chehalis (WA) facility opened in 2002, this acute dialysis nurse taught the buttonhole technique to all the dialysis staff. The dialysis staff then formed a continuous quality improvement (CQI) team for implementation of a buttonhole cannulation program (see Table 1), and developed the action plan seen in Table 2.

The dialysis staff member assesses the AVF access for the bruit and thrill. Then the patient thoroughly scrubs the access area for 2 minutes prior to being seated in the dialysis chair. While predialysis weight and vital signs are being checked, the dialysis staff member places sterile gauze moistened with normal saline over each buttonhole site, gently securing the gauze in place with paper tape. This process moistens and loosens any scab material at the buttonhole site and then the gauze is used to gently remove the scab. Finally, the cannulation sites are disinfected per facility protocol, allowing the disinfectant to dwell for the appropriate time noted in the access cannulation policy.

Outcomes. Buttonhole cannulation began with four patients. At the time of this article, 60% of the 42 patients with AVFs are using buttonhole access. The review of data for patients with buttonhole access, as compared to those patients using AVFs with a site rotation protocol, found there to be no increase in the access infection rates or the need for angioplasty intervention to treat stenosis or thrombosis.

One difference between results of the rope ladder versus buttonhole cannulation method is a significant difference in the access infiltration rates: 7% for the site rotation method and 0% for the buttonhole method. Another difference observed in our unit is the amount of time to achieve hemostasis at the needle puncture sites after fistula needle removal: an average of 8  minutes for the rotated sites compared to an average of 5 minutes for the buttonhole sites (see Table 3). There was no observable aneurysm formation at the buttonhole cannulation sites.

The greatest difference,however, involves a more subjective factor – that of patient satisfaction. When patients with a buttonhole access were surveyed regarding satisfaction with the cannulation procedure, there was 100% agreement that the buttonhole technique increases the ease and decreases the discomfort of access cannulation, compared to cannulation with sharp-beveled needles. Staff members also express increased satisfaction, especially as it relates to the ease of removal and safety of using blunt-beveled (buttonhole) needles that eliminate needle stick injuries without the need for the protective needle sheath, which is necessary for safe use of sharp-beveled needles.

Discussion. The buttonhole technique is not necessarily the best method for every patient. It is very useful, however, in patients with very short AVF access and in patients with maturing and fragile vascular access sites. A successful buttonhole cannulation program requires the utilization of an access manager, as well as a routine vascular access monitoring regimen, which includes physical assessment of the AVF (bruit and thrill), venous pressure monitoring, and intra-access blood flow monitoring.

Useful tools in the development of access cannulation skills include the Constant Site Method of Cannulation by Medisystems Corporation (2004) and Dr. Twardowski’s video, “The Buttonhole Technique for AVF Cannulation” (2000). In addition, the Northwest Renal Network offers a very effective cannulation instruction program with “hands-on” experience (Ball, 2004; Northwest Renal Network 2004). Effective surgical creation of AVF vascular access and a quality access cannulation program helps increase the use of AVFs in this dialysis practice area to approximately 80%, the result of almost a decade of collaboration among the members of the vascular access planning team (Trea, Seagrove, Griffith, & Nguyen, 2005).

A Plan to Prevent Aneurysms, Samaritan Dialysis Centers
Corvallis and Lebanon, Oregon
Virginia Riffle, RN, CDN, Vascular Access Manager
Samaritan Dialysis Services initially began using the buttonhole technique for patients with AVFs who had a limited area to cannulate or those with an aneurysm to prevent the aneurysm from enlarging. There had been a few cases in the past where a fistula had to be ligated due to a rapidly enlarging aneurysm. We wanted to prevent this problem from recurring in other patients.

As the buttonhole procedure was implemented in the units, there was slight resistance from some staff members to the change. Now that we have been doing buttonhole for some time, there are no complaints from the staff. Some staff members believe that it takes slightly more time to do the buttonhole procedure, due to the removal of scabs, but not enough that they feel it is problematic to the turnover schedule or is noticeable to the patients. As we successfully implemented the procedure, some patients began requesting to have buttonhole cannulation, either from their own past experience of having problems with cannulations or from hearing other patients talk about less pain and longer access life.

The problem we have experienced in implementing the buttonhole procedure has been in regards to having a staff member consistently scheduled with a certain patient long enough to establish a buttonhole track. We have found that it takes longer than six consecutive sticks, as cited in the European literature, and usually takes 10 or more cannulations. We have two dialysis centers with staff members rotating between them, and, at times, we have requested a volunteer to agree to work Saturdays until the buttonhole tunnel is established. We will sometimes temporarily transfer a patient to a different dialysis shift to meet the staff member’s schedule. Our Lebanon unit charge nurse has come in on her days off to do sticks, as she is very enthusiastic about the buttonhole procedure and is working on getting 100% of the AVFs in her unit on buttonhole cannulation by 2006.

At the time of this report, we have 15 patients with functioning fistulas (47% buttonholes) at the Lebanon unit and 22 functioning fistulas (27% buttonholes) at the Corvallis unit. After consulting with staff and patients regarding infiltrations and multiple needle sticks, it was widely recognized that the buttonhole procedure helps alleviate both of these problems. In an informal survey, the patients have reported that they experience less pain with the buttonhole technique. Occasionally, there is difficulty switching to blunt needles, and we have one patient who sometimes complains of pain, but if we carefully stay with sharp needles, then that problem is alleviated.

It is well documented that the infection rate in AVFs is less than grafts and catheters, as has been our experience. We have experienced one buttonhole site that developed a superficial infection. The infection was treated with oral antibiotics until the site healed, at which time buttonhole cannulation resumed. There has been no observable evidence of aneurysm formation at the buttonhole sites.

As our nephrologists and dialysis staff members continue to encourage our surgeons to place fistulas whenever possible, we will have some challenging fistulas to cannulate. These fistulas will need to be protected and preserved, and the buttonhole technique helps us attain these goals.�

The Buttonhole Technique and the Development of a Patient Satisfaction Survey
Puget Sound Kidney Centers, Everett, WA
Dennis Scherting, BSN, RN, CNN, Nurse Manager, Clinical Education  
At the Puget Sound Kidney Centers (PSKC) in Everett, WA, the buttonhole technique was introduced in the Fall of 2003. Interest in this procedure was initiated by the conversations with a vendor at the 2003 ANNA National Conference in Chicago earlier that spring. Through the summer, information was gathered from a number of sources. It was remarkable to discover that this process had quite a history, dating back into the 1960s.

In our four facilities, PSKC (73% AVF rate), PSKC-South (61.9% AVF rate), PSKC-Smokey Point (64.9% AVF rate), and PSKC-Whidbey Island (70% AVFs), all patient care procedures are reviewed and approved by the Medical Director. With information coming to a number of individuals from a number of sources, we had some difficulty settling on an acceptable approach as our standard. Perhaps the greatest obstacle - the same person establishing the buttonhole track- did not have to be addressed. At PSKC, most of the patient care staff work three 13-hour shifts, usually M-W-F or T-Th-S. They care for the same patients for a 3-month period then will move to a new area.

As we initiated the buttonhole technique, staff members were excited to institute something new. There were a few patients with whom we had difficulty establishing buttonhole tracks in the “standard” 10 sticks with sharp needles. Moving to blunt (don’t use the word “dull”) needles proved difficult, because we made the switch too soon. The time to establish the buttonhole must be individualized. Otherwise, when moving too quickly, one runs the risk of making a conical track, not one shaped like a tube. Bleeding difficulties and higher infection rates can occur. In light of these troubles we increased our standard to 14 sharp sticks.

Another issue that arose unexpectedly related to placing the blunt needle in an established buttonhole on the proximal forearm. In several patients, the skin was readily movable and the subcutaneous tissue loose or thick with loss of skin elasticity. This occasionally caused difficulty with the alignment of the skin puncture site and the vessel hole. There was need to gently “search” for the vessel buttonhole so the blunt needle could be properly placed using reasonable pressure to enter the vessel. At times, the vessel hole could not be found, and a sharp needle was placed elsewhere. There was no aneurysm formation noted at buttonhole sites.

 

A patient survey was designed and sent to all patients with buttonhole access (61) with a 75% response rate. Figure 1 shows that 70% of the patients experienced less pain, and 20% felt no difference in pain with the buttonhole technique. Sixty-three percent of patients responded that it took less time to insert buttonhole needles than conventional needles (see Figure 2). More new patients (less than 1 year) were buttonholed than those patients in their second year of dialysis, but there were no comments to explain why this pattern emerged. Did doctors prefer this for their new patients? Were newer patients more open to trying a different technique? Did patients come to dialysis with knowledge of this alternative technique (see Figure 3)? The responses regarding complications (see Figure 4), which are probably the most important from the patient’s perspective, indicate that this technique decreased events of missed sticks and infiltrations substantially. And finally, 94% of the patients were satisfied with the buttonhole technique (see Figure 5). It would have been interesting to survey the entire population of patients whose accesses were cannulated to ascertain comparative data between the two cannulation techniques.

A stable buttonhole process is also a great stepping-stone for suggesting the patients place the needles themselves. The staff can offer training and guidance to those patients who express an interest, and also use the patients who self-cannulate, to act as mentors and share their experiences.

Program Development: Challenges and Successes
Skagit Valley Kidney Center, Mt. Vernon, WA
Liz Swift, BSN, RN, CNN, Clinical Educator
When starting our buttonhole program, our clinical educator came in and performed all of the preliminary sticks and worked with the Network to create a log sheet for documentation of the process and any associated problems (see Table 4). This system became very cumbersome, as this individual would have to come in before and after work, as well as on days off. After the first four or five buttonholes were established, the staff members were polled to see how many would be interested in learning to create new buttonholes.

In-service education programs on the new procedure and protocols were offered to all staff, and procedures were written and put into effect to assure continuity of the buttonhole cannulation process. Unfortunately, the staff at the kidney center did not want to work the every-other-day schedule that the patients do, so staffing was a problem, and having people come in on their time off was not practical or fiscally responsible.

In an unrelated turn of events, our patient care technicians changed to 8-hour days, 5 days per week, from the previous four 10-hour shifts. This new schedule allowed more consistency during the creation of the buttonhole tracks. When the technician is off on a day that the patient is dialyzing, other staff members do not use the buttonholes for that treatment. The practice is to have the same cannulator until the switch is made to blunt needles, and there really are no exceptions to this rule. We tried several times to have more than one person working on track creation, and it ended up with dead ends and cannulation problems after switching to blunt needles. I believe that creating a track that is consistent by finding a way to have the same cannulator each time is the key to success with the Buttonhole Technique.

Table 5 summarizes the challenges and the successes we have seen at our facility. Surveying your patients and staff will allow you to identify how to proceed with your buttonhole program.

Summary
From the information in this article, there appear to be several areas for improvement when choosing the buttonhole technique for AVF cannulation.

• Standardized education is needed, because creation of the track in the buttonhole technique is different from cannulation using site rotation (Ball, 2006).
• A continuous quality improvement (CQI) process will enable nurses to track cannulation techniques separately, looking at infections, missed sticks, infiltration/hematoma, aneurysm formation, and patient satisfaction.
• The experience of these four facilities suggests that staffing patterns are a major barrier in beginning a buttonhole cannulation program. A staffing plan would be beneficial prior to starting a buttonhole program. Who will train the staff members in the buttonhole technique? How many staff will be buttonhole cannulators? Are staff members willing to alter their work schedules to match a patient’s dialysis schedule? When the buttonhole program begins, how many patients can initially be offered the option?

References
Ball, L.K. (2004). Using the buttonhole technique for your AV fistula. Retrieved February 15, 2007 from http://www.nwrenalnetwork.org/fist1st/fist1st.htm .
 
Ball, L.K. (2006). The buttonhole technique for arteriovenous fistula cannulation. Nephrology Nursing Journal, 33(3), 299-305.

Marticorena, R.M., Hunter, J., MacLeod, S., Petershofer, E., Dacouris, N., Donnelly, S., et al. (2006). The salvage of aneurismal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators. Hemodialysis International, 10, 193-200.

Medisystems (2004). Constant-site cannulation with buttonhole® needles. Seattle, WA : Author.

Northwest Renal Network (2004). Cannulation resources. Retrieved February 15, 2007 from http://www.nwrenalnetwork.org/fist1st/ffcannu.htm.

Treat, L., Seagrove, D., Griffith, C., & Nguyen, V. (2005, January/February). Strategies to increase AV fistula use in a community-based nephrology practice. National Kidney Foundation Chronic Kidney Disease Best Practice Newsletter, 2(1).

Twardowski, Z. (1995) Constant site (buttonhole) method of needle insertion for hemodialysis. Dialysis & Transplantation, 24, 559-560.

Twardowski, Z.. (2000). Buttonhole method of needle insertion into AV fistulas. Columbia, MO: University of Missouri-Columbia (Executive Producer).