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Development of competencies for the use of bedside ultrasound for assessment and cannulation of hemodialysis vascular access.

BACKGROUND

Bedside ultrasound technology for assessment and real-time cannulation of hemodialysis (HD) vascular access (VA) has become standard of practice in several HD units in Canada and worldwide (Schoch, Du Toit, Marticorena, & Sinclair, 2015). The main goal for embracing this technology is to provide the highest quality vascular access care for patients with end stage renal disease (ESRD) at any stage in the maturation process and with any degree of complexity of the vascular access (Donnelly & Marticorena, 2012).

As with most clinical procedures, the use of bedside ultrasound (US) requires specialized training. In many units, this is currently obtained with a series of didactic sessions and hands-on practice in simulation settings with phantom models prior to its use in the clinical setting with patients. In a collaborative approach, HD vascular access nurses throughout the country performing expanded roles in the use of bedside ultrasound technology identified levels of competency that can assist new users of this technology to practise safely and effectively, taking into consideration the degree of complexity of the vascular access under evaluation.

Basic ultrasound competencies can be achieved by most with daily practice and, as with any other hands-on procedure, "practice makes perfect". It takes approximately 500 cannulations of combined new and complex accesses to achieve the highest level of competencies described in this document (Marticorena et al., 2014).

POSITION STATEMENT

Nurses who have attained advanced competency in the use of bedside ultrasound can function independently and can assess and cannulate accesses of varied complexity to allow for initiation of hemodialysis therapy safely and in a timely fashion. They can troubleshoot cannulation complications and function as mentors for nurses from the basic to the advanced level. The nurses will provide written documentation of their assessment and intervention in the patient's medical record. HD nurses who have attained the highest level of competency, as defined in this document, can be designated as Hemodialysis Vascular Access Advanced Users of Bedside Ultrasound.

TRAINING PROGRAMS

Policies, procedures, and educational programs incorporating ultrasound technology have been developed to assist HD nurses to attain competencies at both local institutional, regional, and provincial levels (i.e., St. Michael's Hospital's Access to Science in Hemodialysis symposia in Toronto since 2004; St. Paul's Hospital's Quarterly Vascular Access Mentorship Course events in Vancouver since 2011; and the University of Ottawa's Vascular Access Update courses since 2013). These educational programs are based on national recommendations (CANNT, 2015) and international guidelines (National Kidney Foundation Kidney Disease Outcomes Quality Initiative, 2006), and include didactic teaching, as well as hands-on sessions with phantom models and in the clinical setting with patients. Validation of the level of competency is done at the local level and under the supervision of an expert user. The trainees receive specialized education and training by local educational modules, by website educational resources, or a combination of both that include: (1) vascular anatomy and physiology (AnatomyZone, 2015), (2) web-based HD vascular access educational modules endorsed by the Ontario Renal Network and available via secure websites at the institutional level, (3) basic ultrasound physics (Hoffman, Rumsey, & Nixon, 2008), (4) operation of the ultrasound equipment, and (5) hands-on clinical assessment and real-time cannulation in accesses of varied complexities. All performance criteria are tested at each level of competency following completion of the training program. Advanced level of competency is achieved when all performance criteria are met at each level of competency described below.

PERFORMANCE CRITERIA AND COMPETENCY LEVELS

To promote and encourage safe use of ultrasound technology in HD, performance criteria and competency levels with their corresponding key skills are presented in this document. HD nurses who have reached an advanced level of competency have the ability to perform vascular access assessment using advanced knowledge and judgment to determine the level of access complexity, as well as to determine whether a cannulation procedure can be performed safely. HD nurses with advanced competency are knowledgeable regarding vascular anatomy and physiology, and surgical and diagnostic imaging procedures. They communicate effectively with all stakeholders (i.e., multidisciplinary team) and are able to mentor other nurses to obtain competencies from the basic to advanced levels.

Basic Competency Level

1. The HD nurse performs complete physical assessment of the access prior to utilizing the portable ultrasound:

* Explains procedure to the patient or to the instructor during practice.

* Demonstrates all three components (i.e., look, listen, and feel) as outlined in the self-learning package:

* Look: Rolls up the sleeve; assesses the entire arm; looks for collateral vessels on forearm, upper arm, and chest wall; looks for redness, swelling, warmth, coolness compared to other arm, bruising, aneurysmal formations, or oozing

* Listen: Uses a stethoscope; starts at the anastomosis and listens to the entire length of the access paying attention to changes in the pitch of the bruit

* Feel: Starts at the anastomosis and uses fingertips to palpate the entire vessel, noting areas that are deep, bulging, narrow, or hard; palpates for the thrill, which should be present at the anastomosis and diminish as the vessel is palpated upstream

* Plans cannulation sites for both arterial and venous needles

2. The HD nurse demonstrates theoretical knowledge of the appropriate use of the portable ultrasound device in the following situations:

* New access assessment: Identifies and correctly describes anastomosis, access depth, diameter, and length of cannulation segment

* Small access diameter on clinical evaluation--diameter should be at least 0.6 cm for optimal cannulation (National Kidney Foundation Kidney Disease Outcomes Quality Initiative, 2006)

* Deep access on clinical evaluation--depth of access should be less than 0.6 cm from skin surface for optimal cannulation (National Kidney Foundation Kidney Disease Outcomes Quality Initiative, 2006) and guide use of the appropriate needle length, i.e., standard 1 in., % in. for shallow depth, and 1 % in. for deeper access (Marticorena & Donnelly, 2012)

* Cannulation of a new access until successfully needled with standard 15-gauge needles

* Assessment for the presence of vein valves, collateral veins or vein branches, or veins that run adjacent to the fistula or graft, which may compromise optimal cannulation

* Tortuous cannulation segments that are challenging to cannulate--the access should have areas of adequate length to accommodate a one-inch needle

* Post-radiological or surgical intervention access assessment, i.e., selection of adequate cannulation area

* Determination of degree of access thrombosis (i.e., absent bruit or thrill, firm to touch, pain) with or without visible erythema

* Suspected access stenosis based on clinical evaluation by palpation and auscultation and on clinical indicators (e.g., change in the trend of dynamic pressures, inability to achieve prescribed blood flow, or decrease in access flow of 25% or greater)

* History of difficult cannulation: multiple infiltrations, multiple needle insertions, or clot aspiration during cannulation

* Location of peripheral venous access for venipuncture for blood draw or intravenous (IV) infusion in patients followed in the chronic kidney disease (CKD) clinic or in peritoneal dialysis with a history of difficult venous access as per hospital policy

3. The HD nurse demonstrates theoretical knowledge of the basic principles of ultrasound and can explain:

* Basic physics in ultrasound use: the transducer as the source of energy and how sound waves are transmitted

* Transducer parts: face, footprint, size, shape

* Images in the screen: B-Mode ("brightness mode", two-dimensional black, white and grey scale images), and Color Doppler Mode (two-dimensional colour image of blood flow)

4. The HD nurse demonstrates theoretical and practical knowledge of the operation of the ultrasound device:

* Positions the ultrasound unit for direct visualization of the screen and maintains a comfortable position for scanning when possible

* Positions the patient in comfortable position when possible

* Turns on ultrasound unit and adjusts depth and gain

* Locates the notch (marker) and tests the position of the probe with respect to the image on the screen

* Understands importance of stabilizing probe on the skin surface: Holds the probe with hand stability and applies adequate pressure to scanning area (maintaining circular shape of vessel in short axis)

* When finished, adequately disinfects and turns off the ultrasound unit and stores the ultrasound following manufacturer's advice

5. The HD nurse demonstrates appropriate knowledge and actions when troubleshooting the ultrasound machine:

* Portable ultrasound will not turn on: Checks that the power cord is plugged into the back of the device; plugs the other end of the power cord into an outlet to charge the device

* Portable ultrasound image is too dark or too light for proper visualization: Adjusts gain or uses "Auto Gain" button if available; uses the quick user guide; reports appropriately to the technical department

* Adjusts the depth for optimal visualization

6. The HD nurse demonstrates theoretical knowledge of three basic probe manipulations and their respective application:

* Sliding: To assess the entire length of the access and locate any structure surrounding the vessel

* Rotation: To change view from short axis to long axis and vice versa

* Compression: To differentiate veins from arteries or determine thrombosis

7. The HD nurse utilizes the portable ultrasound to cannulate a phantom model in real-time in the presence of the instructor (at least 10 times or until all are demonstrated):

* Locates phantom access in short and long axis

* Demonstrates sliding probe manipulation when performing a longitudinal assessment along the cannulation segments of a phantom access

* Demonstrates compression probe manipulation

* Targets vessel in short axis

* Introduces needle in short axis in the centre of the anterior phantom vessel wall

* Locates needle tip in short and long axis

* Demonstrates the rotation probe manipulation from short axis to long axis for needle advancement

* Introduces needle in long axis and advances needle in long axis

* Introduces needle in short axis and advances needle in short axis

8. The HD nurse utilizes the portable ultrasound to cannulate good functioning VA in real time in patients (at least three times in a fistula and three times in a graft):

* Demonstrates sliding probe manipulation for assessment of the cannulation sites

* Demonstrates compression probe manipulation to locate arteries surrounding cannulation sites

* Demonstrates adequate probe positioning to target the vessel and determines vessel direction

* Cannulates access in short axis and advances needle in long axis

* Locates the tip of the needle in short and long axis

9. The HD nurse demonstrates knowledge of infection control practices and disinfection of the portable ultrasound device using disinfectant agents approved by the institutional Infection Control department following the manufacturer's advice and as per institutional policy:

* Examines the portable ultrasound device and probe prior to use for visible signs of blood; if present, thoroughly cleans with approved disinfectant for the ultrasound machine

* Protects ultrasound probe with adequate cover in presence of open wounds, body fluid substance, or potentially infectious skin surface

* When the examination is complete, thoroughly cleans the ultrasound probe and portable ultrasound device

10. The HD nurse demonstrates proper verbal and written communication of the following findings to the corresponding authorities (vascular access coordinator, physician, nurse practitioner, charge nurse, etc.) and documents in the appropriate section of the medical chart:

* Diameter of 0.6 cm or less

* Depth greater than 0.6 cm

* Cannulation segment length less than 6 cm which does not accommodate hemodialysis needles available (needles are % in., 1 in., or 11/4 in. length)

* Hematoma that may compromise successful cannulation

* Stenosis (50% decrease in diameter compared to baseline)

* Thrombosis (indicated by partial or total occlusion of the access with flow verification by colour Doppler)

* Any findings that the nurse feels may compromise successful cannulation

Intermediate Competency Level

1. The HD nurse demonstrates practical knowledge of the operation of the ultrasound for taking measurements, pictures, video clips, and the use of colour Doppler:

* Uses calipers to measure depth, diameter, and length of the cannulation segment

* Determines direction of the vessel

* Identifies areas of uneven depth

* Uses colour Doppler for patency assessment

* Identifies collaterals and/or accessory vessels

2. The HD nurse demonstrates theoretical and practical knowledge of the five basic probe manipulations:

* Sliding: To assess the entire length of the access

* Rotation: To change view from short axis to long axis and vice versa

* Compression: To differentiate veins from arteries or determine thrombosis

* Tilting: To extend the plane of imaging front and back (locates the needle tip in a narrow acoustic window)

* Angling: To extend the plane of imaging side to side (in irregular surface areas such as an aneurysmal formation)

3. The HD nurse utilizes the portable ultrasound to guide cannulation of vessels of irregular depth, diameter, and direction in phantom models in the presence of instructor:

* Targets vessel in short and long axis

* Introduces needle in short axis and advances needle in long axis

* Introduces needle in long axis and advances needle in long axis

* Introduces needle in short axis and advances needle in short axis

4. The HD nurse utilizes the portable ultrasound to cannulate VA in real-time selecting adequate needle size and appropriate angle of insertion in the presence of instructor:

* New fistula: at least ten successful cannulations

* New graft: at least ten successful cannulations

* Tortuous fistula with long cannulation segments (greater than 6 cm)

5. The HD nurse demonstrates accurate understanding of ultrasound images and identifies the following:

* Native vessel wall versus prosthetic graft wall

* Presence of valves

* Collateral vessels or vein branches (indicated by a vessel joining the fistula or branching out of the fistula and that may run underneath, beside or on top of the access)

* Areas of vessel wall calcification or calcified valves

* Presence of implants: coils, stents, surgical staples, metal cannulation guides (VWING)

* Presence of aneurysms or pseudoaneurysms

* Presence of stenosis indicated by a narrowing of the access greater than 50% of the baseline diameter: Uses ultrasound visualization to measure degree of narrowing

* Presence of partial or total thrombosis (unable to feel a thrill or hear a bruit, access very firm to the touch and painful without signs of inflammation or infection)

* Deep access unable to be palpated due to swelling, prior infiltration, or presence of hematoma

* Tortuous access challenging to cannulate (the access should have areas of adequate length to accommodate a one-inch needle, which maximizes the distance between the arterial and venous needles)

Advanced Competency Level

1. The HD nurse utilizes the portable ultrasound to cannulate VA in real time selecting adequate needle size and appropriate angle of insertion for the following in the presence of instructor:

* Small fistula: less than 0.6 cm

* Deep fistula: greater than 0.6 cm

* Tortuous fistula: greater than 6 cm of straight cannulation segments

2. The HD nurse demonstrates advanced theoretical and practical knowledge of the portable ultrasound and identifies different types of artifact:

* Reverberation artifact: repeated image of the same structure multiple times (with dialysis needles in short or long axis)

* Enhancement artifact: visualization of structures that do not exist (a mirage of the same image underneath or beside the scanning area)

* Acoustic shadowing: highly attenuating structures (bone, newly inserted graft, surgical implants)

3. The HD nurse utilizes the portable ultrasound to make measurements (in short axis and long axis) using calipers:

* Edema, seroma, or any fluid collection

* Perivascular hematoma or intramural blood collection

* Thrombus within aneurysms or pseudoaneurysms

* Aneurysmal and pseudoaneurysmal areas

4. The HD nurse utilizes the portable ultrasound to cannulate successfully (in short axis and long axis) in the presence of the following:

* Stenotic areas (50% decrease in diameter or less) compared to baseline

* Thrombosis (indicated by partial or total occlusion of the access) with flow verification by colour Doppler

* Deep access: depth greater than 1 cm

* Marginal access: less than 0.6 cm diameter

* Tortuous access: cannulation segments of greater than 6 cm

* Surgical staples and or other implants (stents, VWING, coils, etc.)

* Hematoma: well defined or diffuse

* Blood extravasation, back wall infiltration, intramural blood leak

* Blood leak during first cannulation (successful cannulation and resolution of blood leak)

* Partial thrombus or fibrin tail

* Areas of gross edema, seroma, or other fluid collection

* New graft: ePTFE, rapid use, Polyurethane

* New HeRO graft

* Avoidance of stented areas

* Identification of arterial and venous imaging sheaths post diagnostic imaging intervention

* Post diagnostic imaging intervention in the presence of a single sheath for hemodialysis (when single needle HD is not available)

* Buttonhole tunnel track location and indication of depth and direction for BH needle insertion

* Cannulation infiltrations and incorrect needle placement requiring needle repositioning to reach target and obtain adequate pump speed during hemodialysis, respectively

* Venipuncture or IV cannula insertion for blood collection or medication infusion in renal patients with very small peripheral vessels

5. The HD nurse has the ability to mentor a novice user of ultrasound and demonstrates the following:

* Holds probe to assist cannulation

* Guides trainee in needle insertion in short and long axis

* Corrects trainee's needle insertion to ensure cannulation is achieved without complications

* Rescues unsuccessful needle placement

6. The HD nurse demonstrates theoretical and practical knowledge in the following measurements with bedside ultrasound:

* Locates tunnel tracks for BH

* Measures VA velocity and volume flow with colour Doppler

* Measures pulse wave velocities

* Measures intimal-media wall thickness

SUMMARY AND CONCLUSIONS

Use of ultrasound for hemodialysis vascular access assessment and real-time cannulation requires specialized training. In order to obtain basic hand-eye coordination, theoretical sessions on ultrasound use, as well as practical sessions using phantom models are recommended prior to its use in the clinical setting with patients. New users of this technology need to consider that all competencies can be achieved with daily use of ultrasound at the bedside. It takes approximately 500 guided cannulations to achieve the highest level of competency described above.

REFERENCES

AnatomyZone (2015). Anatomy zone: Cardiovascular. Retrieved from: http://anatomyzone.com/category/tutorials/cardiovascular/

Canadian Association of Nephrology Nurses and Technologists (2015). Nursing recommendations for the management vascular access in adult hemodialysis patients. Retrieved from http:// www.cannt.ca/member_files/Standards/CANNT-VA%20 Guidelines-2015Oct16.pdf

Donnelly, S.M., & Marticorena, R.M. (2012). When is a fistula mature? The emerging science of fistula cannulation. Seminars in Nephrology, 32(6), 564-571.

Hoffman, B., Rumsey, H., & Nixon, M.S. (2008). Physics and technical facts for the beginner. Ultrasound guide for the emergency physician: An introduction. http://www.sonoguide.com/physics.html

Marticorena, R., & Donnelly, S. (2012). Prolonging access survival: The principles of cannulation. In T.S. Ing, M.A. Rahman, & C.M. Kjellstrand (Eds.), Dialysis history development and promise: Building on knowledge to secure a better future (pp. 185192). Hackensack, NJ: World Scientific.

Marticorena, R.M., Kumar, L., Dhillon, G., Tria, J., Zevart, D., Sirpal, S., ... Donnelly, S.M. (2014). Real-time imaging of vascular access to optimize cannulation practice and education: Role of the access procedure station [Abstract]. Journal of the American Society of Nephrology, 25, 891.

National Kidney Foundation Kidney Disease Outcomes Quality Initiative (2006). Clinical practice guidelines for vascular access--Guideline 3. Cannulation of fistulae and grafts and accession of hemodialysis catheters and port catheter systems. Retrieved from http://www2.kidney.org/professionals/ KDOQI/guideline_upHD_PD_VA/

Ontario Renal Network (n.d.). Vascular Access Assessment and Cannulation Training Video [Video file]. Retrieved from http://www.renalnetwork.on.ca/hcpinfo/body_and_vascular_access/cannulation_training_video/#.VeWil_lViko

Schoch, M., Du Toit, D., Marticorena, R.M., & Sinclair, P.M. (2015). Utilising point of care ultrasound for vascular access in haemodialysis. Renal Society of Australasia Journal, 11(2), 78-82.

ABOUT THE AUTHORS

Rosa M. Marticorena, RN, BScN, CNeph(C), DCE, Graduate Student, Institute of Medical Science, University of Toronto, Clinical Research Coordinator III, Nephrology Research Offices, St. Michael's Hospital, Toronto, Ontario, William Osler Health System, Brampton, Ontario

Linda Mills, RN, CNeph(C), Body Access Coordinator, St. Joseph's Healthcare, Hamilton, Ontario

Kelly Sutherland, RN, CNeph(C),Vascular Access Coordinator, St Joseph's Healthcare, Hamilton, Ontario

Norma McBride, RN, Body Access Coordinator, St Joseph's Healthcare, Hamilton, Ontario

Latha Kumar, RN, MScN (Ed), CNeph(C), Dialysis Access Coordinator, William Osler Health System, Brampton, Ontario

Jovina Concepcion-Bachynski, RN(EC), MN-NP, CNeph(C), Nurse Practitioner--Nephrology, University Health Network, Toronto, Ontario

Carol Rivers, RN, BN(c), CNeph(C), Renal Access Coordinator, Trillium Health Partners, Credit Valley Hospital, Mississauga, Ontario

Elizabeth J. Petershofer, RN, Vascular Access Coordinator, Hemodialysis/Home Dialysis/Nocturnal Dialysis, St. Michael's Hospital, Toronto, Ontario

Joyce Hunter, RN, CNeph(C), Vascular Access Coordinator, Hemodialysis/Home Dialysis/Nocturnal Dialysis, St. Michael's Hospital, Toronto, Ontario

Rick Luscombe, RN, BSN, CNeph(C), Vascular Access Clinical Nurse Leader, Providence Health Care, St. Paul's Hospital, Vancouver, British Columbia

Sandra Donnelly, MSc, MD, FRCP, Corporate Chief of Medicine, William Osler Health System, Brampton, Ontario, Assistant Professor, University of Toronto, Toronto, Ontario. Scientist, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario

Address for correspondence: Rosa M. Marticorena, William Osler Health System, 2100 Bovaird Dr. East, Brampton, ON L6R 3J7. Tel: 905-494-2120 ext 57989; Email: rosamyrna.marticorena@wilHamoslerhs.ca
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Title Annotation:PRACTICE CORNER
Author:Marticorena, Rosa M.; Mills, Linda; Sutherland, Kelly; McBride, Norma; Kumar, Latha; Bachynski, Jovi
Publication:CANNT Journal
Article Type:Report
Geographic Code:1CONT
Date:Oct 1, 2015
Words:3404
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