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Use of Ultrasound Guidance During Cannulation of Arteriovenous Fistulas.

Individuals with end stage renal disease (ESRD) overwhelmingly choose outpatient hemodialysis as their renal replacement therapy (United States Renal Data System [USRDS], 2017). Most patients on hemodialysis (62.7%) use an arteriovenous fistula (AVF) for access, with 17.7% using an arteriovenous graft (AVG), and 19.4% using a central venous catheter (CVC) (USRDS, 2017). AVFs are the most optimal vascular access for hemodialysis due to their high durability, low infection risk, and low rate of interventional procedures needed to maintain patency (Pisoni, Zepel, Port, & Robinson, 2015).

The way needles are inserted (cannulation) into an AVF/AVG plays a role in the longevity of the access (Parisotto et al., 2014). Cannulation methods currently used are rope ladder, buttonhole, and same site. Research comparing these techniques for insertion pain, prevalence of missed cannulation, prevalence of pseudo-aneurism development, and potential for infection is abundant (Parisotto et al., 2014; Santoro et al., 2014; van Loon, Kessel, van der Sande, & Tordoir, 2009b).

Ultrasound-guided cannulation to establish peripheral intravenous (IV) access can decrease the number missed cannulations and time to successful cannulation (Brannam, Blaivas, Lyon, & Flake, 2004; Brauman, Braude, & Crandall, 2009). Ultrasound use can also increase user confidence for successful cannulation (Blaivas & Lyon, 2006; Brannam et al., 2004, 2009). However, literature regarding the impact of using ultrasound guidance during the cannulation of AVFs and AVGs is scarce.

Purpose and Objectives

Purposes of this project were to:

* Determine if ultrasound-guided cannulation of AVFs decreased the number of missed cannulations.

* Determine staff and patient perceptions regarding cannulation.

* Initiate a quality incentive program (QIP) to implement an evidence-based ultrasound-guided policy and procedure, training program, and competency evaluation at a hospital-based hemodialysis facility.

The project included an evaluation of patient and staff perceptions regarding ultrasound-guided cannulation and data collection from electronic medical records (EMRs) for patients on hemodialysis comparing the number of missed cannulations pre-ultrasound availability to post-ultrasound availability.

Background

Types of Dialysis Accesses Requiring Cannulation

AVFs are the optimal vascular access for hemodialysis. Unfortunately, AVFs are more difficult to place, have a 35.9% failure rate, and for those that successfully mature, require an average of 132 days to maturation (USRDS, 2017).

AVGs are the second most desirable access type. AVGs can be cannulated earlier after creation than AVFs, but are 3.8 times more likely to thrombose and require thombectomy, and are 3.0 times more likely to require access intervention to maintain patency compared to a fistula (Oliver, 2015). They are also more prone to infections than fistulas (10% versus 5% over course of use), and AVG infections may require removal of the AVG whereas AVF infections usually respond well to antibiotics (Oliver, 2015).

Missed Cannulations

Preservation of an access, prevention of access infections, and successful cannulation with minimal attempts are major concerns for nephrology professionals. Parisotto and colleagues (2014), in a retrospective study, determined that cannulation techniques influence AVF and AVG survival. Errors in cannulation can result in damage to the AVF or AVG. The most common error in cannulation is infiltration. Several studies have found that AVFs are two times more likely to suffer missed cannulations compared to AVGs (van Loon et al., 2009a, b). During a five-year period, Lee, Barker, and Allon (2006) found a 5.2% annual rate of major infiltration during cannulation. A major infiltration is defined as an infiltration that resulted in a large hematoma that precluded fistula use until resolution of the hematoma (Lee et al., 2006). New AVFs (less than six months in age) had a greater chance of suffering an infiltration than older, more established AVFs. Lee and colleagues (2006) found that missed cannulations could lead to hematoma formation and extravasation that, in turn, make subsequent attempts to cannulate difficult. A patient with a compromised access from a hematoma and/or extravasation is at greater risk for shortened or skipped hemodialysis treatments until the access heals sufficiently to allow cannulation (Lee et al., 2006). These patients are also at greater risk for placement of a CVC as a bridge access until the AVF or AVG heals (Schnoch, du Toit, Marticorena, & Sinclair, 2015). CVCs, compared to AVFs, have an adjusted relative hazards of death rate of 1.5 (95% Cl 1.02.2) (Oliver, 2015).

Use of Ultrasound Guidance

Literature regarding the use of ultrasound guidance during cannulation of AVFs and AVGs is scarce. No randomized control study research could be found on this topic. Ultrasound use during insertion of peripherally inserted central lines and peripheral IV access is available. Ultrasound use within emergency departments demonstrated an increase in the percentage of successful peripheral vein cannulations (Blaivas & Lyon, 2006; Brannam et al., 2004; Brauman et al., 2009). Ultrasound use has also demonstrated a decrease in the time to successful cannulation and an increase in the first attempt success rate during placement of CVCs (Dolu, Goksu, Sahin, Ozen, & Eken, 2015).

Methods

Project Design

Utilizing Roger's Innovation Diffusion Theory (Langley et al., 2009) and Kotter's Change Management Model (Webster & Webster, 2018), this project's purpose was to develop and implement an evidence-based policy and procedure related to ultrasound-guided cannulation of AVFs and AVGs. Data to determine the effect of ultrasound guidance on the number of missed cannulations were collected from the EMRs of 53 patients on hemodialysis. Patient perceptions regarding ultrasound-guided cannulation was examined. The structure, process, and outcomes as they related to access cannulation were reviewed to guide a practice change and policy development in a hospital's hemodialysis department. Results of this project may suggest a change in practice for hemodialysis access cannulation or at least support further research into the use of ultrasound-guided cannulation.

Setting

This project took place in a hospital-based hemodialysis department. The department has 13 dialysis stations. Twelve stations are located in a large unit that has half walls and privacy curtains separating the hemodialysis stations from each other.

Sample/Participants

The hemodialysis center provided an average of 554 outpatient hemodialysis treatments per month; 69% of the patients received treatment through an AVF and 6.9% through an AVG during the data collection phases. Inclusion criteria included use of an AVF for hemodialysis access during the study period phases. Additional data gathered included diabetes status and age of patients, age of the AVF, and years of cannulation experience of staff on the date of the missed cannulation.

Procedures

Approval Process

The project was a requirement for a Doctorate of Nursing Practice (DNP) program; therefore, approval was obtained from the university's Institutional Review Board. Letters of support were obtained from the medical director of the hemodialysis department and the dialysis department director. Approval was obtained from the hospital Ethics Committee that monitors HIPAA compliance. Patient and staff consent forms were created with guidance from the university's Institutional Review Board consent form guidelines.

Questionnaires

Questionnaires to obtain data regarding patient and staff perceptions on the use of ultrasound-guided cannulation were developed using closed-ended questions. The patient questionnaire consisted of 17 questions (see Table 1). Ten questions utilized a 5point Likert scale with response options ranging from 5 (strongly agree) to 1 (strongly disagree); a response of 3 corresponded to "uncertain." Two of the remaining seven questions elicited a "yes" or "no" response regarding the use of topical and/or injected subdermal lidocaine for pain control pre-needle insertion. The remaining five questions were used to collect data regarding the number of missed cannulations, use of the ultrasound-guided cannulation technique, and the impact on treatments caused by missed cannulations (delayed and/or interrupted treatment and/or bruised access).

The staff questionnaire consisted of 17 questions (see Table 2). Ten questions utilized a 5-point Likert scale with response options ranging from 5 (strongly agree) to 1 (strongly disagree); a response of 3 corresponded to "uncertain." The remaining seven questions helped collect data regarding the number of missed cannulations, use of ultrasound-guided cannulation technique, and the impact of missed cannulations on patients (delayed and/or missed treatment and/or bruised access).

Participation was voluntary. Patients, after explanation of the survey's purpose, were offered the option to participate during their hemodialysis treatment. Staff members were approached at staff meetings, and after an explanation of the survey's purpose, were requested to complete the survey. The completed surveys were kept in a locked box at the nurses' station.

Electronic Medical Record Review

Treatment information for each chronic outpatient hemodialysis treatment was electronically entered into an EMR. Patients who met inclusion criteria were assigned a number. The list of patients' names and associated numbers were kept in a secure electronic document. After consulting the university's Statistical Consulting Center, the recommended major variables assessed were:

* The date of the missed cannulation.

* The age of the AVF at the time of missed cannulation.

* The age of the patient.

* The patient's diabetes status.

* The number of successful cannulation attempted during each phase.

Data collection occurred during three phases. Phase 1, the six months immediately preceding the purchase of a bedside ultrasound machine for the hemodialysis department, occurred from October 1, 2013, to March 31, 2014. Due to the extended period between the purchase of the ultrasound machine and the implementation of this project, Phase 2 was divided into two phases. Phase 2A, the six months immediately post purchase of the ultrasound machine, occurred from April 1, 2014, to September 30, 2014. Phase 2B, the seven months immediately prior to the implementation of the ultrasound-guided cannulation policy and procedure, training program, and competency evaluation process, occurred from January 1, 2017, to July 31, 2017 Phase 3, the three months post-introduction of the ultrasound-guided cannulation policy and procedure, training program, and competency evaluation period, occurred from August 1, 2017, to October 31, 2017.

Analysis

Data from each EMR phase were manually entered into Microsoft Excel. The university statistical department analyzed data used to answer the following questions:

1. Did the presence of the bedside ultrasound machine affect the number of missed cannulations?

2. Did the introduction of the ultrasound-guided cannulation policy and procedure and training program affect the number of missed cannulation?

3. Was the diabetes status of the patient associated with miscannulation?

4. Was the age of the AVF associated with missed cannulation?

5. Was the age of the patient associated with missed cannulation?

6. Was the experience of the cannulator (nurse) associated with missed cannulation?

Data from the completed patient and staff surveys were manually entered into Microsoft Excel. No implausible entries (missing answers) were discovered among the Likert-type questions; however, some were noted among the quantitative questions. Descriptive statistics were used to summarize results of the questions. To address the question regarding staff and patient perceptions of ultrasound-guided cannulation, responses were computed using a mean (M) score with standard deviation (SD) for each of the 10 Likert scale questions.

Results

Findings

Demographic information for participants and cannulators is shown in Tables 3, 4, and 5. During Phase 1, 34 patients met inclusion criteria. Nineteen patients had diabetes, and 15 did not. Patient ages ranged from 30.9 to 84.1 years (M = 64.7, SD = 11.97). The age of AVFs ranged from 58 to 2,583 days (M = 763.08, SD = 664.02). Years of cannulation experience among cannulators ranged from 6 months to 25 years (M = 9.31, SD = 7.94).

During Phase 2A, 38 patients met inclusion criteria; 21 with diabetes and 17 without. Patient ages varied from 31 to 84 years (M = 65.08, SD = 11.42). The age of AVFs ranged from 50 to 2,897 days (M = 96.15, SD = 815.85). Years of cannulation experience among cannulators ranged from 9 months to 25 years (M = 9.35, SD = 789).

During Phase 2B, 25 patients met inclusion criteria; 14 had diabetes, and 11 did not. Patient ages varied from 34 to 81 years (M = 6755, SD = 10.13). The age of AVFs ranged from 40 to 3,576 days (M = 1181.03, SD = 1197.96). Years of cannulation experience among cannulators ranged from 1 to 28 years (M = 9.22, SD = 8.40).

Between Phases 2B and 3, a large shift occurred from patients dialyzing in-center to patients dialyzing at home. At the conclusion of Phase 3, 52% of the dialysis facility's patient population on hemodialysis was dialyzing at home. Therefore, the number of patients meeting inclusion criteria for Phase 3 declined to 17 patients. Eleven had diabetes, and six did not. Patient ages varied from 34 to 79 years (M = 67.06; SD = 2.71). The age of AVFs ranged from 287 to 3,778 days (M = 1164.56; SD = 1221.57). Years of cannulation experience among the cannulators ranged from 1 to 28 years (M = 9.22; SD = 8.40).

Fourteen patients met inclusion criteria during the patient survey process. Inclusion criteria included AVF as primary access and cognitive ability sufficient to comprehend survey questions. The 14 patients who met criteria for inclusion were approached individually during their hemodialysis treatment, the informed consent was read to each individual patient, questions were answered, and each qualifying patient was given the opportunity to complete a Likert-scaled survey (see Table 1). Seven patients completed the survey and returned it to a locked box located at the nurses' station.

Twelve staff members who cannulated accesses were educated about the project during a staff meeting in which the informed consent was read, questions were answered, and staff were given the opportunity to complete a Likert-scaled survey (see Table 2). Nine staff members completed surveys and returned them to a locked box located at the nurses' station.

For this project, answers to two questions were sought. The first question was whether the ultrasound-guided cannulation of AVFs decreased the number of missed cannulations. The second question asked for staff and patient perceptions regarding cannulation. Results of staff and patient surveys and data analysis of missed cannulations are presented in the following categories:

* Staff perceptions with staff survey responses for quantitative and Likert scale questions.

* Patient perceptions with patient survey responses for quantitative and Likert scale.

* EMR data analysis of missed cannulations for each collection phase by diabetes status and total patient population.

* Observational data on the effects of patient and fistula age on missed cannulation.

Staff Perceptions

Nine out of 12 staff members (75%) completed and returned the staff survey. Data relied on memory recall of staff members who completed the survey. The Likert scale survey items were analyzed at the interval measurement scale (mean) using a score of 5 (strongly agree) to 1 (strongly disagree). See Tables 6 and 7 for further details of obtained responses.

Patient Perceptions

Seven out of 14 eligible patients (50%) completed and returned the patient survey. Two questions elicited either a yes or no answer. Quantitative data relied on memory recall of patients who completed the survey. The Likert scale survey items were analyzed at the interval measurement scale (mean) using a score of 5 (strongly agree) to 1 (strongly disagree). See Tables 8 and 9 for further details of obtained responses.

EMR Data Analysis of Missed Cannulations

Per the university's lead statistician, in order to detect causation, the sample size had to consist of at least 1,900 cannulation attempts for Phase 1 to Phase 2, and 1,500 cannulation attempts from Phase 2 to Phase 3.

There were three phases of data collection from the included patients' EMRs. The date, ages of the AVF and the patient, the patient's diabetes status, and years of cannulator experience were gathered for each date the patient suffered a missed cannulation. Variables assessed were number of failures and successes, and the point estimate of proportion of failure comparing patients with diabetes to those who did not have diabetes (see Table 10). Table 11 summarizes the total number of missed cannulations, and Figure 1 is a graphic representation of the missed cannulations by study phase.

Observation of data noted a clustering of missed cannulations occurring on the same patients during Phase 1 and Phase 2A. Three patients suffered greater than 10 missed cannulations each during Phase 1, and two patients suffered greater than 10 missed cannulations each during Phase 2A.

Observational Data on the Effects of Patient and AVF Age on Missed Cannulation

Data collected appear to support findings of Kamata, Tornita, and Iehara (2016) stating that new AVFs (less than 6 months in age) had a greater chance of suffering an infiltration than older, more established AVFs. Table 4 demonstrates that patients with no or one missed cannulation had older AVFs than those who suffered two or more missed cannulations. Patient age also affects the AVF cannulation success rate (Kamata et al., 2016). Table 3 demonstrates that patients who had no missed cannulations were typically younger than those who did. During data collection periods, 18 different cannulators accessed AVFs. Cannulator experience plays a role in cannulation success, although some cannulators can stay in a state of "perpetual novice" (Harwood, Wilson, & Oudshoorn, 2016). Phases 1 and 2A had 13 different cannulators. Phases 2B and 3 had 18 different cannulators. Years of cannulation experience varied from less than one year to 28 years (M = 9.22, SD = 8.40). Table 5 examines the effects of cannulator experience on missed cannulations. Cannulators with less than five years of experience had the greatest percentage of missed cannulations. Variation occurred during phases 2B and 3 in which cannulators with 22+ years of experience had 37.93% of missed cannulations. A possible explanation for this could be that the most experienced cannulators were those cannulating the most difficult accesses.

Discussion

Ultrasound-guided cannulation to establish peripheral IV access can decrease the number of missed cannulations and the time to successful cannulation of the patient access (Brannam et al., 2004; Brauman et al., 2009). Ultrasound use can also increase user confidence for successful cannulation (Blaivas & Lyon, 2006; Brannam et al., 2004; Brauman et al., 2009). This cannulation technique is well suited for the hemodialysis population.

Summary of Results: Patient and Staff Surveys

Patients received an average of three treatments per week, with two cannulation attempts per treatment (one needle for arterial access and one for venous return), or equivalently 12 treatments with 24 cannulation attempts per month. Seven patients would have had approximately 84 treatments. If ultrasound-guided cannulation were utilized 32 times for the approximately 84 attempts, this would be a patient-reported usage rate for this cannulation technique of 38%. Staff who cannulate reported a 56% usage rate for all patients. Implausible responses were noted within the patient bruising question because there were no missed cannulations during the last month, but there were 10 reported incidences of bruising due to missed cannulation. Perceptions of staff cannulators and patients varied. Staff cannulator responders felt cannulation skills varied among nurses more than patient responders felt they varied (staff M = 4.11, SD = 0.33; patients' M = 3.14, SD = 1.77). Staff cannulator responders were also more familiar with ultrasound availability than patients who responded (staff M = 4.44, SD = 0.53; patients' M = 3.86, SD = 1.46). Staff cannulator responders also felt there were fewer missed attempts if ultrasound-guided cannulation was used compared to patient responders (staff M = 4.33, SD = 0.87; patients' M = 3.43, SD = 0.98). Self-reported proficiency by staff also varied from patient perception of proficiency (staff M= 4.22, SD = 0.53; patients' M = 3.57, SD = 0.98). Staff responses to questions regarding training and the existence of a policy and procedure demonstrated a need for both elements (staff M = 3.67, SD = 1.12; and M = 2.78, SD = 1.09, respectively).

Summary of Results: Missed Cannulations

Patients with diabetes appeared to have fewer missed cannulations after the introduction and availability of the ultrasound machine, with a decrease in proportion of failure from 22 per 1,000 to 1.3 per 1,000 from Phase 1 to Phase 3. There was more variability in missed cannulations among patients who did not have diabetes. During Phases 1 and 2B, patients with diabetes had a greater risk for missed cannulations than patients who did not have diabetes. From Phase 1 data, we would expect patients with diabetes to have 15.3 more missed cannulations per 1,000 cannulations than patients who do not have diabetes. From Phase 2B data, this expected number would be 0.6 per 1,000 cannulations. Phases 2A and 3 had a lessened chance of patients with diabetes having missed cannulations.

Impact of Patient and Fistula Age and Cannulator Experience

During each phase, more patients experienced no missed cannulations than patients who did experience missed cannulations (52.94%, 73.68%, 56.00%, and 76.47%). Within data collection phases, patients who were younger experienced fewer missed cannulations than older patients. Fistula age appeared to be related to the number of missed cannulations, with younger fistulas experiencing more missed cannulations than older ones. These findings coincided with the research of Kamata and colleagues (2016). During Phases 1 and 2A, cannulator years of experience appeared to be related to the number of missed cannulations with fewer years equating to more missed cannulations. Phase 2B and Phase 3 data did not support this, with 51.33% of the missed cannulations being cannulators with eight years of experience or less versus 48.27% of the missed cannulations being among cannulators with nine years or more of experience.

Assumptions and Study Limitations

Some assumptions were made regarding the use of ultrasound guidance during the cannulation of hemodialysis accesses. Drawing upon research regarding the use of ultrasound during peripheral IV catheter insertions, it was assumed there would be a positive correlation between the use of ultrasound and successful cannulation within the dialysis population. It was also assumed the nephrology nurse cannulating hemodialysis accesses had a basic competency level regarding access assessment and use of the ultrasound machine.

The age and diabetes status of the patient, years of experience of the cannulator, and the age of the AVF were noted for each missed cannulation during the three phases of data collection. It was assumed the access maturity, patient age and diabetes status, and cannulator experience would impact the success rate of cannulation; however, the age/maturity of the access and years of cannulator experience were not gathered for each successful cannulation attempt during the three phases of data collection. This presented a limitation to address questions regarding the age of the access and canulator experience impact on miscannulation. Only the impact of diabetes on missed cannulation could be addressed statistically. However, the question could not be addressed via any inferential methods due to the multiplicity of records for the same patient and nurses; thus, cannulation attempts in the dataset are not independent (Powell, 2017). A second limitation was that data related to the actual use of the ultrasound machine during cannulation could not be captured; only the presence of the machine within the department and staff/patient recall of its use.

Limitations for this project included the lack of literature supporting the use of ultrasound guidance during cannulation as a widespread best practice technique; although, Marticorena and colleagues (2015) stated ultrasound use "has become standard of practice in several hemodialysis units in Canada and worldwide" (p. 28). The literature review found mention of ultrasound guidance being introduced in advanced cannulation workshops conducted in Australia and Canada (Marticorena et al., 2015; Schnoch et al., 2015). A 2015 case study suggested that ultrasound guidance "is a potentially cost-effective approach for cannulation of fistulas that are difficult to access" (Patel, Stern, Brown, & Bhatti, 2015, p. 434). None of these articles had research that unequivocally supported the use of routine ultrasound guidance for access cannulation. The statistical review of data regarding the impact of ultrasound-guided cannulation showed a decrease in the number of missed cannulations within this targeted hemodialysis population, but unfortunately, the sample size was not large enough to determine whether the change was significant.

Another limitation of the project was the practice of ultrasound was already in use within the targeted hemodialysis unit. Staff have been using ultrasound without the benefit of standardized training, guidance from policy and procedures, and assurance of competency in ultrasound-guided cannulation. Finally, data obtained relied on staff and patient recall, and may not accurately reflect the true number of missed cannulations, use of ultrasound, access bruising, and treatment interruption.

Implications for Future Research, Education and Practice

The goal of this project was to determine the impact of ultrasound guidance on cannulation, and to create policy and procedures, staff competencies, and staff training modules with the information obtained. Very little literature could be found regarding the use of ultrasound-guided cannulation within the ESRD population. Further research with larger patient populations is needed before determining if ultrasound-guided cannulation is best practice.

Conclusion

Results of this project demonstrated a need for an ultrasound-guided cannulation policy and procedure and a standardized training program. It appears the availability of an ultrasound machine decreased the number of missed cannulations. Staff comments included: "Most ultrasound guidance with cannulation is used to verify the placement of needles," and "I have used the ultrasound machine to check needle placement of patients who have moved their arm and potentially dislodged needle." Using ultrasound to determine the location of the tip of the needle in the lumen of the access is also beneficial. As one patient commented: "If they [nurses] use the ultrasound before they stick [cannulate]--it makes the stick a lot better. They know where to go."

References

Blaivas, M., & Lyon, M. (2006). The effects of ultrasound guidance on the perceived difficulty of emergency nurse-obtained peripheral IV acess. The Journal of Emergency Medicine, 3/(4), 407-410.

Brannam, L., Blaivas, M., Lyon, M., & Flake, M. (2004). Emergency nurses' utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients. Academy of Emergency Medicine, //(12), 1361-1363.

Brauman, M., Braude, D., & Crandall, C. (2009). Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. American Journal of Emergency Medicine,

27, 135-140.

Dolu, H., Goksu, S., Sahin, L., Ozen, O., & Eken, L. (2015). Comparison of an ultrasound-guided technique versus a landmark-guided technique for internal jugular vein cannulation. Journal of Clinical Monitoring and Computing, 29(1), 172-182. doi:10.1007/s10877-0149585-3

Harwood, L.E., Wilson, B.M., & Oudshoorn, A. (2016). Improving vascular access outcomes: attributes of AVF cannulation success. Clinical Kidney Journal, 9(2), 303-309. doi:10. 1093/ckj/sfv L58

Kamata, T., Tornita, M., & Iehara, N. (2016). Ultrasound-guided cannulation of hemodialysis access. Renal Replacement Therapy, 2(7). doi:10: 1186/s41100-016-0019-1

Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The improvement guide: A practical approach to enhancing organization performance (2nd ed.). San Francisco, CA; Jossey-Bass.

Lee, T., Barker, J., & Allon, M. (2006). Needle infiltration of arteriovenous fistulae in hemodialysis: Risk factors and consequences. American Journal of Kidney Diseases, 47(6), 1020-1026. doi:10.1053/j.ajkd.2006.02.181

Marticorena, R.M., Mills, L., Sutherland, K., McBride, N., Kumar, L., Bachynski, J.C., ... Donnelly, S. (2015). Development of competencies for the use of bedside ultrasound for assessment and cannulation of hemodialysis vascular access. CANNT Journal, 25(4), 28-32.

Oliver, MJ. (2015). Arteriovenous fistulas and grafts for chronic hemodialysis access. UpToDate. Retrieved from https://www.uptodate.com/contents/ arteriovenous-fistula-creation-for-hemodialysis-and-its-complications Parisotto, M.T., Schoder, V.U., Miriunis, C., Grassmann, A.H., Sccatizzi, L., Kaufmann, P., ... Marcelli, D. (2014).

Cannulation technique influences arteriovenous fistula and graft survival. Kidney International, 86(4), 790797. doi: 10.1038/ki.2014.96

Patel, R.A., Stern, A.S., Brown, M., & Bhatti, S. (2015). Bedside ultrasonography for arteriovenous fistula cannulation. Seminars in Dialysis, 28(4), 433434. doi:10.11n/sdi.12394

Pisoni, R.L., Zepel, L., Port, F.K., & Robinson, B.M. (2015). Trends in US vascular access use, patient preferences, and related practices: An update from the US DOPPS practice monitor with international comparisons. American Journal of Kidney Disease, 65(6), 905-915.

Powell, M. (2017). Ultrasound and miscannulation in chronic outpatient hemodialysis treatment. Bozeman, MT: Montana State University Statistical Consulting and Research Services.

Santoro, D., Benedetto, F., Mondello, P., Pipito, N., Barilla, D., Spinelli, F., Ricciardi, C.,. Barilla, D. (2014). Vascular access for hemodialysis: current perspectives. International Journal of Nephrology and Renovascular Disease, 7, 281-294. doi: 10.2147/ijnrd.s46643

Schnoch, M., du Toit, D., Marticorena, R., & Sinclair, P.M. (2015). Utilising point of care ultrasound for vascular access in haemodialysis. Renal Society of Australasia Journal, 77(2), 78-82.

United States Renal Data System (USRDS). (2017). 2017 United States Renal Data System annual report. Retrieved from http://www.usrds.org/ van Loon, M.M., Kessel, A.G., van der Sande, F.M., & Tordoir, J.H. (2009a). Cannulation and vascular access-related complications in hemodialysis: Factors determining successful cannulation. Hemodialysis International, 73(4), 498-504.

van Loon, M.M., Kessel, A.G., van der Sande, F.M., & Tordoir, J.H. (2009b). Cannulation practice patterns in haemodialysis vascular access: Predictors for unsuccessfull cannulation. Journal of Renal Care, 35(2), 82-89. doi: 10.1111/j.1755-6686.2009.00092.x

Webster, V., & Webster, M. (2018). Successful change management--Kotter's 8-step change model. Retrieved from https://www.leadershipthoughts.com/ kotters-8-step-change-model/

Alice Luehr, DNP, RN, CNN, is Director of Dialysis, St. Peter's Health, Helena, MT, and President-Elect of ANNA's Big Sky Chapter.

Acknowledgement: Funding for the data analysis was provided by the National Institute of General Medical Sciences of the National Institutes of Health under award number P20GM203474 for this service.

Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can be found on page 435.

Caption: Figure 1. Missed Cannulations by Study Phase
Table 1

Patient Questionnaire--Use of Ultrasound Guidance for
Cannulation of AVF--Patient Evaluation

Cannulation: Putting        Strongly
the Needles into             Agree     Agree   Uncertain
the Access

1    My access is easy to
     cannulate (access
     with the needle).

2    I become anxious
     when thinking about
     having my access
     cannulated.

3    I have more than one
     missed cannulation
     attempts per week.

4    Cannulating my
     access is painful.

5    Cannulation skills
     vary among staff.

6    I am familiar with
     the ultrasound
     machine used to
     assist in
     cannulation of
     dialysis access.

7    If the ultrasound
     machine is used
     during cannulation,
     it makes cannulating
     my access less
     painful.

8    If the ultrasound
     machine is used
     during cannulation,
     there are less
     missed attempts.

9    If the ultrasound
     machine is used
     during cannulation,
     there is less
     bruising of my
     access.

10   Staff are proficient
     at using the
     ultrasound machine.

Cannulation: Putting                   Strongly
the Needles into            Disagree   Disagree
the Access

1    My access is easy to
     cannulate (access
     with the needle).

2    I become anxious
     when thinking about
     having my access
     cannulated.

3    I have more than one
     missed cannulation
     attempts per week.

4    Cannulating my
     access is painful.

5    Cannulation skills
     vary among staff.

6    I am familiar with
     the ultrasound
     machine used to
     assist in
     cannulation of
     dialysis access.

7    If the ultrasound
     machine is used
     during cannulation,
     it makes cannulating
     my access less
     painful.

8    If the ultrasound
     machine is used
     during cannulation,
     there are less
     missed attempts.

9    If the ultrasound
     machine is used
     during cannulation,
     there is less
     bruising of my
     access.

10   Staff are proficient
     at using the
     ultrasound machine.

Do you use Emla (numbing) cream on your access?   Yes   No

11   In the Last Month (Last 12 Treatments)        Number

12   Number of missed needles you have had.

13   Number of times your access was bruised
     due to missed cannulations.

14   Number of times ultrasound was used to
     aid in cannulation of your access.

15   Number of times your dialysis treatment
     was cut short due to needle issues.

16   Number of times you had to come in on
     your normal day off to get your
     treatment due to needle issues.

Additional Comments:

Table 2

Staff Questionnaire--Use of Ultrasound Guidance for
Cannulation of AVF--Staff Evaluation

1    In the last seven workdays, I have had __ missed cannulations
     in __ attempts.

2    Number of times ultrasound guidance was used during the
     missed cannulation attempts: __

Cannulation: Putting the Needles      Strongly
into the Access                       Agree      Agree     Uncertain

3    Cannulation skills vary among
     staff.

4    I am familiar with the
     ultrasound machine used to
     assist in cannulation of
     dialysis accesses.

5    If the ultrasound machine is
     used during cannulation it
     makes cannulating accesses
     less painful.

6    If the ultrasound machine is
     used during cannulation there
     are less missed attempts.

7    If the ultrasound machine is
     used during cannulation there
     is less bruising of accesses.

8    The staff is proficient at
     using the ultrasound machine.

9    There is adequate training on
     how to use the ultrasound
     machine.

10   There are policy and
     procedures in place regarding
     the use of ultrasound guidance
     for cannulation of AVFs and
     AVGs.

11   I am proficient at using the
     ultrasound machine during
     cannulation.

12   I am proficient at cannulating
     AVFs and AVGs.

Cannulation: Putting the Needles                 Strongly
into the Access                       Disagree   Disagree

3    Cannulation skills vary among
     staff.

4    I am familiar with the
     ultrasound machine used to
     assist in cannulation of
     dialysis accesses.

5    If the ultrasound machine is
     used during cannulation it
     makes cannulating accesses
     less painful.

6    If the ultrasound machine is
     used during cannulation there
     are less missed attempts.

7    If the ultrasound machine is
     used during cannulation there
     is less bruising of accesses.

8    The staff is proficient at
     using the ultrasound machine.

9    There is adequate training on
     how to use the ultrasound
     machine.

10   There are policy and
     procedures in place regarding
     the use of ultrasound guidance
     for cannulation of AVFs and
     AVGs.

11   I am proficient at using the
     ultrasound machine during
     cannulation.

12   I am proficient at cannulating
     AVFs and AVGs.

In the Last Month                          Number

13   Number of missed cannulations you
     have had.

14   Number of times you have bruised
     and access due to missed
     cannulations.

15   Number of times you used ultrasound
     guidance to aid in cannulation of
     accesses.

16   Number of times one of your
     assigned patient's dialysis
     treatments was cut short due to
     needle issues.

17   Number of times one of your
     assigned patients had to come in on
     his/her normal day off to get
     his/her dialysis treatment due to
     needle issues.

Additional Comments:

Notes: AVF = arteriousvenous fistula, AVG = arteriovenous graft.

Table 3

Number of Missed Cannulations with Mean Patient Age

Phase           Missed
             Cannulations          0          1        2 to 5

1 N=34    Number of patients       18         4          9
          (percentage)          (52.94%)   (11.76%)   (26.47%)
          Mean patient age in     61.2       68.9       67.8
          years (SD)            (13.74)     (5.47)     (8.56)
2A N=38   Number of patients       28         4          3
          (percentage)          (73.68%)   (10.53%)   (7.89%)
          Mean patient age in     63.7       64.7       75.6
          years (SD)            (12.09)     (7.02)     (9.69)
2B N=25   Number of patients       14         6          5
          (percentage)          (56.00%)   (24.00%)   (20.00%)
          Mean patient age in     66.3       70.3       67.7
          years (SD)            (10.89)    (10.26)     (9.03)
2B N=25   Number of patients       13         3          1
          (percentage)          (76.47%)   (17.65%)   (5.88%)
          Mean patient age in     68.3       58.2       79.0
          years (SD)             (6.59)    (20.60)

Phase           Missed
             Cannulations       6 to 9    10 to 14     15+

1 N=34    Number of patients       0         2          1
          (percentage)           (0%)     (5.88%)    (2.94%)
          Mean patient age in     N/A       69.4      75.1
          years (SD)                      (17.54)
2A N=38   Number of patients       1         1          1
          (percentage)          (2.63%)   (2.63%)    (2.63%)
          Mean patient age in    58.4       75.6      75.6
          years (SD)
2B N=25   Number of patients       0         0          0
          (percentage)           (0%)       (0%)      (0%)
          Mean patient age in     N/A       N/A        N/A
          years (SD)
2B N=25   Number of patients       0         0          0
          (percentage)           (0%)       (0%)      (0%)
          Mean patient age in     N/A       N/A        N/A
          years (SD)

Note: AVF = arteriovenous fistula.

Table 4

Number of Missed Cannulations with Mean AVF Age

Phase           Missed
            Cannulations 0          0          1        2 to 5

1 N=34    Number of patients       18          14         9
          (percentage)          (52.94%)    (11.76%)   (26.47%)
          Mean fistula age in    1389.78      68.9      672.92
          days (SD)             (821.70)     (5.47)    (474.82)
2A N=38   Number of patients       28          4          3
          (percentage)          (73.68%)    (10.53%)   (7.89%)
          Mean fistula age in    1368.46      64.7     1049.33
          days (SD)             (789.97)     (7.02)    (13.01)
2B N=25   Number of patients       14          6          5
          (percentage)          (56.00%)    (24.00%)   (20.00%)
          Mean fistula age in    1674.36      70.3      719.35
          days (SD)             (1351.02)   (10.26)    (847.49)
3 N=17    Number of patients       13          3          1
          (percentage)          (76.47%)    (17.65%)   (5.88%)
          Mean Fistula age in    1269.77      58.2      293.0
          days (SD)             (1137.54)   (20.60)    (10.39)

Phase           Missed
            Cannulations 0      6 to 9    10 to 14     15+

1 N=34    Number of patients       0         2          1
          (percentage)           (0%)     (5.88%)    (2.94%)
          Mean fistula age in     N/A      166.59    990.71
          days (SD)                       (98.93)    (38.93)
2A N=38   Number of patients       1         1          1
          (percentage)          (2.63%)   (2.63%)    (2.63%)
          Mean fistula age in   133.67     308.90    114.82
          days (SD)             (48.77)   (12.26)    (44.04)
2B N=25   Number of patients       0         0          0
          (percentage)           (0%)       (0%)      (0%)
          Mean fistula age in     N/A       N/A        N/A
          days (SD)
3 N=17    Number of patients       0         0          0
          (percentage)           (0%)       (0%)      (0%)
          Mean Fistula age in     N/A       N/A        N/A
          days (SD)

Note: AVF = arteriovenous fistula.


Table 5

Years of Cannulator Experience with Number of Missed Cannulations

Phase      Years                   1 to 4     5 to 8    9 to 13

1 and 2A   Number of                 6          0          4
           cannulators (N=13)     (46.15%)              (30.77%)
           (percentage)
           Number of missed          68         0          22
           cannulations (N=118)   (57.63%)              (18.64%)
           (percentage)
2B and 3   Number of                 7          4          2
           cannulators (N=18)     (38.89%)   (22.22%)   (11.11%)
           (percentage)
           Number of missed          13         2          0
           cannulations (N=29)    (44.83%)   (6.90%)
           (percentage)

Phase      Years                  14 to 17   18 to 21     22+

1 and 2A   Number of                 0          2          1
           cannulators (N=13)                (15.38%)   (7.69%)
           (percentage)
           Number of missed          0          17         11
           cannulations (N=118)              (14.41%)   (9.32%)
           (percentage)
2B and 3   Number of                 2          1          2
           cannulators (N=18)     (11.11%)   (5.56%)    (11.11%)
           (percentage)
           Number of missed          3          0          11
           cannulations (N=29)    (10.34%)              (37.93%)
           (percentage)

Table 6

Staff Survey Responses (n=9)

Item                                                Response

In the last seven work days, I have had X missed    2/10
cannulations in X responses.                        (20%)

Number of times ultrasound guidance was used        2/2
during the missed cannulation attempts.             (100%)

In the last month number of missed cannulations     4
you have had.

Number of times you have bruised an access due to   2
missed cannulations in the last month.

Number of times you used ultrasound guidance to     47
aid in cannulation of access in the last month.

Number of times one of your assigned patient's      1
dialysis treatments was cut short due to needle
issues in the last month.

Number of times one of your assigned patients had   1
to come in on his/her normal day off to get
his/her dialysis treatments due to needle issues
in the last month.

Table 7

Mean Scores for Each Item in Staff Survey (n=12)

Item                                                  Mean (SD)

Cannulation skills vary among staff.                 4.11 (0.33)

I am familiar with the ultrasound machine used to    4.44 (0.53)
assist in cannulation of dialysis access.

If the ultrasound machine is used during             3.44 (0.73)
cannulation, it makes cannulating less painful.

If the ultrasound machine is used during             4.33 (0.87)
cannulation, there is less missed attempts.

If the ultrasound machine is used during             4.00 (1.12)
cannulation, there is less bruising of accesses.

Staff are proficient at using the ultrasound         3.89 (0.78)
machine.

There is adequate training on how to use the         3.67 (1.12)
ultrasound machine.

There are policy and procedures in place regarding   2.78 (1.09)
the use of ultrasound guidance for cannulations of
AVFs and AVGs.

I am proficient at using the ultrasound machine      4.22 (0.67)
during cannulation.

I am proficient at cannulating AVFs and AVGs.        4.56 (0.53)

Notes: AVF = arteriousvenous fistula, AVG = arteriovenous graft.

* Observational data on the effects of
cannulator experience on missed
cannulation.

Table 8

Patient Survey Responses (n=7)

Item                                                 Response

Do you use EMLA cream on your access (Y/N)?         2/5 (40%)

Does the nurse inject lidocaine prior to putting    7/7 (100%)
in your needles?

Number of missed cannulations you have had in the       0
last month.

Number of times your access was bruised due to          10
missed cannulations in the last month.

Number of times ultrasound was used to aid in           32
cannulation of your access in the last month.

Number of times your assigned dialysis treatments       5
was cut short due to needle issues in the last
month.

Number of times you had to come in on your normal       0
day off to get your treatments due to needle
issues in the last month.

Table 9

Mean Scores for Each Item in Patient Survey (n=7)

Item                                                Mean (SD)

My access is easy to cannulate.                     3.43 (1.62)

I become more anxious when thinking about having    2.43 (1.81)
my access cannulated.

I have more than one missed cannulation attempts    1.57 (0.79)
per week.

Cannulating my access is painful.                   2.57 (1.72)

Cannulation skills vary among staff.                3.14 (1.77)

I am familiar with the ultrasound machine used to   3.86 (1.46)
assist in cannulation of dialysis access.

If the ultrasound machine is used during            3.00 (1.0)
cannulation, it is makes cannulating my access
less painful.

If the ultrasound machine is used during            3.43 (0.98)
cannulation, there are less missed attempts.

If the ultrasound machine is used during            3.14 (1.35)
cannulation, there is less bruising of my access.

The staff is proficient at using the ultrasound     3.57 (0.98)
machine.

Table 10

Summary of Missed Cannulation per Diabetes Status

Phase   Diabetes   Total Number of    Number of     Number of
         Status     Cannulations     Cannulation   Cannulation
                                      Failures      Successes

1         Yes           2,700            60           2,640
           No           2,085            14           2,071
2A        Yes           2,671            15           2,656
           No           2,039            29           2,010
2B        Yes           1,977            15           1,962
           No           1,141             8           1,133
3         Yes            773              1            772
           No            441              5            436

Phase   Diabetes   Proportion of Failure
         Status    per 1,000 Cannulations

1         Yes               22.2
           No                6.7
2A        Yes                5.6
           No               14.2
2B        Yes                7.6
           No                7.0
3         Yes                1.3
           No               11.3

Table 11

Total Number of Missed Cannulations

Phase      Total        Number of     Number of     Proportion
        Cannulations   Cannulation   Cannulation    of Failure
                        Failures      Successes     per 1,000
                                                   Cannulations

1          4,785           74           4,711          15.5
2A         4,710           44           4,666           9.3
2B         3,118           23           3,095           7.3
3          1,214            6           1,208           4.9
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Author:Luehr, Alice
Publication:Nephrology Nursing Journal
Article Type:Report
Date:Sep 1, 2018
Words:7172
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