title: Buttonhole cannulation in hemodialysis: improved outcomes and increased expense--is it worth it?
abstract: BACKGROUND
  Access to an adequate blood flow is a requirement for successful hemodialysis (HD). This often means repeated cannulation of an arteriovenous fistula (AVF), which can lead to damage that needs repair and revision. The Buttonhole (BH) method offers a successful cannulation with minimal damage.
  
  
  METHODS
  A prospective cohort research study was initiated in two HD units in St. John's, Newfoundland and Labrador, to assess the effects of cannulating AVFs using the BH technique from the patient and nurse perspective.
  
  
  METHODS
  Twenty-five nurses and 29 patients completed questionnaires at four times throughout the three-month study period, rating their confidence levels about BH cannulation issues. Patients also provided information on the pain of the cannulation and the frequency of cannulation complications. Nurses documented data on arterial and venous pressures, and hemostasis times. Patient charts were also reviewed for complications requiring extensive interventions such as AVF repair or Central Line Catheter (CVC) placement. The cost of providing the BH cannulation was also examined.
  
  
  RESULTS
  At the end of the study, it was noted that cannulation pain was statistically reduced with both the arterial (p = .002) and venous (p = .010) needles, and vessel pressures and hemostasis times were decreased slightly or stayed the same throughout the study. The frequency of access infections, however, increased, although not significantly. Using a 10-point Likert scale in which a score of > or = 8 indicates a high level of confidence, 77.5% of nurses and 73.9% of patients reported a high level of confidence in the nurses' abilities to use the BH technique effectively. In terms of expense, no significant changes were noted in frequency of procedures required for AVF repair with the BH cannulation, although an increase of approximately $358.80 per patient per year for BH supplies was noted.
  
  
  CONCLUSIONS
  BH cannulation did provide significant improvements. However, the increase in infection rate was an issue of concern. The additional cost of the BH procedure should be weighed against the positive outcomes realized.
authors.affiliation: Patient Research Centre, Memorial University, St. John's, Newfoundland. vludlow@nl.rogers.com
authors.forename: Valerie
authors.initials: V
authors.lastname: Ludlow
mesh_terms: D000704:Analysis of Variance; D001166:Arteriovenous Shunt, Surgical / Q000295:instrumentation*; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D002404:Catheterization / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000451:nursing / Q000523:psychology; D002983:Clinical Competence; D003362:Cost-Benefit Analysis; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D009523:Newfoundland and Labrador; D024802:Nurse's Role / Q000523:psychology; D015403:Nursing Evaluation Research; D015404:Nursing Methodology Research; D009740:Nursing Staff / Q000523:psychology; D010146:Pain / Q000209:etiology / Q000517:prevention & control; D011446:Prospective Studies; D006435:Renal Dialysis / Q000295:instrumentation*; D020377:Self Efficacy; D011795:Surveys and Questionnaires; D016896:Treatment Outcome