The culture of vascular access cannulation among nurses in a chronic hemodialysis unit.

The native arteriovenous fistula (AVF) is the vascular access of choice for patients on chronic hemodialysis (HD) because of its longevity and lower complication rate. Yet from 2001 to 2004 in Canada, there has been a notable increase in both incident and prevalent central venous catheter (CVC) use with a corresponding decrease in AVF use over the same time period (Moist, Trpeski, Na, & Lok, 2008). A similar trend has been found in other countries (Moist, Chang, Polkinghorne, & McDonald, 2007). There are a number of contributing factors to low AVF use in patients on chronic hemodialysis. While some of these factors may be patient-related, nursing interventions specific to cannulation may be a contributor. To date, little is known about HD nurses' attitudes and experiences regarding cannulation. The purpose of this study was to describe the culture and everyday practices of vascular access cannulation of the AVF from the perspective of the HD nurse. An ethnographic research design was employed, utilizing qualitative methods. Ten HD nurses were interviewed using a semi-structured interview tool, and a number of themes were generated from the interviews. One overarching theme of "perpetual novice" was evident, acknowledging the failure to transition from novice to expert cannulator despite working in HD for a number of years. Other common themes that emerged from the interviews were a) the lack of fistulas, b) the fistula as a "hard sell" to patients, c) the skill of cannulation, and d) the assembly-line approach to care. As a result of a number of factors, HD nurses were unable to acquire the skills necessary to become an expert cannulator. Moreover, the decrease in opportunities to practise cannulation has resulted in wide variation in skill level among HD nurses. To improve cannulation skills and achieve successful cannulation of AV fistulas, HD nurses identified a number of educational strategies that should take place. They also identified the need for an improved documentation system in order to track cannulation-related problems. Results of this study may be helpful in understanding the culture of cannulation in a chronic HD unit and in directing future educational, supportive, and practice interventions for HD nurses.

Impact of single-needle therapy in new chronic hemodialysis starts for individuals with arteriovenous fistulae.

The native arteriovenous fistula (AVF) is the "gold standard" for hemodialysis (HD) vascular access. Unfortunately, AVFs can develop complications including inadequate maturation, cannulation difficulties and needle infiltration. In an effort to increase successful cannulations, decrease complications and subsequent central venous catheter (CVC) use, our centre introduced single-needle (SN) dialysis in April 2006 for new chronic patients receiving their first six HD treatments. The purpose of this study was to evaluate the impact of implementing SN dialysis on the incidence of CVC placements, investigative procedures required (e.g., arteriography), and missed HD treatments within the first three months of commencing dialysis. A secondary objective was to compare these data with double-needle (DN) dialysis treatments from the previous year. Retrospective chart reviews were conducted for all new chronic HD outpatient starts from April 2005 to 2006 for patients using DN dialysis and from April 2006 to November 2007 for those using SN. Information gathered included demographic data, location and vintage of the AVF, laboratory parameters, frequency of CVC placements, arteriography, and missed HD treatments due to cannulation difficulties. In total, data pertaining to 11 DN and 22 SN patients were collected. Of the 11 DN patients, 2 (18.2%) required a CVC placement in the first three months of treatment as compared to 2 (9.1%) using SN dialysis. Similarly, arteriographic investigations of the AVF were required in 4 (36.4%) DN versus 3 (13.6%) SN patients. There were a total of 19 missed treatments (8 DN; 11 SN). Dialysis blood work results were within safe and acceptable levels for those receiving SN dialysis. Use of SN dialysis for the first six HD treatments resulted in fewer mean CVC placements and investigations while main-raining adequate laboratory parameters. These results lend support for further research in this area.

Predictors of hemodialysis central venous catheter exit-site infections.

Central venous catheter (CVC) exit-site infections contribute to bacteremia and patient morbidity and mortality among patients on hemodialysis. This structured observational study examined predictors of positive CVC exit-site infections. Hemodialysis nurses documented the physical appearance of the CVC exit site for sites they believed to be infected and required a swab culture. Additional information that pertained to the catheter, exit-site care and demographic data were also collected. No patient characteristics were associated with an exit-site infection. However, the type of dressing (p=0.007) and cleansing solution (p=0.007) used were positively associated with an exit-site infection. Negative exit-site culture reports were more likely to have dressings changed weekly (p=0. 03). The size of peri-wound erythema (p=0.008) was also associated with a higher incidence of exit-site infections. Patients with dry crust present at the exit site were more likely to have negative culture results (p=0.03). A large number of negative swab culture results (71%) were obtained suggesting that further nursing education is needed. The results of this study contribute to our understanding of the physical characteristics of an infected CVC exit site. Given the morbidity and mortality associated with CVC infections, more nursing research is needed in this area.