Using e-learning to increase the preparedness and confidence of nurses to perform buttonhole cannulation

Arteriovenous fistulae are considered the gold standard for haemodialysis vascular access. Their use can be fraught with complications for both the patient and cannulator, with knowledge, expertise and skills being key factors in reducing access associated morbidity. There is mounting evidence demonstrating the efficacy of the buttonhole technique. One disturbing problem noted with the buttonhole experience has been an increased rate in site infections, anecdotally attributed to poor buttonhole site preparation. Enhanced knowledge and skills for nurses are crucial in increasing patient comfort and improving outcomes.

Although knowledge and skill acquisition related to vascular access are often the focus of individual institutional educational initiatives, a national evidence based program that provides free equitable access to all nurses does not exist in Australasia. A survey of Australasian Nephrology Educators’ identified the need for more effective and consistent delivery of clinical education for nurses using innovative, web‐based approaches that support the tenets of e-learning methodologies. This paper will discuss the development and implementation of an e-learning program for buttonhole cannulation. The preparedness of participants to professionally engage with buttonhole cannulation and their self-efficacy (estimates) in undertaking learning about the clinical procedure using e-learning will be evaluated. In addition it will highlight the benefits of inter‐organizational partnerships and how they can facilitate positive change in teaching and learning practices aimed at improving patient outcomes. This project has unique characteristics that collectively provide value, distinction and innovation to patients, nurses, and renal departments across Australasia. As the e-learning program is founded on evidence based practice this project is easily transferable to an international context.

Topical arnica and mucopolysaccharide polysulfate (hirudoid) to decrease bruising and pain associated with haemodialysis cannulation - related infiltration: a pilot study

ABSTRACT
Background: 

A mechanistic study of the intestinal absorption of crypotanshinone, the major active constituent of Saliva miltiorrhiza

The nature of intestinal absorption of most herbal medicine is unknown. Cryptotanshinone (CTS) is the principal active constituent of the widely used cardiovascular herb Salvia miltiorrhiza (Danshen). We investigated the oral bioavailability of CTS in rats and the mechanism for its intestinal absorption using several in vitro and in vivo models:1) Caco-2 cell monolayers; 2) monolayers of MDCKII cells overexpressing P-glycoprotein
(PgP); and 3) single-pass rat intestinal perfusion with mesenteric vein cannulation. The systemic bioavailabilities of CTS after oral and intraperitoneal administration at 100 mg/kg were 2.05 and 10.60%, respectively. In the perfused rat intestinal model, permeability coefficients based on CTS disappearance from the luminal perfusate (P_lumen) were 6.7- to 10.3-fold higher than permeability coefficients based on drug appearance in venous blood (P_blood). P_blood significantly increased in the presence of the P-gP inhibitor, verapamil. CTS transport across Caco-2 monolayers was pH-, temperature- and ATP-dependent. The transport from the apical (AP) to the basolateral (BL) side was 3- to 9-fold lower than that from the BL to the AP side. Inclusion of verapamil (50 µM) in both AP and BL sides abolished the polarized CTS transport across Caco-2 cells. Moreover, CTS was significantly more permeable in the BL to AP than in the AP to BL direction in MDCKII and MDR1-MDCKII cells. The permeability coefficients in the BL to AP direction were significantly higher in MDCKII cells overexpressing PgP. These findings indicate that CTS is a substrate for PgP that can pump CTS into the luminal side.

Increased blood pressure later in life may be associated with perinatal n-3 fatty acid deficiency

Hypertension is a major risk factor for cardiovascular and cerebrovascular disease. Previous work in both animals and humans with high blood pressure has demonstrated the antihypertensive effects of n−3 polyunsaturated fatty acids (PUFA), although it is not known whether these nutrients are effective in preventing hypertension. The predominant n−3 PUFA in the mammalian nervous system, docosahexaenoic acid (DHA), is deposited into synaptic membranes at a high rate during the perinatal period, and recent observations indicate that the perinatal environment is important for the normal development of blood pressure control. This study investigated the importance of perinatal n−3 PUFA supply in the control of blood pressure in adult Sprague-Dawley rats. Pregnant rat dams were fed semisynthetic diets that were either deficient in (DEF) or supplemented with (CON) n−3 PUFA. Offspring were fed the same diets as their mothers until 9 wk; then, half of the rats from each group were crossed over to the opposite diet, creating four groups, i.e., CON-CON; CON-DEF; DEF-DEF, DEF-CON. Mean arterial blood pressures (MAP) were measured directly, at 33 wk of age, by cannulation of the femoral artery. The phospholipid fatty acid profile of the hypothalamic region was determined by capillary gas-liquid chromatography. The tissue phospholipid fatty acid profile reflected the diet that the rats were consuming at the time of testing. Both groups receiving DEF after 9 wk of age (i.e., DEF-DEF and CON-DEF) had similar profiles with a reduction in DHA levels of 30%, compared with rats receiving CON (i.e., CON-CON and DEF-CON). DEF-DEF rats had significantly raised MAP compared with all other groups, with differences as great as 17 mm Hg. DEF-CON rats had raised MAP compared with CON-CON rats, and DEF-DEF rats had higher MAP than CON-DEF rats, despite the fact that their respective fatty acid profiles were not different. These findings indicate that inadequate levels of DHA in the perinatal period are associated with altered blood pressure control in later life. The way in which these long-term effects are produced remains to be elucidated.

Proof of Concept : developing a peer reviewed evidence-based interactive e-learning programme

Knowledge and skill acquisition related to vascular access are traditionally individual institutional educational initiatives. Australia currently has no national evidence based education programme for renal nurses. A survey of Australian and New Zealand Nephrology Educators' conducted in 2009, identified the need for more effective and consistent delivery of clinical education for nurses using innovative, web-based approaches supporting the tenets of e-learning methodologies. This paper discusses the development, implementation and proposed evaluation of a peer reviewed Australasian e-learning programme on buttonhole cannulation. It will further highlight the benefits of inter-organisational partnerships and how these partnerships can facilitate positive change in teaching and learning practices. This project has unique characteristics that collectively provide value, distinction and innovation to nurses, patients and renal departments. As the e-learning programme was founded on a platform of evidence-based practice it is therefore easily transferable to an international context.

Advanced vascular access workshop for dialysis nurses : a three-year review

There is increased awareness regarding the benefits of ultrasound for vascular access surveillance and guided cannulation in haemodialysis. However, finding time to train staff whilst working within the clinical setting is challenging. In 2009 a workshop was introduced in Victoria to provide a platform for nursing staff to learn advanced skills in surveillance and cannulation in a safe, supportive environment. The workshop covered topics such as: assessment and cannulation; surgical perspectives in vascular access; radiological perspectives in vascular access; surveillance and monitoring; cannulation competency package; antegrade/antegrade cannulation; and introduction to ultrasound plus five hours of practical sessions. Feedback from the workshop over the past three years has been positive, and staff have benefited from the both the theoretical and clinical components of the workshop. The success of this workshop highlights the demand for continuing education within the renal workforce.

Improving renal patient care without compromising safety: interactive simulated e-learning

The nephrology educators network [NEN] recognised in 2007 that inequities existed in the access and delivery of evidence based renal education programs particularly to nurses in regional and remote areas. To address this, a web-based approach to learning, through the development of peer reviewed, interactive nephrology e-learning programs was adopted. These programs aligned with the tenets of e-learning instructional design and afforded more effective and consistent clinical support and induction for nurses in the renal specialty. The e-learning programs promote a standardised evidence-based approach to nephrology education and were developed by content experts from across Australia and New Zealand. The design methodology avoided the duplication of resources while also encouraging knowledge transfer between participating health organisations.

This paper will discuss the development and successful implementation of these e-learning programs across renal healthcare units in Australasia. Implemented packages include: Introduction to Buttonhole Cannulation – featuring an interactive ultrasound and cannulation application; Introduction to Haemodialysis; Introduction to Peritoneal Dialysis [PD], featuring simulated PD machines, allowing for the teaching of troubleshooting without compromising patient safety. E-learning programs are further supported through interactive case scenarios that present unfolding real world simulations and enable learners to meet different patients and manage their care while learning about key messages relating to renal health. Modules currently in development include; Acute Kidney Injury; Fluid Assessment, Water Quality and Vascular Access. The implementation of these programs assist the facilitation of positive change in teaching and learning practices in nephrology nursing aimed at improving patient outcomes.

Renal access coordinators' impact on hemodialysis patient outcomes and associated service delivery: a systematic review

Background
Renal access coordinators contribute specifically to dialysis access care for people with chronic and end stage renal disease. Since the introduction of renal access coordinators into Australia in the early 2000s, there have been anecdotal examples of associated improvements in patient outcomes and service delivery; however scant published quantitative evidence exists. Thus, the impact of the implementation of renal access coordinators has not undergone a rigorous review to date.

Objective
The objective of this systematic review was to critically appraise and synthesize the best available evidence related to the impact of renal access coordinators on dialysis patient outcomes and associated service delivery.

INCLUSION CRITERIA

Types of participants
This review considered studies that included renal access coordinators (noting variations of the titles) and adult hemodialysis patients (aged 18 years and over).

Types of intervention(s)
This review considered studies that evaluated the effectiveness of the renal access coordinator. This role typically consists of clinical and administration duties such as providing pre dialysis access coordination, access surveillance patient education and nurse education.

Types of studies
The types of studies considered within this review included experimental and epidemiological study designs. Thus randomized controlled trials (RCT), non-randomized controlled trials, and quasi-experimental, before and after studies, prospective and retrospective cohort studies were considered as were case control studies, analytical cross sectional studies and descriptive cross sectional studies.

Types of outcomes
Patient outcomes considered included: days to first vascular access complication (such as stenosis or thrombosis) and/or primary intervention (such as angioplasty or surgical intervention); percentage of central line insertions (negative); rate of arteriovenous fistula (AVF)/arteriovenous graft (AVG)/central venous catheter (CVC) at start of dialysis (incidence); prevalent rate of AVF/AVG/CVC; time to occlusion of AVF and time from referral to surgery. Service outcomes included: knowledge/up skilling of renal nurses; cannulation skills, ultrasound skills, knowledge of anatomy and physiology and other access related knowledge.

Search strategy
The search strategy aimed to locate published and unpublished studies, utilizing a three-step searching approach. Studies published in English from 1990 to October 2013 were considered for inclusion in this review.

Methodological quality
The studies were assessed by two independent reviewers using the appropriate standardized critical appraisal instruments from the Joanna Briggs Institute.

Data collection
Data were extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute, namely JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

Data synthesis
This review aimed to conduct meta-analyses of the findings: however, because of the limitations of the data found, this was not possible and so the findings are presented in a narrative format.

Results
Five studies were identified for inclusion in the review. No RCTs were found, therefore four of the five studies were pre-post intervention cohort studies and one was a prospective quality assurance report. Data were heterogeneous and thus did not allow for meta-analysis. All studies included multidisciplinary teams with variable emphasis on the renal access coordinator role. The pre post intervention cohort studies measured incident and/or prevalent AVF, AVG and CVC rates in the hemodialysis population and the quality assurance report measured the difference in patency rates between AVF and AVG. All discussed the role of central coordination as a contributor to the success of vascular access care.

Conclusions
This review found insufficient data to make firm conclusions about the impact that renal access coordinators have on patient outcomes. The results of this review suggest an association between renal access coordinators and improved patient outcomes. These improved patient outcomes were apparent in an increase in incident and prevalent AVFs, and a decrease in the incidence and prevalence of CVCs. Both associations are correlated with a reduction in infection rates, length of hospital stay and healthcare costs.

Vascular access e-learning : the essentials

Objectives
Form a working group of renal vascular access nurses to develop peer reviewed, accessible, evidence based e-leaning modules related to vascular access principles and practice.

Key messages
Vascular access training and guidelines are often unit specific but the core principles of vascular access care are generally transferable. The vascular access e-learning module aims to utilize resources to minimize wasted time developing and keeping multiple individual vascular access training packages up to date.
Vascular access education is delivered from a variety of resources such as educators, senior staff and vascular access nurses. This e-learning module allows renal units the opportunity to provide a national learning package with general consensus on terminology and up to date evidence based practice.
Recently there has been a rise in the use of ultrasound to assess and perform image guided cannulation in vascular access to improve patient outcomes. There is only a small window of opportunity to provide education in ultrasound use. This module will provide education on this and other aspects of vascular access practices and patient care.

Implications for clinical practice
Implications include access to standardized learning packages based on current evidence based practice, eencouraging the utilization of new technology (e.g. Ultrasound observation and interpretation of results), reinforcing the underpinning knowledge of anatomy and physiology of vascular access, standardizing practice benefits to patients and nurses moving between dialysis units, improving accessibility by transitioning learning to smart phones and tablets and providing an opportunity for international collaboration related to vascular access e-learning concepts.

Utilising point of care ultrasound for vascular access in haemodialysis

Learning outcomes: On completion of this continuing professional development activity, participants will be able to: • Discuss basic ultrasound principles; • Define the roles and responsibilities of the nurse in point of care ultrasound; • Identify strategies to utilise ultrasound to provide quality cannulation practice; • Identify anatomic structures on an ultrasound picture; • Identify anomalies in the anatomy such as thrombus, stenosis, aneurysm and pseudoaneurysm; • Describe the advantages and disadvantages of using ultrasound for assessment and cannulation; • Enable staff to reflect on their current approaches to assessment and cannulation.