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.

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.

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.

Challenging the distal-to-proximal cannulation technique for administration of anti-cancer therapies : a prospective cohort study

Background: Distal-to-proximal technique has been recommended for anti-cancer therapy administration. There is no evidence to suggest that a 24-hour delay of treatment is necessary for patients with a previous uncomplicated venous puncture proximal to the administration site. Objectives: This study aims to identify if the practice of 24-hour delay between a venous puncture and subsequent cannulation for anti-cancer therapies at a distal site is necessary for preventing extravasation. Methods: A prospective cohort study was conducted with 72 outpatients receiving anti-cancer therapy via an administration site distal to at least one previous uncomplicated venous puncture on the same arm in a tertiary cancer centre in Australia. Participants were interviewed and assessed at baseline data before treatment and on day 7 for incidence of extravasation/phlebitis. Results: Of 72 participants with 99 occasions of treatment, there was one incident of infiltration (possible extravasation) at the venous puncture site proximal to the administration site and two incidents of phlebitis at the administration site. Conclusions: A 24 hour delay is unnecessary if an alternative vein can be accessed for anti-cancer therapy after a proximal venous puncture. Implications for practice: Extravasation can occur at a venous puncture site proximal to an administration site in the same vein. However, the nurse can administer anti-cancer therapy at a distal site if the nurse can confidently determine the vein of choice is not in any way connected to the previous puncture site through visual inspection and palpation.

Evaluation of inflow cannulation site for implantation of right-sided rotary ventricular assist device

Right heart dysfunction is one of the most serious complications following implantation of a left ventricular assist device (LVAD), often leading to the requirement for short or long term right ventricular support (RVAD). The inflow cannulation site induces major haemodynamic changes and so there is a need to optimize the site used depending on the patient's condition. Therefore, this study evaluated and compared the haemodynamic influence of right atrial (RAC) and right ventricular (RVC) inflow cannulation sites. An in-vitro, variable heart failure, mock circulation loop was used to compare RAC and RVC in mild and severe biventricular heart failure (BHF) conditions. In the severe BHF condition, higher ventricular ejection fraction (RAC: 13.6%, RVC: 32.7%) and thus improved heart chamber and RVAD washout was observed with RVC, which suggested this strategy might be preferable for long term support (ie. bridge to transplant or destination therapy) to reduce the risk of thrombus formation. In the mild BHF condition, higher pulmonary valve flow (RAC: 3.33 L/min, RVC: 1.97 L/min) and lower right ventricular stroke work (RAC: 0.10 W, RVC: 0.13 W) and volumes were recorded with RAC. These results indicate an improved potential for myocardial recovery, thus RAC should be chosen in this condition. This in-vitro study suggests that RVAD inflow cannulation site should be chosen on a patient-specific basis with a view to the support strategy to promote myocardial recovery or reduce the risk of long-term complications.

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

ABSTRACT
Background: 

Simulation-based ultrasound-guided central venous cannulation training program

PURPOSE: To propose a simulation-based ultrasound-guided central venous cannulation skills' training program, during residency.METHODS: This study describes the strategies for learning the ultrasound-guided central venous cannulation on low-fidelity bench models. The preparation of bench models, educational goals, processes of skill acquisition, feedback and evaluation methods were also outlined. The training program was based on key references to the subject.RESULTS: It was formulated a simulation-based ultrasound-guided central venous cannulation teaching program on low-fidelity bench models.CONCLUSION: A simulation-based inexpensive, low-stress, no-risk learning program on low-fidelity bench models was proposed to facilitate acquisition of ultrasound-guided central venous cannulation skills by residents-in-training before exposure to the living patient.

Evaluation of a novel needle guide for ultrasound-guided phantom vessel cannulation

We evaluated a novel, sled-mounted needle guide for ultrasound-guided vessel cannulation. Fifty medical students were randomly assigned to use ultrasound with the sled (sled group, n = 23) or ultrasound without the sled (control group, n = 27) for vessel cannulation in a phantom. For each of 15 attempts we recorded cannulation time and designated a successful cannulation as 1 and a failure as 0. Our primary outcome was the mean overall success rate. The median (IQR [range]) number of successes in the sled group and control group were 15.0 (13.0-15.0 [11.0-15.0]) and 11.0 (9.0-13.0 [6.0-15.0]), respectively (p < 0.001). Cannulation time decreased from the first to the last attempt in the sled group from 7.0 s (6.0-10.0 [4.0-16]) s to 4.0 s (3.0-4.0 [1.0-6.0]) s and in the control group from 35.0 s (27.0-35.0 [11.0-35.0]) s to 7.0 s (5.0-10.0 [3.0-25.0]) s. The sled group demonstrated a shorter cannulation time at each attempt (p < 0.001). The novel sled improved the success rate and efficiency of ultrasound-guided phantom vessel cannulation.

Aortic flow patterns resulting from right axillary artery cannulation

Right axillary artery (RAA) cannulation is increasingly used in cardiac surgery. Little is known about resulting flow patterns in the aorta. Therefore, flow was visualized and analyzed. A mock circulatory circuit was assembled based on a compliant transparent anatomical silicon aortic model. A RAA cannula was connected to a continuous flow rotary blood pump (RBP), pulsatile heart action was provided by a pneumatic ventricular assist device (PVAD). Peripheral vascular resistance, regional flow and vascular compliance were adjusted to obtain physiological flow and pressure waveforms. Colorants were injected automatically for flow visualization. Five flow distributions with a total flow of 4 l/min were tested (%PVAD:%RBP): 100:0, 75:25, 50:50, 25:75, 0:100. Colorant distribution was assessed using quantitative 2D image processing. Continuous flow from the RAA divided in a retrograde and an antegrade portion. Retro- to antegrade flow ratio increased with increasing RAA-flow. At full RBP support flow was stagnant in the ascending aorta. There were distinct flow patterns between the right- and left-sided supra-aortic branches. At full RBP support retrograde flow was demonstrated in the right carotid and right vertebral arteries. Further studies are needed to confirm and evaluate the described flow patterns.