**6. A value-based approach relying on best nursing practices learned from NephroCare**

### **6.1 VA cannulation**

VA cannulation method is still an "art" and procedure that reflects local unit practices and personal nursing skills [130]. Interestingly, despite the impact needling has on VA survival and patient outcome, there is no universal or standardised method proposed for proper cannulation [143].

There are three cannulation methods used by nursing staff: rope-ladder, area cannulation and buttonhole [144]. The rope-ladder (site-rotation) method appears to be the most used worldwide being considered as the safest one. It consists of alternating puncture sites at a defined distance from the previous one along the VA vessel as an attempt to prevent aneurysm formation, stenosis and repeated trauma by multiple punctures. The area (one-site-itis) puncture is the insertion of the needles in the same general area of 2–3 cm, session after session [145]. This method exposes to weakness VA wall with progressive dilation leading to false aneurysm. The buttonhole (constant-site) method is less used in centre but seems of great interest for patient self-cannulating their own VA. It consists in creating a track by cannulating repeatedly the same spot and angle with sharp needle over 6–9 weeks. Once the track is formed, then a blunt needle can be used for subsequent cannulation. Buttonhole cannulation appears to be less painful and create less anxiety than rope-ladder but exposes to a more risk of infection. Nursing vascular access procedures are detailed in a separate document accessible and downloadable from the website: https://www.edtnaerca.org/academy/ publications.

## **6.2 Patients bearing chronic tunnelled central venous catheter (tCVC)**

Despite strong recommendations from best clinical practice guidelines, the use of tCVC is very common and tends to increase over time in almost all countries either in incident (10–80%) and prevalent (2–48%) dialysis patients [20]. Such trend most likely reflects change in medical profile of dialysis patients (e.g., advanced age, comorbidities, short life expectancy and repeated failures of VA creation), change in medical practices (e.g., easy access to CVC and shortage of motivated vascular surgeon) and poor or fragmented management of CKD patients (e.g., late referral). Interestingly, prevalence of tCVC in prevalent patients varies from 20 to 40% in Europe.

#### **6.3 Nurse perspective: skills, training and responsibilities**

Nurses play a crucial role in the management of all VAs. VA assessment, cannulation and care are mandatory skills for dialysis nurses: failure to correctly perform this operation may result in serious complications for the patients [145].

### *6.3.1 Competencies and responsibilities*

A highly-skilled dialysis nurse is required to ensure that each cannulation/connection procedure is carried out with minimal or no complications. At every dialysis session, and before each cannulation/connection, ensure that the patient's VA is functional and has no problems in obtaining the optimal blood flow ensuring an adequate dialysis [43]. The competencies and responsibilities to achieve this are as follows:

**41**

*Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare…*

*DOI: http://dx.doi.org/10.5772/intechopen.84987*

• The nurses should have competence in:

○ AVF/AVG cannulation techniques and care

○ AVF/AVG and CVC assessment

○ CVC connection and care

complications

*6.3.2 Hand hygiene*

performed.

○ Management of complications

○ Patient education related to VA care

• The nurses should have responsibility for:

○ Ensuring patient comfort and safety

material and patient following strictly the hygienic rules.

*6.3.3 Personal protective equipment (PPE) and work uniform*

and masks, protect HCWs and patients.

*6.3.4 Patients general condition assessment*

other signs or symptoms of complications.

workplace and the home.

○ Reporting and documenting all complications relating to VA

○ Liaising with the dialysis medical team to early identify and manage

Before starting the cannulation procedure for AVF/AVG or the connection of the CVC, the Registered Nurse (RN) must assure the preparation of the environment,

The impact of health care-associated infections implies prolonged hospital stay,

PPE (hand and face protection, aprons and gowns) serves to protect HCW from hazards and preventable injuries in the workplace. Some PPE items, such as gloves

Uniforms are not considered as PPE. Nonetheless they provide the HCW with professional attire that supports the HCW in carrying out her or his work in the dialysis unit, while at the same time preventing cross-contamination between the

Prior to any HD treatment, assessment of patient's general condition to identify

The nurse needs to weigh the patient and compare the value with the last post dialysis weight and to the prescribed dry weight. Blood pressure and pulse must be

potential problems that may arise during the treatment should be performed: temperature (as a routine, only for CVC), diet, loss of appetite, vomiting, diarrhoea and any other intercurrences between treatments like cramps, bleeding or some

long-term disability, increased resistance of microorganisms to antimicrobials, massive additional financial burden, high costs for patients and their families and excess deaths [146]. In accordance with the WHO hand hygiene should routinely be *Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare… DOI: http://dx.doi.org/10.5772/intechopen.84987*

	- AVF/AVG and CVC assessment
	- AVF/AVG cannulation techniques and care
	- CVC connection and care

*Vascular Access Surgery - Tips and Tricks*

method proposed for proper cannulation [143].

**from NephroCare**

**6.1 VA cannulation**

publications.

from 20 to 40% in Europe.

*6.3.1 Competencies and responsibilities*

**6. A value-based approach relying on best nursing practices learned** 

VA cannulation method is still an "art" and procedure that reflects local unit practices and personal nursing skills [130]. Interestingly, despite the impact needling has on VA survival and patient outcome, there is no universal or standardised

There are three cannulation methods used by nursing staff: rope-ladder, area cannulation and buttonhole [144]. The rope-ladder (site-rotation) method appears to be the most used worldwide being considered as the safest one. It consists of alternating puncture sites at a defined distance from the previous one along the VA vessel as an attempt to prevent aneurysm formation, stenosis and repeated trauma by multiple punctures. The area (one-site-itis) puncture is the insertion of the needles in the same general area of 2–3 cm, session after session [145]. This method exposes to weakness VA wall with progressive dilation leading to false aneurysm. The buttonhole (constant-site) method is less used in centre but seems of great interest for patient self-cannulating their own VA. It consists in creating a track by cannulating repeatedly the same spot and angle with sharp needle over 6–9 weeks. Once the track is formed, then a blunt needle can be used for subsequent cannulation. Buttonhole cannulation appears to be less painful and create less anxiety than rope-ladder but exposes to a more risk of infection. Nursing vascular access procedures are detailed in a separate document accessible and downloadable from the website: https://www.edtnaerca.org/academy/

**6.2 Patients bearing chronic tunnelled central venous catheter (tCVC)**

trend most likely reflects change in medical profile of dialysis patients

this operation may result in serious complications for the patients [145].

**6.3 Nurse perspective: skills, training and responsibilities**

Despite strong recommendations from best clinical practice guidelines, the use of tCVC is very common and tends to increase over time in almost all countries either in incident (10–80%) and prevalent (2–48%) dialysis patients [20]. Such

Nurses play a crucial role in the management of all VAs. VA assessment, cannulation and care are mandatory skills for dialysis nurses: failure to correctly perform

A highly-skilled dialysis nurse is required to ensure that each cannulation/connection procedure is carried out with minimal or no complications. At every dialysis session, and before each cannulation/connection, ensure that the patient's VA is functional and has no problems in obtaining the optimal blood flow ensuring an adequate dialysis [43]. The competencies and responsibilities to achieve this are as

(e.g., advanced age, comorbidities, short life expectancy and repeated failures of VA creation), change in medical practices (e.g., easy access to CVC and shortage of motivated vascular surgeon) and poor or fragmented management of CKD patients (e.g., late referral). Interestingly, prevalence of tCVC in prevalent patients varies

**40**

follows:

	- Ensuring patient comfort and safety
	- Reporting and documenting all complications relating to VA
	- Liaising with the dialysis medical team to early identify and manage complications

Before starting the cannulation procedure for AVF/AVG or the connection of the CVC, the Registered Nurse (RN) must assure the preparation of the environment, material and patient following strictly the hygienic rules.

#### *6.3.2 Hand hygiene*

The impact of health care-associated infections implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, massive additional financial burden, high costs for patients and their families and excess deaths [146]. In accordance with the WHO hand hygiene should routinely be performed.

#### *6.3.3 Personal protective equipment (PPE) and work uniform*

PPE (hand and face protection, aprons and gowns) serves to protect HCW from hazards and preventable injuries in the workplace. Some PPE items, such as gloves and masks, protect HCWs and patients.

Uniforms are not considered as PPE. Nonetheless they provide the HCW with professional attire that supports the HCW in carrying out her or his work in the dialysis unit, while at the same time preventing cross-contamination between the workplace and the home.

#### *6.3.4 Patients general condition assessment*

Prior to any HD treatment, assessment of patient's general condition to identify potential problems that may arise during the treatment should be performed: temperature (as a routine, only for CVC), diet, loss of appetite, vomiting, diarrhoea and any other intercurrences between treatments like cramps, bleeding or some other signs or symptoms of complications.

The nurse needs to weigh the patient and compare the value with the last post dialysis weight and to the prescribed dry weight. Blood pressure and pulse must be evaluated and all treatment parameters should be validated. When using a CVC, the catheter exit site must be examined thoroughly for the presence of any signs of infection. A physical assessment of the VA must be carried out before every treatment.
