Development and Implementation of an Induction / Orientation Package for Dialysis Nurses

This project aims to develop an induction/orientation package for dialysis nurses to improve the lifespan of dialysis access. The package will equip nurses with the knowledge and skills of AVF cannulation, reduce needle-induced vessel injuries and related complications, eliminate and minimize AVF related infections, and enhance professionalism competencies during clinical practice. The project objectives include improving nurses and medical care professionals with knowledge and skills regarding AVF cannulation procedures and protocols, reducing needle-induced vessel injuries and related complications, and eliminating and minimizing AVF related infections.

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Development and Implementation of an Induction / Orientation Package
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Project: Basic (dialysis) needle cannulation training session in the induction package for
novice dialysis nurses to improve the lifespan of dialysis access.
Problem Statement
When possible, the arteriovenous fistula (AVF) is preferred as the first choice for the
hemodialysis vascular access. However, the cannulation is one the major causes of AVF
failure and complications(Brouwer, 2011). Puncturing blood vessels with a needle usually
causes tissue injury thus triggering leucocytes adhesion, smooth muscles cells mitigation
from the media to the intima and finally proliferation(Lok and Foley, 2013). This cascade
usually leads to venous stenosis through blood vessel thickening and hyperplasia thus acting
as the most frequent cause of access failure(Melnick, 2016). In addition, needle –induce
vessel injury can also lead to hematoma, infiltration, AVF loss and aneurysms. One of the
most significant complications from vessel induced injury is infiltration(Santoro et al., 2014).
Studies suggest that, one infiltration can lead to more than three extra months of catheter
dependency and that the approximately annual infiltration rate is more than 5.5%(Vale,
Lopez-Vargas and Polkinghorne, 2012).
A risk for infection in patients with AVF is also a major issue that needs to be
addressed. For Nurses and medical health care professional to minimize the AVF injuries
and infections, effective cannulation techniques must be used(Melnick, 2016). This includes
the use of ascetic techniques, paired and right needles and required skills in order to meet
individual patient needs(Santoro et al., 2014). Therefore, using of needles that help to reduce
vessel injuries is important. Other than that, it is important to control pain and maintain the
patient physical integrity of the cannulated site(Melnick, 2016). In addition, one cannot

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discount the need of controlling infections and reduction of anxiety in patients undergoing
cannulation.
Project Goal
The major goal of this project is to enforce all nurses and medical health professionals in a
dialysis unit with the knowledge and skills of AVF cannulation. This knowledge is intended
to train dialysis nurses and equip them with confidence and skills prior to cannulating
patients. Therefore, nurses will be able to perform cannulation procedures, control infections
and enhance professionalism competencies during their clinical practice in a safe and stress-
free environment thus improving quality and safe care of patients.
Problem Justification
Proper hemodialysis treatment in the dialysis units depends on how well a vascular
access is functioning. This is determined by excellent patency, good blood flow and potential
for a repetitive cannulation with two needles(Schinstock et al., 2011). The use of AVF is
crucial as it provides a chance for longevity and reduction of morbidity and mortality.
According to Kidney Health Australia 2012, infections, stenosis, and thrombosis are the three
major complications of AVF in hemodialysis patients (Vale, Lopez-Vargas and
Polkinghorne, 2012). About 50% of mortality is reduced when patients switch to AVF than
those who remain in catheter dependant thus proper preservation of AVF is an important
aspect of care to increase patient’s survivor(Vale, Lopez-Vargas and Polkinghorne, 2012).
Due to that reason, it is of importance for nurses to develop proper skills and professional
standards when performing AVF cannulation.
Infections form one of the major mortality and morbidity factor for patients
undergoing dialysis. In 2010, about 11% of deaths in patients undergoing dialysis in the

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world were due to infections (Vale, Lopez-Vargas and Polkinghorne, 2012). The Canadian
Morbidity Study shows that AVF and AVG related infections are at a rate of 4.5% and 19.7%
annually. In addition, infections have been the leading cause of admissions accounting for
102 admissions per 1000 patients per year(Vale, Lopez-Vargas and Polkinghorne, 2012).
Other than that, repeated cannulation of AVF places patients at risk for infection. This is due
to the fact that, during the procedure, bacteria can be either be directly introduced to the
blood circulation or through the local access(Melnick, 2016). Adhering to infection control
policies is crucial as it helps to reduce access sites infections. Therefore proper cannulation
and care of AVF in patients undergoing dialysis is significant as it can minimize the chances
of hospitalization.
Needle infiltration of new fistulas is usually one of the major complications that are
most common in aged patients. One infiltration can prolong catheter dependence by more
than three months(Lee, Barker and Allon, 2006). Therefore, needle infiltration can only be
reduced by good cannulation techniques. Effective cannulation techniques, proper fistula
examination, and control of infections form a basis for effective vascular access with minimal
risks thus improving the overall patient quality and safe care(Saha and Allon, 2017).
Project Objectives
 To improve nurses and medical care professionals with knowledge and skills
regarding AVF cannulation procedures and protocols. This, in turn, will enhance
career development and improve nursing clinical practice in a dialysis unit.
 To reduce needle induce vessel injuries and related complications such as thrombosis
and aneurysm. This will lead to reduced pain and psychological effects on patients
such as anxiety thus improving quality and safe care.

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 To eliminate and minimize AVF related infections through the use of proper
cannulation procedure, reduce chances of frequent cannulation, and by ensuring safety
precaution and asceptic techniques are always observed.
Project Outputs
 Use of literature review summaries- Literature reviews will be used to evaluate what
studies say about the effects of poor cannulation, incidents, and statistics of AVF, and
most common related infections and microorganisms involved .
 Procedure assessment tools which will be used to measure the level of practical
understanding.
 National guidelines, standards, and policies
 A report
 Verbal and written presentation

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References
Brouwer, D. J. (2011) ‘Cannulation Camp: Basic needle cannulation training for dialysis
staff’, Dialysis and Transplantation. doi: 10.1002/dat.20622.
Lee, T., Barker, J., and Allon, M. (2006) ‘Needle Infiltration of Arteriovenous Fistulae in
Hemodialysis: Risk Factors and Consequences’, American Journal of Kidney Diseases. doi:
10.1053/j.ajkd.2006.02.181.
Lok, C. E., and Foley, R. (2013) ‘Vascular access morbidity and mortality: Trends of the last
decade’, Clinical Journal of the American Society of Nephrology. doi:
10.2215/CJN.01690213.
Melnick, D. M. (2016) ‘Vascular access for hemodialysis’, in Illustrative Handbook of
General Surgery: Second Edition. doi: 10.1007/978-3-319-24557-7_41.
Saha, M. and Allon, M. (2017) ‘Diagnosis, treatment, and prevention of hemodialysis
emergencies’, Clinical Journal of the American Society of Nephrology, pp. 357–369. doi:
10.2215/CJN.05260516.
Santoro, D.Benedetto, F. ,Modello, P., Pipito, N., Barrrila,.D and Cernaro, V. (2014)
‘Vascular access for hemodialysis: Current perspectives’, International Journal of
Nephrology and Renovascular Disease. doi: 10.2147/IJNRD.S46643.
Schinstock, C. A. Albright, R.C., Williams, A., Dilon,J and Jensen, B (2011) ‘Outcomes of
arteriovenous fistula creation after the fistula first initiative’, Clinical Journal of the
American Society of Nephrology. doi: 10.2215/CJN.11251210.
Vale, E., Lopez-Vargas, P. and Polkinghorne, K. (2012).Nursing Care of Arteriovenous
Fistula/Arteriovenous Graft. 1-23. Available at: http://www.cari.org.au/Dialysis/dialysis
%20vascular%20access/Nursing_care_of_AVF_AVG.pdf.

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