The Buttonhole Technique: Strategies
To Reduce Infections Continuing Nursing
Lynda K. Ball
he buttonhole technique has
Copyright 2010 American Nephrology Nurses’ Association
been utilized in the United
States for over 10 years, and it Ball, L. (2010). The buttonhole technique: Strategies to reduce infections. Nephrology
has been very effective in Nursing Journal, 37(5), 473-478.
reducing pain associated with cannu-
lation, empowering patients to learn The buttonhole technique has gained popularity over the last decade in the United States.
to self-cannulate, and decreasing The fact that it is a relatively new technique, which requires a change to current cannu-
complications related to site rotation lation practice, has contributed to several unforeseen complications that have led to
cannulation. Unfortunately, there is increased infection rates in AV fistulae. To keep this technique a viable option for
one aspect of this technique that may patients, it will be necessary to understand the potential infection risks and implement
impact its use – high infection rates. strategies to reduce the incidence of infection.
Over the course of the last 20 years,
there has been very limited published Goal
literature identifying concerns or To provide an overview of strategies in reducing infection while performing the but-
complications associated with the but- tonhole technique.
tonhole technique. It has only been
within the last four years that research Objectives
has been published citing infection as 1. Explain a process that patient care staff can institute to prevent buttonhole infec-
a potential problem requiring the tions.
renal community’s attention (Doss, 2. Discuss the implications of using sharp needles long-term.
Schiller, & Moran, 2008; Marticorena 3. Describe how improper cannulation technique can cause an infection in a but-
et al., 2006, 2009; van Loon, tonhole cannulation site.
Goovaerts, Kessels, van der Sande, &
Lynda K. Ball, MSN, RN, CNN, is the Quality
Improvement Director, Northwest Renal Network, Tordoir, 2009; Verhallen, Kooistra, & nique is that it reduces the variability
Seattle, WA, a Member of the Nephrology Van Jaarsveld, 2007). This article dis- that occurs as the results of staff mem-
Nursing Journal Editorial Board, and a Member cusses specific issues associated with bers’ different cannulation skill sets.
of ANNA’s Greater Puget Sound Chapter. She may the buttonhole technique and identi- It must be understood that button-
be contacted via e-mail at firstname.lastname@example.org
fies strategies to reduce the incidence hole is not just a variation on site rota-
Disclaimer: The analyses upon which this publica- of infection. tion cannulation, but rather, an entire-
tion is based were performed under Contract ly different way of performing cannu-
Number HHSM-500-2006-NW016C entitled End lation. How staff members cannulate
Stage Renal Disease Networks Organization for the Understanding the Technique
States of Alaska, Idaho, Montana, Oregon, and
for site rotation depends on their
Washington, sponsored by the Centers for Medicare What exactly is the buttonhole background (for example, phle-
& Medicaid Services, Department of Health and technique? It is a technique that fools botomist, IV nurse, no experience)
Human Services. The content of this publication does the fistula into thinking that only one and their initial cannulation training.
not necessarily reflect the views or policies of the person is cannulating it. The biggest As a result, there is great variability in
Department of Health and Human Services, nor
does mention of trade names, commercial products, advantage of the buttonhole tech- how needles are inserted.
or organizations imply endorsement by the U.S.
Government. The author assumes full responsibility
for the accuracy and completeness of the ideas pre-
sented. This article is a direct result of the Health This offering for 1.0 contact hour is provided by the American Nephrology Nurses’ Association
Care Quality Improvement Program initiated by the
Centers for Medicare & Medicaid Services, which
has encouraged identification of quality improve- ANNA is accredited as a provider of continuing nursing education (CNE) by the American
ment projects derived from analysis of patterns of Nurses Credentialing Center’s Commission on Accreditation.
care, and therefore, required no special funding on
the part of this contractor. Ideas and contributions to ANNA is a provider approved by the California Board of Registered Nursing, provider number
the author concerning experience in engaging with CEP 00910.
issues presented are welcomed. Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.
Statement of Disclosure: The author reported no This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
actual or potential conflict of interest in relation to ing nursing education requirements for certification and recertification.
this continuing nursing education article.
Nephrology Nursing Journal September-October 2010 Vol. 37, No. 5 473
The Buttonhole Technique: Strategies to Reduce Infections
Figure 1 Figure 2
Breaking Through the Epithelial Lining of the Tunnel Infection
Down the Tunnel
Staff unable to cannulate
~ Not following the
angle of entry
~ Not holding the
skin taut every cannulation
~ Creates pockets that can allow
bacteria and blood to collect
which can cause a tunnel
Note: Photo by Tony Samaha, MD.
Figure 3 the buttonhole tunnel can keep com-
Alteration in Scab Size Due to Manipulation plications to a minimum (Ball, 2006).
It is important to keep the tunnel as
(Center), Normal Scab Size (Lower Right)
close to the diameter of the needle as
possible to reduce the amount of
manipulation down the tunnel.
Manipulation can cause a break in the
epithelium lining, which could allow
a niche for bacteria or creation of
multiple tunnels. Either of these situa-
tions could set the patient up for the
development of a tunnel infection
(see Figures 1 and 2). Having scabs
that are larger than the diameter of
the needle is one indication the tunnel
has been entered at multiple angles of
insertion, was created using a too-
steep angle of insertion, or someone
was “searching” for the tunnel (see
In addition to a single creator, if
the advantages of arteriovenous (AV)
Note: Photo by Tony Samaha, MD. graft cannulation to the buttonhole
technique can be applied, it should
aid in creating well-developed button-
hole sites. The first advantage of AV
The buttonhole technique limits have no input, nor does it matter how grafts is they are firm and large. How
this variability to the cannulation skill you would have done it differently. do we get AV fistulae to resemble
set of one individual – the creator of Cannulation needs to be done exact- grafts? By always using a tourniquet
the buttonhole sites. It now requires a ly the way it was done by the original to plump up the vessel to enable a
“follow the leader” approach to can- cannulator, or damage to the button- complete assessment, determine how
nulation, which has been the hardest hole site will occur. deep the vessel is to identify the cor-
concept to grasp with this technique. rect angle of insertion, and know
When you are the follower, site loca- exactly where the center of the blood
Tunnel Creation vessel is located. The second advan-
tion, directionality, and angle of inser-
tion have been pre-determined; you Using only one person to create tage of AV grafts is they do not roll.
474 Nephrology Nursing Journal September-October 2010 Vol. 37, No. 5
One reason grafts are not cannulated that staff adhere to this contact time to cannulation training, staff members
immediately after placement is so ensure the maximum amount of are taught to insert the needles with
they can “set” in place by tissue Staphylococcus aureus is removed prior the hub coming into contact with the
growth around the graft. By pulling to cannulation. The recommenda- patient’s skin to maximize the amount
the skin taut (Ball, 2005), it enables tions from the research for cleaning of needle within the blood vessel, but
the skin to come down over the top of buttonhole sites is as follows (Doss et this is not the best practice for button-
the vessel, preventing it from rolling. al., 2008; Verhallen et al., 2007): hole cannulation. By repeatedly push-
In the buttonhole technique, we do • Patients must wash the access just ing the needle against the skin of a
not want to retract the skin as we do before sitting down in the dialysis buttonhole site, the underlying struc-
in site rotation because when the skin chair. ture of the skin collapses, causing the
returns to its original location, it could • Staff members must clean button- hub to bury itself inside a cave-like
move the needle tip out of position. hole sites before scab removal indented buttonhole site. This results
Instead, if the skin is stretched taut using the manufacturers’ recom- in the scab being very difficult to
from side-to-side, it will allow the vein mendations. reach and remove, causing staff mem-
to be stable but not cause needle • The scabs must be removed com- bers to have to dig around the exit
movement. Everyone who button- pletely. site. Incomplete scab removal or tis-
holes needs to realize both of these • Staff members must re-clean but- sue trauma at the exit site can lend to
two actions must be used from the tonhole sites with an antibacterial bacteria being transferred down the
first cannulation until the buttonhole agent using the manufacturer’s tunnel and into the bloodstream.
site is used for the last time. Everyone recommendations. Another avenue that may need to
must do the entire process exactly the • The buttonhole sites are then can- be pursued is whether or not to mask
same to be able to access the sites nulated. when accessing buttonhole cannula-
every time. In addition to skin cleaning, com- tion sites. Several studies of peritoneal
plete scab removal is essential. Since exit sites have shown a significant
patients sit in their chairs for four association of nasal carriage of
Preparing the Buttonhole Sites
hours, Staphylococcus aureus comes Staphylococcus aureus with exit site
back onto their skin; when scab for- infections. Since the majority of
It has been well documented for mation occurs post-dialysis, the patients on dialysis and their staff are
over 20 years that patients on dialysis Staphylococcus aureus becomes incorpo- never checked for the presence of
have more Staphylococcus aureus on rated into the scabs. Moistening scabs Staphylococcus aureus, it could be one
their skin and in their nares than the before removal helps reduce pain, but source of infection that is overlooked.
general population (Kaplowitz, care must be taken so trauma at the Buttonhole sites are truly exit sites,
Comstock, Landwehr, Dalton, & exit site is minimized to prevent exit and thus, should be treated as such.
Mayhall, 1988). As a result, staff site infections. Several dialysis providers have incor-
members must be rigorous in their Many studies have been done on porated the use of masks for button-
technique when it comes to skin reducing the incidence of exit site hole cannulation.
cleaning prior to inserting needles infections for both peritoneal and
into the patient’s sterile bloodstream. central venous catheters. Jaber (2005) Use of Sharp Needles
In the current literature, response to reviewed several randomized con-
buttonhole infections has been to trolled trials of prophylactic topical The buttonhole technique requires
establish a protocol of meticulous ointments, and they all reduced infec- the alignment of the tunnel and the
cleaning prior to cannulation. It starts tions at exit sites compared to non- entrance through the blood vessel
with the patient washing the access treated exit sites. Only a couple small wall. There are three main reasons
just before sitting down in the dialysis studies looked at eliminating button- why this alignment does not stay true,
chair. Patient resistance to this must hole exit site infections by incorporat- making it difficult to insert blunt nee-
be met by providing rationale. ing antimicrobial prophylaxis. dles (see Figure 4). One reason is can-
Showering at home is not sufficient Marticorena et al. (2006, 2009) used nulators trying to guide the needle
cleaning for the insertion of needles betadine or polysporin on the gauze down the tunnel, referred to as
(Ball, 2007a). Patients must know when withdrawing needles, while manipulating or “futzing” with the
their skin needs to be as clean as pos- Nesrallah, Cuerden, Wong, and needle. If the tunnel that has been
sible just prior to inserting needles, Pierratos (2010) utilized mupirocin created is the diameter of the needle,
and it needs to be cleaned in conjunc- ointment. Results from both groups then the needle can find its way down
tion with the staff members’ cleaning showed a reduction or elimination of without any difficulty. By pushing on
routine. Each manufacturer has a rec- buttonhole infections. the tunnel, the cannulator can dis-
ommended contact time that their A new phenomenon has recently place the tunnel from the entrance to
agent must have to effectively kill been identified at the exit site – hub- the blood vessel wall; this is evi-
bacteria (Ball, 2007b). It is imperative bing (Ball & Mott 2010). In routine denced by meeting resistance and the
Nephrology Nursing Journal September-October 2010 Vol. 37, No. 5 475
The Buttonhole Technique: Strategies to Reduce Infections
Figure 4 annual meeting stressing that button-
Inability to Successfully Insert Blunt Needles hole “requires rigorous education and
in a Buttonhole Site training of the staff” after seeing a rise
in infectious events during the second
year of buttonhole cannulation,
Why You Meet Resistance
“probably as a result with less atten-
needle tion for careful disinfection.” The
➤ Manipulating the flap
Fistula First Breakthrough Initiative
needle (n.d.) has created a Buttonhole Skills
Cannulation Checklist that is avail-
able on the Fistula First Web site for
➤ Patient drinking
use by the renal community.
➤ Tourniquet vs. no
tourniquet fistula wall Cannulation is an invasive proce-
dure. More focus needs to be placed
on cannulation competencies, incor-
porating practice guidelines, evi-
dence-based research/practice, and
inability to advance the needle into site where the tunnel would be locat-
manufacturers’ recommendations to
the bloodstream. A second reason is ed. This will preserve the integrity of
ensure compliance with accepted
due to the patient drinking excessive the tunnel for future use.
cannulation practices. Now is a good
amounts of fluid or having excessive In the last five years, it has been
time to review infection rates by can-
fluid as a result of the extended time shown that using sharp needles long-
nulation type, as well as the policies
since the last dialysis or an inadequate term creates a lot of scarring of the
and procedures for incorporation of
last dialysis. As the fluid increases and tunnel and of the blood vessel wall.
new evidence-based practice changes,
remains in the blood vessels, the The recommendation from the
and look at the skill set of each mem-
blood vessels will stretch to accom- Fistula First Breakthrough Initiative
ber of the patient care staff. If the but-
modate the increased volume, thus (n.d.) is to no longer use sharp needles
tonhole technique continues to have
shifting the vessel wall entrance out of long-term. The best demonstrated
higher infection rates than site rota-
position with the tunnel. The third practice, touch cannulation technique
tion cannulation, its use will be pro-
reason is cannulators not doing the (Mott & Prowant, 2008), decreases
hibited. It is paramount to have a safe
buttonhole procedure identically – the ability of staff members to manip-
and effective cannulation technique
the tourniquet versus the non-tourni- ulate needles, resulting in better can-
that will benefit both patients and
quet method. nulation success.
staff. The buttonhole can be that tech-
It is important to remember any-
nique if best practices in cleaning the
thing that will alter the amount of Competency Reviews site, creating and maintaining the but-
fluid in the vein will change the posi-
tonholes, and cannulation are fol-
tion of the opening into the blood- Failure to consistently conduct
stream. The way to realign the tunnel cannulation competency reviews has
and opening is to position the blunt led to deviation from policy and pro-
needle up to the point of resistance cedures, shortcutting to speed turn Ball, L.K. (2005). Improving AV fistula
and lift the tunnel slightly until the around times, and poor cannulation cannulation skills. Nephrology Nursing
opening is found. What the cannula- practice. Labriola, Crott, and Jadoul Journal, 32(6), 611-618.
tor should not do is re-enter the site (2009) presented an abstract at the
with a sharp needle. While this will be American Society of Nephrology’s
successful, it will also cannulate in a
small area, creating the potential for
aneurysm formation, especially if
done on a regular basis. If unable to Nephrology Nursing Journal Editorial Board Statements of Disclosure
find the opening to the bloodstream In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclo-
after moving the tunnel, then the nee- sure are published with each CNE offering. The statements of disclosure for this offering are published below.
dle should be removed and a Band-
Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant and research coordinator, is on the speakers’
Aid® placed over the buttonhole site; bureau, and has sat on the advisory board for Genentech.
the site should be rotated with a sharp
Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen,
needle elsewhere, avoiding a three- Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the
quarter inch in front of the buttonhole recipient of unrestricted educational grants from OrthoBiotech and Roche.
476 Nephrology Nursing Journal September-October 2010 Vol. 37, No. 5
Ball, L.K. (2006). The buttonhole tech- Kaplowitz, L.G., Comstock, J.A., Mott, S., & Prowant, B.F. (2008). The
nique for arteriovenous fistula cannu- Landwehr, D.M., Dalton, H.P., & “touch cannulation” technique for
lation. Nephrology Nursing Journal, Mayhall, C.G. (1988). Prospective hemodialysis. Nephrology Nursing Jour-
33(3), 299-304. study of microbial colonization of the nal, 35(1), 65-66.
Ball, L.K. (2007a). The importance of washing nose and skin and infection of the Nesrallah, G.E., Cuerden, M., Wong,
your access. Retrieved from http://www. vascular access site in hemodialysis J.H.S., & Pierratos, A. (2010). Staphy-
nwrenalnetwork.org/WashYourAccess. patients. Journal of Clinical Mircobiology, lococcus aureus bacteremia and button-
pdf 26(7). 1257-1262. hole cannulation: Long-term safety
Ball, L.K. (2007b). Preparing the vascular Labriola, L., Crott, R., & Jadoul, M. and efficacy of mupirocin prophylax-
access for cannulation. Retrieved from (2009). Higher infection rate after is. Clinical Journal of the American
http://www.nwrenalnetwork.org/fist switch to buttonhole cannulation of Society of Nephrology, 5, 1047-1053.
1st/cleanaccess.pdf native arteriovenous fistulas: Impor- doi: 10.2215/CJN.00280110
Ball, L.K., & Mott, S. (2010). How do you tance of staff (re)-education. Journal of Van Loon, M.M., Goovaerts, T., Kessels,
prevent indented buttonhole sites? the American Society of Nephrology, 20, A.G.H., van der Sande, F.M., &
Nephrology Nursing Journal, 37(4), 427- 688A. Tordoir, J.H.M. (2009). Buttonhole
428, 431. Marticorena, R.M., Hunter, J., MacLeod, needling of haemodialysis arteriove-
Doss, S., Schiller, B., & Moran, J. (2008). S., Petershofer, E., Dacouris, N., nous fistula results in less complica-
Buttonhole cannulation – An unex- Donnelly, S., & Goldstein, M.B.. (2006). tions and interventions compared to
pected outcome. Nephrology Nursing The salvage of aneurysmal fistulae the rope-ladder technique. Nephrology
Journal, 35(4), 417-419. utilizing a modified buttonhole can- Dialysis Transplant, 25(1), 225-230.
Fistula First Breakthrough Initiative (n.d.). nulation technique and multiple Verhallen, A.M., Kooistra, M.P., & Van
Buttonhole cannulation skills checklist. cannulators. International Society for Jaarsveld, B.C., (2007). Cannulating
Retrieved from http://fistula.mem- Hemodialysis, 10, 193-200. in haemodialysis: Rope-ladder or
berpath.com/LinkClick.aspx?file Marticorena, R.M., Hunter, J., Cook, R., buttonhole technique? Nephrology
ticket=Vs5E4bGEHzY%3d&tabid= Kashani, M., Delacruz, J., Petershofer, Dialysis Transplantation, 22, 2601-
127 E., ... Goldstein, M.B. (2009). A sim- 2604.
Jaber, B.L. (2005). Bacterial infections in ple method to create buttonhole can-
hemodialysis patients: Pathogenesis nulation tracks in a busy hemodialysis
and prevention. Kidney International, unit. Hemodialysis International, 13(3),
67, 2508-2519. 316-321.
Nephrology Nursing Journal September-October 2010 Vol. 37, No. 5 477
The Buttonhole Technique: Strategies to Reduce Infections ANNJ1017
The Buttonhole Technique: Strategies to Reduce Infections
Lynda K. Ball, MSN, RN, CNN
1.0 Contact Hour Complete the Following:
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Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at
1. What would be different in your practice if you applied what you have learned To provide an overview of strategies in
from this activity? reducing infection while performing the
____________________________________________________________ buttonhole technique.
____________________________________________________________ Please note that this continuing nursing education activity does not
____________________________________________________________ contain multiple-choice questions. This posttest substitutes the mul-
tiple-choice questions with an open-ended question. Simply answer
____________________________________________________________ the open-ended question(s) directly above the evaluation portion of
____________________________________________________________ the Answer/Evaluation Form and return the form, with payment, to
the National Office as usual.
Evaluation disagree agree
2. By completing this offering, I was able to meet the stated objectives
a. Explain a process that patient care staff can institute to prevent buttonhole infections. 1 2 3 4 5
b. Discuss the implications of using sharp needles long-term. 1 2 3 4 5
c. Describe how improper cannulation technique can cause an infection in a buttonhole cannulation site. 1 2 3 4 5
3. The content was current and relevant. 1 2 3 4 5
4. This was an effective method to learn this content. 1 2 3 4 5
5. Time required to complete reading assignment: _________ minutes.
I verify that I have completed this activity ________________________________________________________________________________
478 Nephrology Nursing Journal September-October 2010 Vol. 37, No. 5