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					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 lball@nw16.esrd.net
                                                          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
                            Buttonhole Tunnel

                Down the Tunnel
                Staff unable to cannulate
                 ~ Not following the
                                                       Incorrect angles
                                                            Correct angle
                   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
                                                                                         Figure 3).
                                                                                             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
For Cannulation
                                             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
                                            fistula wall
                                                                                                             Cannulation Checklist that is avail-
                                                                                                             able on the Fistula First Web site for
               ➤ Patient drinking
                                                                                                             use by the renal community.
                 excessively                                    tunnel

               ➤ 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

                                 ANSWER/EVALUATION FORM
                      The Buttonhole Technique: Strategies to Reduce Infections
                                                    Lynda K. Ball, MSN, RN, CNN
          1.0 Contact Hour                          Complete the Following:
      Expires: October 31, 2012                     Name: ____________________________________________________________
      ANNA Member Price: $15
         Regular Price: $25                         Address: __________________________________________________________

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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.

                                                                                                                       Strongly               Strongly
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