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St. Michael’s Hemodialysis nurses create vascular access best practice program

Toronto, October 24, 2013

By Kendra Stephenson

Lundy Malfara, a hemodialysis nurse and co-leader of the Expert Nurse Cannulation Program, shows vascular access on a patient using ultra-sound technology.
Lundy Malfara, a hemodialysis nurse and co-leader of the Expert Nurse Cannulation Program, shows vascular access on a patient using ultra-sound technology. (Photo by Yuri Markarov)

Two nurses in the Hemodialysis Unit, Lundy Malfara and Elizabeth Petershofer, have developed an Expert Nurse Cannulation Program for vascular access that improves both patient and staff experiences.

Based on positive feedback about the program at St. Michael’s, the initiative is being implemented at Toronto East General Hospital as a best practice.

Vascular access is how a hemodialysis machine is connected to a patient’s vein using cannular devices, or needles. Each hemodialysis patient receives a minimum of two needles into his or her vascular access on every visit to the unit, with most patients receiving treatment about three times a week.

“The needles involved in hemodialysis are a huge source of anxiety for our patients,” said Joyce Hunter, vascular access coordinator for the Hemodialysis Unit. “Most people aren’t fond of needles to begin with, but these patients are having upwards of six very large needles inserted on a weekly basis.”

The program was developed after the cannulation process was identified as the greatest source of patient stress, as well as stressful for hemodialysis nurses. Malfara and Petershofer championed the initiative to improve nurses’ ability to administer the needles used to attach the dialysis machine to the patient’s vein.

“The biggest motivations behind this program were to improve patient experience, decrease anxiety and further staff skills,” said Malfara, program leader and expert nurse cannulator. “The main idea is to mentor and educate hemodialysis nurses to become experts at cannulation, which then improves patient care.”

The program uses a combined approach of expert knowledge, known best practices and the use of technology, such as an ultra-sound machine for easier approach and vision of a vascular access site.

"The main idea is to mentor and educate hemodialysis nurses to become experts at cannulation, which then improves patient care."

“Another policy is that after two failed attempts at vascular access, an identified expert must step in for the patient’s comfort and safety,” said Malfara. “There are also cannulation experts dedicated for new patients or those with difficult vascular access situations.”

The initiative teaches nurses how to conduct a pre-assessment of the patient, troubleshooting skills, applied best practices for disinfecting and hygiene, as well as patient and family education.

“The culture in the units has definitely changed because of this program,” said Hunter. “If nurses aren’t comfortable or there’s a complicated patient, they know there’s an expert to consult. The environment is very supportive and learning-based for staff. Most importantly, the anxiety of our patients has decreased.”

About 21 nurses have been trained in the Hemodialysis Unit, but all 60 nurses will eventually have the opportunity to improve their skills and possibly become “experts” with the help of Malfara and Petershofer and other mentors.

Hunter spends one day each week at Toronto East General Hospital teaching the program to hemodiaylsis nurses, including ultra-sound machine training. There is potential for the program to be applied in other Ontario hospitals – and even as a national initiative.

The Expert Nurse Cannulation Program was informed by the Registered Nurses’ Association of Ontario’s 'Establishing Therapeutic Relationships' and 'Professionalism in Nursing’ best practice guidelines and contributed to St. Michael’s designation as an RNAO Best Practice Spotlight Organization.'

About St. Michael’s Hospital

St Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.