After half a decade or more at university, armed with all that knowledge gained through sheer hard work, you are set upon on the wards to look after the unwell. However, once you are qualified you realised that the majority of the House Officers work load is comprised of ward rounds, organising tests, venepuncture and cannulation¹. 

However, though this does sound disheartening, one must remember that these skills, and in particular cannulation is a valuable talent and is part of routine practice and is probably the most commonly performed invasive medical procedure².

Cannulation skills are taught and practiced at university with great emphasis on using a sterile technique. However, from personal experience little is said about which arm to actually use and when to avoid cannulation. Additionally little consideration is given towards patient comfort. I plan to audit cannulation practice in order to assess current skill levels and changes that can be made to make this vital practice safer and more comfortable for the patient.

• To assess current cannulation practice.
• To identify the level of communication between the patient and those cannulating.
• To identify changes that can be made to current protocol to make cannulation more acceptable for the patient.

1. All patients will be asked their hand dominance

This is a fundamental question to ask as patients need there dominant hand to be free in order to carry out their activities of daily living (ADL), for example, eating, dressing and hygiene functioning^3,4. Additionally I will also collect data as to whether the cannula was in the dominant hand or not.

Standard: 100%

2. All patient will have the procedure explained to them

Again, this is fundamental as it forms part of informed consent. We do not expect a full account of what the procedure entails, but the patient should have a basic understanding of what the procedure is and why it is being done^5,6. From experience, this only takes a few seconds at most.

Standard: 100%

3. All patients, within reason, will be asked if they have any reason not to use a certain arm for cannulation, for example, if they have fistulas or have had breast surgery.

I think this is a very important question to ask as one may have never seen the patient before and will thus know little about them. I have almost cannulated people in an arm with a fistula and a patient who had had a mastectomy. This runs the risk of making the fistula defunct or introducing infection. Additionally, one must ask the patient about breast surgery (in a way that does not worry the patient) as there is a risk of lymphostasis and thus is an extra risk of infection⁷. Asking these questions, in my opinion, is quick and easy and can be done whilst preparing equipment, thus does not increase the time taken to cannulate significantly.

Standard: 100%

Data was collected from 100 medical and surgical inpatients during February 2008. Gender: 55% of patients were male, and 45% female. Mean age was 64.04 years (Range 22-91 years SD: 15.02).

Table 1.  Audit Results

Overall, 46% of all patients reported adverse effects to ADL as a result of their cannula.

The dominant hand was cannulated in 62% of cases, of these 65.57% had adverse effects on ADL. Of the patients who had their non-dominant hand cannulated, 15.38% reported adverse effects. This amounted to a significant difference between these two groups of patients (Chi-squared 24.12, df=1 p<0.0001).

None of the criteria were achieved pointing towards a large gap in communication between patients and health care professionals. By not explaining the procedure there is a failure in informed consent. Health care professionals also run the risk of complications to patients’ health due to not asking about contraindications to cannulation. Of the 7 patients that were asked about hand dominance, 5 of them were breast cancer patients, and this knowledge triggers the question. This leaves only 2 patients of the remaining 93 who were asked about contraindications without a known trigger, which points towards a serious breach in patient care.

A significant difference was found between the effects on ADL of those cannulated in the dominant compared to the non-dominant hand. This shows the importance of asking this simple question. However, there are many reasons that a dominant hand has to be cannulated. For example, poor venous access in the non-dominant hand; patient preference; if one cannot access the non-dominant hand due to obstruction, for example furniture etc; and any cellulites or oedema.

Our Audit shows a significant breach in patient communications and care which have been shown to lead to adverse effects on a patients ADL. We have suggested relevant changes and re-audit will take place once the proposals are accepted.

We propose a change to current protocol to include that all patients are asked their hand dominance and any contraindications, as well as having the procedure explained to them fully.

Health Care Professionals should always try the non-dominant hand first and only resort to the dominant hand in cases where this fails.

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