Simplifying ankle brachial pressure index for leg ulcer management

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1 Product focus feature Simplifying ankle brachial pressure index for leg ulcer management Sylvie Hampton Compression therapy is a key component of venous leg ulcer management. Best practice guidelines recommend that an ankle brachial pressure index (ABPI) is determined before applying full compression to establish if peripheral arterial disease (PAD) is present. However, a recent study by Guest et al (2015) highlighted that 84% of patients with a wound to the foot or leg have no recorded ABPI. The reasons for this are thought to be insufficent time to carry out the assessment (Chamanga et al, 2014), and lack of competency (Worboys, 2006). KEYWORDS: Ankle brachial pressure index Venous leg ulcer Dopplex ABility Peripheral arterial disease Venous leg ulcers (VLUSs) are the most common type of leg ulcer (Scottish Intercollegiate Guidelines Network [SIGN], 2010), with one in 170 adults having a VLU (Guest et al, 2015). Patients with VLUs often present with repeated cycles of ulceration, healing and recurrence. Ongoing management and prevention of recurrence should therefore be seen as a priority (Ashby et al, 2014), not only to promote patient wellbeing and prevent the detrimental impact that VLUs can have on quality of life, but also because of the significant burden that they can have on community nurse caseloads and resources (Chamanga et al, 2014). A number of clinical best practice guidelines exist that provide pathways to ensure optimal leg ulcer management (SIGN, 2010; Wounds UK, 2016). However, research on difficulties in wound care shows that some patients are treated incorrectly, or are treated without having been diagnosed (Weller and Evans, 2012), Sylvie Hampton, independent tissue viability nurse consultant, Wound Care Consultants Ltd, Hailsham with some healthcare professionals not always entirely following recommended clinical guidelines (Lagerin et al, 2007; Edwards et al, 2013), despite specific training in guideline-based treatment of leg ulcers (Lagerin et al, 2007). Twenty-two trials identified by the Cochrane Data review consistently showed that compression encouraged healing of ulcers (Cullum et al, 2004). In spite of this, research has shown that 50 60% of patients with venous leg ulcers are not being treated with compression (Srinivasaiah et al, 2007; Vritis, 2013). The reasons for this are unclear, but it is suggested that practitioners may be frightened of undertaking a new process or cannot obtain the necessary equipment, or lack the knowledge of how to use the required equipment to assess a patient s arterial status (Hampton, 2014). More recently, Guest et al (2015) identified that 84% of patients with a wound to the lower limb have no ankle brachial pressure index (ABPI) recorded. It may also be that the time required for measuring ABPI with a handheld Doppler device is no longer available to nurses who are responsible for the safety of patients when applying compression. Chamanga et al (2014) identified that there is insufficient time to complete leg ulcer assessments and care plans, leading to poor communication and insufficient time to deliver leg ulcer care. Whatever the reason, it means that lack of clinical assessment, including ABPI measurement, of patients with limb ulceration in the community leads to long periods of ineffective and often inappropriate treatment (Guest et al, 2015). In the author s clinical opinion, this has to change, and the easiest way to increase potential for healing is to make ABPI assessment simpler and quicker so that any person, with minimum training, can undertake it. This article introduces an automatic ABPI device (Dopplex ABility, Huntleigh Healthcare) that takes minutes, rather than the 45 minutes to an hour required using a handheld Doppler device. It also looks at a tool for assessing competency in using Dopplex ABility. UNDERTAKING ABPI ASSESSMENT Community nurses spend approximately 25 50% of their working time attending to patients with leg ulcers (Simon et al, 2004), and there is a mismatch between increasing levels of patient need in the community, compared with the actual numbers of community staff available to deliver it (Royal College of Nursing [RCN], 2012). This mismatch has led to a dilution of skill mixes, partly due to a decline in highly skilled community practitioners (RCN, 2012). This situation is exacerbated by the fact that community nurses have a 54 JCN 2018, Vol 32, No 5

2 Ankle Brachial Index Why it is essential to measure both arms Example a) One Arm Right Arm 110 Right Ankle Ankle Brachial : 110 = 0.96 Left Ankle You would INCORRECTLY compress Example b) Both Arms Right Arm 110 Right Ankle Current guidelines specify you should measure both arm pressures and take the highest. (NICE, ESC, ACC/AHA, TASC2 and Aboyans et al*) Otherwise: You could misdiagnose PAD (Vowden & Vowden; 2018)** You could apply compression to a patient with PAD which could lead to an adverse incident (Vowden & Vowden; 2018)** You should always follow evidence based practice Automatic systems which measure the pressure in only one arm contradict the guidelines and may miss or incorrectly classify cases of PAD. Join the #correctabi #2arms Ankle Brachial : 140 = 0.75 For more information contact or visit Huntleigh Healthcare Ltd. 35 Portmanmoor Rd. Cardiff. CF24 5HN Left Arm 140 Left Ankle You would NOT compress Dopplex Ability is an automatic ABI system that correctly measures systolic pressures in all four limbs. * NICE, CG147 (Peripheral arterial disease: diagnosis and management 2018); ESC - European Society of Cardiology (Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery, European Heart Journal, 2017); ACC/AHA - American College of Cardiology/American Heart Association (Guideline on the management of Patients with Lower Extremity Peripheral Artery Disease, Circulation, 2017); Measurement and Interpretation of the Ankle-Brachial Index (Aboyans et al, Circulation, 2012); TASC2 - Inter-Society Consensus for the Management of Peripheral Arterial Disease (Journal Of Vascular Surgery, 2007) ** Vowden P & Vowden K (The importance of accurate methodology in ABPI calculation when assessing lower limb wounds, BJCN, 2018)

3 higher age profile, with 38% being aged over 50 in comparison to 23.6% in the acute sector (RCN, 2012). Peripheral arterial disease (PAD) is associated with a three to sixfold increased risk of death from cardiovascular causes (Fowkes et al, 2008), and is frequently asymptomatic, particularly in those who are less mobile. Therefore, it is under-diagnosed, hence being termed a silent, but lethal epidemic (Hirsh et al, 2005). ABPI measurement has been the foundation of non-invasive PAD diagnosis for several decades, and thus is pivotal to any primary care PAD screening strategy (Lewis at al, 2016). In the author s clinical opinion, there is no excuse for not providing nurses with the equipment they need to do their job effectively. If nothing can get done without going through several layers of management, the organisation is not going to be very effective (Center for Community Health and Development, 2017). Any good manager knows that to do a job well, the tools must be provided. Indeed, when managers ask employees to accomplish a goal without providing necessary resources, credibility (and healing) is lost (Gallup Survey Q02). In Australia, the majority of practice nurses reported that they do not routinely use, or have confidence in using, a Doppler to measure ABPI before compression application and are not responsible for application of compression therapy (Weller and Evans, 2012). This will certainly lead to poor healing. When undertaking an ABPI with a handheld Doppler (commonly used by district nurses in the UK), pressures should be taken in each arm and leg (National Institute for Health and Care Excellence [NICE], 2016). The highest pressure of each is used to calculate the ABPI, which is achieved by placing A over B and dividing the highest ankle pressure by the highest brachial pressure for each leg. The normal result of that division should be 1. However, between 0.8 and 1.2 is considered normal and compression can be used. However, such assessment is time-consuming, as the patient s blood pressure must be normalised throughout the body, so resting patients for 20 minutes beforehand is important. As said, it is also necessary to measure both arm pressures and take the highest for the ABPI calculation. If only one arm pressure is used, this could lead to a misdiagnosis of PAD and an inappropriate treatment regimen. DOPPLEX ABILITY In the author s clinical opinion, fast, effective ABPI assessment contributes to cost-effective care, i.e. quicker assessment time enables more patients to have their ABPI measurement taken and thus their suitability for compression therapy identified. This, in turn, could lead to more appropriate and timely care, thereby improving outcomes and relieving pressure on hospital clinics (Clarke-Moloney et al, 2006) and the community nursing services. Dopplex ABility (Figure 1) is a simple, fast method of assessing ABPI. Using the device requires minimal training and it produces results within three minutes without the need for the patient to rest before assessment. In a busy clinic or the community, where time is so important, this three-minute assessment is a great advantage. A printout of the results is also provided, which can be placed in patient s notes with a copy provided for them to take away. The device is light and portable, so can be carried from clinic to clinic or to a patient s home, which can lead to improved clinical pathways, as it speeds up the assessment process. This is important for nurses with busy caseloads, as it helps to ensure that other patients are seen on time. Dopplex ABility also automatically records ankle pulse volume waveforms, which provides pictorial evidence to aid diagnosis. This dual diagnostic device can rule out PAD with a high degree of accuracy and is of particular value in patients who are prone to arterial calcification, such as diabetics (Lewis et al, 2016). The assessment can be undertaken without removing socks or tights, with the four cuffs being easily applied. The automatic interpretation of ABPI means that healthcare assistants can easily and safely undertake the assessment. The printout is then provided to the doctor or the qualified nurse who would then decide on the appropriate treatment according to the results of the printout. A handheld Doppler can also be used to listen to foot pulses. There are three sounds to listen for, with the best being the three sounds of a normal elastic artery. Two sounds are still not a problem, but usually reflect a lessening in artery elasticity. The worrying sound is that of a dog barking or a steam train sound. This is the result of an artery that has no elasticity and is furred and incompressible, with the blood being forced through an artery which has a small diameter. The latter should warn the nurse that the macro artery is not normal and compression should not be used. A second assessment tool is the use of an oximeter to note the oxygen saturations, which should be between 95% and 100%. Also, pinching the nail bed or, if the nail is too thick, pinching the pad of the toe until it whitens, then counting the seconds until it reflushes, will provide information on the tiny capillaries. This is particularly useful in the case of diabetes. The reflush should take between two and three seconds. Longer than seven seconds is indicative of severe micro vessel disease. Figure 1. Dopplex ABility. 56 JCN 2018, Vol 32, No 5

4 WOUND CARE be undertaken remotely using the printout, which can be placed in the patient s notes on computer. Integral easy grip handle Integrated thermal printer (can be used with paper or label rolls) CONCLUSION Clear display showing test status, numerical results, waveform and interpretation Simple user interface op le Lt d Colour-coded, easy connect tubing The most important factor determining the rate of healing of any wound is an adequate arterial blood supply to the leg. Without assessment of a patient s arterial status, compression cannot be safely applied and wound healing can be compromised. All nurses in the community should undertake ABPI as part of routine, holistic leg ulcer assessment. Dopplex ABility makes this assessment simple and speeds up the process. Using the device to measure ABPI increases potential for appropriate treatment, which, in turn, leads to improved healing rates and reduced workload. JCN 1 Pe Figure 2. Dopplex ABility is applied to the four limbs. Each cuff is clearly labelled for the individual limb and the leads are colour coordinated. Button press to Undertake Test COMPETENCY FRAMEWORK ASSESSMENT FORMS Simple operation and minimal training Arms and legs simultaneously 3 Minutes to complete the test C ar e 2 Quadrilateral measurements, reduces assessment time No patient rest time required with fast results While any member of the multidisciplinary team can undertake assessment using the device, interpretation of the results still requires input of a qualified nurse, GP or clinician. However, this can W ou nd Figure 3. The process. Newly employed qualified clinicians (nurses/podiatrists/occupational or physiotherapists), with no tissue viability experience, can be shown how to use the Dopplex ABility and then be assessed for competency. Forms can be used or adapted for the individual clinic, hospital or in the community (Tables 1 and 2). Figure 4. The printout provides a visual and accurate tool for the doctor or nurse to interpret. REFERENCES Ashby RL, Gabe R, Ali S, et al (2014) VenUS IV (Venous Leg Ulcer Study IV) compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model. Health Technol Assess 18(57): Center for Community Health and Development at the University of Kansas (2017) Developing a Management Plan. Section 1: chap 15. Available online: management-plan/main A Chamanga E, Christie J, McKeow E (2014) Community nurses experiences of treating patients with leg ulcers. J Comm Nurs 28(6): Clarke-Moloney M, Keane N, Kavanagh E (2006) An exploration of current leg ulcer management practices in an Irish community setting. J Wound Care 15(9): Cullum N, Nelson EA, Fletcher AW, Sheldon TA (2004) Compression for venous leg ulcers. Cochrane Database Syst Rev (2): CD Edwards H, Finlayson K, Courtney M, Graves N, Gibb M, Parker C (2013) Health service pathways for patients with chronic leg ulcers: identifying effective pathways for JCN 2018, Vol 32, No 5 57

5 Table 1: Competency framework assessment form Name of student Contact Place of work Named mentor Grade of mentor Assessor Date Signed Pass Mark Fail facilitation of evidence-based wound care. BMC Health Services Res 13: 86 Fowkes FGR, Murray GD, Butcher I, et al (2008) Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 300(2): Gallup Survey Q02: I have the materials and equipment I need to do my work right. Available online: Public/en-us/Question/QUESTION_2 Guest JF, Ayoub N, McIlwraith T, et al (2015) Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open. Available online: e Hampton S (2014) Removing the fear from venous ulcer assessment and application of compression. PCNR 5. Available online: Hirsch AT, Haskal ZJ, Hertzer NR, et al (2005) Guidelines for the management of patients with peripheral arterial disease endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 47(6): Lagerin A, Nilsson G, Törnkvist L (2007) An educational intervention for district nurses: use of electronic records in leg ulcer management. J Wound Care 16(1): Lewis JEA, Williams P, Davies JH (2016) Noninvasive assessment of peripheral arterial disease: Automated ankle brachial index measurement and pulse volume analysis compared to duplex scan. SAGE Open Medicine 4: 1 9 National Institute for Health and Care Excellence (2016) Peripheral arterial disease: diagnosis and management. Clinical Guidelines [CG] 147. NICE, London. Available online: guidance/cg147 Royal College of Nursing (2012) The Community Nursing Workforce in England. RCN, London Scottish Intercollegiate Guidelines Network (2010) Management of chronic venous leg ulcers - A national clinical guidelines. SIGN, Edinburgh. Available online: ac.uk./pdf/qrg120.pdf Simon DA, Dix FP, McCollum CN (2004) Management of venous leg ulcers. Br Med J 328(7452): Table 2: Dopplex ABility assessment Knowledge marks 1 10 with 160 = pass (76%) Describes the rationale for testing ABPI Describes the ABPI results that can be safely compressed Describes the rationale for the patient not talking or moving during the Dopplex ABility assessment Interprets the wave forms obtained by Dopplex ABility (would understand the need to identify the Dicrotic notch) Compares Dopplex ABility results with the arterial sounds Discusses the rationale for the secondary tests that are undertaken (leg colour/o 2 /capillary refill time/foot warmth/foot colour) Describes the rationale for undertaking toe PPG Discusses different types of compression that may be used, based on the results of the Dopplex ABility and physical assessment Understands the rationale for the patient being supine during the Dopplex ABility assessment Describes Doppler measurements before and after exercise. Is aware that the leg pressure will decrease further in patients after exercise if there is atherosclerosis present Can provide the rationale for alternative assessment for diabetic patients and can describe the assessment techniques Assessment of practical skills Prepares the patient for the assessment ensures their comfort Asks the patient to not speak or move for the length of the test and explains the reasons Describes the process to the patient and what to expect in the assessment Ensures the cuffs are correctly placed Informs the patient of progress during the test Interprets the Dopplex ABility printout can note the Dicrotic Notch Undertakes hand-held Doppler and correctly interprets arterial sounds Correctly assesses colour of leg/colour of foot Correctly undertakes capillary reflush time and oxygen saturation Records results correctly Ensures that GP and colleagues are able to obtain the recorded results through letters or assessment documentation Srinivasaiah N, Dugdall H, Barrett S, et al (2007) A point prevalence survey of wounds in north-east England. J Wound Care 16(10): 413 6, Vritis MC (2013) The economic impact of complex wound care on home health agencies. J Wound Ostomy Continence Nurs 40(4): Weller C, Evans S (2012) Venous leg ulcer management in general practice practice nurses and evidence based guidelines. Aust Fam Phys 41(5): Worboys F (2006) How to obtain a resting ABPI in leg ulcer management. Wound Essentials 1: Wounds UK (2016) Best Practice Statement. Holistic management of venous leg ulceration. Wounds UK, London Demonstrates theoretical understanding Signed by trainer /mentor Demonstrates skill (marks 1 10) 58 JCN 2018, Vol 32, No 5