Arterial assessment of the lower limb and foot: perceived benefits and disadvantages of current methods in contemporary practice

Background:

Peripheral artery disease (PAD) is a subtype of atherosclerotic cardiovascular disease, most commonly affecting arteries of the lower limb. PAD brings a significant burden to healthcare systems. This paper presents the results of a cross-sectional survey investigating current practices and perceptions surrounding vascular assessment performed by healthcare practitioners in community and acute care. An online survey using several social media channels, professional societies and personal networks was distributed for a nominal period of 3 months.

Methods:

Responses were received from 247 practitioners working in community and hospital settings across Great Britain and Northern Ireland. The largest group were podiatrists followed by community nurses, tissue viability nurses, vascular nurses and doctors. Practitioners frequently undertook assessments at multiple locations. Taking vascular assessments were part of their daily (n=151, 61%) or weekly (n=62, 25%) role. For the remainder, assessments were made less regularly; monthly (n=23, 9%) or rarely (n=10, 4%). Several systems were in use for vascular assessment, the majority manually operated.

Results:

Across the range of instrumentation used, numerous equipment issues were reported. Of 390 stated problems, Doppler probe malfunction/casing breakage (n=160, 41%) was the most common followed by flat batteries (n=134, 34%), problems with arm and ankle cuffs (n=54, 14%) and burst toe pressure cuffs (n=24, 6%). Other issues included loose wires, faulty electronics, tubing detachment from cuffs and loss of waveform. Practitioners frequently employed multiple methods of vascular assessment. Of the 247 respondents, ankle-brachial pressure index was used by the majority (n=194, 79%), whilst toe pressure measurements for calculating toe-brachial pressure index were used by 109 (44%). Numerous barriers were identified in performing assessments: lack of time, lack of equipment, lack of training and lack of confidence. Participants also reported patient-based barriers including lack of patient mobility to lie supine, lower limb oedema and discomfort during assessment. It may be prudent for future technologies to consider alternative assessment methods to prevent limitations of assessment on those with swollen, calcified and broken friable tissue and for those who are unable to lie in a supine position without experiencing discomfort and pain.

Conclusion:

Based on the results of this work, there is justification to pursue development of novel technologies which, in the future, would make it easier for healthcare practitioners to assess lower limb and foot circulation with ease, greater accuracy and at lower cost to the NHS.

Why we undertook the work:

Many people have poor blood supply to the legs, which is known as peripheral arterial disease (PAD). This has a burden both for the patient and for healthcare services. It is important that assessments are used to make sure people have the right care at the right time. There are a range of tests used by healthcare professionals to assess and diagnose PAD. We wanted to explore what tests were used and what health practitioners thought about them. This was to help think about what devices might be useful in the future to help, or even to improve, PAD assessment.

What we did:

An electronic survey was sent out to healthcare professionals asking them what assessments they used, how easy these were to complete, how long it took them and if there were any problems with completing them.

What we found:

The survey was completed by 247 people. The largest group to complete the survey were podiatrists followed by community nurses, tissue viability nurses, vascular nurses, doctors and lymphoedema nurses. Manual assessments were most often used for measuring ankle and arm blood pressure to understand how healthy a patient’s blood supply to the legs was. However, there were some difficulties in assessing patients. This was due to broken equipment, lack of equipment, lack of training or patient health issues. Patient health issues included being unable to lie flat, having very swollen lower legs, or the assessment causing pain, meaning it could not be completed.

What this means:

Future technology to assess lower limb circulation could be improved. Alternative systems could be developed to improve assessment of the circulation in patients with PAD.