document type: guideline reference version number : 1850 4

Collated by Clinical Effectiveness Clinical Guidelines for the Management of Peripheral Arterial Disease (PAD)Version 4 (February 2021) of 36

Contents Clinical Guidelines for Podiatrists

for the management ofPage

1 Introduction 3

2 Purpose 3

3 Definitions 3

4 Responsibilities 4

5 Assessment and diagnosis 4

6 Referral requirements 13

7 Podiatric management 16

8 Monitoring compliance and effectiveness 17

9 Training and support 17

10 Associated documentation 18

11 References 18

Document Type: GuidelineReferenceNumber : 1850

VersionNumber: 4

NextReview Date: 5 February 2024

Title: Clinical Guidelines for the Management of Peripheral ArterialDisease (PAD)

Document Author: Podiatry Team Leader

Applicability: Podiatrists


Appendix A Summary flow chart of arterial evaluation of the lower limb 21

Appendix B Differential diagnosis 22

Appendix C Guidelines for letter 23

Appendix D Diagram of lower limb vessels 24

Appendix E Iceberg of peripheral arterial disease 25

Appendix F Lifestyle Team 26

Appendix G Podiatry PAD assessment form 27

Appendix H Letter to GP 29

Appendix I Acute limb ischaemia letter template 32

Appendix J Internal referral form for ABPI 34

Appendix K PAD leaflet 35

Appendix L ABPI leaflet 35

Appendix M Doppler Assessment 36

Appendix N Foot and leg circulation plan 37

Appendix O Acute Diabetic Foot Referral Form 38


Peripheral Arterial Disease (PAD) Guidance for Podiatrists

1. Introduction

Peripheral Arterial Disease (PAD) is a common and significant presentation in many patientsunder the care of the Podiatry Service of Torbay and South Devon NHS Foundation Trust(TSDFT). About 20% of people aged over 60 years have some degree of PAD (NationalClinical Guideline Centre, 2012). The prevalence is greater in people with cardiovasculardisease and risk factors such as diabetes mellitus, smoking, and dyslipidaemia than in thegeneral population (Gresele et al, 2011).

PAD is a range of arterial syndromes characterised by atherosclerotic obstruction of the lowerextremity arteries (BMJ 2011), and is a marker of patients who are at increased risk ofcardiovascular events, even when it is asymptomatic (NICE CG 147).

· Acute limb ischaemia has an incidence of around 1 in 12,000 people per year (Powelland Davies, 2010)

· Chronic limb ischaemia is much more common than acute ischaemia (Powell andDavies, 2010).

· Critical limb ischaemia occurs in around 1% of all people with peripheral arterial disease[Gresele et al, 2011], with an estimated annual incidence of between 50 and 1000 newcases per 1 million population [European Stroke Organisation et al, 2011].

2 Purpose

To support the clinical practice of Podiatrists within TSDFT with regard to the assessment andmanagement of patients presenting with PAD.

The information and standards in this document will support and promote the followingprinciples:

· Evidence based clinical practice· High quality patient care· Continuity of assessment techniques· Continuity of decision making and patient management across the service· Supporting individual clinical decisions/discretion

3 DefinitionsPodiatrist A registered health profession who diagnoses and treats

disorders, diseases and deformities of the feet (HCPC 2012)

PodiatryAssistant

Non-registered staff who undertake a variety of delegatedpodiatric clinical activities within a defined framework

PAD Peripheral Arterial Disease is the term used to describe anarrowing or occlusion of the peripheral arteries, affecting theblood supply to the lower limbs

ABPI Ankle Brachial Pressure Index

HCPC Health and Care Professions Council

GP General Practitioner

http://cks.nice.org.uk/peripheral-arterial-disease#!references/-609881








4 Responsibilities

4.1 The Head of Podiatry Services will be responsible for the implementation and monitoringof this guideline. It will be presented at A staff meeting and an audit of compliance will becarried out.

4.2 This guideline applies to all Podiatrists and Podiatry Clinical support workers employed bythe Podiatry Service of Torbay and South Devon NHS Foundation Trust.

4.3 Podiatry students of the University of Plymouth’s Podiatry Programme working underhonorary contracts within the Trust are also governed by this and allied documents. Thiswill be included in Induction packs

4.4 Qualified staff (HCPC Registered Podiatrists) will retain responsibility and accountabilityfor the actions of clinical support workers and students in their supervision.

4.5 The terms “staff” and “podiatrist(s)” are used in this document to encompass all thoseindividuals detailed in paragraphs 4.2 and 4.3. All such persons are responsible forengaging with, and implementing, the content of this document in their clinical practice.

5. Assessment and Diagnosis

Diagnosis of PAD is based mainly on patient history, with examination and ABPI being used toconfirm the disease. PAD is sub-classified as either occlusive or aneurismal.

In occlusive disease, the lumen is narrowed either in a chronic or acute manner. In aneurismaldiseases, weakening of the arterial media results in focal dilation of a blood vessel.

See appendix A for summary flow chart of arterial assessment and management. Seeappendix B for differential diagnosis

5.1 A holistic assessment of all patients presenting to the Service must include:

Table 1 Standards of assessment for podiatry patients

5.1.1Patients must be assessed for the presence of peripheral arterial disease if they have symptomsor risk factors (Lyden et al 2006; NICE CG147).5.1.1.1 Symptoms of PAD See Table 2

Standard RationaleEstablish and document thepatient’s main reason for referralto the Service

Establishment of the patient’s presenting complaintis vital. Failure to focus upon this can lead to non-compliance and dissatisfaction from the patient(Kroenke 1998)

Establish and record currentsymptoms (if present)

To determine the nature of the presenting problem,and to identify and ‘red flag symptoms’ that mayindicate a serious underlying pathology

Record a complete medical andsurgical history, includingcurrent medication

To establish any potential risks, and to determine theeffect of this history on lower limb health, functionand performance

Record and assess keypersonal information, includingsocial status, activity types andlevels, smoking status, diet andnutrition

To determine if any of these factors have a role inthe presenting problem, or present as barriers toimproving foot health/function or future attendancewith the Service


Table 2

Symptoms suggestive of PADIntermittent ClaudicationRest PainIschaemic PainLower limb ulcerationNon-healing wounds/ tissue loss/gangrene

5.1.1.2 Risk factors for PAD.

The majority of patients with lower limb PAD are asymptomatic, and may not present with ‘classicsymptoms’ of intermittent claudication (Lyden et al 2006). See Apendix G for Iceburg of PAD. Thisindicates that the majority of people with PAD have no symptoms. Therefore, it is vital that risk factorsfor PAD are considered (Bartholomew et al 2006) and appropriate referrals made so that risk factormodification and long term follow up can be properly monitored (Sign 2006). See Table 3

Table 3 Risk factors for PAD

Risk factors for PADSmoking. For people aged over 50 years of age, the principal risk factor for PAD is smoking. Lessthan 5% of people presenting with PAD have never smoked. Smoking appears to be a strongerrisk factor for peripheral arterial disease than for coronary artery disease, and evidence for lowerlimb arterial disease suggests that the risk from smoking is dose dependent. Stopping smoking isassociated with a rapid decrease in the incidence of claudication. After one year of stopping, theincidence is equivalent to that in non-smokers. (Clinical Knowledge Summaries September 2015).Patients with PAD should be actively discouraged from smoking (Sign 2006).

Diabetes Mellitus (a five-fold increase in risk of developing critical limb ischaemia compared withpeople without diabetes). Clinical Knowledge Summaries, September 2015. People with both PADand diabetes are at increased risk of cardiovascular events. Optimal glycaemic control isrecommended for patients with PAD and diabetes in order to reduce the incidence ofcardiovascular events (Sign 2006).

Hypertension. Elevated blood pressure is a well-established risk factor for mortality,cardiovascular and cerebrovascular events. Hypertensive patients with PAD are at considerablyincreased risk of Reno- vascular disease (Sign 2006).

Hypertensive patients with PAD should be treated to lower their blood pressure (Sign 2006).

Hyperlipidaemia. Lipid lowering therapy with a statin is recommended for patients with PAD andtotal cholesterol >3.5mmol/l (Sign 2006).

Chronic kidney disease (CKD). PAD is highly prevalent among persons with CKD. The presenceof PAD in CKD patients markedly increases the short term risk of heart attack and stroke, andserves as the key cause of limb loss and mortality, with such rates being much greater than that ofthe general population. The risk of PAD increases as estimated Glomerular Filtration Rate (eGFR)values decreases. Patients who require dialysis have an increased risk of PAD. The chronic uremicstate is associated with systemic inflammation in dialysis patients leads to hypoalbuminemia andan increased risk of PAD.The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines2012 recommend that all patients should be evaluated for PAD at the time of dialysis. KDOQIhighlighted the need to provide medical interventions more promptly (including lifestyle, medicationor revascularization strategies) during earlier stages of kidney disease.The KDIGO guidelines recommended that adults with non-dialysis chronic kidney disease (CKD)be regularly examined for signs of PAD. (Garimella 2014).


Elevated inflammatory markers.Raised Inflammatory markers which include C- reactive protein (CRP) , monocytes, fibrinogen andhomocysteine have been shown to be independent predictors of myocardial infarction and stroke inasymptomatic individuals, and also predictive of onset of symptomatic PAD. Several interventionshave been shown to reduce CRP levels including diet, moderate alcohol consumption statins,fibrates and fish oil (Khawaja, 2009).If when checking cyberlab you notice abnormal blood results highlight to the GeneralPractitioner(GP).

Thrombophilia Thrombophilias can be defined as a group of inherited or acquired disorders thatincrease a person's risk of developing thrombosis (abnormal "blood clotting") in the veins orarteries. A quarter of patients with peripheral vascular disease have evidence of thrombophilia (Viget al, 2006).

Older age 20% of the UK population aged 55-75 has PAD, of whom 5% have symptoms.Men over age 60 are at greater risk for PAD. Women after menopause exhibit the same risks asmen over age 60 (National Institute for Health and Care Excellence NICE 2011).

History of coronary artery disease/myocardial infarction/ischaemic heart diseaseOf the patients with known PAD, approximately 30% to 50% have evidence of coronary arterydisease.When a diagnosis of PAD is made, the patient should have a full cardiovascular risk assessment.(Dhaliwal,G and Mukherjee D,2007).

Inform GP of your findings to ensure correct management.

Iron deficiency anaemiaIron deficiency anaemia is prevalent among patients with critical limb ischaemia. Anaemia and itsseverity are independent predictors of mortality and limb loss in patients with PAD. (Desormais I etal 2014).

The World Health Organization (WHO) 2001 defines anaemia as:

§ In men over 15 years of age: Hb below 13 g/100 mL.§ In non-pregnant women over 15 years of age: Hb below 12 g/100 mL.

Inform GP if you note anaemia in conjunction with PAD.

Overweight or obese.Obesity is adversely associated with a number of cardiovascular risk factors and increased risk ofmortality.Those patients with Body Mass Index (BMI) over 30 should be treated to reduce their weight(Scottish Intercollegiate Guidelines Network (SIGN) 2006).

Discuss with patient and if consent is given, refer to lifestyles team and copy GP into the referral.

https://www.ncbi.nlm.nih.gov/pubmed/?term=Dhaliwal%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22477268

https://www.ncbi.nlm.nih.gov/pubmed/?term=Mukherjee%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22477268

https://www.ncbi.nlm.nih.gov/pubmed/?term=Desormais%20I%5BAuthor%5D&cauthor=true&cauthor_uid=24935912


Family history of vascular diseaseIndividuals with a family history of PAD have nearly double the odds of having PAD relative tothose without such a history (Khaleghi M et al, 2014).

Document the presence of family history and include this in your letter to GP.

COPD/asthmaThere is a high prevalence of asymptomatic PAD in the Chronic Obstructive Pulmonary Disease(COPD)/asthma patient’s.The diagnosis of peripheral arterial disease in COPD is importantbecause it limits the patient's physical activity and impairs their quality of life. In addition it indicatesa high cardiovascular risk that requires therapeutic measures. (Sign 2006).

Check vascular status of podiatry patients with poorly controlled asthma and COPD and inform GPof results. Encourage smoking cessation. Refer to Lifestyles team if patient consents and informGP.

5.1.3 Patients must be assessed for the presence of PAD if they are being considered forinterventions to the leg/foot, e.g. minor surgery (NICE CG 147).

5.1.4 Patients must be assessed for the presence of PAD if they have unexplained leg pain (NICECG 147

5.1.5 Patients must be assessed for the presence of PAD if they present with a new foot ulceration.

Information regarding differential diagnoses of lower limb peripheral disease can be found inAppendix B.

5.2 The vascular status of the patient must be assessed. See Table 4 vascular assessment.

Table 4

Vascular assessment of patientPalpationof pedal pulses

Palpate dorsalis pedis and posterior tibial pulses. Where possible,the popliteal and anterior tibial pulse may also be palpated. If youcan palpate a foot pulse, you will have at least 80mmHg.

Colour and temperature Assess and document the colour and temperature differentials andgradients of both their legs, their feet and toes. The temperaturegradient of the skin is checked using the back of the hands andgently moving them form the pre tibial region of the leg distally overthe dorsum of the foot to the toes whilst keeping contact with thepatients skin.It is important to take into account the ambient temperatureoutdoors and of the room in which the assessment

Doppler Ultrasound Use Doppler Ultrasound using an 8 MHz probe. If the patient hassignificant ankle oedema, a 5MHz probe can be used if available.

As a minimum, staff must record the audible characteristicsproduced by the Dorsalis Pedis and Posterior Tibial arteries.


Where possible, staff may also record the audible characteristicsproduced by the digital, anterior tibial and popliteal and peronealarteries. When possible use headphones.

Sub capillary refill time Record sub capillary refill time at the apex of the hallux of both feet(where absent, the next available digit should be used).

Ankle brachial pressureindex (ABPI)

See Table 5 for ABPIIndications, contraindications,and when an ABPI does notneed to be done.

See Table 6 Interpretation ofABPI results

Objective evidence to substantiate the presence or absence ofsignificant PAD may be acquired reliably (except in those withheavily calcified vessels).

The ABPI is also predictive of atherosclerosis and cardiovasculardisease at low values (less than 0.9), and can indicate an increasedrisk of cardiovascular morbidity and mortality. (Clinical KnowledgeSummaries September 2015).

· See Appendix J for Podiatry ABPI referral form. The nextpodiatrist to review the patient is responsible for ensuringthat the subsequent action plan has been complete.

· Issue and explain ABPI leaflet· Issue and explain PAD leaflet Appendix K.

Toe Brachial PressureIndex (TBPI)

See Table 7 to interpretresults

There is much less calcification of the toe arteries.Carry out TBPI and document results if :

· Incompressible arteries· Abnormally high ABPI (ABPI of 1.2 or over)· Diabetic· Too painful at ankle to carry out ABPI

The TBPI result may be lower than the ABPI. ABPI of ≥1.2 whichwill indicate a falsely high reading may be due to arterialcalcification. In situations such as this, the lower TBPI reading isconsidered to be the more accurate representation of PAD.

Buergers test The Buerger's test is a useful adjunct to routine peripheral vascularassessment and, if positive, suggests more severe ischaemia withdistal limb artery involvement.

Table 5. ABPI Indications, contraindications and when an ABPI is not required.

N.B Podiatrists must document rationale in the patient’s clinical records for not arranging an ABPI

An ABPI must beundertaken in the followingcircumstances: (unlesscontraindicated):

ABPI is contraindicated when/ifthe patient:

An ABPI does not need to beundertaken when:

The patient is a non-traumatic amputee with oneor more monophasic signal.

If ABPI too painful to perform inpatients with acute cellulitis orpainful ulcerations at the ankle. Toebrachial pressure index(TBPI) canbe considered.

The patient has non-audiblepulses on the Doppler. (If nonaudible pulses check Dopplermachine volume, positioning ofthe probe to account foranatomical variance and use


headphones to eliminate background noise). Refer tovascular team if symptomaticof PAD

Any non-traumatic amputeesreceiving long term care fromthe Podiatry Service musthave an ABPI completedannually.

Has Reflex Sympathetic DystrophySyndrome/ Complex PainSyndrome

The patient has a fullcomplement of biphasic/triphasicsignals

The patient develops anulcer, and has known PAD.

Has a caution for measuring bloodpressure, e.g. fistulae for dialysis,removal of lymph glands - use theother arm.Proceed with caution in patientswho have had a stent or graft if itextends into the lower calf.Do not use a cuff on anyone with anarteriovenous shunt (fistula,anastomosis) for kidney dialysis orlymph node damage.

The patient is currently receivingassessments and/orinterventions from the VascularTeam- if unsure check oninfoflex for record of vascularappointments and results

The patient has a wound ontheir foot that has failed toheal after 2 weeks oftreatment or showing noimprovement and or whenthe it is deteriorating.

Patients with suspected or knownacute deep vein thrombosis (DVT)or superficial thrombophlebitis.

The patient has had an ArterialDuplex Scan or angiography inthe last 12 months and therehave been no new ulcers,deterioration of ulcers, orworsening PAD symptoms. Staffshould check Picture ArchivingCommunications System(PACS) for details, and put acopy of the report (whereavailable) into the patient’srecords for future reference.Staff who are unable to accessPACS (or Infoflex must askanother member of staff who hasaccess to the system to checkfor these results.

A differential diagnosis ofPAD is being considered.

Recent surgery, ulcers, casts orbandages that cannot or should notbe compressed by pressure cuffs.

If a previous duplex scan hasshown that calcification ispresent, the ABPI should not beattempted. If no previous duplex,staff should try to compress anankle artery in the first instance,and if it is not compressible, theprocedure must be discontinued.The ABPI, if obtained for thisgroup of patients, should betreated with significant cautionand the issue clearly stated inany correspondence regardingthe patient’s condition. TBPIshould then be undertaken.

The patient reports asignificant deterioration insymptoms.

Any new diabetic foot wound.


It should be noted that ABPIsmay be less reliable inpatients with diabetes orpatients with knowncalcification of their arteries.

If the patient has been discharged from the vascular team, and a significant deterioration is suspected,this should be highlighted to the patient’s GP and contact the vascular clinic for advice.

Table 6 Interpretation of ABPI results

ABPI less than 0.9 Presence of PAD

ABPI less than 0.8 Record as ischaemia when using SINBAD scoreABPI of less than 0.5 Critical limb ischaemia

ABPI is high (1.2 or more) Consider the possibility of PAD, may indicate arterialcalcification, particularly if the person has diabetes orrenal failure. Take into account other symptoms andsigns, and seek specialist advice if unsure of thediagnosis

Table 7 Interpretation of TBPI results

TBPI > 0.7 Normal indicating no arterial disease

TBPI = 0.64 - 0.7 Borderline peripheral Arterial disease

TBPI < 0.64 Abnormal indicating peripheral arterial disease

TBPI < 0.6 Record as ischaemia when using SINBAD score

5.3 Diagnosis of chronic Lower Limb Ischaemia

5.3.1 Peripheral arterial disease may lead to intermittent claudication or critical limb ischaemia.

5.3.2 Intermittent claudication may cause calf, posterior thigh or buttock pain when there isnarrowing of the femoral or popliteal artery. (See Appendix D for diagram of lower limbarteries).

5.4 Assessment of the severity of claudication pain.

Intermittent claudication is the most common initial symptom of lower limb PAD (NICE,2012).




5.4.1 Rutherford Classification

As treadmills are not used in podiatry, assessment of severity of claudication is not within thepodiatrist’s remit, however a referral to vascular clinic via the GP could be requested if there is adiscrepancy between history and clinical signs as it provides objective evidence of a patientsmaximum walking distance (Sign 2006).

Stage 0 AsymptomaticStage 1 Mild claudicationStage 2 Moderate claudicationStage 3 Severe claudicationStage 4 Ischaemic rest painStage 5 Ischaemic ulceration of the toesStage 6 Severe ischaemic ulcers or frank gangrene

5.4.2 Epidemiology of Intermittent Claudication

Among patients with intermittent claudication, 16% will experience a worsening of their claudicationsymptoms, 7% will require lower extremity bypass surgery, and fewer than 4% will need primaryamputation. (Primary amputation is where significant PAD leads straight to a major-above or belowknee amputation). Approximately 1.4% of patients with intermittent claudication will progress toischemic rest pain and/or gangrene. This rate is markedly higher among smokers and people withdiabetes. See Appendix G Iceburg of PAD.

5.4.3 Features of intermittent claudication :

5.4.3.1 Cramp-like pain after walking a predictable distance that is relieved by rest and reproducedby walking the same distance again.

5.4.3.2 Distal pulses that may be felt at rest but disappear on exercise to the point of pain.

5.4.3.3 Increase in symptoms with stairs/incline.

5.4.4 Staff must document:

5.4.4.1 Claudication distance

5.4.4.2 Time taken for symptoms to subside

5.4.4.3 Effect of walking on an incline or stairs

5.4.4.5 Which leg and muscle group(s) affected

5.5 Features of critical limb ischaemia: Table 8


Features of critical limb ischaemia

Rest pain · Often described as relentless, unbearable, or burning pain in the foot.· This may be worse at night because the elevation of the leg in bed

further limits perfusion.· People may report sleeping with the leg hanging out of bed, or

sleeping in a chair to relieve the pain.· Nocturnal pain is pain in the foot at night relieved by hanging the leg

out over side of bed· Pain is made worse by elevating the leg and of sufficient severity to

cause the patient to wake.· Rest pain is usually preceded by a history of intermittent claudication

but occasionally is not (for example intermittent claudication may nothave been clinically apparent in a person with limited mobility).

· Patients may habitually get out of bed for the toilet or to make a cup oftea at night. They may need direct questioning to ascertain that theyare prompted to get out of bed by the pain.

· If there is an underlying condition such as diabetes, over time theperipheral nerves may begin to degenerate (neuropathy) and the painwill subside. The patient may think the problem is resolving, but in factit may be worsening. If this is noted it should be communicated to thepatient’s GP with a recommendation for vascular referral. Phonevascular clinic if advice is needed.

· True rest pain - constant pain for > 2 weeks requiring analgesia.Dependent rubor · Red or purple colour of the foot when not elevated-“ sunset foot”

· Patients with severe, chronic lower limb ischemia manifest early palloron elevating the leg above the level of the heart and rubor withdependency.

Absent foot pulses · May be due to anatomical variance, oedema, background noise orlow volume. Check pulses by hand, check position and angle ofDoppler probe, use headphones

ABPI results ofless than 0.5 orabsolute systolicpressure of 50(with or without afoot ulcer) or less

· Suggests the presence of critical limb ischemia.· Absolute pressure is the highest systolic measurement at the ankle

before it is divided with the brachial to give the ABPI.· (If patient has ankle pressure of 70 mm Hg or less with a foot ulcer,

and has diabetes refer urgently to the podiatry wound specialist teamat Torbay Hospital).

Tissue viabilitychanges

· Ulcers or gangrene in a patient with chronic ischemia or criticalischemia will indicate a potential for imminent limb loss.

5.5.1 Patients with critical limb ischaemia require an urgent referral for vascular assessment bythe vascular team 01803 655594- secretary. Also contact vascular practitioners on 07833402078/07867 201759. [email protected].

Ensure the GP receives a copy of the referral. Use letter template on O Drive (shared podiatrydrive) - Clinic Letters-Acute limb ischaemia (Appendix I).

Same day referral should be made and referrals should not be delayed.

5.6 Acute limb ischaemia develops quickly. There is a sudden decrease in limb perfusion, usuallyproducing new or worsening symptoms and signs, and often threatening limb viability. It canoccur in people who have had no previous symptoms [Norgren et al, 2007]. Not all people withacute limb ischaemia have risk factors [Brearley, 2013].

mailto:[email protected]




5.6.1 Typical features of acute limb ischaemia (The six Ps) include:

Pain- constantly present and persistent. Pulseless -ankle pulses are always absent. Pallor- (or cyanosis or mottling). Power -loss or paralysis.

Paraesthesia- or reduced sensation or numbness. Perishing- with cold.

N.B Not all of these are necessarily present

5.6.2 If there is ischaemia due to an embolus:Usually cardiac in association with atrial fibrillation.Onset is acute (seconds or minutes).Ischemia is usually profound (because there is no collateral circulation).Skin changes of the feet (such as marbling) may be visible. This can be a fine reticularblanching or mottling in the early stages, progressing to coarse, fixed mottling.There is not usually a history of claudication, and pulses are usually present in the other leg.

5.6.3 If there is ischaemia due to thrombosis: Thrombosis secondary to atherosclerosis. Onset is insidious (hours or days). Ischaemia is less severe (due to collateral circulation).

There will often be a history of claudication, and pulses in the other leg may also be absent.

5.6.4 The evolution to paresthesia and paralysis reflects the presence of severe potentiallyirreversible ischemia.

These patients should be sent straight to Accident and Emergency (A&E) Departmentimmediately, phone ahead and send with covering letter (See Appendix A and Appendix Kcovering letter).

6 Referral Requirements

6.1 Podiatrists must inform the patient’s GP, in writing, of the presence of any level of PAD tosupport the GP in managing the patient’s risk factors to prevent further deterioration. (SeeAppendix I).

6.2 Patients who present with intermittent claudication do not necessarily need to be referred tosecondary care for more detailed examination. A GP will, in the first instance, advise the patientabout the importance of exercise, will manage cardiovascular risks (e.g. by prescribing anti-platelets or statins), and embark on vasoactive drug treatments. A referral into secondary caremay be sought by the GP when the symptoms do not resolve or deteriorate further (NICECG147 2012).

6.3 Notify GP of results describing the signs and symptoms if:

6.3.1 Circulation is within the normal limits (ABPI = 0.9 – 1.2) (TBPI above 0.7). The patientcurrently does not have active foot ulceration. The podiatry service will therefore continue witha treatment plan which may includes a 6 monthly foot check or regular appointments for footcare depending on the patients other comorbidities.

6.3.2 Good foot pulses are present; however patient reports symptoms of intermittent claudication ofless than 100 m.

6.3.3 When the ABPI result falls in the 0.5-0.89 range, regardless of symptoms if no ulceration orTBPI < 0.64 for optimisation of risk factors


6.3.4 When the ABPI result falls in the 0.5-0.6 range, with deteriorating or non healing ulcer that apodiatry referral has been made to the vascular department . Assistant practitioners are unableto refer to the vascular department so are therefore required to alert a podiatrist to review andaction urgently.

6.3.5 If ABPI <0.5 where no symptoms, inform the GP (if no symptoms, vascular surgeons would notoperate due to the substantial risks).

6.3.6 If calcification or false highs on ABPI (i.e. ABPI >1.2 or incompressible) conduct a TBPI

6.3.7 If the patient displays any significant increase in pain refer for further pain management.

6.3.8 When the patient reports rapid deterioration in the intermittent claudication symptoms over ashort period of time e.g. 2-3 weeks of 100 m or less if there is no foot ulceration present.

6.3.8 Requesting a review of medications if required i.e. is the patient on an antihypertensive, astatin 40mg and antiplatelet such as clopidogrel or aspirin 75mg.

6.3.9 If there is a 20-30mmHg difference in the systolic pressure in the brachial arteries of each arm,or 15 mmHg for those with diagnosed hypertension. Differences of these magnitudes arepotential indicators of increased risk of cardiovascular episodes, increased mortality, aorticarch and subclavian stenosis (Clark et al 2012). Sub clavian stenosis

6.4 If a patient does not meet the criteria for ongoing care, it must be made clear to the GP if thepodiatry service will not be continuing to monitor the patient’s lower limb arterial supply. Theletter must contain the caveat that the GP can re-refer the patient to the service should theirclinical needs or medical risk status increase, placing the patient at greater risk of significantdeterioration in their foot health.

6.5 Compression hosiery/bandaging. If the ABPI results are <0.7 and the patient is wearingcompression hosiery the results must be communicated with Practice and District nursing teamsor the Lower Limb Therapy Service ([email protected]) as a matter of urgency,back this up with a letter outlining findings and concerns, and if concerned regarding the viabilityof the limb due to signs of critical limb ischaemia remove compression hosiery (Vowden 2001).Any verbal communication must be followed up by a letter which should include risk factors.(5.1.1.3).

6.6 Patient should be referred directly to the vascular clinic, with the view for further vascularassessment and possible intervention if presenting with:

6.6.1 Rest pain/critical limb ischaemia (< 0.5 ABPI or <50mmHg) - with or without tissue loss. Truerest pain is constant pain for > 2 weeks requiring analgesia (Nocturnal pain, however, is pain inthe foot at night relieved by hanging the leg out over the side of the bed.).

6.6.2 If there is tissue loss and absent pulses. TBPI < 0.6 ABPI 0.5 or below( equivalent toe pressure )or absolute ankle pressure less than 50mm with non healing or deteriorating wound

6.7 Refer to the vascular department using generic email [email protected].

6.7.1 Put “for attention of vascular practitioners” in the subject box.

6.7.2 Referrals must include name, address, date of birth, NHS number, medical history, medications,vascular assessment details, main vascular complaints. See Appendix K

6.7.3 Send copy to the patient’s GP.



6.7.4 The Podiatry department has a baton phone available for staff to call if they require adviseabout PAD, wound care and the referral process. This manned between 08.30 and 16.00Monday – Friday 07870501703.

6.8 Diabetic foot ulcers with PAD

6.8.1 If SINBAD score of 3 or above. Refer to level 2 Podiatry at Torbay Hospital immediately.(SINBAD is an acronym wound scoring tool which stands for Site, Ischaemia, Neuropathy,Bacterial infection, Area, Depth).

6.8.2 If SINBAD score of 2 and no improvement within 2-4 weeks refer to Torbay Hospital Podiatrylevel 2 via podiatry appointments, copying the diabetes podiatry specialists with the referraldetails.

6.9 Wound Ischaemia Foot Infection Classification (WIFI) (Mills et at, 2014)The new classification system takes into account foot wound depth and infection as well aslimb perfusion and is titled WIfI (wound, ischemia, and foot infection)and is a means ofassessing outcomes and efficacy of interventions. Use the WIFI to assist in SINBAD scoring.Follow local guidelines for vascular referrals- see appendix A

Wound – Clinical Category

Ischemic rest pain; Pre-gangrenous skin change, without frank ulcer or gangrene.

Minor tissue loss: small shallow ulceration) < 5 cm2 on foot or distal leg (Pedis or UT Class1); no exposed bone unless limited to distal phalanx.

Major tissue loss: deeper ulceration(s) with exposed bone, joint or tendon, ulcer 5-10 cm2 notinvolving calcaneus –); gangrenous changes limited to digits. Salvageable with multiple digitalamps or standard trans-metatarsal amputation (TMA) + skin coverage.

Extensive ulcer/gangrene > 10 cm2 involving forefoot or midfoot; full thickness heel ulcer > 5cm2 + calcaneal involvement. Salvageable only with complex foot reconstruction, non-traditional TMA (Chopart/Lisfranc); flap coverage or complex wound management needed.

WIFI Classification of ischaemiaGrade ABPI Ankle systolic pressure Toe brachial

pressure index

None 0.8 or above 100mmHg or more 60mmHg or moreMild to moderate 0.6 -0.79 70-99 mmHg 40-59mmHg or moreModerate to severe 0.40-0.59 50-69 mmHg 30-39mmHgSevere Less than 0.4 Less than 50 mmHg Less than 30mmHg

lClinical manifestation of infection IDSA (Infectious

Diseases Society ofAmerica)/PEDIS(PerfusionExtent/sizeDepth/tissue lossInfectionSensation.Infection severity)


Wound without purulence or manifestations of infection UninfectedInfection present, as defined by the presence of at least 2 of thefollowing items:

Local swelling or indurationErythema >0.5 to ≤2 cm around the ulcerLocal tenderness or painLocal warmthNo local complications or systemic illnessPurulent discharge (thick, opaque to white, or sanguineous secretion)

Mild

Infection in patient who is systemically and metabolically stable but hasone or more of the following:

Cellulitis extending 2cm, lymphangitisSpread beneath fasciaDeep tissue abscessGangreneMuscle, tendon, joint or bone involvement

Moderate

Infection in patient with systemic or metabolic toxicity Severe

7. Podiatric Management

7.1 Patients who have an ABPI conducted by an assistant practitioner will send the results back tothe referring clinic. It is the next podiatrist’s responsibility to check review the results andensure that the arising action plan has been completed.

7.2 Patients with PAD must receive written and verbal education from Podiatry staff to empowerthem to manage their condition and to enable them to self-monitor for signs of deterioration.Patients with PAD and diabetes should be treated according to the current NICE Guidelines. Itis vital to make patients aware that making changes to their lifestyle will have a positive impacton disease outcomes (NICE CG 147).

7.3 Patients with suspected PAD should be given a PAD Leaflet (Appendix K), and the content ofthe leaflet explained.

7.4 All patients with peripheral arterial disease who are smokers should be signposted to the NHSStop Smoking Service, and the health benefits of not smoking reinforced.

7.5 Any patient with suspected PAD and obesity (measured using the Body Mass Index) should beencouraged to speak to their GP about weight management strategies, which could include areferral by the GP, to the Weight Management Service. All patients with BMI over 40 or BMIover 35 with co-morbidities can be referred. See Appendix F.

7.6 Provide general advice on exercises and lifestyle e.g. eat 5 pieces of fruit and vegetables aday. Encourage patients to walk at least 25 minutes per day. Explain to the patient that this canbe broken down into smaller sections which add up to 25 minutes.

7.7 Patients with peripheral arterial disease should receive regular evaluation of their symptoms ifthey meet the service criteria for ongoing care. At each follow-up appointment, they must beasked if there has been a change (either an improvement or deterioration), or whether theirsymptoms are stable.

7.8 Advise patients who are being discharged after their initial assessment to see GP or practicenurse if problems occur. Patients referred to podiatry for a vascular assessment presenting


with low podiatric needs must be discharged back to GP’s care after a provision of foot careand footwear advice and appropriate information leaflets. The results of assessment andintervention (e.g. ABPI test) must be communicated to patient’s GP and referrer. Any patientswith PAD must, as a minimum, have an annual review with a podiatrist.

7.9 Stable claudication. If there is no deterioration in symptoms or tissue loss/ulceration presentthe patient may only warrant attention to his/hers lifestyle (see Appendix F). Encourage thepatient to walk through the claudication pain, if possible, to develop a collateral blood supply.During the assessment, check the patient’s medication. The Heart Protection Guidelinesrecommend Aspirin 75mg and/or Clopidogrel 75mg and Simvastatin 40 mg. (If the patient isnot, then alert the GP when communicating on the PAD assessment as per recommendationfrom the vascular department of Torbay Hospital. N.B. Some patients may be on Warfarin orother anticoagulants.

7.10 Podiatry patients with stable claudication should have an Ankle Brachial Pressure Index (ABPI)test conducted as a part of their annual review.

7.11 Communicate your clinical findings and care plan with the patient’s GP. See Appendix ,for letter guidelines.

7.12 If a patient reports a significant deterioration, the Podiatrist must undertake a thoroughassessment of the patient’s lower limb arterial supply. If a patient is receiving delegated carefrom a Podiatry Assistant, the patient must be referred back to a Podiatrist for review.

7.13 As a minimum, a Podiatrist must palpate the patient’s pulses, listen to them on a 5 or 8 MHzDoppler, and check the patient’s sub capillary refill time. An ABPI must also be considered.Use internal referral form for ABPI (Appendix J). The results of this assessment of the patientshould be communicated to the patient’s GP (Appendix I).

7.14 Post vascular surgery treatment of podiatry patients

Each podiatry patient with PAD should have their vascular status re-assessed after by-passsurgery or angiography. Graft surveillance is provided by the vascular clinic and it shouldcommence 6 weeks post surgery.

8 Monitoring Compliance and Effectiveness

8.1 The Head of Podiatry Services will retain overall accountability and responsibility for thecontent, monitoring and implementation of this document.

8.2 Periodic clinical audit, patient satisfaction surveys and an annual peer review of staffcompliance and competency will be included in the on-going process to monitor quality,compliance and effectiveness.

8.3 Responsibility for undertaking the various review processes will be devolved by the Head ofPodiatry Services to competent staff members.

8.4 Audits and patient satisfaction surveys will be registered, published and actioned in line withcurrent Trust policy whilst peer reviews will be subject to internal scrutiny and as a part of theannual appraisal processes.

9 Training and staff support

Follow-up training sessions on vascular assessment should be provided for all podiatrists aswell as podiatry clinical support workers.

Item % Exceptions


All podiatrists and podiatry Clinical SupportWorkers will be trained and competency assessedduring induction with regards to how to recognisethe signs and symptoms of PAD and how toundertake the associated tests such as ABPI,Doppler and Buerger’s Test

100

All podiatrists will understand the referral pathwayto the Vascular Assessment Clinic

100

Podiatry staff will receive bi- annual vascularassessment training sessions delivered by avascular practitioner. Individual staff developmentneeds may also be addressed as part of theirannual appraisal and line management supervision

100

All podiatrists to attend CPD vascular updatesevery three years as per Health and CareProfessions Council (HCPC )recommendations

100

The staff will be informed of up-to-date changes inpolicies and guidelines

100

How will monitoring be carried out? Peer review

When will monitoring be carried out? Annually

Who will monitor compliance with the guideline? Lead podiatrists/team leads

10. Associated documentation

Scottish Intercollegiate Guidelines Network 89 Diagnosis and Management of PeripheralArterial Disease October 2006;https://www.researchgate.net/publication/332590145_Diagnosis_and_management_of_peripheral_arterial_disease_-_Scottish_Intercollegiate_Guidelines_Network_SIGN_89

References

Bartholomew, JR Oline, JW (2006) Pathophysiology of peripheral arterial disease and risk factorsfor its development Cleveland Clinic Journal of Medicine vol. 73(S4) pp S8-14

BMJ Best Practice Guidelines (2012) Peripheral Vascular Disease

Clark, CE Taylor, RS Shore, AC Campbell JL (2012) The difference in blood pressure readingsbetween arms and survival: primary care cohort study British Medical Journal vol. 344

Clinical Knowledge Summaries September 2015 National Institute for Health and CareExcellence on Lower limb peripheral arterial disease: diagnosis and management [National ClinicalGuideline Centre, 2012; NICE, 2012

https://www.researchgate.net/publication/332590145_Diagnosis_and_management_of_peripheral_arterial_disease_-_Scottish_Intercollegiate_Guidelines_Network_SIGN_89







Desormais I et al Anemia, 2014. An independent predictive factor for amputation and mortality inpatients hospitalized for peripheral artery disease. Eur J Vasc Endovasc Surg. 2014 Aug;48(2):202-7.doi: 10.1016/j.ejvs.2014.04.005. Epub 2014 Jun 14.

Dhaliwal,G MBBS and Mukherjee D,2007.Peripheral arterial disease: Epidemiology, natural history,diagnosis and treatment Int J Angiol. 2007 Summer; 16(2): 36–44.PMCID: PMC2733014.

Garimella P, Hirsch A (2014). Peripheral Artery Disease and Chronic Kidney Disease: Clinical Synergyto Improve Outcomes Adv Chronic Kidney Dis. 2014 Nov; 21(6): 460–471. Published online 2014 Oct24. doi: 10.1053/j.ackd.2014.07.005 Last accessed 8.11.2020

Health and Care Professions Council (2012) Chiropodists/Podiatrists [online]

Khaleghi M et al, 2014.Family History as a Risk Factor for Peripheral Arterial DiseaseDOI: http://dx.doi.org/10.1016/j.amjcard.2014.06.029 Last accessed 17.9.2020

Khawaja F and Kullo I ,2009 Novel markers of peripheral arterial disease Vasc Med. 2009 Nov; 14(4):381–392.

Kroenke, K. (1998) Patient Expectations for care: How hidden is the agenda? Mayo ClinicProceedings vol. 73 p.191-193

Lyden, SP Joseph D (2006) The Clinical Presentation of Peripheral Arterial disease and guidance forearly recognition Cleveland Clinic Journal of Medicine vol. 73(S4) pp s15-21

Mills JL et al. The Society for Vascular Surgery Lower Extremity Threatened Limb ClassificationSystem: Risk stratification based on wound, ischaemia and foot infection. Journal of Vascular Surgery2014; 59:220-34

National Institute for Health Clinical Excellence (2012) Lower Limb Peripheral Arterial Disease:diagnosis and Management- Clinical Guideline 147 Issued August 2012

NICE cost impact statement: peripheral arterial disease 2011

Ray, SE Srodon, PD Taylor, RS Dormandy, JA (1994) Reliability of ankle:brachial pressure indexmeasurement by junior doctors British Journal of Surgery vol. 81(2) pp. 188-90

Ruff D (2003) Doppler Assessment: Calculating the Ankle Brachial Pressure Index Nursing Times vol.99(42) pp 62Sign 89 Diagnosis and managementof peripheral arterial disease. October 2006

Sontheimer, DL (2006) Peripheral Vascular Disease:Diagnosis and Treatment American Family Physician vol. 73(11) pp. 1971-76

Vig et al , 2006 The prevalence of thrombophilia in patients with symptomatic peripheral vasculardisease 11 April 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.10.1002/bjs.5300.

Vowden, P (2001) Doppler assessment and ABPI: Interpretation in the management of leg ulcerationWorld Wide Wounds

Vowden, P (2012) Understanding the ankle brachial pressure index to treat venous ulceration WoundsUK vol. 8(1) pp. S10-S15

https://www.ncbi.nlm.nih.gov/pubmed/?term=Desormais%20I%5BAuthor%5D&cauthor=true&cauthor_uid=24935912

https://www.ncbi.nlm.nih.gov/pubmed/24935912

https://www.ncbi.nlm.nih.gov/pubmed/?term=Dhaliwal%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22477268

https://www.ncbi.nlm.nih.gov/pubmed/?term=Mukherjee%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22477268

https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=25443571

https://dx.doi.org/10.1053%2Fj.ackd.2014.07.005

http://www.ajconline.org/action/doSearch?searchType=authorLookUp&author=Khaleghi,%20Mahyar&prod=HA

http://dx.doi.org/10.1016/j.amjcard.2014.06.029

https://www.ncbi.nlm.nih.gov/pubmed/?term=Khawaja%20FJ%5BAuthor%5D&cauthor=true&cauthor_uid=19808725

https://www.ncbi.nlm.nih.gov/pubmed/?term=Kullo%20IJ%5BAuthor%5D&cauthor=true&cauthor_uid=19808725


Appendix A

Summary Flow Chart of Podiatry Arterial Evaluation of the Lower Limb

Consider vascularreferral


Appendix B

Differential Diagnoses

Podiatrists should consider a differential diagnosis but still refer if concerned highlighting thealternatives conditions which may mimic PAD.

The table below, taken from Sontheimer (2006) shows the differential diagnoses of PAD thecharacteristics associated with these conditions.

Differential diagnosis may also include:

Neuritis

May include pain, paraesthesia , paresis (weakness), hypoesthesia (numbness), anesthesia,paralysis, wasting, and disappearance of the reflexes. Possible causes include: shingles, leprosy,Guillain-Barre syndrome, diabetes, Vitamin B12 deficiency, MS, alcohol dependency etc.

Neuropathic Pain

A complex, chronic pain state. With neuropathic pain, the nerves are damaged or dysfunctional,causing a variety of symptoms including numbness, pain and tingling.

Chilblains

These are small, itchy and painful reddish blue swellings which develop on the fingers and toes whenthe skin cools down, causing the tiny blood vessels to constrict severely. Because of the poor bloodsupply, chilblains sometimes don’t heal very quickly and can become infected. Sufferers of Raynaud’sphenomena can be prone to chilblains.

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Paresthesia

http://en.wikipedia.org/wiki/Paresis

http://en.wikipedia.org/wiki/Hypoesthesia

http://en.wikipedia.org/wiki/Anesthesia

http://en.wikipedia.org/wiki/Paralysis

http://en.wikipedia.org/wiki/Reflexes


Appendix C

Guidelines for referral letters

Include:

Date of referral, name and designation, address and contact details of referrer

Name, NHS number and date of birth

The symptoms

The clinical findings are . . .

Dorsalis pedis/posterior tibial pulses are palpable/non palpable

Doppler signals:

Ankle Brachial Pressure Index (ABPI)

Positive or negative Buerger’s sign

Associated risk factors are . . .

Our treatment plan is . . .

Copy to


Appendix D

Diagram of lower limb vessels


Appendix E

The iceberg of peripheral arterial disease


Appendix F

Lifestyles Team

You can self-refer or ask patients to self-refer by calling 0300 456 1006, or by emailing them [email protected].

Alternatively, you can download an electronic Healthy Lifestyles referral form and email it ordownload a printable form.

Services they provide include:smoking cessationWeight managementFitnessDiabetes control


https://icon.torbayandsouthdevon.nhs.uk/areas/healthy-lifestyles/Documents/healthy-lifestyles-electronic-referral-form.docx


Appendix G

Tick where appropriate:- Face form in notes or patient had capacity gave verbal consentto treatment test completed with patient lying flat or propped position.

Name: N.H.S: D.O.B:

Dr. Date: Time:

Subjective symptoms1. Do you get pain or discomfort in your legs(s) when you walk?Unable to walk

· If “yes” to question 1, please answer the following questions2. Does the pain ever begin when you are standing or sitting still?3. Do you get it when you walk uphill or in a hurry?4. Do you get it when you walk at an ordinary pace on the level?5. Does this pain disappear when you rest for less than 10 minutes?If yes to any of these questions they are red flags indicating intermittentclaudication

YES / NO

YES / NOYES / NOYES / NOYES / NO

If applicable claudication distance?If claudication, has patient been on a supervised exercise programme? YES / NORest painTrue (constant pain in foot/feet for more than 2/52 not relived by analgesia)?Nocturnal (pain in foot/feet at night relived hanging over side of bed)?

YES / NOYES / NO

Foot ulceration? YES / NOIs patient on medications as recommended vascular disease?(antihypertensive, Clopidogrel 75mg (NICE 2010) (or equivalent - Aspirin75mg and 40mg Simvastatin as per Heart Protection Study (2002).

YES / NO

Any reason for not carrying out ABPI? Yes / No/ Details:(e.g.Breast Cancer, Kidney Fistulas, Lymph nodes)

YES / NO

Blood pressure: Pulse:

Medication:

Risk Factors for peripheral arterial disease (PAD)History of smoking/details YES / NODiabetes (details to include latest HbA1c) YES / NORetinopathy (details i.e. laser) YES/NO

BMICOPD / Asthma YES / NOIschaemic Heart Disease YES / NOAortic stenosis (stents in heart or narrowing of Aorta / Aortic Valve) YES / NOHypertension YES / NOHigh cholesterol YES / NO


RIGHT FOOT LEFT FOOTDorsalis Pedis - hand Yes / No Yes / NoDorsalis Pedis -doppler Monophasic / Biphasic Monophasic / BiphasicPosterior Tibial - hand Yes / No Yes / NoPosterior Tibial - doppler Monophasic / Biphasic Monophasic / BiphasicSub capillary refill Seconds SecondsABPI Manual/Huntleigh Manual / Huntleigh Manual / HuntleighBuerger’s sign Positive / Negative Positive / NegativeColour Normal /Blanching/ Rubour

CyanosedNormal / Blanching / Rubour

CyanosedTemperature Normal / Warm / Cold Normal / Warm / ColdSkin Tone Normal / Abnormal Normal / AbnormalNail Condition Normal / Abnormal Normal / Abnormal

ABPI MANUAL TEST RESULTSBoth Highest Leg / Highest Arm

RIGHT LEFTARMDORSALIS PEDISPOSTERIOR TIBIALRESULTToes pressure

‘NICE guidelines suggest peripheral arterial disease with an ABPI value of 0.9 and less. However the ABPIresult should be viewed with caution in diabetes due to arterial calcification causing falsely elevatedresult. If you feel further assessment is necessary refer to the vascular team’.

Family history of vascular disease YES / NOKidney disease (eGFR) YES / NOAnaemia YES / NOPrevious vascular interventionsDetails:

YES / NO

Advice given:The value of regular exercise and general dietary advice. YES / NOReferred to Torbay Stop Smoking Service. YES / NOReferred to Torbay Lifestyles Team. YES / NOI would be grateful if you would consider referring for asupervised exercise programme.

YES / NO

PAD Leaflet and advice given YES / NO

Completed by; ……………………………………………… Signature……………………………………………………Designation………………………………………………………………….Date………………… Time…………………


Appendix H

Letter to GP

Department of Podiatry and OrthoticsCastle Circus Health Centre

Abbey RoadTorquay

TQ2 5YH 01803 217712

8 February 2021Dear Dr

RE:DOB:NHS:

Clinic Date:

This patient was seen today for lower limb peripheral arterial assessment to give a reading of anAnkle-Brachial Pressure Index (ABPI) / Toe-Brachial Pressure Index (TBPI) because they have oneor more monophasic pulses / are diabetic with a foot ulceration.

ABPI results

Right legLeft leg

The test was conducted using a manual ABPI technique / Huntington Dopplex machine.

Following the test, we have deemed the patient to (Please select and amend / delete)

· (Normal with no wound) have circulation within the normal limits (ABPI = 0.9 – 1.2) (TBPIabove 0.7). The patient currently does not have active foot ulceration. The podiatry servicewill therefore continue with the original treatment plan which includes a 6 monthlyfoot check / regular appointments for foot care / A referral has been made to aPodiatrist for a review of the treatment plan.

· (Normal with wound) have circulation within the normal limits (ABPI = 0.9 – 1.2) (TBPIabove 0.7). The patient has an active ulceration on the foot so the Podiatry service willcontinue to manage this. There is currently no indication for a referral to the vasculardepartment.

· (Moderate no wound) have moderate peripheral arterial disease (ABPI = 0.5 - 0.89) (TBPI =0.64-0.69). The patient currently does not have active ulceration. The podiatry service willcontinue with the original treatment plan which includes a 6 monthly foot check /regular appointments for foot care / A referral has been made to a Podiatrist for areview of the treatment plan. Health and lifestyle education has also been delivered. The


patient will receive an annual ABPI test within the Podiatry service of which we will informyou of the results. If you feel appropriate, can you please arrange a review of this patient.

· (Moderate with wound) have moderate peripheral arterial disease (ABPI = 0.5 - 0.89) (TBPI= 0.64-0.69). The patient has an active ulceration on the foot therefore the Podiatry servicewill continue to manage this. The Podiatry service will consider a referral to the vasculardepartment if the wound does not improve within the next 4 weeks. If you feel appropriate,can you please arrange a review of this patient.

· (Severe no wound) have severe peripheral arterial disease (ABPI 0.49 and under). Thepatient currently does not have active foot ulceration, rest pain or intermittent claudication.The podiatry service will therefore continue with the original treatment plan whichincludes a 6 monthly foot check / regular appointments for foot care / A referral hasbeen made to a Podiatrist for a review of the treatment plan. The patient has beeninformed of their high risk status and has been given appropriate advice. If you feelappropriate, can you please arrange a review of this patient.

· (Severe with wound) have severe peripheral arterial disease (ABPI 0.49 and under). Thepatient has an active ulceration on the foot therefore the Podiatry service will continue tomanage this. In addition to this I have made a referral to the vascular department at TorbayHospital and also the specialist wound care Podiatry service at Torbay Hospital.

· (Rest pain) have severe peripheral arterial disease (ABPI 0.49 and under) with rest pain. Anurgent referral to the vascular has department at Torbay Hospital has therefore been made

· (False high / incompressible) a result of 1.2 or over indicating a falsely high reading. Theremay be a possibility that there has been calcification of the arteries leading to these readingstherefore the results are inconclusive. The podiatry service will therefore continue withthe original treatment plan which includes a 6 monthly foot check / regularappointments for foot care / A referral has been made to a Podiatrist for a review ofthe treatment plan. If you feel appropriate, can you please arrange a review of this patient.

The TBPI result was lower than the ABPI. This can be due to increased calcification within the largerarteries which will give a falsely high result. We have therefore for this purpose used the TBPI resultas being a more accurate representation of peripheral artery disease.

An onward referral has been made to the ‘Stop Smoking Service’ / ‘Healthy Lifestyles Team’.

It has been identified that there is a difference between brachial pressures of 20-30mm Hg. Thismay indicate sub-clavian stenosis. Can you please make an onward referral to the vasculardepartment, Torbay Hospital for further investigations?

In accordance with the NICE guidelines and “Heart Protection Study 2002”, can you please considerprescribing an anti-hypertensive, Clopidogrel/Aspirin and Statin if required?

Advice has been given to keep as active as possible with regular walking and gentle exercise and toreport any new leg or foot symptoms to a health care professional. The importance of a healthybalanced diet combined with weight loss has been discussed highlighting the impact that this has onthe cardiovascular risk.

Yours sincerely

Assistant Practitioner


Copies:

GP

patient

podiatry records


Appendix IReferral letter for Acute Limb Ischaemia

Department of Podiatry and OrthoticsCastle Circus Health Centre

Abbey RoadTorquay

TQ2 5YH

Telephone : 01803 217712

Dear Dr

Patients Name:_______________________________________________________________

NHS Number: ______________________________ Date of Birth: _____________

This patient presented in the podiatry clinic today with acute limb ischaemia

We have alerted the on call medical registrar and have informed the Torbay Hospital Podiatry team,and the Vascular team on 01803 655594 /07833 402078/07867 201/759

Current medication

Relevant medical history

The patient has a podiatry appointment on ____________________________ at ___________am/pm


If the patient is admitted and unable to attend for this appointment please can someone contact thepodiatry appointments office on 01803 217712. Or email [email protected]

Yours sincerely

Podiatrist

Copies:

Patient’s GPPodiatry records



Appendix J

PODIATRY ABPI (ankle brachial pressure index)

INTERNAL REFERRAL

PATIENTS NAME: NHS NUMBER: DOB:

MEDICATION:

VASCULAR STATUS:

PALPABLE:

REASON FOR REFERRAL:(please attach a copy of the treatment plan if this referral is to aid with settinga treatment plan)

PREVIOUS ABPI RESULT: Right leg Left leg Date

Factors to take into account for ABPI : (fistula, breast cancer, able to lie flat ornot, ability to transfer to couch, language barrier, reduction in capacity, etc)

Referring podiatrist Name:

Date referred:

Date of follow up with podiatrist:

(Form to be saved in completed forms on the ABPI referral section on the “O” drive.

To do this click on “Save as”, “completed forms”, then click to letter of the patients

surname and save under the patients full name.)


Appendix K

Linked to Patient Information Leaflet 25020 - Peripheral Arterial Disease

Appendix LLinked to Patient Information Leaflet 25275 – Ankle Brachial Pressure Index

http://www.torbayandsouthdevon.nhs.uk/uploads/25020.pdf

http://www.torbayandsouthdevon.nhs.uk/uploads/25275.pdf

Collated by Clinical Effectiveness Clinical Guidelines for the Management of Peripheral Arterial Disease (PAD)Version 4 (February 2021) Page 37 of 38

Appendix MDoppler Assessment

Ankle Brachial Pressure Index (ABPI) / Toe Brachial Pressure Index (TBPI)Patient name NHS number

Date of ABPI / TBPI Date of birthClinician name Signature of

clinician

Right Left

Brachial systolic pressure

mmHg

Brachial systolic pressure

mmHg

Blood pressure mmHg

Left foot and ankle signals andpressure

Dorsalis pedis- mono/bi/tri mmHg

Posterior tibial -mono/bi/tri mmHg

Right foot and ankle signals andpressure

Dorsalis pedis mono/bi/tri mmHg

Posterior tibial mono/bi/tri mmHgRight toepressure

mmHg

Left toepressure

mmHg

Highest brachial mmHg

mmHG

Highest right ankle

mmHg

Right ABPIRight TBPI

Highest Left ankle

mmHg

Left ABPILeft TBPI

SEVERE peripheral arterial disease(PAD) / critical limb ischemia

ABPI < 0.5, TBPI <0.64

Or Absolute pressure of 50mmHg or belowwith tissue loss and / or true ischaemic restpain.

MODERATE PAD

ABPI >0.5-<0.9, TBPI0.64-0.7

With or withoutsymptoms (e.g.claudication)

NORMAL ARTERIAL SUPPLY

ABPI ranges >0.9- <1.2, TBPI 0.7

Refer to summary flow chart appendix A of PAD guidelines for referral guidelines


Appendix N

Your foot and leg circulation care plan

Name: Date

Following your assessment today we found that you have:

o Mild peripheral arterial disease- evidence of a reduction in blood flow to your legs and feeto Moderate peripheral arterial disease- significantly reduced blood flow to your legs and feeto Severe peripheral arterial disease- severely reduced blood flow to your legs and feet

Peripheral arterial disease increases the risks of a heart attack, stroke and if severe, legamputation. Peripheral arterial disease is a narrowing, hardening or blockage of the main bloodvessels in the legs. This reduces the blood and oxygen flow to your legs which can result inaching/cramp in the calf or thigh muscles during walking. This is called intermittent claudication.Importantly- It can be successfully treated.By making specific lifestyle related changes you can reduce your risks of heart attacks, strokes orworsening leg and foot problems. The podiatry team can support you to make any of these changesif you are interested.

Risk factors for circulation damage You(tick)

Interested in reducing risk (Yes/ No)

SmokingAny amount of tobacco or nicotine

High blood pressureResting blood pressure greater than 140/90Raised lipid levels (cholesterol)Total above 4 or LDL greater than 2Raised blood glucose levels with diabetesHBA1c greater than 53Lack of cardiovascular (heart) exerciseLess than 2.5 hours per week of light exerciseExcessive weightBody mass index over 30

Following our assessment and our decisions today, we will refer you to the following services fortreatment or support:

o Your GP for review of medicines, blood pressure, cholesterolo The vascular department (to consider further specialist assessment and treatments)

o Lifestyles team for:o Smoking cessation team (for support and information to help you quit)o Weight management team for support reducing weighto Supervised exercise classo Help with diabetes control

Podiatrists can refer or ask patients to self-refer by calling 0300 456 1006, or by emailing themat [email protected].



Appendix OACUTE DIABETIC FOOT REFERRAL FORM

Send to:[email protected] Or telephone podiatry appointments on 01803 217711 (8.45-15.45 hours)or the Foot protection team at Torbay 01803 655102 (09.00-16.00)

Referral from: Home visits / Torbay Hospital Diabetic Multidisciplinary Team / Community / In-patientReferral to: Home visits / Torbay Hospital Diabetic Multidisciplinary team / Community / In-patient(please delete as appropriate) Name NHS Number DOB

Medical History:

Medication (please list or attach prescription):

SUSPECTED CHARCOT YES NODiabetic Risk Status: Non-diabetic / Low / Increased / High / UlceratedIf diabetic, has the National Diabetic Foot Audit been completed: Yes / No Date of 12 wk ………./24 wk……….review / patient refusedSINBAD SCORE out of /6 Site: hindfoot? Yes No

Ischaemia: clinical PAD? Yes No

Neuropathy:sensory loss?

Yes No

Bacterial infection: Clinical? Yes No

Area: 1cm² or more? Yes No

Depth: tendon or bone Yes No

SINBAD score: 0 – 2 =Refer to Community Diabetes andWound Specialist Podiatrist

SINBAD score: 3 or above =Refer to Level 2 Podiatry

Domiciliary patients should be reviewedby a Wound Specialist Podiatrist if thewound remains static or is deterioratingTests and Investigations performed:Neurological Status Right Foot Left FootVascular Status Right Foot Left FootKnown to Vascular? Yes / No Orthotist involved? Yes / NoBespoke Footwear? Yes / No Insoles? Yes / NoReason for referral:

Current dressing regime/treatment plan:

Last Community Podiatryappointment:

Next Community Podiatry appointment:

Planned Discharge Date District Nursing team involved?Frequency of visit?

Yes / No

Antibiotics Prescribed? Yes / No Name, dose and duration:

Referring Podiatrist Date Referred

Assessment date: Assessment clinic: Emergency treatmentdate:

Emergency treatmentclinic


Collated by Clinical Effectiveness Clinical Guidelines for the Management of Peripheral Arterial Disease (PAD)Version 4 (February 2021) Document Control Information

11. Document Control Information

This is a controlled document and should not be altered in any way without the expresspermission of the author or their representative.

Please note this document is only valid from the date approved below, and checks shouldbe made that it is the most up to date version available.

If printed, this document is only valid for the day of printing.

This guidance has been registered with the Trust. The interpretation and application ofguidance will remain the responsibility of the individual clinician. If in doubt contact a seniorcolleague or expert. Caution is advised when using clinical guidance after the review date,or outside of the Trust.

Have you identified any issues on the Rapid (E)quality ImpactAssessment. If so please detail on Rapid (E)QIA form. Yes ☐

Please select Yes No

Does this document have implications regarding the Care Act?If yes please state: ☐ ☐

Does this document have training implications?If yes please state: ☐ ☐

Does this document have financial implications? ☐ ☐

Ref No: 1850

Document title: Clinical Guidelines for the management of peripheral ArterialDisease (PAD)

Purpose of document:To support the clinical practice of Podiatrists within Torbay andSouth Devon NHS Foundation Trust with regard to theassessment and management of patients presenting with PAD.

Date of issue: 5 February 2021 Next review date: 5 February 2024Version: 4 Last review date: September 2020Author: Podiatry Team LeaderDirectorate: CommunityEquality Impact: The guidance contained in this document is intended to be

inclusive for all patients within the clinical group specified,regardless of age, disability, gender, gender identity, sexualorientation, race and ethnicity & religion or belief

Committee(s)approving thedocument:

Clinical Director – Pharmacy and PrescribingCare and Clinical Policies Group

Date approved: 2 February 2021Links or overlaps withother policies:

Collated by Clinical Effectiveness Clinical Guidelines for the Management of Peripheral Arterial Disease (PAD)Version 4 (February 2021) Document Control Information

If yes please state:

Is this document a direct replacement for another?If yes please state which documents are being replaced: ☐ ☐

Document Amendment History

DateVersion

no.Amendment

summary Ratified by:11 November2014

2 Care and Clinical Policies

26 January 2017 2 Review dateextended

Care and Clinical Policies Group

26 July 2017 3 Revised Professional Practice AssociateDirector for WCDTClinical Director of Pharmacy

19 February 2018 3 Review dateextended from 2years to 3 years

5 February 2021 4 Revised Care and Clinical Policies GroupClinical Director – Pharmacy andPrescribing

Collated by Clinical Effectiveness Clinical Guidelines for the Management of Peripheral Arterial Disease (PAD)Version 4 (February 2021) The Mental Capacity Act

The Mental Capacity Act 2005

The Mental Capacity Act provides a statutory framework for people who lack capacity to makedecisions for themselves, or who have capacity and want to make preparations for a time when theylack capacity in the future. It sets out who can take decisions, in which situations, and how theyshould go about this. It covers a wide range of decision making from health and welfare decisions tofinance and property decisions

Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacityunless it is established that they do not. This is an important aspect of law that all health and socialcare practitioners must implement when proposing to undertake any act in connection with care andtreatment that requires consent. In circumstances where there is an element of doubt about aperson’s ability to make a decision due to ‘an impairment of or disturbance in the functioning of themind or brain’ the practitioner must implement the Mental Capacity Act.

The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice,which provides guidance and information about how the Act works in practice. The Code of Practicehas statutory force which means that health and social care practitioners have a legal duty to haveregard to it when working with or caring for adults who may lack capacity to make decisions forthemselves.

All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, MentalCapacity Act 2005 Practice Guidance, information booklets and all assessment, checklists andIndependent Mental Capacity Advocate referral forms on ICON.

https://icon.torbayandsouthdevon.nhs.uk/areas/mental-capacity-act/Pages/default.aspx

Infection Control

All staff will have access to Infection Control Policies and comply with the standards within them inthe work place. All staff will attend Infection Control Training annually as part of their mandatorytraining programme.

“The Act is intended to assist and support people who maylack capacity and to discourage anyone who is involved incaring for someone who lacks capacity from being overlyrestrictive or controlling. It aims to balance an individual’sright to make decisions for themselves with their right to beprotected from harm if they lack the capacity to makedecisions to protect themselves”. (3)

https://icon.torbayandsouthdevon.nhs.uk/areas/mental-capacity-act/Pages/default.aspx

Collated by Clinical Effectiveness Clinical Guidelines for Podiatrists for the management ofPeripheral Arterial Disease (PAD)

Rapid (E)quality Impact AssessmentVersion 4 (February 2021)

Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies)

Policy Title (and number) 1850 CLINICALGUIDELINES FOR THEMANAGEMENT OFPERIPHERAL ARTERIALDISEASE (PAD

Version and Date 8.11.2020 Version 4

Policy Author Podiatry Team LeaderAn (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantagepeople whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected.Who may be affected by this document?Patients/ Service Users ☐ Staff x Other, please state… ☐

Could the policy treat people from protected groups less favorably than the general population?PLEASE NOTE: Any ‘Yes’ answers may trigger a full EIA and must be referred to the equality leads belowAge Yes ☐ Nox

☐

Gender Reassignment Yes ☐ No☐x

Sexual Orientation Yes ☐ No☐x

Race Yes ☐ No☐x

Disability Yes ☐ No☐x

Religion/Belief (non) Yes ☐ No☐x

Gender Yes ☐ No☐x

Pregnancy/Maternity Yes ☐ No☐x

Marriage/ Civil Partnership Yes ☐ Nox☐

Is it likely that the policy could affect particular ‘Inclusion Health’ groups less favorably thanthe general population? (substance misuse; teenage mums; carers1; travellers2; homeless3;convictions; social isolation4; refugees)

Yes ☐ No☐x

Please provide details for each protected group where you have indicated ‘Yes’.

VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusionIs inclusive language5 used throughout? Yes ☐x No☐ NA ☐

Are the services outlined in the policy fully accessible6? Yes ☐x No☐ NA ☐

Does the policy encourage individualised and person-centered care? Yes x☐ No☐ NA ☐

Could there be an adverse impact on an individual’s independence or autonomy7? Yes ☐ No☐x NA ☐

EXTERNAL FACTORSIs the policy a result of national legislation which cannot be modified in any way? Yes ☐ Nox

What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?)To act as a guideline for podiatrists when treating PAD.

Who was consulted when drafting this policy?Patients/ Service Users ☐

x

Trade Unions ☐ Protected Groups (including Trust Equality Groups) ☐

Staff ☐

x

General Public ☐ Other, please state… ☐

What were the recommendations/suggestions?


Rapid (E)quality Impact AssessmentVersion 4 (February 2021)

Please contact the Equalities team for guidance:

For Devon CCG, please email [email protected] & [email protected] Torbay and South Devon NHS Trusts, please call 01803 656676 or email [email protected]

This form should be published with the policy and a signed copy sent to your relevant organisation.1 Consider any additional needs of carers/ parents/ advocates etc, in addition to the service user2 Travelers may not be registered with a GP - consider how they may access/ be aware of services available to them3 Consider any provisions for those with no fixed abode, particularly relating to impact on discharge4 Consider how someone will be aware of (or access) a service if socially or geographically isolated5 Language must be relevant and appropriate, for example referring to partners, not husbands or wives6 Consider both physical access to services and how information/ communication in available in an accessible format7 Example: a telephone-based service may discriminate against people who are d/Deaf. Whilst someone may be able to act on theirbehalf, this does not promote independence or autonomy

Does this document require a service redesign or substantial amendments to an existingprocess? PLEASE NOTE: ‘Yes’ may trigger a full EIA, please refer to the equality leads below

Yes ☐ No☐x

ACTION PLAN: Please list all actions identified to address any impactsAction Person responsible Completion date

AUTHORISATION:By signing below, I confirm that the named person responsible above is aware of the actions assigned to themName of person completing the form Podiatry Team Leader SignatureValidated by (line manager) Head of Podiatry Signature





Clinical and Non-Clinical Documents – Data ProtectionVersion 4 (February 2021)

Clinical and Non-Clinical Policies – Data Protection

Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure thatall policies and procedures developed act in accordance with all relevant data protectionregulations and guidance. This policy has been designed with the EU General DataProtection Regulation (GDPR) and Data Protection Act 2018 (DPA 18) in mind, andtherefore provides the reader with assurance of effective information governance practice.

The UK data protection regime intends to strengthen and unify data protection for allpersons; consequently, the rights of individuals have changed. It is assured that theserights have been considered throughout the development of this policy. Furthermore, dataprotection legislation requires that the Trust is open and transparent with its personalidentifiable processing activities and this has a considerable effect on the way TSDFTholds, uses, and shares personal identifiable data.

Does this policy impact on how personal data is used, stored, shared or processed in yourdepartment? Yes ☐ No ☐

If yes has been ticked above it is assured that you must complete a data mapping exerciseand possibly a Data Protection Impact Assessment (DPIA). You can find more informationon our GDPR page on ICON (intranet)

For more information:· Contact the Data Access and Disclosure Office on [email protected],· See TSDFT’s Data Protection & Access Policy,· Visit our Data Protection site on the public internet.

https://icon.torbayandsouthdevon.nhs.uk/areas/gdpr/Pages/default.aspx


https://icon.torbayandsouthdevon.nhs.uk/areas/information-governance/Policies/TSDFT%20Policy%20Data%20Protection%20and%20Access.pdf

https://www.torbayandsouthdevon.nhs.uk/about-us/data-protection/