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The Diabetic
Foot Journal

Introduction to the latest competency dimension: Peripheral vascular disease

Martin Fox, Joanne McCardle

In June 2012, TRIPodD-UK launched the Podiatry Competency Framework for Integrated Diabetic Foot Care in collaboration with Foot in Diabetes UK (FDUK), the Society of Chiropodists and Podiatrists (SCP), and The Diabetic Foot Journal. This document set in motion a new era for podiatrists across the UK; for this first time, we have a clearly mapped route by which a podiatrist can progress their skills from a generalist to a specialist clinician. The framework has now been adopted across the four nations and is recognised as a benchmark for existing and future diabetic foot care, from screening all the way through to active foot disease, and the competencies required at each level to deliver them.

The vision for the framework was always that it would be organic and had the potential to evolve and grow as required. In 2012, FDUK considered the value of including an additional specific competency dimension for peripheral vascular disease (PVD). FDUK and TRIEPodD-UK recognise PVD to be a critical area of patient management, and an area that the podiatry profession is not fully clear and consistent on what the scope of practice could or should be.

PVD, and in particular arterial disease, is integral to the adverse outcomes that lie at the heart of diabetic foot disease – chronic lower limb wounds, amputation, and the high rates of related cardiovascular mortality in the foot ulcer and amputee population (Jude et al, 2001; Halperin, 2002). Therefore, the competencies to detect and manage lower-limb vascular disease have now been defined and published for clinicians to use as they see fit (over page).

You will see that the PVD competency dimension is in the style of the other dimensions within the framework; easy to follow. There are competencies from healthcare assistant level to podiatry consultant level practice. This dimension was achieved through wide stakeholder consultation from key opinion leaders, vascular surgeons, podiatrists, educationalists, and has endorsement from SCP. The consultation process was essential because some of the more advanced competencies are currently only practiced by a few podiatrists in the UK. Traditionally, elements of the clinical assessment (e.g. femoral pulse examination or palpation of the abdomen opportunistically for undiagnosed large abdominal aortic aneurysm) have been the domain of vascular surgeons. However, with PVD being widely “under-diagnosed and under treated” – leading to preventable morbidity and mortality – in the UK (Belch et al, 2007), the need for optimum diagnosis and best management of PVD and related conditions is paramount.

While we acknowledge that some of the advanced competencies may new territory for some clinicians, we believe that, in the modern NHS, professional boundaries need reviewing and where appropriate, revising. This is just one example. However, we must also be sensible and if you are entering the advanced skills spectrum, it must be done with an element of caution, governance, and undertaken in alliance with other healthcare professionals.

FDUK, TRIEPodD-UK, and SCP are united in the belief that the route for podiatrists to safely develop and carry out a full range of PVD-related clinical diagnostic skills requires definition. Advanced diagnostic and decision-making competencies in PVD need to be acquired by podiatrists working in partnership with local hospital-based vascular teams. It will require clinicians being mentored by our vascular surgeon colleagues and working alongside them in vascular outpatient clinics. This is how we can become competent in recognising and managing the patient with PVD. 

Similar to the other dimensions in the framework, there is an educational component of the PVD dimension. Engagement with postgraduate study relating to vascular disease will ensure that robust knowledge underpins the competencies.

We hope that, like us, you will find this new dimension an aspiring, defining, and useful addition to the existing framework toolkit.

Competency statement 
14. Peripheral vascular disease

14.1 Level A: Healthcare technician

  • Clearly communicates to carers and patients why foot pulse palpation is necessary.
  • Able to palpate for the presence or absence of foot pulses.
  • Assigns a foot ulcer risk score based on the result of pulse palpation and other screening tests, in line with national guidance and/or local protocols.
  • Records the foot pulse results on the relevant patient records system/s.
  • Explains the results of the foot pulse assessment and risk score to the patient and/or carer in an appropriate manner.
  • Aware of, and can explain, signs and symptoms that would warrant an urgent reassessment by podiatry teams.
  • Aware of, and appropriately uses, local referral protocols where foot pulses are not palpable.

14.2 Level B: Podiatry assistant/ practitioner
As for Level A.

14.3 Level C: Qualified podiatrist

As for Level B, and:

  • Able to carry out a basic peripheral arterial assessment, including clinical history, palpation of foot pulses and Doppler insonation of post tibial, anterior tibial, peroneal and popliteal pulses; undertake an ankle brachial pressure index assessment (ABPI) and record the information on the relevant system.
  • Able to identify and recognise symptoms likely to be due to intermittent claudication, embolic disease, ischaemic rest pain, venous, lymphatic or vasospastic disease. 
  • Able to recognise clinical signs of ischaemic, embolic, venous, lymphatic or vasospastic disease, such as ischaemic skin changes, oedema, venous skin changes and leg ulceration.
  • Aware of local policies and services available to further assess or treat these conditions. 
  • Able to make appropriate, specific referrals for specialist assessment and interventions.

14.4 Level D: Specialist podiatrist
As for Level C, and:

  • Able to carry out an assessment of peripheral arterial status, including handheld Doppler insonation of foot, peroneal and popliteal arteries and ABPI.
  • Able to understand and interpret ABPI readings in the context of clinical findings.
  • Communicates the clinical diagnosis to the patient and explains interventions available and implications of treating or not treating the PVD. 
  • Able to make appropriate referrals in relation to lifestyle, medicine or surgical interventions, depending on the severity of PVD and patient choice.
  • Able to identify acute/critical limb ischaemia and facilitate urgent referral to a vascular multidisciplinary team (MDT). 
  • Provides and facilitates the training of colleagues in lower limb peripheral vascular assessment and clinical management. 

14.5 Level E: Advanced podiatrist
As for Level D, and:

  • Able to carry out a range of non-invasive diagnostic assessments and interpretation of results for lower limb PVD, in line with national clinical guidance and local vascular team preference  (eg, palpating popliteal and femoral pulses and abdominal aorta for associated aneurysm pulsation, TBPI, TcPO2, Doppler venous assessment).
  • Initiates and reviews the impact of key non-surgical vascular interventions such as, medicines, structured exercise, support to quit smoking, compression bandaging/hosiery and wound care. 
  • Helps the patient and/or carer understand the implications of their PVD, in relation to potential morbidity, disease management and risks to life and limb. 
  • Provides education and training to colleagues in all aspects of lower limb clinical vascular assessment and decision making.  
  • Develops local evidence-based PVD care/referral pathways in partnership with local vascular teams and all other clinical stakeholders who assess and manage lower limb problems in people with diabetes.

This competency can be mapped to the following:
KSF core dimensions: C1 Communication, C4 Service Improvement, HWB1 Promotion of Health and Wellbeing, HWB6 Assessment and Treatment Planning, HWB7 Interventions and Treatments, HWB9 Equipment and Devices to Meet Health and Wellbeing Needs.

In June 2012, TRIPodD-UK launched the Podiatry Competency Framework for Integrated Diabetic Foot Care in collaboration with Foot in Diabetes UK (FDUK), the Society of Chiropodists and Podiatrists (SCP), and The Diabetic Foot Journal. This document set in motion a new era for podiatrists across the UK; for this first time, we have a clearly mapped route by which a podiatrist can progress their skills from a generalist to a specialist clinician. The framework has now been adopted across the four nations and is recognised as a benchmark for existing and future diabetic foot care, from screening all the way through to active foot disease, and the competencies required at each level to deliver them.

The vision for the framework was always that it would be organic and had the potential to evolve and grow as required. In 2012, FDUK considered the value of including an additional specific competency dimension for peripheral vascular disease (PVD). FDUK and TRIEPodD-UK recognise PVD to be a critical area of patient management, and an area that the podiatry profession is not fully clear and consistent on what the scope of practice could or should be.

PVD, and in particular arterial disease, is integral to the adverse outcomes that lie at the heart of diabetic foot disease – chronic lower limb wounds, amputation, and the high rates of related cardiovascular mortality in the foot ulcer and amputee population (Jude et al, 2001; Halperin, 2002). Therefore, the competencies to detect and manage lower-limb vascular disease have now been defined and published for clinicians to use as they see fit (over page).

You will see that the PVD competency dimension is in the style of the other dimensions within the framework; easy to follow. There are competencies from healthcare assistant level to podiatry consultant level practice. This dimension was achieved through wide stakeholder consultation from key opinion leaders, vascular surgeons, podiatrists, educationalists, and has endorsement from SCP. The consultation process was essential because some of the more advanced competencies are currently only practiced by a few podiatrists in the UK. Traditionally, elements of the clinical assessment (e.g. femoral pulse examination or palpation of the abdomen opportunistically for undiagnosed large abdominal aortic aneurysm) have been the domain of vascular surgeons. However, with PVD being widely “under-diagnosed and under treated” – leading to preventable morbidity and mortality – in the UK (Belch et al, 2007), the need for optimum diagnosis and best management of PVD and related conditions is paramount.

While we acknowledge that some of the advanced competencies may new territory for some clinicians, we believe that, in the modern NHS, professional boundaries need reviewing and where appropriate, revising. This is just one example. However, we must also be sensible and if you are entering the advanced skills spectrum, it must be done with an element of caution, governance, and undertaken in alliance with other healthcare professionals.

FDUK, TRIEPodD-UK, and SCP are united in the belief that the route for podiatrists to safely develop and carry out a full range of PVD-related clinical diagnostic skills requires definition. Advanced diagnostic and decision-making competencies in PVD need to be acquired by podiatrists working in partnership with local hospital-based vascular teams. It will require clinicians being mentored by our vascular surgeon colleagues and working alongside them in vascular outpatient clinics. This is how we can become competent in recognising and managing the patient with PVD. 

Similar to the other dimensions in the framework, there is an educational component of the PVD dimension. Engagement with postgraduate study relating to vascular disease will ensure that robust knowledge underpins the competencies.

We hope that, like us, you will find this new dimension an aspiring, defining, and useful addition to the existing framework toolkit.

Competency statement 
14. Peripheral vascular disease

14.1 Level A: Healthcare technician

  • Clearly communicates to carers and patients why foot pulse palpation is necessary.
  • Able to palpate for the presence or absence of foot pulses.
  • Assigns a foot ulcer risk score based on the result of pulse palpation and other screening tests, in line with national guidance and/or local protocols.
  • Records the foot pulse results on the relevant patient records system/s.
  • Explains the results of the foot pulse assessment and risk score to the patient and/or carer in an appropriate manner.
  • Aware of, and can explain, signs and symptoms that would warrant an urgent reassessment by podiatry teams.
  • Aware of, and appropriately uses, local referral protocols where foot pulses are not palpable.

14.2 Level B: Podiatry assistant/ practitioner
As for Level A.

14.3 Level C: Qualified podiatrist

As for Level B, and:

  • Able to carry out a basic peripheral arterial assessment, including clinical history, palpation of foot pulses and Doppler insonation of post tibial, anterior tibial, peroneal and popliteal pulses; undertake an ankle brachial pressure index assessment (ABPI) and record the information on the relevant system.
  • Able to identify and recognise symptoms likely to be due to intermittent claudication, embolic disease, ischaemic rest pain, venous, lymphatic or vasospastic disease. 
  • Able to recognise clinical signs of ischaemic, embolic, venous, lymphatic or vasospastic disease, such as ischaemic skin changes, oedema, venous skin changes and leg ulceration.
  • Aware of local policies and services available to further assess or treat these conditions. 
  • Able to make appropriate, specific referrals for specialist assessment and interventions.

14.4 Level D: Specialist podiatrist
As for Level C, and:

  • Able to carry out an assessment of peripheral arterial status, including handheld Doppler insonation of foot, peroneal and popliteal arteries and ABPI.
  • Able to understand and interpret ABPI readings in the context of clinical findings.
  • Communicates the clinical diagnosis to the patient and explains interventions available and implications of treating or not treating the PVD. 
  • Able to make appropriate referrals in relation to lifestyle, medicine or surgical interventions, depending on the severity of PVD and patient choice.
  • Able to identify acute/critical limb ischaemia and facilitate urgent referral to a vascular multidisciplinary team (MDT). 
  • Provides and facilitates the training of colleagues in lower limb peripheral vascular assessment and clinical management. 

14.5 Level E: Advanced podiatrist
As for Level D, and:

  • Able to carry out a range of non-invasive diagnostic assessments and interpretation of results for lower limb PVD, in line with national clinical guidance and local vascular team preference  (eg, palpating popliteal and femoral pulses and abdominal aorta for associated aneurysm pulsation, TBPI, TcPO2, Doppler venous assessment).
  • Initiates and reviews the impact of key non-surgical vascular interventions such as, medicines, structured exercise, support to quit smoking, compression bandaging/hosiery and wound care. 
  • Helps the patient and/or carer understand the implications of their PVD, in relation to potential morbidity, disease management and risks to life and limb. 
  • Provides education and training to colleagues in all aspects of lower limb clinical vascular assessment and decision making.  
  • Develops local evidence-based PVD care/referral pathways in partnership with local vascular teams and all other clinical stakeholders who assess and manage lower limb problems in people with diabetes.

This competency can be mapped to the following:
KSF core dimensions: C1 Communication, C4 Service Improvement, HWB1 Promotion of Health and Wellbeing, HWB6 Assessment and Treatment Planning, HWB7 Interventions and Treatments, HWB9 Equipment and Devices to Meet Health and Wellbeing Needs.

REFERENCES:

Belch J, Stansby G, Shearman C et al (2007) Peripheral arterial disease – a cardiovascular time bomb. British Journal of Diabetes & Vascular Disease 7: 236–9
Halperin JL (2002) Evaluation of patients with peripheral vascular disease. Thromb Res 106: V303–11
Jude EB, Oyibo SO, Chalmers N, Boulton AJ (2001) Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care 24: 1433–7

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