Quality Measures Resource Guide: PAD Awareness: Take the Extra Steps to Save the Feet

September is Peripheral Artery Disease (PAD) Awareness Month. As we all know, wound healing begins with a “CSI” — clinical scientific identification — investigation. This means having an understanding of underlying etiologies. Are we looking at the signs and symptoms of PAD? As everyone prepares for implementation of ICD-10-CM, let’s take a closer look at how this change can really help us think critically “beyond the band-aid” and to optimize limb salvage. Let’s start with the patient’s history versus the patient’s wounds.

PAD represents the peripheral arterial flow to lower extremities; however, it is a cardiovascular disease that impacts the entire body. It is when the artery walls develop plaque that hardening or calcification occurs and compromises blood flow.  Yes, even to the toes. Consider these startling statistics:

• In the United States there are 8-12 million people living with PAD.¹
• Over the age of 50, one in 20 Americans lives with PAD. Those diagnosed with diabetes see their chances for PAD increase to one in three. ²
• 65% of PAD-related amputations occur in patients who have never had arterial studies to identify whether or not they have adequate arterial flow.
• More than 70% of those living with PAD will die of cardiovascular disease. ³
• Living with a nonhealing wound on the leg or foot may indicate PAD.

Earlier CSI investigation can prevent amputation and decrease risk of other cardiovascular complications.

PAD increases one’s risk by:

• 40% for cerebrovascular event and
• 20%-60% for myocardial infarction.

All healthcare providers are feeling the impact of the looming changes related to ICD-10.  How can we use this to our advantage? By investigating our patients’ history before we look at the cause of the wound or the wound itself. In a typical day, it is not uncommon in your advanced outpatient wound care clinic to have approximately as many as 75% patients presenting with lower extremity ulcers. Looking one step further, how many of those patients will be living with comorbid diabetes, hypertension, and/or smoking addiction? This is even before considering a history of heart attack and/or stroke. The move towards quality-based care and the new coding system only intensifies the importance of documenting all comorbidities to support medical necessity.

Implementing Arterial Assessment Guidelines

Improving care quality improves patient outcomes. Identifying the need for best practices in your wound clinic is not enough. These measures must be implemented into clinical pathways.

Typical patient example: 55-year-old obese patient living with hypertension and diabetes who smokes presents with two chronic wounds. One on his leg is draining; the other on his foot is an ulcer that developed due to wearing his work boot. At first glance the former appears to be a venous ulcer while the other is a diabetic foot ulcer. Consider: 1) Patient lives with neuropathy (a precursor to calcified vessels); 2) The history of risk factors; 3) Shiny legs, lack of hair growth due to lack of arterial/ capillary flow; 4) Existence of a pulse does not necessarily mean adequate flow. Get those Dopplers and listen. If sounds are biphasic or monophasic, there’s compromised arterial/capillary flow. Many patients live with multiple comorbidities, which means they may have mixed etiologies. All patients living with lower extremity ulcers must have arterial assessment to identify whether or not they have adequate flow. Bedside ankle-brachial index (ABI) testing may not be enough due to “falsely elevated results” in patients with non-compressible vessels. Always obtain waveforms and Doppler sounds. A normal or above-normal ABI may have dampened waveforms or monophasic sounds — this is PAD. In high-risk patients, augment ABI with waveforms, Doppler, skin perfusion pressure, and/or transcutaneous oximetry.

When to refer: Recommendations are to follow best practice: < 0.9 and > 1.2 could indicate arterial flow complications. The sooner the patient is referred, the more likely a foot can be saved. Not all patients will need intervention. It’s best to ensure no underlying arterial flow to specific angiosomes, which may be impacting wound healing, is missed. Where to refer: As wound care technologies change, so do vascular technologies. Being the informed patient advocate means the provider has taken the time to understand the concept of an endovascular specialist/interventionist. These are physicians who are targeting with advance technologies the specific angiosomes to restore arterial flow to the vessel directly impacting the lower extremity wounds, including those below the knee and even below the ankle.

References 

1. Yost ML. Diabetic Foot Ulcers, peripheral arterial disease and critical limb ischemia. The SAGE Group. 2010.

2. Moyer-Harris A. The underestimation of PAD & its impact on wound care. TWC. 2015;9(5):10-13.

3. National Heart, Lung and Blood Institute. Risk Factor Clustering and the Metabolic Syndrome. Accessed online: www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/full-report-chapter-12.

Audrey Moyer-Harris is owner of LEAP Synergies Inc.  This resource guide is made possible through the support of Hollister Inc., Libertyville, IL. The statements made within are not connected to any officials or providers affiliated with the company.