How to deliver the best medical therapy (BMT) to the peripheral vascular disease (PVD) patient was the subject of a series of presentations given at the Birmingham Masterclass, organised by Andrew Bradbury, in January.
Professor Richard Hobbs presented the primary care perspective and talked about the guidelines and recommendations that have arisen to help prevent cardiovascular disease.
Shelagh Murray then put forward the vascular nurse specialist’s perspective. The organisation of claudicant clinics is very dependent on local needs, agreement of pathways by GPs, patient preference and very much on the experience of the nurse involved. Irrespective of which profession provides the service, the aims of claudicant care provision are to improve walking distance and quality of life of the patient, to give continuity of care and ongoing monitoring to prevent disease progression and avoid the need for amputation, and to prevent secondary cardiovascular and cerebrovascular complications. The essence of a nurse-led claudicant service relies on developing a partnership with the patient and providing care continuity. “So, what is the future of nurse led clinics?” posed Murray. “Well, nurse-led clinics can enhance care and risk factor management and free up surgeons’ time for more complex care. Nurses are good at undertaking thorough assessments and history taking.”However, the care required for claudicants demands a proactive, autonomous role from the nurse, who is often responsible for the patients’management.
Components of BMT
- Exercise
- Smoking cessation
- Dietary and foot care advice
- Blood pressure management (although Murray says this falls out of nurses expertise and patients should be referred back to their GP or a blood pressure unit)
- Medication
Medical components for secondary prevention are a vital part of claudicant care. Are nurse specialists able to deliver this? It requires excellent communication, development of practical protocols for care, prescribing considerations, referrals to other specialist services and liaison with the patients’GPs.
Murray said: “BMT requires a patient centric approach, a quality service and a reduction in errors of care. I believe that we can provide this by nurse-led care, but safety is essential. Nurse specialists can’t do it on their own. Streamlining the pathways of the medical components of BMT may require support from a vascular surgeon or essential risk management service.
“In summary, delivery of BMT by nurse specialists requires sufficiently skilled nurses, thorough assessment of patients by staff and risk factors, excellent rapport and communication with GPs, patients and other services, agreed protocols for prescribing the medical components of BMT and support from vascular surgeons as required and perhaps in the future the support of a vascular physician. I believe that BMT very much requires teamwork.
Tony Nicholson provided an interventionalist’s view: “I believe that delivery of endovascular surgery is best done by those people who are specially trained in all aspects of endovascular surgery. It is very important to give patients what they want, to have few complications and be able to deal with them as they arise. So a vascular specialist or endovascular specialist who is not able to treat complications such as arterial ruptures, embolus, branch artery perforation and has to rely on other forms of treatment – is not worth his salt.
“I believe that the best way to deliver therapy is for the vascular radiologist and the vascular surgeon from now on to be best friends. Not in the way that the US and Great Britain are best friends and not in the way that Great Britain and France are best friends, but perhaps in the way that two best friends may get together and go out for a pint and try and meet a few girls – that sort of thing.
“We also need to work very closely with our cardiologists and we also need to work closely with nephrologists, and where available vascular physicians. Only in this way can we deliver what the patient wants.
“To achieve this, vascular radiologists and vascular surgeons have to have equal status and equal clinical responsibility, if we are going to work well in a team. That means we have to have equal status in pre- and post- decision-making, consent and treatment.
“In future, there has to be changes in the way in which vascular radiology training is acquired. There have to be changes in job plans to allow out-patient and ward work, and the radiologist to do less of the routine stuff around stuff around any radiology department.
“We have to start providing a service that is 24 hours a day seven days a week, because I am sure that everyone in this room would accept that it is totally unacceptable that a patient can appear in my hospital with an acutely ischaemic leg and within two hours be up and walking about revascularised with a bit of lysis and angioplasty. Whereas in a hospital less than 20 miles away he has a very, very good chance of having that right leg removed.
“That situation has to stop. This is going to take trained and experienced vascular surgeons and radiologists to do that working together. They must have state-of-the-art vascular labs providing all available diagnostic and therapeutic modalities. They must be able to do PTA, stent, stent-grafting, thrombolysis and suction thrombectomy where indicated.
Dimitri Mikhalidis, a vascular physician, said: “In general, PVD patients in the UK do not receive comprehensive preventative treatment when compared with patients with coronary heart disease. This is probably because of a lack of awareness of the considerable vascular risk associated with PVD.”He highlighted smoking, hypertension, lipids, haemostasis and glycaemia as risk factors. Mikhalidis said that it is essential to deal with all of these risk factors and not to select those that are of special interest to the team delivering the prevention service. “There is a need to provide a comprehensive preventive service (in both primary and secondary care) if the standard of care for PVD patients is to rise. In order to achieve this objective we need a considerable education programme. Also nurse specialists can be trained to deliver a substantial proportion of the care.
Professor Cliff Shearman provided his own view, as a vascular surgeon, of how to deliver BMT to PVD patients, which he described as a fairly disillusioning field. “In the last decade we haven’t done much to ensure that patients get BMT.
We have claudicant clinic, and exercise and smoking cessation programmes, but Shearman said that he is disappointed in how successful these programmes have been. Considering the large number of patients at risk and the impact on cardiovascular mortality that could be achieved why is the level of awareness and success of risk factor reduction programmes in PVD patients so poor, especially compared to those for patients with coronary artery disease? Risk reduction programmes need to be designed around the patients rather than the surgeons. PVD has a low profile (compared with ischaemic heart disease). Work needs to be done to increase patients’awareness of this condition. Why is there a National Service Framework about to be published for diabetes when PVD is far more prevalent and a greater cause of morbidity and death?
Risk factor management offers the promise of a major reduction in morbidity and mortality for patients with PVD. “The vascular surgeon should have a major role in ensuring patients receive adequate care in this respect, but at present we do not seem to be doing well” concluded Shearman.
