Critique of Elements in Chapter I -...

Running head: RISK OF PERIPHERAL VASCULAR DISEASE 1

Risk of Peripheral Vascular Disease in Patients with Type II Diabetes Mellitus

in One Outpatient Clinic

Steven Marinos AGNP

Dr. Theresa Galakatos, Faculty Mentor and Chair

Mark Heffington MD, Clinic Medical Director

Debbie Bourn-Hammerlie, Clinic Manager

In Partial Fulfillment of the Requirements for the Degree

Doctoral of Nursing Practice

Maryville University

RISK OF PERIPHERAL VASCULAR DISEASE 2

Abstract

Background: Peripheral vascular disease (PVD) is a known complication of type 2 diabetes mellitus (T2DM) and risk for PVD increases with obesity, hyperlipedemia, hypertension, smoking, and inactivity. An effective clinical intervention for PVD prevention is ankle brachial pressure index (ABPI) assessment using Doppler ultrasound. A paucity of research exists on reinforcing this procedure to reduce morbidity in the outpatient clinical setting. This quality improvement project for patients with T2DM examined a population at high risk for PVD and created a new PVD prevention policy. Objective: Risk of PVD in patients with T2DM was examined in one outpatient clinic setting. A PVD prevention policy was developed for patients with T2DM to assess ABPIs with Doppler ultrasound on the first visit to reduce morbidity i.e. leg ulcers, infections, and amputations.

Design: A retrospective chart review was performed between January 1, 2017 and December 31, 2017. Twenty-five medical records were obtained using ICD – 10 billing codes for T2DM and PVD. Male and female patients, age 45 - 65 years old, with at least two clinic visits were included in this project.

Results: Demographic results showed 56% female, an average age of 57(5.54), and 40% African American, 32% Caucasian, 16% Hispanic, and 4% Asian. Eighty four percent were overweight, 76% had a history of smoking, 76% taking T2DM medication known for peripheral neuropathy effects, 52% were physically inactive, and 32% had hypertension. At the first clinic visit, 72% of patients with T2DM had weak or absent pedal pulses, 56% had abnormal or critical ABPIs with Doppler ultrasound, and 72% were referred for vascular surgery or to the emergency room.

Conclusions: This T2DM patient population was at high risk for PVD morbidity. Assessing ABPIs with Doppler ultrasound and implementing early PVD treatment is critical for every patient with T2DM in this outpatient clinic setting. In order to reduce morbidity, improve quality of life, and reduce health care costs, it is critical for providers to implement PVD prevention strategies and design context-based policies.

CRITIQUE OF ELEMENTS IN CHAPTER I 3

Table of Contents

Abstract ………………………………………………………………………………...................2

Chapter One - Introduction . . .…………………………………………………………………....6

Purpose …………………………………………………………………………………....6

Significance to Nursing Practice ………………………………………………………….7

Conclusion ………………………………………………………………………………..8

Chapter Two ……………………………………………………………………………………...9

Review of the Literature.….………………………………………………………………9

Evaluation of PVD………………………………………………………………………..9

PVD Interventions……………………………………………………………………….10

Quality Care and Quality of Life………………………………………………………...10

Theoretical Framework.……………………………………………….............................11

Conclusion ………………………………………………………………………………11

Chapter Three ……………………………………………………………………………………13

Methodology …………………………………………………………………………….13

Setting …………………………………………………………………………………...13

Sample …………………………………………………………………………………...13

Sampling Plan……………………………………………………………………………13

Data Sources ………………………………………………………….............................14

Data Management Plan...………………………………………………………………...14

Protection of Human Subjects …………………………………………………………..14

Conclusion……………………………………………………………………………….15

Chapter Four ...…………………………………………………………………………………..16


Data Analysis ……………………………………………………………………………16

Results …………………………………………………………………………………...17

Demographic Data ………………………………………………………………………18

Conclusions………………………………………………………………………………19

Chapter Five……………………………………………………………………………………...20

Discussion …………………………………………………………………….................20

Implications ……………….…………………………………………………..................21

Recommendations ………………………………………….............................................22

Conclusion……………………………………………………………………………….23

References ……………………………………………………………………………………….24


List of Tables

Table 4.1 T2DM Patient Demographics ……………………………………………….16

Table 4.2 T2DM Pedal Pulses and ABPIs……………………………………………...17

Table 4.3 Provider Recommendations at the First Clinic Appointment …………….....17

Table 4.4 AHA/ACC PVD Guideline Risk ……….…………………………………....18


Chapter One: Introduction

Over 30 million Americans are diagnosed with diabetes and 8.5 million have a diagnosis

of peripheral vascular disease ([PVD]; Centers for Disease Control and Prevention [CDC],

2016). Factors that increase risk of PVD include history of diabetes, smoking, age greater than

sixty years, hypertension, and high cholesterol. Therefore, it is imperative that primary care

providers (PCPs) assess for risk factors in patients with diabetes using evidence-based tools like

the ankle-brachial pressure indices (ABPIs) with ultrasound (US) Doppler (CDC, 2016). Normal

values for ABPI range from 0.9 mm/Hg to 1.20 mm/Hg and abnormal and critical values start

below 0.9 mm/Hg, and at or below 0.65 mm/Hg, respectively. Monitoring ABPI ranges with US

Doppler, maintaining tight glycemic control of blood sugars, and management of risk factors

(smoking cessation, life-style changes, statin drugs, anti-platelet therapy) are essential

interventions to reduce PVD symptoms and other vascular problems (Crawford, Welch, Andras,

& Chappell, 2016; Rintala, Paavilainen, & Åstedt-Kurki, 2014; Welch, Robinson, Stevenson, &

Atkins, 2016).

Between 12-14% of the population in the United States suffer from PVD and are

asymptomatic (Nott, King, & Koddourau, 2013). Until recently, patients underwent a procedure

by a radiologist to test for PVD. Today, PCPs evaluate PVD in the outpatient setting without the

use of radiology. Calculations of ABPIs start with a systolic blood pressure measurement in the

arterial artery at the ankle level; this number is then divided by the measurement reading of the

brachial artery. A fall in blood pressure at the ankle would suggest a stenosis in an artery

between the central body arteries and ankle. ABPIs are non-invasive and have a good interrater

reliability. Patients with ABPIs below 0.8 mm/Hg are at high risk for peripheral artery disease


(PAD) and potential leg ulcers due to decreased blood flow (Vowden & Vowden, 2013; Welch,

Robinson, Stevenson, & Atkins, 2016).

Prompt interventions are key in the prevention, delay, or reversal of PVD symptoms and

can improve difficulties in walking, pain, numbness, and coldness in lower extremities (Formosa,

Gatt, & Chocklingam, 2012). PCPs who assess, diagnose, and treat early signs and symptoms of

PVD can prevent diabetic foot ulcers, venous stasis ulcers, multiple toe or limb amputations, and

reduce mortality (Formosa et al., 2012; Nott, King, & Koddourau, 2013).

The purpose of this project was to evaluate patients with type 2 Diabetes Mellitus

(T2DM) and identify risk of PVD by ABPI with US Doppler in one outpatient setting. The

question answered by this Doctor of Nursing Practice (DNP) project was the following: In

patients with T2DM, age 45-65, would preventive assessment of PVD using ABPIs with US

Doppler improve outcomes in one outpatient setting?

Significance to Nursing Practice

According to the American Association of Nurse Practitioners (AANP, 2017), 60% of

nurse practitioners (NPs) see three or more patients per hour. Therefore, it is reasonable for NPs

to include a simple Doppler US exam on patients with T2DM as a disease prevention measure

during an outpatient visit then provide health counseling with lifestyle changes and therapeutic

interventions (medications, physical therapy). Benefits of this DNP project that directly apply to

NP practice are: 1) use evidence to guide practice and 2) improve health outcomes and quality of

patient care.

Complications of diabetes and PVD due to decreased blood flow to the legs that impact

activities of daily living (ADLs) and quality of life include neuropathy, pain, ulceration, and

amputation (Peachman, 2016). Patients may experience alteration in their ability to


independently walk, toilet, shop, perform self-hygiene, and participate in social gatherings

(Fong, Mitchell, & Hong, 2015). Furthermore, patients with absent ABPIs and a diagnosis of

gangrene have a 75% risk for amputation and absent pulses in both arteries of the ankle increase

risk for mortality (Felix, Sigel, & Gunther, 2016). Thus, it is crucial for NPs to aggressively treat

abnormal or critical ABPIs of the lower extremities, following PVD guidelines to improve

outcomes (Welch, Robinson, Stevenson, & Atkins, 2016).

Conclusion

Chapter One identified the problem of PVD in patients with T2DMs and significance to

NP practice. Assessment of ABPIs with US Dopplers can reduce morbidity and mortality in

patients with T2DM. Yet, missing are policies and protocols to support these preventive

interventions. Chapter Two provides a synthesis of the current literature related to T2DM and

PVD, definition of terms, and theoretical framework. Chapter Three includes the methodology of

the DNP project. A presentation of the results is provided in Chapter Four. Chapter Five includes

discussion of the findings, implications to practice, and recommendations.


Chapter Two: Literature Review

Patients with T2DM need preventive PVD assessment, close monitoring, and aggressive

symptom management. It is critical for PCPs to empower individuals to choose healthy lifestyles

and make changes that reduce risk factors and the burden of disease. One critical approach to

reduce PVD risk in patients with T2DM is the early detection (ABPIs with US Doppler) and

preventive interventions (medications, physical therapy). The purpose of this DNP project was to

evaluate patients with T2DM to reduce PVD risk and identify policies and protocols that would

decrease risk of PVD and improve outcomes. The goal is to promote PCP actions that reduce

risk.

Three themes emerged from a review of the current literature on patients with T2DM and

PVD. Theme One identifies methods for evaluating PVD. Theme Two presents PVD

interventions. Quality care and quality of life are presented in Theme Three.

Theme One: Evaluation of PVD

Most patients with early onset of PVD are asymptomatic and do not seek treatment until

adverse symptoms appear including claudication, lower leg pain, or lower extremity ulcerations

(Nott, King, & Koddourau, 2013). Vowden and Vowden (2013) report that PCPs frequently

consult wound care or surgical interventions for patients presenting with ABPIs at 0.8 mm/Hg.

Mild PVD was identified at 0.8 mm/Hg but should be adjusted for patients diagnosed with PVD

or PAD (Vowden & Vowden, 2013).

Patients with T2DM benefit most from an annual ABPI assessment with US Doppler to

determine a baseline index and to establish responsive, patient centered care plans (Newman et

al., 2017). US Doppler standards to assess ABPIs require systematic use, consistent rest time,

and precise cuff placement to assure accuracy (Sihlangu & Bliss, 2012). A few studies report no


valid PVD tests available in the outpatient setting while other studies identify two tests, vibration

perception threshold (VPT) and ABPIs (Ogbera, Adeleye, Solagebera, & Azenabor, 2015;

Sihlangu and Bliss, 2012; Welch, Robinson, Stevenson, & Atkins, 2016).

Theme Two: PVD Interventions

Early treatment of PVD can prevent disease progression and help patients avoid surgical

revascularization or amputation (Baila, Parnia, Panaite, & Salagean, 2015). Furlong (2015)

reported that patients with PVD have improved outcomes with lower extremity compression

stockings and should have US Doppler tests every 4 months when there are venous ulcers. PVD

symptoms improved (able to walk long distances without pain) when patients were prescribed

antiplatelet therapy, exercise, balanced nutrition counseling, and lipid lowering medication

treatments (Meyers, Murasaki, Bishop, Wait, & Smith, 2017). Furthermore, PVD symptoms

decreased when patients quit smoking due to the reduction in chemicals found in tobacco

products that cause the lining of the vascular system to become swollen, invite plaque formation,

and decrease blood flow to distal limbs (Nelson et al., 2015). It is clear from the literature on

PVD interventions that severe symptoms can be avoided, and PCPs must act proactively to

reverse or delay PVD progression.

Theme Three: Quality Care and Quality of Life

Comprehensive care for patients with PVD, including diagnosis, treatment, and ongoing

outpatient management, is available, yet health disparities do exist based on socioeconomic

status, ethnicity or race, and geographic location (Suckow & Stone, 2015). Suckow and Stone

(2015) emphasized the need for PCPs to diligently implement affordable, accessible care plans

and help with resource acquisition. In severe instances of PVD where amputation was warranted,

physiological counseling helped patients to prepare for amputation, adapt to a restricted life,


adopt problem solving capabilities, and engage in activities with social support versus social

(Washington & Williams, 2016). In one study, after patients received an Osseointegrated

transtibial implant post amputation, quality of life improvements was noted on mobility,

activities of daily living, and pain status (Atallah et al., 2017). The patient experience is complex,

yet opportunities for quality care and quality of life can be easily managed by PCPs.

Theoretical Framework

Lewin’s Theory of Planned Change was the most appropriate theory for this DNP project

due to the importance of implementing sustainable changes into the practice setting (Whitehead,

Dittman, & McNulty, 2017). There are three phases to Lewin’s theory: unfreeze, change, and

refreeze. The first step is to unfreeze, or let go of the settled in natural habits, Lewin refers to this

first step as “ready to change.” The second step is “change” or implementation of the change.

The third step is to “refreeze” or continue the identified change into practice. For this DNP

project, the unfreeze stage was used to educate staff on the need for every patient with T2DM to

receive ABPIs with Doppler ultrasound at their first clinic appointment. The change stage

included development of a PVD prevention policy and protocol for patients with T2DM reduce

morbidity, improve quality of life, and to reduce health care costs. The refreeze stage will

include spot checks with staff to ensure there is consistent implementation of the PVD

prevention policy. The three stages of Lewin’s Planned Change model were ideal for this

outpatient setting where there were no restraining forces and excellent driving forces including

constant leadership and staff support and effective use of scarce resources in effort to deliver

safe, quality care.

Conclusion


The literature identifies early assessment of PVD in patients with T2DM as critical.

Absent is a standardized evidence-based PVD prevention policy and protocol for every patient

with T2DM. Use of ABPIs with US Doppler in the outpatient setting is reasonable. Lewin’s

Theory of Planned Change is the most applicable strategic resource to implement organizational

changes for this DNP project. Quality care and quality of life strategies are relevant and valuable

to the practice setting, yet health promotion and disease prevention i.e. PVD prevention policies

must become a priority.


Chapter Three: Methodology

The research question identified in Chapter One identified the importance of early

assessment of ABPIs using the US Doppler and prompt treatment of PVD to optimize patient

outcomes. Yet, there is a paucity of research on use of ABPI with US Doppler as a routine

preventive intervention for patients with T2DM. This DNP project was designed to address this

gap in the current literature and to create PVD prevention policy and protocol to support care that

improves population health. To answer the DNP question, a non-experimental retrospective

design was utilized.

Setting

The setting for this project was a rural outpatient clinic in the southeastern region of the

United States. The clinic has a board of directors, is managed by a director and clinic managers,

and is staffed by a per diem nurse practitioner, mid-wife, and diabetic educator nurse and

physicians with experience in family practice. This clinic serves a low income, poverty level

population including migrant farm workers and patients without insurance are eligible for

services. The clinic receives no federal funds and operates on grants from local government,

charities, and private funds.

Sample

Medical records were selected based on the inclusion and exclusion criteria discussed

under the sampling plan. Patients with T2DM are treated for PVD at this clinic. Furthermore,

licensed physicians or NPs examined patients at this outpatient clinic.

Sampling Plan

A convenience sample was selected for this DNP project during January 1, 2017 through

December 31, 2017. A sample size of 25 patients was supported, using a confidence interval of


19.51 (Moron, Burson, & Conrad, 2017). Sample size calculation based on the clinic’s annual

census of 2500 patients.

The primary investigator (PI) identified patients using the below inclusion and exclusion

criteria. Inclusion criteria: 1) patient visited clinic within January 1, 2017 through December 31,

2017, 2) female or male patients, 3) age of 45-65 years old, 4) patient has had at least two visits

at the clinic within this timeframe, 5) medical chart includes an ICD-10 billing code for diabetes

and PVD, and 6) chart contains data required for the data collection sheet (see Appendix A).

Exclusion criteria: 1) patients who have history of amputation(s) or surgery to correct PVD, and

2) patients who refused ultrasound Doppler or lower extremity examination for pedal pulses.

Data Sources

Clinical data was collected from each patient’s medical record including: age (45-65),

gender, race, and ethnicity, pedal pulses, ABPI with US Doppler, and whether patients had risk

for PVD according to the American heart Association (AHA), and American College of

Cardiologists (ACC). The age range of 45-65 was selected due to average age range for new

onset of T2DM. Patients with T2DM demonstrate early signs of PVD before the suggested at-

risk age of 65 set forth by the AHA-ACC PVD guidelines. Guidelines were followed for data

collection at this outpatient clinic (i.e., physical activity, smoking history, hypertension, BMI).

Data were collected on PVD treatment recommendations depending on the patient’s ABPI with

US Doppler and pedal pulse strength. Data on Metformin were included in the project due to

reports that Metformin can mask PVD symptoms with drug induced neuropathy (Jacobs, 2015).

Data Management Plan

Data collection was conducted in a private, secured medical records office at the

outpatient clinic. The PI transcribed all data from the medical chart onto an Excel spreadsheet


that was password protected on a personal computer and kept in a secured office. Only de-

identified data were collected.

Protection of Human Subjects

The PI followed the Health Insurance Portability and Accountability Act (HIPAA)

Privacy Rule utilizing the Safe Harbor method of de-identification of 18 patient identifiers.

Patient information was excluded from data collection: 1) names; 2) geographic subdivisions

smaller than a state; 3) all elements of dates (except year); 4) telephone numbers; (5) vehicle

identifiers; 6) fax numbers; 7) device identifiers and serial numbers; 8) email addresses; 9) web

universal resource locators (URLs); (0) social security numbers; 11) internet protocol (IP)

addresses; 12) medical record numbers; 13) biometric identifiers; 14) health plan beneficiary

numbers; 15) full-face photographs; 16) account numbers; 17) any other unique identifying

number, and; 18) certificate/license numbers (Office of Civil Rights and USDHHS, n.d.).

Conclusion

Chapter Three presented the methodology for this DNP project. The setting, sampling

plan, data sources, data management plan, and protection of human subjects were thoroughly

discussed. Data collected was analyzed and findings for this project are presented in Chapter

Four.


Chapter Four: Results

In Chapter Four, the findings of this DNP project are presented. In one outpatient clinic

setting, a retrospective review of 25 charts examined PVD risk in patients with T2DM. A

complete analysis was performed on demographics and clinical assessment data including pedal

pulses and ABPIs with US Doppler. Further analysis of conditions that place patients at

increased risk for PVD included data collection on BMI, smoking history, inactivity,

hypertension, and hyperlipidemia. One of the aims of this project is to implement early PVD

prevention strategies and policy to reduce morbidity i.e. leg ulcers, infection, and amputations.

Table 4.1 illustrates the demographics of this sample. There were 14 (56%) females and

11 (44%) males. The mean age was 45-65 years old with an average age of 57(5.54). The race

and ethnicity of this sample consisted of 40% African American, 32% Caucasian, 16 %

Hispanic, 8% other, and 4% Asian. This sample does not accurately represent this regions larger

Caucasian (67%) and Hispanic (15%) populations yet it is reasonable to infer the differences are

due the eligibility criteria at this outpatient clinic setting allowing all patients with no health

insurance.

Table 4.1

T2DM Patient Demographics (n = 25)

Age Range

45-65

Mean

57.36

Standard Deviation

5.54

Gender Female

56% (14)

Male

44% (11)

Race/Ethnicity African American40 % (10)

Caucasian32% (8)

Hispanic16% (4)

Other8% (2)

Asian4% (1)


Findings reported in this section identify pedal pulses and ABPIs of the sample

population. Seventy two percent of patients with T2DM were found to have weak (44%) or

absent pulses (28%); 56 % of patients with T2DM had abnormal (40%) or critical (16%) ABPIs

using US Doppler. Further, 78% of patients with T2DM showed clinical signs of PVD and in

need of surgical or emergency room referral; four of these patients refused ABPI with US

Doppler – no data in the medical record explained this patient response.

Table 4.2

T2DM Pedal Pulses and ABPIs (n = 25)

Pedal Pulses Weak44% (11)

Absent28% (7)

Strong28% (7)

Ankle brachial Pulse Index Readings

Abnormal40% (10)

Normal28% (7)

Critical16% (4)

Refused16%16% (4)

Table 4.3 reveals provider recommendations at the first clinic appointment. Forty percent

of patients with T2DM were referred to a vascular surgeon, 32% were referred to the emergency

department, and 12% were prescribed new medications i.e. aspirin or statin drugs to decrease

plaque formation within cardiac vessels. Sixteen percent of patients with T2DM had no changes

made to their current treatment regimen.

Table 4.3

Provider Recommendations at the First Clinic Appointment (n = 25)

Vascular surgery Referral

40 % (10)

Emergency Department Referral

32% (8)

New Medications 12% (3)

No Change in Medication Regimen

16% (4)


The American Heart Association (AHA) and American College of Cardiologists (ACC)

PVD guidelines identify conditions that place patients at increased risk including: obesity (body

mass index [BMI] greater than 25), history of smoking, use of Metformin (adverse effects

include peripheral neuropathy), inactivity, hyperlipidemia, and hypertension (equal to or greater

than 130/80 mmHg). Lipid results were unavailable during the initial clinic visit therefore not

reported as data in this project. Table 4.3 illustrates AHA/ACC PVD risk factors for this sample.

Table 4.4

AHA/ACC PVD Guideline Risk (n = 25)

A PVD prevention policy and protocol was implemented at the outpatient clinic during

this project and included the following content: a) all patients with T2DM will receive ABPIs

with US Doppler at first clinic appointment; b) patients with PVD symptoms and

abnormal/critical ABPIs will receive appropriate surgical or emergency room referrals and

treatment interventions, and repeat APBIs with US Doppler in three or four months or annually if

the patient returns for an appointment after a surgical intervention; c) patients with PVD

symptoms and ABPIs within normal limits will receive a repeat ABPI with US Doppler in one

year and every six months if ABPI > 0.85 mm/Hg; d) patients with no PVD symptoms and

abnormal/critical ABPIs will receive appropriate surgical or emergency room referrals and

treatment interventions, and repeat APBIs with US Doppler in three or four months or annually if

Overweight/ObesityBMI >25

84% (21)

Current Smoker, or Recently Quit

76% (19)

Currently Taking Metformin

76% (19)

No exercise, or Physical Activity

52% (13)

Hypertension>130/80

32% (8)


the patient returns for an appointment after a surgical intervention; and e) patients with no PVD

symptoms and ABPIs within normal limits will receive a repeat ABPI with US Doppler in one

year and every six months if ABPI > 0.85 mm/Hg.

Conclusion

In this DNP project, a retrospective chart review of patients with T2DM with PVD

revealed the need to establish a PVD prevention policy at one outpatient clinic. Based on this

evidence, best practice supports the use of ABPIs with US Doppler on every T2DM patient at

this outpatient clinic setting. The T2DM patient population at this outpatient clinic demonstrated

high risk for PVD morbidity, a majority requiring prompt medical intervention. Findings from

this DNP project informed the new PVD prevention policy. In this outpatient clinic, PVD

prevention interventions based on current evidence, are now being implemented and closely

monitored in order to reduce morbidity, improve quality of life, and reduce healthcare costs.

Discussion, implications, and recommendations are reviewed in Chapter Five.


Chapter Five: Discussion, Implications, and Recommendations

Discussion

In this chapter, a summary of the findings, implications to practice, and recommendations

for future research are presented. This DNP project achieved its purpose in answering the

following question: In patients with T2DM, would the use of ABPIs with Doppler ultrasound for

PVD prevention improve outcomes i.e. delay or reverse PVD onset? ABPI assessment with US

Doppler on patients with T2DM reveal the need for early detection and treatment that can delay

or reverse PVD onset avoiding lower extremity ulcers, infection, and amputation. Policies must

support this

A retrospective chart review of 25 patients with T2DM and PVD was performed to

evaluate risk of the patient population served at one outpatient clinic setting. The first clinic

appointment revealed that 72% of patients with T2DM had PVD symptoms with weak or absent

pedal pulses and abnormal or critical ABPIs warranting surgical or emergency room referrals.

This project established an at-risk population in need of a PVD prevention policy. A PVD

prevention policy allows providers to perform ABPIs with US Doppler on patients with T2DM

who are symptomatic or asymptomatic at the first clinic appointment. Manual palpation to assess

strength of peripheral pulses varies yet evaluation of ABPIs with US Doppler provides greater

detail such as pedal strength, pressure from blood flow, and location of restrictions.

AHA/ACC guidelines identified risk factors for PVD including diabetes, age, obesity,

smoking history, hypertension, hyperlipidemia, and inactivity or lack of exercise – all risk factors

were present in this patient population at the first clinic visit, except hyperlipidemia due to

unavailable lab results. The age range of this patient population was set at 45 to 64 years old due

to national average age range for onset of T2DM and eligibility criteria for Medicare coverage


beginning at age 65. The average age of this population was 57(5.54) years and indicates the

need for PVD prevention including smoking cessation and prescribed supervised exercise to

delay or reverse onset of PVD symptoms. Findings confirm a population at high risk in need of

early assessment and intervention to reduce morbidity including leg ulcers, infections, and

amputations. Particular attention on patient education interventions and anxiety management

must be paid to patients who refuse ABPI with US Doppler assessments, as four patients refused

ABPI assessment in this project.

Due to the findings of this project, a PVD prevention policy was initiated. All patients

with T2DM now receive APBI assessment with US Doppler. Current and new patients with

T2DM that seek healthcare at this outpatient clinic will benefit from this practice change. Free

clinics however have limited resources and referrals to providers from clinics that serve the

uninsured are limited in the services they can provide. Funding opportunities for follow up

services would decrease healthcare disparity (Felix, Sigel, and Gunther 2016).

Implications

Nurses with advanced degrees have the unique opportunity to provide PVD assessment

and early intervention to their patients with T2DM in their roles as primary care providers.

Nurses are clinically trained to palpate peripheral pulses grading a bounding pulse at +4, normal

pulse at +3, diminished pulse at +2, faint pulse at +1, and no pulse at 0. Nurses with advanced

degrees including nurse practitioners and nurses with a doctorate degree, must go beyond status

quo training and strive to improve care based on current evidence and population needs. Nurses

have the education and skills to intervene at the system level, evaluate patient populations,

implement evidence-based care, implement sustainable interventions, and develop policy. The

PVD prevention policy created in this DNP project reflects this expertise at the doctoral level.


Nurses must collaborate with their peers, administrators, and staff to identify population needs,

reduce risk, and advocate for quality care through policy development. For policy development,

Lewin’s Change Model provided the essential framework for policy implementation and

stakeholder buy-in. Unfreezing, change, and refreezing provided the implementation strategy for

this quality improvement project and the identified driving and restraining forces provided

imminent considerations.

Recommendations

It is critical to reduce the gap between PVD detection and patient complaint of pain,

infection, or ulceration and monitor patient response to PVD interventions including medication

adherence, smoking cessation, and increase in activity regimens. Providers should set

benchmarks to reduce PVD risk in the patient populations they serve. Larger sample sizes should

be examined as a lower or higher average age may be revealed along with additional

opportunities for quality improvement.

A cost benefit analysis should be performed to evaluate purchase and use of US Doppler

and health care dollars saved by preventive care versus just in time care. Each clinic should

assess their patient population for PVD risk and efficacy of early intervention and prevention.

Clinics must consider funding sources or health care grant opportunities for US Doppler as not

every clinic purchases this technology.

When implementing PVD prevention intervention strategies, providers must consider

socioeconomic status and literacy level of patients and develop patient centered care plans that

include control of A1C, medication adherence, American Diabetic Association (ADA) diet,

physical exercise, smoking cessation, and weight management. Realistic goals should be

discussed, and routine patient education should be deliverables.


Conclusion

Through ABPI assessment using US Doppler can reduce risk in patients with T2DM.

Providers must prepare PVD prevention policies that address the needs of the patient populations

served and provide PVD interventions that can delay or reverse morbidity and reduce healthcare

costs. Nurses must collaborate with their peers, staff, and administrators to implement patient

centered care plans based on current evidence. Care plans must be delivered in a culturally

competent manner and include patient education at the patient’s literacy level. AHA/ACC PVD

guidelines instruct providers to monitor risk factors and provide interventions that slow the

progression of PVD. Patients must be empowered to make informed decisions by their providers

based on current evidence.

Nurses who incorporate current evidence into practice, analyze patient population data,

and implement practice changes through policy development, ensure that safe health care is

delivered. Nurses must continue to develop their expertise in navigating health care systems,

change management, and collaboration. Nurses are the first line of defense in ensuring that best

practices are reaching their patients and should continue to exert appropriate initiative to

advocate for the patients they serve. This DNP project was a success in that resources were

available (US Doppler) and agreement in an optimal plan of care for patients with T2DM could

be realized.


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