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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.
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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
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Data Analysis ……………………………………………………………………………16
Results …………………………………………………………………………………...17
Demographic Data ………………………………………………………………………18
Conclusions………………………………………………………………………………19
Chapter Five……………………………………………………………………………………...20
Discussion …………………………………………………………………….................20
Implications ……………….…………………………………………………..................21
Recommendations ………………………………………….............................................22
Conclusion……………………………………………………………………………….23
References ……………………………………………………………………………………….24
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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
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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
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(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
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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.
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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
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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,
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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
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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.
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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
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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
CRITIQUE OF ELEMENTS IN CHAPTER I 15
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.
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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)
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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)
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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)
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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.
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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
CRITIQUE OF ELEMENTS IN CHAPTER I 21
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.
CRITIQUE OF ELEMENTS IN CHAPTER I 22
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.
CRITIQUE OF ELEMENTS IN CHAPTER I 23
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.
CRITIQUE OF ELEMENTS IN CHAPTER I 24
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