Standard Operating Procedure for Use of Handheld Dopplex Vascular Doppler Ultrasound Within Adult Community Services

Transcription

1 Standard Operating Procedure for Use of Handheld Dopplex Vascular Doppler Ultrasound Within Adult Community Services Reference No: Version: 1.1 Approved by (Committee name): G_CS_35 LCHS Trust Board Date approved: 26 th August 2014 Name of originator/author: Name of responsible committee/individual: LCHS Tissue Viability Team Quality Scrutiny Group Date issued: September 2016 Review date: November 2016 Target audience: All Clinical Staff Undertaking Doppler Assessments. Distributed via: Team Meetings, Link Champions, Intranet 1

2 Standard Operating Procedure for Use of Handheld Dopplex Vascular Doppler Ultrasound Within Adult Community Services Version Control Sheet Version Section/Para/ Appendix Version/Description of Amendments Date 1 New Policy August 2014 TVT 1.1 Extended November 2016 TVT Author/Amended by Copyright 2016 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2

3 Standard Operating Procedure for Use of Handheld Dopplex Vascular Doppler Ultrasound Within Adult Community Services Policy Statement Background Statement Responsibilities Training Dissemination Resource implication The purpose of this standard operating procedure is to standardise how the handheld Dopplex Vascular Doppler ultrasound is used as an integral part of leg ulcer assessment. This document offers guidance to ensure that all Doppler assessments are performed in a correct and timely manner, and results are interpreted and acted upon correctly. Compliance with this guidance is an expectation of all practitioners and will be the responsibility of all LCHS clinicians. It is the responsibility of operational managers and service leads to ensure that appropriate mechanisms are in place to support the implementation and ongoing application of this guidance, including appropriate training and maintenance of competencies. Intranet Heads of Clinical Services Matrons Tissue Viability Specialist Nurses & Tissue Viability Champions Tissue Viability/ Leg Ulcer Management Training All practitioners trained and proficient in Doppler assessment. This guideline has been developed to facilitate standardised practice in undertaking a Doppler assessment. There are no identified additional resource implications, unless it is identified that current provision is inadequate. 3

4 Standard Operating Procedure for Use of Handheld Dopplex Vascular Doppler Ultrasound Within Adult Community Services Contents i. Version control sheet ii. Policy statement 1. Introduction and background.p.5 2. Benefits of a Doppler assessment p.5 3. Indications for a Doppler Assessment.p.6 4. Contraindications for Doppler Assessment...p.6 5. Safety and Accuracy..p.6 6. Supporting Documentation.p.7 7. Implications of inaccurate vascular assessment..p.7 8. Results..p.8 9. Error reporting p Maintenance p Procedure and rationale.. p Competency Framework..p Handheld Doppler log book...p References..p.16 4

5 Introduction and Background A handheld Dopplex Vascular Doppler ultrasound is a non- invasive diagnostic device used to detect blood flow in both veins and arteries. The Doppler probe emits high frequency ultrasound waves, when the waves hit the red blood cells moving in an artery, their frequency changes and the probe detects the doppler shift converting it to an audible signal (Nursing Times, 2002). In vascular assessment, the direction and velocity of blood flow is measured to identify whether the patients arterial blood vessels are healthy or diseased (Beldon, 2010). This Standard Operating Procedure (SOP) aims to ensure accuracy of the results leading to correct diagnosis of vascular status and appropriate care. LCHS has handheld Dopplex Vascular Dopplers available for use by relevant Practitioner. The RCN (1998) recommends that all patients with a leg ulcer should have their ankle brachial pressure index (ABPI) recorded as part of a holistic assessment. When performed according to the recommended procedure, an ABPI is a means of aiding clinical judgement and enables the identification of those patients with a compromised arterial blood supply (Moffatt, Martin & Smithdale, 2007). A lower limb Doppler assessment should be performed by a practitioner who has received the appropriate training to enable them to demonstrate competency in the following areas that are applicable to them: the safe and correct use of the equipment (MHRA 2006) gaining consent and preparation of the patient (Department of Health (DH) 2001, DH 2005) Clinical examination and general assessment. Identifying indicators of venous and arterial disease. Undertaking an Ankle Brachial Pressure Indices assessment and interpretation of the results. The appropriate use of compression therapy. To fulfil this procedure, Staff Groups are responsible for keeping up to date with their knowledge, skills and competencies in line with local and national policies (Way 2002, Skills for Health, 2008) Benefits of a Doppler Assessment Doppler ultrasound assessment (ABPI) is used to exclude Peripheral Arterial Occlusive Disease (PAOD) together with the findings of a full clinical history and physical examination. The exclusion of PAOD indicates that the patient has venous disease and is probably appropriate for Type 3 high compression therapy (40mmHg at the ankle). Compression therapy in the treatment of venous disease: Reduces blood pressure in the superficial veins Aids venous return of blood to the heart by increasing the velocity of flow in the deep veins Reduces oedema 5

6 Indications for a Doppler Assessment The Lincolnshire Community Health Services Clinical Standard for The Assessment and Management of Lower Limb Ulceration (2010) states that a full leg ulcer assessment will take place within 6 weeks of the initial presentation or prior to this if there is a new wound and the patient has known or obvious venous or arterial disease or if the ulcer has appeared spontaneously. Contraindications for a Doppler Assessment Suspected DVT Cellulitis Severe pain Ulceration over the pedal pulse points Safety and Accuracy Poor or inaccurate results may occur if any of the following are present: If the patient is not laid flat, a false high reading may be obtained. Where the patient is unable to lay flat the legs should be elevated to the level of the heart and the position of the patient documented. An incorrect cuff size will result in inaccurate pressures: o Too short or too narrow a cuff results in an overestimation of pressure o Too large a cuff will underestimate the pressure. If the cuff is deflated too quickly, the first beat can be missed. Repeated inflation of the cuff or leaving the cuff inflated for more than a few moments can alter the pressures and may cause the patient unnecessary discomfort. If the signal does not occlude on inflating the cuff, this indicates severe calcification. Stop the procedure to avoid pressure damage to the limb and great discomfort to the patient. Care must be taken to ensure that too much pressure is not applied to the probe when locating the artery, as this may lead to occlusion. When measuring the ankle pressures ensure the cuff is positioned over the ankle. If over the calf, the calf brachial index pressure will be measured. The pressure obtained relates to the cuff position and not the probe. Arterial disease can affect the upper limbs and a significant difference between brachial pressures (>15mmHg) can potentially indicate aortic arch disease. The accuracy of the central systolic pressure is greatly improved when both brachial pressures are obtained and the highest reading used. The accuracy of the results is questionable when only one arm is measured and there are significant variations in the remaining limbs. At least two ankle pressures should be recorded from each ankle. Variations in arterial pressures should be taken into account when considering compression therapy. A difference of 15mmHg or more between two ankle pressures can indicate PAOD in the artery with the lower pressure. The result can be inaccurate if the patient has high blood pressure; repeat the test after the condition has been treated. Gross oedema of the lower limbs can also cause the result to be inaccurate. It can make the pedal pulses difficult to detect. 6

7 (Moffatt et al, 2007) Supporting Documentation Clinical Practice Guidelines: The Nursing Management of Patients with Venous Leg Ulcers, Recommendations. (RCN, 2006) Implications for the organisation of inaccurate vascular assessment Potential litigation Healthcare acquired infection Increased pharmacy costs Increased hospital admissions Potential need for long-term nursing or residential care with the resulting bed days lost. Increased complaints Impacts on other DoH targets Increased morbidity Implications for the patients of inaccurate vascular assessment in Primary Care Loss of limb Inappropriate treatment Failure to heal Fear and anxiety Poor patient confidence Unnecessary discomfort & pain Increased risk of complications Loss of social life Effect on work Effect on earnings 7

8 Results The ankle brachial pressure index (ABPI) is calculated by using the highest systolic pressure recorded in the ankle and dividing it by the highest systolic pressure in the arm. The result in normal arterial flow should be ABPI: 1.0. This would indicate a safe level to use compression. ABPI Values ABPI < 0.5 Severe PAOD. Refer the patient to the vascular team (may need urgent referral depending upon the severity of symptoms). High compression is contraindicated. If venous disease or oedema is present, light support may be appropriate, but only following specialist guidance. ABPI Moderate to severe PAOD. Refer the patient to the leg ulcer specialist and vascular team if symptomatic. If venous disease or oedema are present, reduced levels of compression therapy may be safe following specialist guidance. ABPI Normal ABPI. High compression is probably safe in the absence of contraindications. ABPI >1.3 May indicate a falsely high reading, especially if signals are Monophasic. The ankle vessels may be non compressible indicating severe calcification, which is more commonly seen in people with diabetes. Falsely high readings may also be a result of incorrect cuff size (i.e. too small) or where there is gross oedema. (Vowden & Vowden, 2001; Ruff, 2003) The results will be assessed as part of the overall leg ulcer assessment by a practitioner who has the knowledge to interpret the results, as a result of attending the leg ulcer management training as provided by the Trust, or attendance at the LBR module B72/73 Leg Ulcer Management. They will consider themselves as competent, following the completion of the leg ulcer assessment competences, which will be peer reviewed every two years, or as required. The practitioner who initiated the assessment is responsible for the results, and identifying if further notification is required to the Specialist Tissue Viability Service and/or GP. This will be done in a timely manner to ensure an appropriate treatment plan can commence, according to the algorithms within the Clinical Standards. The result will be recorded on the SystmOne Doppler Assessment Template in the correct place. Any significant results will be available on SystmOne for the GP, or other healthcare professional to see. Where a patient is registered to a GP who is not on SystmOne then the GP should be made aware that there are results available for the patient. 8

9 If the handheld Doppler has been borrowed from another base, it will be returned in a clean condition with a new battery if necessary. The person returning the handheld Doppler will inform registered keeper if further stock of aqua sonic gel is required. When borrowing a handheld Doppler, if there is not one available in the Practitioners base, it will be booked out via the appropriate keeper of the machine, with details of who has borrowed it and the likely return date. On return, the handheld Doppler log book will be completed regarding the decontamination of the unit. Error reporting In the event of the following: 1. Failure to act upon results, which may lead to a detrimental effect on patient outcomes. An incident report should be completed and the Line manager Informed. The professional in charge of the patients care should also be informed and the test should be conducted again as soon as possible. 2. Equipment failure. A functioning machine should be obtained as soon as possible, to repeat assessment. The malfunctioning machine will be returned to registered keeper- for return to Clinical Engineering for servicing / repair. Maintenance Practitioners should follow guidance in the LCHS Medical Devices Policy (2010), Appendix B Medical Devices Manual: Guidelines and procedures for best practice (2009) with regards to the maintenance of the handheld Doppler. The unit should be checked prior to use by the Practitioner and the probe examined for any damage. Faulty probes should be reported to line manager for replacement. Procedure for Doppler Assessment ACTION Collect the equipment needed: Handheld Doppler ultrasound machine with an appropriate probe 8MHz probe for the detection of peripheral vessels in the standard limb a 5MHz probe for the detection of deep vessels or for use when oedema is present Headphones to detect faint pulses and to block out background noise Water based ultrasound gel Manual sphygmomanometer and appropriate sized cuff (preferably disposable, the bladder within the cuff should cover at least 80% of the 9 RATIONALE To ensure accurate function To ensure accurate function To ensure accurate function To allow transduction to occur To ensure accurate function

10 size of the limb). A waterproof layer to protect the ulcer. Padding to protect the ulcer if it is painful. Tuffie 5 Wipes to clean equipment Calculator or ABPI chart Practitioner to apply appropriate personal protective equipment as per Trust guidelines i.e. disposable apron and gloves Prepare the patient: Explain the procedure to the patient and gain consent. Refer to LCHS policy re consent and mental capacity ( DH, 2005) Ask the patient to lie as flat as possible for minutes. Use this time to complete other parts of the assessment. Patients who are unable to lie flat should be asked to lay as low as possible with their legs elevated to the level of their heart. Cover the ulcer with padding if the ulcer is painful Cover the ulcer with a waterproof layer or cling film to protect To prevent cross infection To ensure patient comfort. To prevent cross infection To ensure accurate calculation of results To prevent cross infection To ensure the patient understands freely consents to the procedure To reduce the effect of gravity on blood flow To ensure patient comfort To prevent cross infection 10

11 ACTION Measuring the brachial systolic pressure: Place an appropriate sized cuff around the upper arm. Check the correct probe is attached to the doppler unit. Locate the brachial pulse and apply ultrasound gel. Angle the probe at 45 degrees facing towards the direction of blood flow moving slowly across the skin until the clearest signal is heard. Inflate the cuff until the signal disappears, then slowly deflate the cuff. Record the pressure at which the signal returns. Repeat the procedure in the other arm and record as before. Remove any traces of gel from patient. RATIONALE To ensure accurate function and measurement To ensure accurate function and measurement To ensure accurate measurement To locate the best signal To record brachial systolic pressure To obtain comparative data To maintain patient s dignity and comfort Measuring the ankle systolic pressures: Place an appropriate sized cuff above the ankle. Locate either the Dorsalis Pedis or Anterior Tibial pulse apply gel and listen to the signal and record whether Triphasic, Biphasic or Monophasic. Inflate the cuff until just after the signal disappears, then deflate the cuff slowly. Record the pressure at which the signal returns. Repeat the procedure for the Posterior Tibial pulse Repeat the procedure for the other leg. Remove any traces of gel from patient and allow patient to replace any clothing. To ensure accurate function and measurement To establish the health of the artery To record Dorsalis Pedis or Anterior Tibial systolic pressure To obtain comparative data To obtain comparative data To maintain patient s dignity and comfort 11

12 Decontaminate the unit with a Tuffie 5 Wipe. To prevent cross infection Remove personal protective equipment and dispose of according to Trust policy Identify the highest ankle systolic pressure in the left leg and divide the result by the highest brachial systolic pressure. Repeat with the highest ankle systolic pressure for the right leg. Document results in appropriate position within Doppler template on SystmOne Explain results to patient Take appropriate action as required according to ABPI result recorded and LCHS Clinical Standard The Assessment and Management of Lower Limb Ulceration (2010). To prevent cross infection To obtain the ankle brachial pressure indices result for each limb. To maintain accurate records To ensure patients understanding. To ensure patient s care is timely and appropriate. 12

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14 Appendix 1 Competency Document for Doppler Assessment Objective: The nurse will be able to accurately and reliably use Doppler Ultrasound for lower limb assessment, interpret results and record findings. Name:... Work area... ASSESSMENT Date: Date: NAME OF ASSESSOR Domains/ Behaviours Indicator Expected response Pass / Fail Pass / Fail Factor 1. Theory a) Demonstrates appropriate understanding of the Hand-held Doppler Ultrasound b) Understands principles and rationale for undertaking a Doppler assessment in accordance with LCHS Clinical Standard: Assessment and Management of Lower Limb Ulceration (2010) Factor 2. Practical a) Preparation of patient i) Understands the use and functions of the Doppler and probe. ii) Understands decontamination process for Doppler and probe i) Explains indications for carrying out procedure ii) Explains contra-indications for carrying out procedure i) Introduction to patient and explanation of procedure * Demonstrates how to change battery, adjust volume and attach headphones. Identifies size of Probe 5 or 8 MHz Explains procedure for cleaning Doppler and Probe in accordance with local Infection Control Policy / Manufacturers Instructions To establish ABPI measurement and vascular supply to lower limbs for suitability of compression therapy Deep vein thrombosis risk of emboli Cellulitis increase level of pain Severe ischaemia risk of further tissue damage Explains procedure to the patients in a clear and straightforward manner 14

15 b) Selection of equipment ii) Patient positioned correctly i) Selection of Doppler and appropriate size (frequency) of probe ii) Selection of correct size blood pressure cuff iii) Selection of appropriate ultrasound gel Removal of any tight / restricting clothing and rested in supine position for minimum period of 15 minutes. If unable to lie supine, elevate lower limbs to level of the heart. Room temperature. Selects mini or multi Dopplex and attaches 8 MHz probe for peripheral vessels close to body surface in normal size limb. 5 MHz for obese/oedematous limbs. The bladder within the cuff should cover at least 80% of the size of the limb. Transmission ultrasound gel for transmitting sound in addition to preventing corrosion of the probe. c) Procedure i) Management of ulcer site. Any wound products/bandages removed and wound should be covered with a waterproof layer to prevent contamination of the blood pressure cuff. ii) iii) Brachial systolic blood pressure is obtained correctly and accurately recorded Brachial blood pressure is obtained accurately and documented. Placing appropriate sized BP cuff correctly just above the elbow. Support patients arm with pillows if required. Location of brachial pulse and application of ultrasound gel. Doppler probe angled at 45 degrees towards direction of blood flow (locating strongest signal) BP cuff inflated / deflated correctly to detect when signal stops and reappears. Actual figure is recorded and documented. Removal of excess gel. Procedure repeated on opposite arm Brachial pressures are recorded and documented. The highest reading from both arms is used for calculation of ABPI measurement 15

16 iv) Ankle systolic blood pressures are obtained correctly and accurately recorded. v) Appropriate calculation of ABPI measurement is obtained. vi) Accurate assessment of foot pulses vii) Maintaining safety, dignity and confidentiality throughout procedure Appropriate sized BP cuff applied correctly just above malleolus on the leg. (cuff upside down to prevent contamination from gel) Dorsalis Pedis pulse located and application of ultrasound gel (if absent anterior tibial pulse is used) Doppler probe angled at 45 degrees towards direction of blood flow. (locate strongest signal) BP cuff inflated/deflated correctly to detect when signal stops and reappears. Actual figures are accurately recorded. Procedure repeated using posterior tibial pulse. Both readings are documented. Excess gel removed. Procedure repeated for opposite leg. The highest brachial pressure and high systolic reading from the two pedal pulses are used to calculate ABPI. Repeat calculation for each leg. E.g. Right leg Highest of two ankle systolic pressures Highest of the two brachial systolic pressures Repeat calculation for recordings from opposite leg. During procedure clinician should demonstrate ability to: distinguish arterial from venous blood supply Distinguish monophasic from biphasic/triphasic signals and record findings. Provision of blankets or sheets to maintain privacy and dignity. Wound management products/bandages reapplied and assist patient to put on clothing as soon as procedure is complete. 16

17 Factor 3. Application viii) Demonstrates awareness of infection control a) Results i) Recognise relevance of ABPI measurement and signal analysis. iii) Interpret results and recognise importance of outcome in management of patients with lower limb disease. iv) Aware of referral to appropriate specialist for further advice Doppler Ultrasound, probe is cleaned with a Tuffie 5 wipe, cuff cleaned in accordance with local policy. Hand washing/gloves used appropriately throughout procedure. Normal ABPI is ABPI of < 0.8 suggests arterial insufficiency. ABPI > 1.3 severe calcification of the arteries. May indicate false high especially if monophasic signals. (usually diabetes) Triphasic signal normal arteries Biphasic mild stenosis Monophasic severe stenosis Factors affecting results: Diabetes, renal disease, rheumatoid disease, atherosclerosis, cardiac arrhythmias ABPI > 1.3 calcification no compression ABPI apply compression ABPI mild peripheral vascular disease. compression with caution ABPI significant arterial disease no compression ABPI < 0.5 severe arterial disease no compression ABPI of < 0.8 or > 1.3 or monophasic signals requires referral to specialist nurse or Vascular surgeon. Assessor signature Learner signature Comments: References: Vowden, Goulding and Vowden (1996), Sign, 1998, Vowden and Vowden (2001), RCN (2006), Moffatt, Martin and Smithdale (2007), Morison, Moffatt and Franks (2007) 17

18 Appendix 2 HANDHELD DOPPLER LOG BOOK ASSET No:. Last Serviced: Date Issued Name of person taking the Doppler NHS number of patient Date Returned Checklist please to confirm: Decontaminated by please print name Battery Check Box contents complete Please ensure that a copy of this form is sent to designated Administrator by the end of every quarter starting June 2013, for auditing purposes. 18

19 REFERENCES Beldon P (2010) Performing a Doppler Assessment: The Procedure. Wound Essentials Vol.5: Department of Health (2001) Medicines and Older People. Implementing medicines related aspects of the NSF for Older People. London: Department of Health Department of Health (2003) Winning Ways: Working together to reduce Healthcare Associated Infection in England. London. Department of Health Department of Health (2005) The Mental Capacity Act code of practice parts 1 and 2, London: Department of Health Lincolnshire Community Health Services (2010) Medical Devices Policy. Lincolnshire Community Health Services Lincolnshire Community Health Services (2010) Clinical Standard for the Assessment and Management of Lower Limb Ulceration. Lincolnshire Community Health Services Medicines and Health care products Regulatory Agency (2006) The medical devices regulations: implications on health care and other related establishments. Bulletin No 18, London: MHRA Moffatt C, Martin R, Smithdale R (2007) Essential Clinical Skills for Nurses: Leg Ulcer Management. London: Blackwell Publishing Nursing Times (2002) Clinical Skills: using a hand-held doppler. Nursing Times 98(51): 29 Royal College of Nursing (1998) Clinical Practice Guidelines: The Nursing Management of Patients with Venous Leg Ulcers. London: Royal College of Nursing Royal College of Nursing (2006) Clinical Practice Guidelines: The Nursing Management of Patients with Venous Leg Ulcers, Recommendations. London: Royal College of Nursing Ruff D (2003) Doppler assessment: calculating an ankle brachial pressure index. Nursing Times 99(42): Skills for Health (2008) Vowden K, Vowden P (2001) Doppler and the ABPI: how good is our understanding? Journal of Wound Care 10(6): Way R. (2002) Assessing Clinical Competence. Emergency Nurse. 9(9):

20 Monitoring Template Minimum requirement to be monitored Process for monitorin g e.g. audit Responsible individuals/ group/ committee Frequency of monitoring/audi t Responsible individuals/ group/ committee (multidisciplinar y) for review of results Responsibl e individuals/ group/ committee for developmen t of action plan Responsibl e individuals/ group/ committee for monitoring of action plan Number and type of incidents connected with doppler assessment. Review of the themes from the incident reports. CNS TV All clinical team leads/matron s Community Nursing Staff Annual Quality and Scrutiny Group Quality and Scrutiny Group members Quality and Scrutiny Group 20

21 Equality Analysis Name of Policy/Procedure/Function* Standard Operating Procedure for Use of Handheld Dopplex Vascular Doppler Ultrasound Within Adult Community Services Equality Analysis Carried out by: Angela Wilson Date: 12/09/14 Equality & Human rights Lead: Rachel Higgins Director\General Manager: Sarah McKowan *In this template the term policy\service is used as shorthand for what needs to be analysed. Policy\Service needs to be understood broadly to embrace the full range of policies, practices, activities and decisions: essentially everything we do, whether it is formally written down or whether it is informal custom and practice. This includes existing policies and any new policies under development. 21

22 Section 1 to be completed for all policies A. B. C. D. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are expected to be Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details Will/Does the implementation of the policy\service result in different impacts for protected characteristics? The purpose of these doppler guidelines is to work towards standardisation of the practice of doppler assessment across the organisation. Implementation and compliance within the guidelines will be the responsibility of all staff. No No Disability Sexual Orientation Sex Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers Yes If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: Angela Wilson Date: 12/09/13 No X X X X X X X X X X 22