Applied Fundamentals of Vascular Science —
Training activity: 11

Details

Perform, interpret and report resting and post exercise ABPI on diseased and normal patients

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Patient centred care and support
• Local SOPs
• National and national guidelines and standards
• Documentation and record keeping
• Use of machine controls
• Principles of doppler ultrasound
• Frequency continuous wave
• Doppler probe to use
• Patient positioning and exam technique.
• ABPI ranges
• Haemodynamics of normal and diseased arteries on continuous wave Doppler
• Effects of limb infection/hyperaemia on haemodynamics
• Optimisation of continuous wave Doppler (angle)
• Impact of disease on Doppler signal
• Safe exercise technique
• Limitations and pitfalls
• Local SOPs for report writing
• Acting on clinically urgent findings
• Referrals and escalation

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to accurately performing all technical steps, measuring, interpreting, and reporting resting and post-exercise ABPI.
• Consider how the learning outcomes apply, specifically in relation to analysing and interpreting the results of a range of vascular scans and preparing the associated diagnostic clinical reports.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the specific technical protocol for post-exercise ABPI (including treadmill speed/duration) and the criteria for abnormal findings in diseased patients.

What is your prior experience of this activity?

• Think about what you already know about physiological vascular assessments or using Doppler ultrasound to obtain pressure measurements.
• Consider possible challenges you might face during the activity, such as ensuring patient safety during the exercise component or accurately locating pulses/obtaining waveforms in a severely diseased limb.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if the patient experiences severe claudication pain during exercise requiring immediate cessation or if the resting ABPI results are critically low.
• Acknowledge how you feel about undertaking this comprehensive diagnostic activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as performing a safe exercise test or correlating haemodynamic profiles (e.g., flow in diseased vessels) with specific ABPI values.
• Identify the specific insights you hope to gain into the clinical significance of differentiating between resting and post-exercise ABPI findings in diagnosing peripheral arterial disease.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of arterial or physiological measurements where interpretation of technical challenges was required.
• Identify important information you need to consider before embarking on the activity, such as reviewing the pathophysiology of flow in diseased vessels and local protocols for ABPI interpretation in patients with diabetes or severe limb ischaemia.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing, interpreting, and reporting resting and post exercise ABPI?
• Are you encountering situations such as:
  • The patient reports severe claudication pain or experiences difficulty maintaining the required pace/duration during post-exercise testing, challenging the adherence to the established protocol?
  • The resting ankle pressure measurements are unexpectedly high in a suspected diseased patient, complicating the interpretation of peripheral arterial disease severity?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to the exercise protocol due to patient symptoms or deciding to switch to alternative measurement techniques due to technical difficulty?
• Consider the steps you are taking in the moment, such as:
  • Immediately stopping the exercise test or switching to alternative measurement positions (e.g., toe pressure assessment) due to patient discomfort or non-compressible vessels.
  • Immediately re-measuring the brachial pressure or confirming probe placement when an initial ABPI reading is highly unusual or contradicts clinical history.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt the established haemodynamic protocol quickly due to technical challenges? Is it affecting your confidence in the resultant interpretation, particularly differentiating between technical error and pathology?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully adapting the reporting format to include alternative measurements (e.g., TBI) while maintaining factual objectivity? Or are you needing support because the ABPI results critically contradict the patient’s clinical symptoms, requiring senior interpretive input?
• What are you learning as a result of the unexpected development? For example, are you mastering a more rigorous approach to patient mobility and safety assessment prior to conducting exercise studies? Or gaining insight into the specific conditions that cause vessel incompressibility?

On action

What happened?

• Begin by summarising the key steps you took when performing, interpreting, and reporting the resting and post exercise ABPI.
• Consider specific events, actions, or interactions which felt important, such as how you managed patient safety during the exercise component or how you correlated haemodynamic profiles (e.g., flow in diseased vessels) with specific ABPI values.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately stopping the exercise test when the patient reported severe claudication pain, or modifying the interpretation due to unexpectedly high resting ankle pressures.
• How did you feel during this experience, e.g., did you feel focused on differentiating between technical errors and pathological findings or stressed by the complexity of interpreting post-exercise drops?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding physiological vascular assessment. What strengths did you demonstrate, e.g., technical accuracy in measuring pressures or the ability to draft clear diagnostic reports?
• What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the interpretation criteria for abnormal post-exercise ABPI results or unfamiliarity with ensuring patient safety during the maximal exercise component?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in accurately analysing and interpreting the results of a range of vascular scans?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the necessary steps when resting ABPI results were critically low, or when technical readings contradicted clinical history, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the efficiency of the measurement phase and the robustness of the interpretive summary.
• What will you do differently next time you approach ABPI assessment, for instance, by proactively reviewing the guidelines for ABPI interpretation in patients with vessel incompressibility (e.g., diabetes) before testing?
• Do you need to practise any aspect of the activity further, such as refining the technique for safe conduct of the exercise test or key learning outcomes related to analysing and interpreting the results of a range of vascular scans?

Beyond action

Have you revisited previous experiences?

• How have your subsequent experiences of performing, interpreting, and reporting resting and post exercise ABPIs since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent patient with peripheral arterial disease presented with unexpected high ankle pressures forced you to re-evaluate the rigidity of your initial interpretation criteria and decision to switch to alternative measurements during your first attempt at this training activity.
• Considering what you understand about physiological vascular assessment, exercise test protocols, and diagnostic reporting now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your ABPI performance and interpretation methodology based on further learning and experiences? For example, how you proactively reviewed and integrated the academic content on ‘flow in diseased vessels’ to better correlate haemodynamic profiles with specific ABPI values.
• Has discussing managing patient safety during the exercise component or the impact of confounding factors (e.g., vessel incompressibility) on ABPI interpretation with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a report where inaccurate classification of ABPI findings led to an inappropriate referral refined your understanding of the critical nature of meticulous interpretation and reporting.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent ABPI performance and interpretation experiences, contributed to your overall confidence and ability in performing, interpreting, and reporting resting and post exercise ABPI, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in performing, interpreting, and reporting resting and post exercise ABPI enables you to confidently perform and interpret a resting ABPI to diagnose peripheral arterial disease during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to ABPI interpretation and reporting? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice immediately when interpreting results that are critically low or contradictory to clinical symptoms, recognizing this falls outside routine interpretation and report preparation scope.
• Looking holistically at your training journey, how has this initial ABPI performance, interpretation, and reporting experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to analysing and interpreting the results of a range of vascular scans and preparing the associated diagnostic clinical reports? For example, how this foundational experience has supported your development in meeting learning outcomes related to analysing and interpreting vascular scans and preparing diagnostic reports.

Relevant learning outcomes

#	Outcome
# 1	Outcome Communicate effectively with a range of patients and other professionals.
# 2	Outcome Assess vascular anatomy using ultrasound.
# 3	Outcome Apply the principles of ultrasound safety and ergonomics whilst performing a scan.
# 5	Outcome Apply the principles of ultrasound physics to adjust and optimise an ultrasound machine to obtain quality images.
# 6	Outcome Analyse and interpret ultrasound images with reference to haemodynamics whilst performing a range of scans.
# 7	Outcome Analyse and interpret the results of a range of vascular scans.
# 8	Outcome Prepare the associated diagnostic clinical reports of the ultrasound scan performed.
# 9	Outcome Identify and communicate scan results to both patients and the multidisciplinary team.
# 10	Outcome Evaluate protocols and national guidelines and their impact of vascular science practice.