Best Practice Statement by Wounds UK about the importance of ABPI testing to improve patient care

Best practice statement authors – expert working group:

Jacqui Fletcher OBE (Chair), Independent Nurse Consultant: Leanne Atkin, Vascular Nurse Consultant, Mid Yorkshire NHS Trust, Research Fellow, University of Huddersfield; Nicci Aylward-Wotton, Research Fellow/Tissue Viability Nurse Consultant, Cornwall Foundation Trust; Gill Boast, GPN Facilitator and Training Programme Lead GPN Foundation School, Staffordshire and Stoke-on-Trent ICB; Julie Hatch, Lead Tissue Viability Nurse, The Princess Alexandra Hospital NHS Trust, Harlow, Essex; Daphne Hazell, GP, West Sussex; CEO, Home Wound Care; Katie Paton, Tissue Viability and Leg Ulcer Specialist Nurse, The Princess Alexandra Hospital NHS Trust, Harlow, Essex; Carole Taylor, Lead Nurse – Tissue Viability Service, East London NHS Foundation Trust; Nicola Wallace, Leg Ulcer Clinical Nurse Specialist – Central London Community Healthcare NHS Trust

In 2023, the National Institute for Health and Care Excellence (NICE) released a diagnostic guidance on the use of automated devices for measuring Ankle Brachial Pressure Index (ABPI) for detecting PAD in patients with leg ulcers. This guidance created uncertainty for many healthcare professionals as it recommended limiting the use of automated Aankle-Brachial Pressure Index (ABPI) devices in patients with or at risk of venous leg ulcers (VLUs). Given the importance of timely ABPI assessments for diagnosing peripheral arterial disease (PAD) and safely initiating compression therapy, many clinicians faced challenges in providing optimal care.

To address these concerns, the Best Practice Statement: Effectively Assessing ABPI in Leg Ulcer Patients was developed by Wounds UK in 2024. This document provides clarity and guidance for clinicians, aiming to standardise the use of ABPI assessments in clinical practice—whether conducted with manual or automated devices. In this, it focuses on the importance of ABPI, the current practice of ABPI measurement, the role of automated ABPI as part of a care pathway, and the future of ABPI measurement.

The statement highlights the role of ABPI testing within a holistic care framework, documents best practices and addresses gaps in research. With this, it seeks to improve patient outcomes, reduce treatment delays, and streamline care pathways for those with leg ulcers. The main message is that performing and documenting ABPI testing in all its various forms will contribute to the quality of patient care.

In this blog you will learn:

• The importance of ABPI testing
• The purpose of the 2024 Best Practice Statement by Wounds UK
• Key best practice statements
• Care pathway for efficient ABPI testing
• The future of ABPI testing in clinical practice

The importance of ABPI testing

Ankle Brachial Pressure Index (ABPI) is a non-invasive test used to detect peripheral arterial disease (PAD) by comparing the systolic blood pressure in the ankle and arm. It is the most common form of arterial assessment, which is crucial in lower limb ulceration management.  

Research shows that 40% of patients with leg ulcers did not have an ABPI measurement or it is unclear whether the measurement was made or not. This probably led to an underuse of compression therapy. [1] Cardiovascular conditions like PAD may also go undetected, which results in delayed treatment and increased risk of complications such as limb amputation or heart disease. Ensuring ABPI is a routine part of leg ulcer care helps improve patient outcomes and guide appropriate therapeutic interventions. Automated ABPI devices can make ABPI testing more efficient and more widely available.

The purpose of the 2024 Best Practice Statement

The 2024 Best Practice Statement (BPS) was developed by Wounds UK to provide clear, evidence-based guidance for clinicians on assessing ABPI in patients with leg ulcers following the 2023 NICE diagnostic guidance on the use automated ankle-brachial pressure index measurement devices to detect peripheral arterial disease in people with leg ulcers.According to the 2024 BPS Chair Jacqui Fletcher OBE, the consequence of the 2023 NICE diagnostic guidance was the following:

Since the release of the guidance from NICE, there has been a lack of clarity for many hospitals and medical teams on how – and, indeed, if – automated ABPI devices should be used. This has led to variations and inconsistencies in clinical practice: while some clinicians recognise the benefits of automated devices, others have been forced to limit use in practice. [1]

 The purpose of the 2024 BPS by Wounds UK is to standardise ABPI testing, whether manual or automated, and address challenges highlighted by healthcare professionals. The BPS aims to clarify best practices, support safe use of automated ABPI devices, and ensure that ABPI is effectively integrated into care pathways, thus reducing delays in treatment and improving outcomes for patients with VLUs.

Key best practice statements

Manual Doppler devices have long been the standard for ABPI testing, but they can be time-consuming and require significant clinical skill. Automated ABPI devices offer a faster and easier alternative, allowing for quicker assessments with less patient discomfort. The BPS encourages the use of both methods within a safe framework, emphasising the need for clinical judgement in interpreting results rather than relying solely on numerical outputs.

The BPS outlines several key recommendations to enhance ABPI testing in leg ulcer patients:

• Any type of ABPI reading should be the final step to confirm clinical suspicion rather than being considered an actual diagnosis. ABPI should always be part of a holistic assessment in all patients considered to require compression therapy. In other words: rather than relying on the numerical reading alone, clinical judgement and full holistic assessment should be used.
• With or without ABPI results, mild graduated compression therapy should start in all patients with leg ulcers if no red flags are present.
• Any used of automated ABPI devices should be documented to build a stronger evidence base for their future use.
• In patients with oedema, ABPI measurements are challenging. The right cuff size and Doppler probe should be used.
• If ABPI testing cannot be performed on the patient (e.g. due to lymphoedema, painful ulceration or obesity), other means such as toe pressure measurement should be considered.
• Regardless of the measurement method, ABPI results should be interpreted by a clinician with the relevant skills and training. Staff training in this domain is essential.
• Communication with the patient is essential – especially before measurement, in terms of warning them about potential initial discomfort and addressing any potential pain issues.
• Alternatives to Doppler testing should be considered if a patient cannot lie down for more than 5 minutes.
• In all patients managed with compression, ABPI measurement should be repeated at 3, 6 or 12-month intervals. This depends on their health status.

Care pathway for efficient ABPI testing

The 2024 BPS also introduces the following care pathway for incorporating efficient automated ABPI testing into practice. Its aim is that as many suitable patients as possible start receiving therapeutic compression in a timely manner.

The future of ABPI testing in clinical practice

The future of ABPI testing lies in developing accurate, efficient methods that can be easily integrated into routine clinical practice. In this, automated ABPI measurement represents an effective method that can be used under appropriate conditions.

By encouraging data collection and ongoing evaluation, the BPS aims to ensure that future advances in ABPI technology are backed by evidence, ultimately leading to improved treatment outcomes. Through proper training, holistic assessment, and accurate documentation of all types of ABPI measurement, healthcare professionals can ensure that their patients receive the best possible care: [1]

As clinicians, it is vital that we all contribute to best practice in this area, by ensuring that testing is carried out on patients who need it, that staff are confident and well informed, and that this informs patient care. Performing and documenting ABPI testing in all its different forms – manual Doppler or automated – will help improve care for patients.