Subspecialty nurses as an essential ingredient for modern vascular service

Abstract

Like most developed countries with an ageing population, the incidence of patients with vascular disease in Hong Kong is predicted to increase rapidly in the next few decades. Coronary, cerebrovascular and peripheral arterial diseases are the usual end result of systemic atherosclerosis, caused by longer life expectancy, high-lipid diet and increasing prevalence of diabetes mellitus. The aetiology and management of many vascular diseases (eg, chronic venous ulcers, ischaemic foot ulcers, post-operative regimental surveillance) are complex and require a dedicated multi-disciplinary team approach to achieve and maintain good-quality vascular service. This team often consists of dedicated vascular surgeons, cardiologists, renal physician, diabetologists, orthopaedic surgeons and vascular specialist nurses.

The concept of vascular specialist nurses is not new. In many Western countries, there are already well-established organisations, such as the United Kingdom Society of Vascular Nurses or United States Society for Vascular Nursing, that officially recognise and honour vascular nursing as a distinct nursing specialty. These societies offer vascular nurses with the necessary guidelines for clinical practice, education, research and professional networking. There are also multiple frequent vascular nursing journals and courses.

The role of a vascular specialist nurse extends far beyond simple dressings for unhealed ulcers or wounds. They form the bridge between the patient (usually with chronic ongoing or recurrent disease) and the vascular surgeons. As the workload increases, it is no longer realistic or practical for vascular or endovascular surgeons to see every patient for monitoring or follow-up. Diabetic foot ulcers, for instance, are disabling for the patient, difficult to manage and frequently recur. They often progress rapidly with worsening sepsis and a significant proportion of patients present with infection requiring major lower limb amputations. Nurse-led dressing clinics would be ideal for the continuity of care for these patients, and with their specialist vascular knowledge they will alert the vascular surgeons if there are doubts about current management plans. The nurse will be able to document progress (by documenting ulcer size or photographs, for instance) and apply appropriate dressings as required. In addition, the nurse will be able to perform simple vascular examination or procedures, such as the use of a hand-held Doppler machine, performing simple bed-side debridement or assisting in the use of vacuum-assisted closure devices. With the help of vascular nurses, it is possible to provide consistency in inpatient and outpatient care and treatment, facilitate interdisciplinary coordination and communication, and improve the overall efficacy and efficiency of patient care.¹ It has also been shown that following peripheral vascular surgery, vascular nursing service can reduce the length of stay in a hospital without adversely affecting morbidity and mortality.²

Likewise, the management of venous ulcers often requires a dedicated nurse-led venous ulcer programme, with local cleaning, application of compression bandages and repeated assessment. The vascular specialist nurse can also coordinate effectively with other members of the vascular team and to arrange admission to a hospital or follow-up imaging appointments.

Increasingly more patients with aortic and peripheral aneurysms are being managed with endovascular aneurysm repair. These patients require long-term repeated time-coordinated computed tomography or duplex scans surveillance to document the sac size, presence of endoleak and stent graft patency. The vascular specialist nurse, with the departmental database of such patients, can arrange the appropriate follow-up scan dates and coordinate the follow-up of vascular outpatient appointments. They can also alert vascular specialists if there are worrying symptoms or signs.

Last but not least, an innovative vascular case management model is highly recommended for the increasing service demands, complexity and needs of the patients, and thereby enhancing nursing professionalism. The vascular nurse clinic is mainly aimed at stable patients, providing them with a comprehensive service (eg, vascular patients suffering from asymptomatic carotid stenosis <70%, abdominal aortic aneurysm <5 cm and varicose veins; Figure 1A–C). It is complementary to the specialist vascular OPD with the aim to assess, monitor and educate vascular patients on risk factor control, lifestyle modification and identification of alarming symptoms. Patients with different classifications of chronic venous disease can opt for conservative or surgical management. Education on lifestyle modification and compression therapy to control symptoms will be given. The establishment of vascular nurse clinics may reduce waiting time in physician's clinic and enhance patients’ background knowledge on their vascular disease.

The vascular nurse clinic in Queen Mary Hospital started in February 2021, and is complementary to our vascular doctor's clinic, on the same floor of our outpatient's building. It is aimed to decrease the workload of the vascular doctor's clinic, while providing professional service for more stable vascular patients. Examples of criteria for referral and follow-up frequency to the vascular nurse clinic is shown in Table 1. The number of new referrals, mainly from within our hospital, increased steadily and the number of patients seen in the nurses’ clinic has also increased over the past few months (Figure 2).

At our institution, we also conduct regional annual courses for current or future vascular specialist nurses, to introduce them to different aspects of elective and emergency vascular and endovascular surgery (Figure 1D). Short lectures on different vascular procedures are given by senior vascular surgeons, followed by visits to an endovascular suite and a hands-on session on vascular simulators, which give them hands-on experience with open and endovascular devices (eg, how to deploy an endovascular stent). These courses aim to familiarise nurses to different aspects of vascular surgery, as well as to inspire and attract new nursing talents to the subspecialty of vascular surgery.

Looking forward, vascular nurse specialists can develop standardised nursing practice by making guidelines, pathways and protocols, thereby providing standardised expert advice and consultancy services within the specialty and across clusters. Vascular nurses can also design their own curriculum and deliver advanced nursing education within the specialty, at the hospital, university or community level, and enhance staff competence by transferring specialised vascular clinical skills and knowledge. It is hoped that eventually evidence-based nursing practice can be conducted across all vascular referral centres and research findings can be incorporated into clinical practice.

No conflict of interests are declared; no funding received.