Discussion
This study highlights the national variation in referral, triage and assessment processes for patients with suspected CLTI, aligning with GIRFT (Getting It Right First Time) findings of variation in the timeliness of care delivered to vascular surgery patients with CLTI across the country.21 We have demonstrated diversity and complexity in the ways vascular surgery networks have tackled the challenge of providing urgent care to these patients, both in terms of structure and process. Each vascular unit covers a unique population, employs different staff and has its own structural and organisational challenges, and the pathways we have described reflect all of these factors.22 The adoption of the CLTI CQUIN (Commissioning for Quality and Innovation) scheme in May 2022, giving Trusts a financial incentive to reduce time-to-revascularisation for inpatients with CLTI,23 may have encouraged units to make changes to pathways, which will have been captured in our work.
Primary care clinicians who refer these patients have many options for how to involve vascular surgery in their care. The multitude of ways patients can enter the pathway reflects the complexity of CLTI, and the range of symptoms with which it can present. Vascular services have thus developed the processes described in order to capture as many of these patients and assess them as quickly as possible. Attending ED is always an option and will be necessary for some patients presenting with CLTI. However, patients who may not require immediate admission are often better served by an emergency clinic model.1 24–26 Such models are in place in 10 of the 12 participating units and were described as the preferred way of assessing emergency referrals, as often imaging is available alongside the clinic and they allow a faster review than a routine clinic appointment.
Even within an emergency clinic model, wide variation was seen across arterial centres in the potential time period between receipt of referral and patient assessment (table 3A). Figure 2 is a reproduction of the PAD-QIF targets for time-to-revascularisation, indicating all patients should be seen within 7 days, and those that require admission within 2 days. It is not always possible to tell from a referral whether a patient will require admission, but only 5 of the 10 arterial centres who use an emergency clinic model are able to meet the 7-day target consistently following a referral received through e-RS, and only 2 of the 10 would meet the 2-day target consistently. This indicates that simply having access to emergency clinic slots is not enough—there needs to be appropriate capacity within the model and supporting triage processes of adequate urgency.
Figure 2PAD-QIF targets for time-to-revascularisation pathways.14 Reproduced with permission of the Journal of Vascular Societies of Great Britain and Ireland. PAD-QIF, Peripheral Arterial Disease Quality Improvement Framework. MDT, multidisciplinary team
Structural factors affecting the process of triage and assessment include the vascular network configuration. Patients referred to non-arterial centres in the six networks where referrals are not diverted to the arterial centre are likely to have longer times from referral to revascularisation and, correspondingly, are more likely to have inferior outcomes.4 Our work confirms that pathways where the patient with suspected CLTI is referred to a non-arterial centre have greater potential times to referral triage and patient assessment. This inequity of care across vascular networks must be a priority for future service improvement.
Another element of structure affecting quality of care is the difference in pathways for patients with and without diabetes, related to commissioning of podiatry services. In 5 of the 12 arterial centres and 8 of the 11 non-arterial centres, podiatrists were not seeing patients who did not have diabetes, meaning that the swift times from referral to podiatry and assessment are only benefiting patients with diabetes with suspected CLTI. This could add a further element of delay to patients with suspected CLTI without diabetes and contribute to the similar outcomes seen by patients with and without diabetes following revascularisation for CLTI, despite patients with diabetes presenting with a greater frequency of tissue loss and having less favourable anatomy for revascularisation.27
Our work exploring available processes in multiple vascular units helps clinicians, managers and commissioners understand how this variation and complexity in structure and process can lead to delays from referral to assessment of patients with CLTI. Benefits are likely to be gained from simplification, and three primary foci for quality improvement have been identified; the triage process, the way networked vascular services approach referrals for suspected CLTI and the provision of care for patients without diabetes compared with patients with diabetes.
Based on the findings of the study, we suggest the following three interventions would improve the speed at which patients with suspected CLTI are reviewed and management instituted:
Same day triage of all network eRS referrals at the arterial centre. This would ensure referrals from across the network are picked up swiftly and triaged appropriately, enabling organisation of suitably urgent review.
Institution of at least four times weekly emergency clinic slots at the arterial centre, ensuring patients can be reviewed and management commenced within national targets. Facility for emergency review at non-arterial centres for patients unable to attend the arterial centre should be provided based on network context.
Expansion of podiatry services to cover patients without diabetes. Currently, patients with diabetes benefit from podiatrists’ clinical expertise and close relationship with vascular surgery, to the detriment of patients without diabetes. This inequality should be eliminated from CLTI pathways.
These complex interventions will require different implementation strategies in the varying contexts of vascular units across the country.
Further work to do has been identified, not least in reducing inequalities in the care offered to English patients with suspected CLTI. Patient-level data can identify the pathways from the community to vascular surgery assessment associated with the best outcomes. Initial work has been carried out by individual vascular units, showing swift access to a limb salvage clinic can improve long-term outcomes compared with alternative pathways,26 but this may not be effective in all contexts. Qualitative research can investigate the experiences of patients, primary care clinicians and vascular surgery clinicians in order to define facilitators and barriers to timely, appropriate care. Repeating the process mapping exercise in the future will demonstrate how pathways have evolved over the time period, and if any changes made were sustainable.
Strengths and limitations
This unique national project demonstrates the variation in referral, triage and assessment processes that currently exists and highlights areas which could be simplified. Previous process mapping studies have focused only on individual patients and not pathway differences between different local contexts, with the majority considering only one centre.11–13 The 12 participating centres represent over 20% of English vascular surgery units and the national coverage is a strength of our work.
This study was limited by the lack of available patient-level data to identify which pathways are used most frequently, and which are the most efficient processes in relation to patient timelines. The individual context of vascular units is likely to be a cause of variation in pathways, and therefore any exemplar pathways identified in this exercise may not function in an alternative context. While a significant proportion of vascular units in England were included in the process mapping exercise, it was impossible to include all vascular units and we are unlikely to have captured all pathways used nationally. Many factors exist outside these pathways that affect timely care and patient outcomes; from patient and primary care clinician recognition of symptoms, to availability of imaging, to surgical or endovascular treatment following assessment. The process mapped, however, is part of the patient journey that vascular surgery units have control over and thus an ability to carry out improvement work.