The role of surgical audit in improving patient management; nasal haemorrhage: an audit study

Abstract

Background: Nasal bleeding remains one of the most common Head & Neck Surgical (Ear Nose and Throat [ENT]/Oral & Maxillofacial Surgery [OMFS]) emergencies resulting in hospital admission. In the majority of cases, no other intervention is required other than nasal packing, and it was felt many cases could ideally be managed at home, without further medical interference. A limited but national telephone survey of accident and emergency departments revealed that early discharge practice was identified in some rural areas and urban departments (where adverse socio-demographic factors resulted in poor patient compliance to admission or follow up), with little adverse patient sequelae. A simple nasal packing protocol was also identified. The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit. Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care.

Methods: Retrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March). Prospective: 60 consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent. New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use.

Results: Previously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days. In the prospective audit the total number of admissions was significantly reduced, by over 70%, (chi2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (chi2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (chi2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estimated saved 201.39 bed days per annum resulting in an estimated annual speciality saving of over pound 50,000, allowing resource re-allocation to other areas of need. Furthermore, bed usage could be optimised for other emergency or elective work.

Conclusion: Exclusion criteria have now been expanded to exclude traumatic nasal haemorrhage. New adjunctive therapies now include direct endoscopic bipolar diathermy of bleeding points, and the judicious use of topical pro-coagulant agents applied via the nasal tampon. Expansion of the audit protocols for use in general practice.This original audit informed clinical practice and had potential benefits for patients, clinicians, and provision of service. Systematic replication of this project, possibly on a regional and general practice basis, could result in further financial savings, which would allow development of improved patient services and delivery of care.

Figure 3

Review of the complications encountered in patients who underwent nasal packing and who were allowed home. Nearly all the patients could be managed on an outpatient or 'office' basis. Unfortunately, one patient who suffered a nosebleed after an alcohol related trauma had to be admitted because a failure of compliance. We subsequently revised the treatment protocol after a multi-disciplinary meeting to exclude traumatic epistaxis where management may have to be surgical in the case of vessel retraction following fracture transaction.

Figure 1

Number of monthly admissions with nasal haemorrhage in the standard (mean monthly admissions over the previous 4 years; small square points) and audit study (small triangular points) over the 7-month (September-March) time interval to allow for seasonal variations. This shows a significant reduction in the numbers of admissions.

Figure 2

Total of monthly referrals and admissions with epistaxis during audit study over the 7-month (September-March) intervention time interval. It should be noted that previously nearly all referrals of epistaxis patients requiring packing had to bee admitted. It can be seen that this was not the case for the study period.