Admission avoidance in tonsillitis and peritonsillar abscess: A prospective national audit during the initial peak of the COVID-19 pandemic

Abstract

Objectives: To report changes in practice brought about by COVID-19 and the implementation of new guidelines for the management of tonsillitis and peritonsillar abscess (PTA), and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED).

Design: Prospective multicentre national audit over 12 weeks from 6 April 2020.

Setting: UK secondary care ENT departments.

Participants: Adult patients with acute tonsillitis or PTA.

Main outcome measures: Re-presentation within 10 days for patients discharged from the ED.

Results: 83 centres submitted 765 tonsillitis and 416 PTA cases. 54.4% (n = 410) of tonsillitis and 45.3% (187/413) of PTAs were discharged from ED. 9.6% (39/408) of tonsillitis and 10.3% (19/184) of PTA discharges re-presented within 10 days, compared to 9.7% (33/341) and 10.6% (24/224) for those admitted from ED. The subsequent admission rate of those initially discharged from ED was 4.7% for tonsillitis and 3.3% for PTAs. IV steroids and antibiotics increased the percentage of patients able to swallow from 35.8% to 72.5% for tonsillitis (n = 270/754 and 441/608) and from 22.3% to 71.0% for PTA (n = 92/413 and 265/373). 77.2% of PTAs underwent drainage (n = 319/413), with no significant difference in re-presentations in those drained vs not-drained (10.6% vs 9.5%, n = 15/142 vs 4/42, P = .846). Univariable logistic regression showed no significant predictors of re-presentation within 10 days.

Conclusions: Management of tonsillitis and PTA changed during the initial peak of the pandemic, shifting towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.

Keywords: Outpatient; ambulatory; discharge; multicentre; observational.

FIGURE 1

Combination graphic to communicate trends in data over 12‐week audit period: 1) The bar chart forming the background shows sequential opening of centres across the UK as the audit period progressed, 2) The box and whisker plots show the median, range and interquartile range of tonsillitis and quinsy patients presenting per centre per week for each of the three 4‐week audit periods, 3) The scatter plot and error bars are COVID‐19 swab rates (%) (diamonds) and positive swab rates (%) (crosses) with 95% confidence intervals, 4) The grey line chart is the 7‐day rolling average of UK cases from 1 March to 31 July (available at: https://coronavirus.data.gov.uk/cases)

FIGURE 2

Sankey chart visualising proportions of patients being admitted or discharged from the ED, with rates of subsequent re‐presentation, stratified by A) IV steroid use for tonsillitis patients and B) drainage for PTA patients