Re-presentation within month
No significant difference was demonstrated for this outcome measure
between loop one and loop two patients (p>0.05). In loop
one, 11 patients all had comorbidities including hypertension and/or
taking anticoagulants. In loop two, 5 patients were healthy whereas 4
had hypertension and/or were taking anticoagulants.
Discussion
This audit investigated the compliance rate and safety implications of
the new “Pack and Home” criteria guidelines implemented during the
COVID-19 pandemic for patients with epistaxis requiring nasal packing.
Prior to the pandemic all those
with epistaxis were admitted as inpatients, whereas following the
introduction of the new guidelines approximately 1/3rdwith nasal packs in situ met the criteria and did not require inpatient
admission. The new “Pack and
Home” criteria resulted in the avoidance of 21 admissions over 6
months, therefore demonstrating an adequate compliance rate with the new
guidelines. 3 patients on the new pathway re-presented within 48 hours,
of which in retrospect one did not meet the criteria and should not have
been put on the outpatient pathway whereas one re-presented with pain
and the other with bleeding. Thus,
with regards to safety
implications, only one patient on the “Pack and Home” pathway
re-presented with bleeding within 48 hours.
The INTEGRATE audit study (1) was able to show that patients can be
safely discharged with epistaxis and managed on an outpatient basis.
Avoidance of admission has implications towards reduced bed occupancy on
surgical wards and reduced opportunities for transmission of hospital
acquired infections. Like our study, the INTEGRATE paper demonstrated
not being packed in the emergency department and being on antiplatelet
medications were significant predictors of re-presentation within 10
days. Our study mainly demonstrated an association between being on an
anticoagulant and having certain co-morbidities, such as AF, with
epistaxis and potential re-bleed rates. Therefore, these are factors
that can impact the chances of successfully managing epistaxis on an
outpatient bases, according to the “Pack and Home” criteria.
Our study also revealed a reduced length of inpatient stay in the second
loop of the audit compared to the first (p <0.05). Reduced
length of stay within the hospital may have positive financial
implications. This was demonstrated in a study by McCrossan et al. (8),
looking at safely discharging patients home with rapid rhinos in situ,
where according to “NICE costings statement” there had been a drop in
cost/bed-day expenses by approximately £11000 due to reduced length of
inpatient stay. Therefore, the “Pack and Home” criteria may influence
financial constraints with regards to the possibility of increasing bed
availability on surgical wards.
Strengths of this audit study include the large study cohort analysed
during a pandemic under difficult circumstances. A key limitation of
this audit is the lack of generalisability of the results. Our study
population consists mainly of an elderly population which can impact the
risk of re-bleeding9 and raise safety concerns with
regards to appropriate outpatient management. A univariate analysis was
not performed in this study therefore we were unable to adjust of
potential confounding, despite their being minimal difference in
baseline characteristics between the first and second loop cohorts.
In summary, our audit study demonstrates the possibility of safely
discharging patients home with epistaxis, requiring nasal packs in situ,
and being managed on an outpatient pathway. Consideration must be taken
towards clinical characteristics of patients that meet the “Pack and
Home” criteria to ensure successful and safe compliance with the
pathway.