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\begin{document}

\title{Tranexamic acid soaked NasoPore\selectlanguage{ngerman}® to improve the management of epistaxis\selectlanguage{english}}



\author[1]{Eleanor Rosario}%
\author[1]{Ekta Sharma}%
\author[1]{Ankit Patel}%
\author[2]{Gabrielle Guvensen}%
\author[1]{Rizal Ashroff}%
\author[1]{Fiona McClenaghan}%
\author[3]{Ahmad Hariri}%
\author[1]{Jonathan Joseph}%
\affil[1]{University College London Hospitals NHS Foundation Trust}%
\affil[2]{University College London Medical School}%
\affil[3]{St. Mary's Hospital}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objectives The aim of this study was to assess the efficacy of a new
emergency department intervention for the management of epistaxis,
aiming to reduce epistaxis admissions. Design Tranexamic acid (TXA)
(500mg/ml) soaked NasoPore\selectlanguage{ngerman}® packing was in the pathway for epistaxis
which did not terminate following 10 minutes of simple first aid. The
pathway was utilised for adult patients presenting with non-traumatic,
anterior epistaxis. Pre- and post-implementation admission rates and
re-attendance rates were recorded by retrospective audit at a large
central London hospital. Results Epistaxis admissions were reduced by
51.7\% (p\textless{}0.05) following the implementation of the TXA-soaked
NasoPore® pathway. Conclusions The significant reduction in epistaxis
admissions demonstrates that this intervention is beneficial for patient
outcomes. This has the potential to be introduced in other A\&E
departments and also pre-hospital settings.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\selectlanguage{ngerman}\textbf{Tranexamic acid soaked NasoPore\textsuperscript{®} to improve
the management of epistaxis}

\emph{Abstract}

\textbf{Objectives}

The aim of this study was to assess the efficacy of a new emergency
department intervention for the management of epistaxis, aiming to
reduce epistaxis admissions.

\textbf{Design}

Tranexamic acid (TXA) (500mg/ml) soaked
NasoPore\textsuperscript{®}packing was introduced to the pathway for
epistaxis which did not terminate following 10 minutes of simple first
aid. The pathway was utilised for adult patients presenting with
non-traumatic, anterior epistaxis.

Pre- and post-implementation admission rates and re-attendance rates
were recorded by retrospective audit at a large central London hospital.

\textbf{Results}

Epistaxis admissions reduced by 51.7\% (p\textless{}0.05) following
implementation of the TXA-soaked NasoPore\textsuperscript{®} pathway.

\textbf{Conclusions}

The significant reduction in epistaxis admissions demonstrates that this
intervention is beneficial for patient outcomes. This has the potential
to be introduced in other A\&E departments and also pre-hospital
settings.

\textbf{Key words:} epistaxis, pathway, admissions, quality improvement,
tranexamic acid

\emph{Key points}

\begin{enumerate}
\tightlist
\item
  Non-dissolvable intranasal packs in the management of epistaxis
  typically result in patients being admitted to hospital
\item
  Non-dissolvable packs are frequently used in A\&E, prior to review by
  the ENT team
\item
  Alternatives to these packs have the potential to reduce epistaxis
  admissions
\item
  Introduction of tranexamic acid-soaked dissolvable packing reduced
  epistaxis admissions in our department
\item
  This intervention has the potential to be introduced more widely and
  in pre-hospital settings
\end{enumerate}

\textbf{The authors declare that there are no conflicts of interest
associated with this work.}

Data is available on reasonable request from the corresponding author.

\emph{\textbf{Introduction}~}

Epistaxis is the most common otolaryngological presentation to accident
and emergency (A\&E) in the UK\textsuperscript{1}. The incidence of
patients attending UK emergency departments with epistaxis is reported
as 108 per 100 000 local population annually\textsuperscript{2}. In
2017, NHS hospital statistics reported 25 000 A\&E attendance with
epistaxis\textsuperscript{3}. Of the total attendances, approximately
25\% require admission or specialist treatment\textsuperscript{2}. In
our local centre, we noted that patients presenting with epistaxis were
frequently treated with non-dissolvable nasal packs in A\&E,
necessitating admission under the Ear, Nose \& Throat (ENT) team.

Current National Institute for Health and Care Excellence (NICE)
guidelines for the management of acute epistaxis suggest 15 minutes of
first aid, followed by silver nitrate cautery if possible and then
non-dissolvable packs such as nasal tampons (e.g.
Merocel\textsuperscript{®}) or inflatable packs (e.g.
Rapid-Rhino\textsuperscript{®}) if bleeding
continues\textsuperscript{4}. A 2020 nationwide epistaxis audit found
that 54.4\% of patients attending with epistaxis were packed with
non-dissolvable packing in A\&E, and a further 18.9\% by an ENT
specialist doctor\textsuperscript{5}.

Non-dissolvable packing is classically associated with hospital
admission\textsuperscript{1}, whereas British Rhinological Society (BRS)
guidelines advocate discharge for patients with dissolvable
packing\textsuperscript{3} (e.g. NasoPore\textsuperscript{®}). In March
2020, in light of covid-19, ENT-UK published new guidelines for
epistaxis management which introduced the use of dissolvable packing in
the treatment algorithm\textsuperscript{6}. Reasons for this were
two-fold. Firstly, to reduce exposure to the upper aerodigestive tract
by healthcare professionals, and secondly to reduce admissions, both
preserving bed capacity and reducing patient exposure to covid-19 in
hospital\textsuperscript{1}.

Despite the above BRS guidance, subsequent national audit of epistaxis
management found A\&E utilisation of dissolvable packing to be only
2\%\textsuperscript{1}. On call ENT doctors reported that
non-dissolvable packs were already inserted by A\&E in 45\% of cases,
prior to their attendance, necessitating admission\textsuperscript{1}.

A 2017 systematic review of intranasal packing for epistaxis noted no
complications related to the use of dissolvable packing in the
management of epistaxis\textsuperscript{7}. Strategies to reduce A\&E
use of non-dissolvable nasal packs, in favour of dissolvable packing,
could reduce epistaxis admissions in UK hospitals whilst maintaining
patient safety.

As well as reducing admission rates, it is important to consider length
of admission and risk of re-bleeding. Systematic review has demonstrated
reduced re-bleeding rates and shorter admissions in epistaxis patients
treated with topical tranexamic acid (TXA), without increased
complication rates\textsuperscript{8}. A 2018 Cochrane review of TXA use
in epistaxis found a 23\% reduction in risk of re-bleeding within 10
days when topical TXA was utilised, however noted a small number of
studies specifically investigating this\textsuperscript{9}.

\textbf{Objectives}

Our rationale for introducing TXA-soaked NasoPore\textsuperscript{®} to
the A\&E epistaxis management pathway was to achieve the following aims.
Firstly, to reduce local epistaxis admissions, and secondly, to achieve
this in a manner which is evidence-based and maintains patient safety.

\emph{Methods}

\textbf{Design}

A new stepwise pathway was introduced for the management of
non-traumatic, anterior epistaxis in A\&E (figure 1). This intervention
involved the collaboration between A\&E and ENT teams. Dissolvable nasal
packing was introduced for epistaxis which did not terminate following
10 minutes of simple first aid. The packing used was TXA (500mg/ml)
soaked NasoPore\textsuperscript{®}.

Patients were discharged if there was no further bleeding one hour after
insertion of TXA-soaked NasoPore\textsuperscript{®}. Awareness of this
pathway was raised with an educational campaign to aid implementation.

Prior to this intervention, if conservative measures were ineffective,
non-dissolvable packs were inserted (typically
Rapid-Rhino\textsuperscript{®}).

A retrospective audit of all epistaxis presenting to A\&E was conducted
pre- and post- implementation of the TXA-soaked
NasoPore\textsuperscript{®} pathway (n=245).

\textbf{Setting}

A large central London hospital.

\textbf{Participants}

All patients aged over 18 presenting to A\&E with spontaneous epistaxis
during the study period. Verbal consent was obtained from patients prior
to pack insertion.

\textbf{Main outcome measures}

Management of epistaxis, admission rates and re-presentation rates were
recorded over seven months pre-implementation, from
01/08/2019-29/02/2020 (n=159), and eight months post-implementation,
from 01/08/2020-31/03/2021 (n=86).~~Data was not collected during the
height of the covid-19 pandemic (March 2020 to July 2020), due to the
confounding effect on admission rates.

Statistical analysis was performed using the two-proportion z-test, with
a significance level p \textless{}0.05.

Reporting is in line with the SQUIRE 2.0 framework for quality
improvement.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\emph{Results}

159 patients presented with epistaxis in the pre-implementation period
(22.7 per month), and 86 in the post-implementation period (10.8 per
month).

In the pre-implementation period, epistaxis terminated with conservative
measures only in 83.0\% of patients. The remaining 17.0\% were packed
with non-dissolvable packs in A\&E, all of whom were admitted to
hospital. In the post-implementation period, 66.3\% terminated with
conservative measures, 5.8\% received non-dissolvable packs, and were
admitted, and 27.9\% received dissolvable packing (TXA-soaked
NasoPore\selectlanguage{ngerman}\textsuperscript{®}). 29.2\% of those receiving
NasoPore\textsuperscript{®} required further packing with
non-dissolvable packs and were subsequently admitted. 2 patients packed
with NasoPore\textsuperscript{®} re-attended with epistaxis (8.3\%), and
3 patients who were discharged following conservative measures
re-attended (5.3\%). See table 1.

27/159 patients in the pre-implementation group required more than
conservative measures (17\%), all of these required admission (100\%).
29/86 patients in the post-implementation group required more than
conservative measures (33.7\%). Of these, 12 patients were admitted
(41.0\%). Therefore, there was a statistically significant (p
\textless{} 0.0001) reduction of 59.0\% in admissions, after discounting
those patients managed with conservative measures only.

After including the 2 patients who re-attended and were admitted
following NasoPore\textsuperscript{®} with TXA administration, the
proportion admitted post-intervention rises to 48.3\%. This results in a
decrease in admissions of 51.7\% in admissions, still statistically
significant (p \textless{} 0.0001).

\textbf{Hosted file}

\verb`image2.emf`  available at \url{https://authorea.com/users/525226/articles/595698-tranexamic-acid-soaked-nasopore-to-improve-the-management-of-epistaxis}



\emph{Discussion}

The introduction of dissolvable nasal packing in the A\&E epistaxis
treatment algorithm was successful in reducing epistaxis admissions
locally. The main strengths of this project were ease of use by the A\&E
team, the initial collaboration between A\&E and ENT teams in the
planning of the project and the capacity to continue the intervention
over time.

The utilisation of dissolvable nasal packs in A\&E departments has been
demonstrated to be drastically lower than the use by otolaryngology
doctors in both the UK and the USA\textsuperscript{1,10}. The average
length of stay for an epistaxis admission is reported as 3.2
days\textsuperscript{11,12}. In the United States of America (USA), the
estimated cost per epistaxis admission is almost
\$7000\textsuperscript{12}.

Not only are hospital admissions costly, they can also be detrimental to
the patient. Patients in hospital are at risk of venous thromboembolism,
falls, physical and cognitive deconditioning and contraction of
nosocomial infections \textsuperscript{13--16}. In addition, during the
covid-19 pandemic, admissions to hospital increased patient risk of
contracting covid-19. In December 2020, 1 in 4 new covid-19 cases were
estimated to have been contracted in hospitals\textsuperscript{17}. As
such, it is of the utmost importance that medical specialties consider
methods to reduce the number of hospital admissions in their patients.

Considerations of introducing NasoPore\textsuperscript{®} to the
epistaxis treatment pathway include cost and availability of
NasoPore\textsuperscript{®}. There is a paucity of research comparing
cost-effectiveness of NasoPore\textsuperscript{®} with non-dissolvable
packs, this analysis would be useful to help emergency departments
decide whether to include NasoPore\textsuperscript{®} in their epistaxis
pathway.

NasoPore\textsuperscript{®} has been found to be superior to
non-dissolvable Merocel\textsuperscript{®} nasal packs with regard to
in-situ pain, pain of removal and re-bleeding rate\textsuperscript{18}.
However, there is limited evidence comparing
Rapid-Rhino\textsuperscript{®} to NasoPore\textsuperscript{®}, although
Rapid-Rhino\textsuperscript{®} is typically better tolerated than
Merocel\textsuperscript{®19}.

There were several limitations to this study. Firstly, it is noted that
33.7\% of epistaxis patients were packed with dissolvable or
non-dissolvable packs post-intervention vs 17\% pre-intervention. It is
possible that A\&E clinicians are more comfortable inserting
NasoPore\textsuperscript{®} than non-dissolvable packs, thereby reducing
the threshold to pack. It is also possible that conservative measures
were applied less effectively (e.g. pinching nose for a shorter period)
as NasoPore\textsuperscript{®} could be used, without requiring
admission as non-dissolvable packing does.

Secondly, the rate of attendance to A\&E with epistaxis was much lower
in the post-implementation period, with a reduction seen of almost 12
per month. The post-implementation period was during the second wave of
the covid-19 pandemic, when reductions in non-covid A\&E attendances
were seen across the world, for example in the UK, Italy and the
USA\textsuperscript{20--22}. It is possible that fear of attending A\&E
meant that patients only attended when epistaxis was severe. This could
offer further explanation as to the increase in the percentage of
patients in the post-implementation group requiring more than
conservative measures. If this is the case, the use of TXA-soaked
NasoPore\textsuperscript{®} is further supported as we saw an decrease
in epistaxis admissions, despite the potentially increased severity
presenting to A\&E.

The covid-19 pandemic in itself may have skewed the admission rates seen
in the study compared to non-covid times, due to enhanced admission
avoidance during this time period. It would be helpful to repeat data
collection in a time period with low covid-19 hospital attendance rates,
in order to confirm long term validity of the intervention.

Increasing use of dissolvable nasal packs in A\&E can reduce the number
of admissions to hospital. Introduction of a formal pathway is a helpful
way to encourage this. This intervention is sustainable if the pathway
is taught to incoming A\&E clinicians and if the stock of
NasoPore\textsuperscript{®} is maintained. There is scope to trial this
pathway across multiple centres and assess whether admissions are
reduced on a larger scale. In addition, TXA-soaked
NasoPore\textsuperscript{®} could be introduced in pre-hospital
settings, for example by paramedics, to reduce the number of initial
A\&E attendances with epistaxis in the first place.

\emph{Conclusion}

Our study has demonstrated the potential to reduce epistaxis admissions
by including a TXA-soaked dissolvable pack step in the A\&E epistaxis
treatment algorithm. In order to achieve this reduction in admissions,
education of A\&E clinicians was required and it is important that this
is repeated on a regular basis in order to maintain the results
observed.

The implementation of this treatment algorithm across the UK requires
A\&E departments to be well stocked with supplies of
NasoPore\textsuperscript{®} and TXA, and for clinicians to be
comfortable using these. Larger scale studies would be helpful to
determine the feasibility of introducing this pathway in both A\&E and
pre-hospital settings, and also to assess patient experience and
satisfaction with dissolvable versus non-dissolvable nasal packing. Next
steps include re-assessment to assess long term adherence and the
post-covid validity.

\emph{Tables \& figures}

\textbf{Figure 1:} TXA-soaked NasoPore\textsuperscript{®} pathway for
emergency clinicians

\textbf{Table 1:} A\&E management and outcome

\emph{}

\emph{References}

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