Improving the quality of assessment and management of nasal trauma in a major trauma centre (MTC): Queen Elizabeth Hospital, Birmingham

BACKGROUND: Nasal fractures present in 39% of patients with facial trauma. These patients are assessed in the emergency department followed by outpatient review in the senior house officer-led emergency ear, nose and throat (ENT) clinic. Inadequate treatment of nasal trauma can result in debilitating functional and aesthetic problems. Inexperienced junior doctors may be apprehensive in assessing nasal trauma resulting in time pressured clinics and suboptimal management. MEASURES: A retrospective review of clinical noting over 3 months was carried out to gauge the extent of the problem. Three baseline measurements for satisfactory quality of assessments included: (1) 3/5 key symptoms elicited by the clinician (epistaxis, rhinorrhoea, nasal airway obstruction, dental malocclusion and diplopia). (2) Presence/absence of ‘septal haematoma’ (SH) and ‘deviated nasal septum’ (DNS) documented. (3) Patient follow-up within 2 weeks after the initial injury. Three Plan-Do-Study-Act (PDSA) cycles were conducted with implementation of interventions (proforma, clinic poster, patient information leaflet and training) as visualised in our ‘driver diagram’. RESULTS: The quality of nasal trauma assessments improved following each intervention. There was an increase from 86% to 100% patients being seen within 2 weeks of the injury. There was an improvement in quality of assessments following the teaching as two-thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) of clinical documentation included ‘rhinorrhoea’ and 83% (PDSA cycle 2) to 100% (PDSA cycle 3) included ‘nasal airway obstruction’. Similarly, two thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) examined and documented the presence/absence of SH and DNS. A 100% improvement in trainee confidence was reported. We are now conducting more comprehensive assessments of nasal trauma patients. CONCLUSION: The need to provide relevant training and support to ENT junior doctors is crucial in their development, as well as to ensure delivery of high-quality patient-centred care.