Standardised management of atraumatic epistaxis for improved outcomes in an emergency department with off-site ear, nose and throat cover - A quality improvement project

PROBLEM DESCRIPTION: Otorhinolaryngology services are not available in all hospitals and atraumatic epistaxis is a common presentation to Emergency Departments (ED). Not all ED staff are experienced in managing epistaxis and there appeared to be a high rate of re-bleeding after treatment provided. We aimed to improve outcome for ED patients presenting with atraumatic epistaxis and staff conditions by creating a Departmental pathway outlining a management plan and ensuring all equipment needed was readily available. METHODS: A retrospective 6-month audit was done to assess current management and re-bleed percentage rates post nasal packing. A team was assembled, stocked a trolley, created an Atraumatic epistaxis ED pathway and promoted its use by staff. Repeated Plan-Do-Study-Act cycles were undertaken. Chosen measures were (1) Reduced re-bleed rates post nasal packing from initial audit levels; (2) Increased nasal packing duration; (3) Improved qualitative feedback by ED doctors (4) 100% E.N.T. trolley stock. RESULTS: Audit showed minimal use of vasoconstrictor spray, a 7-hour mean nasal pack duration, a re-bleed rate post nasal packing of 39% and staff reports of difficulties accessing items required. After introduction of the E.N.T. trolley, there was positive staff feedback regarding improved availability of treatment items and full stocking of the trolley was achieved after repeated cycles. Following introduction of the Epistaxis pathway and staff education, average re-bleed rates post nasal packing dropped* from 39% to 20% in the first cycle; 21% in the third cycle; 25% in the fourth cycle and 14% in the fifth cycle- (*Isolated re-bleed average of 40% observed in the second cycle). Mean nasal packing duration increased from 7 h to 9, 10, 10, 12 and 8 h in the 2-monthly cycles successively. CONCLUSION: The project's aims of improving epistaxis patients' outcomes and improved convenience for ED staff were achieved.