Results
Centres
Data were submitted by 83/86 UK centres who registered to take part (72
in England, 5 in Scotland, 3 in Wales and 3 in Northern Ireland). 2/83
centres submitted data covering the first period only. Centres opened on
the dates shown in figure 1, alongside the median rates of epistaxis
cases referred per centre per week.
Submissions
2,631 cases met the prespecified eligibility criteria across the three
periods (834, 946 and 851 cases respectively). Characteristics of the
population are shown in table 1. Data completeness was high with 99.4%
(n=1,259/1,267) of cases having data for the primary outcome.
The majority of patients were referred from the ED (89.7%
n=2,358/2,630), followed by the ward (5.3% n=140), then ‘other’ (not
otherwise specified) (2.6% n=68) and then the GP (2.4% n=64).
45 patients (1.7%) underwent surgery or interventional radiology,
including 37 SPA ligations (1.4%) and 3 radiological embolisations
(0.1%). 18 patients were recorded as having died within the 10 day
follow-up period (0.68%), with one death due to hypovolaemic shock in
an inpatient who was bilaterally packed (0.04%). Four tumours were
diagnosed: a juvenile nasal angiofibroma; a sinonasal undifferentiated
carcinoma (SNUC); a sinonasal lymphoma; and a nasopharyngeal carcinoma.
Six patients were reported as pregnant (0.23%).
COVID-19
Figure 1 shows the number of patients with suspected or confirmed
COVID-19, at the time of presentation and following testing, for the
three audit periods, alongside the UK incidence of COVID-19. The
prevalence of COVID19 in our epistaxis patients was much lower than
national averages at those times.
Acute management of ED
patients
The intranasal management for each case was assigned into one of four
categories: non-dissolvable packs; dissolvable products; cautery only;
and, no intranasal intervention. Table 2 shows the sequential intranasal
management strategies for epistaxis patients presenting to the ED. ED
clinicians inserted a non-dissolvable pack in 46.7% of patients prior
to ENT referral (n=1,099/2,355), with 22.1% receiving a non-dissolvable
pack at some point from ENT (n=520/2,351), and 48.4% finishing their ED
episode with a non-dissolvable pack (n=1,125/2,322).
ENT clinicians used a dissolvable intranasal product in 34.7% of
patients overall (n=816/2,351), and in 61.1% of those receiving an
intranasal product (n=816/1,336). The commonest reason given for not
using a dissolvable product was that the patient was already packed
(45.9% n=673/1,466), followed by bleeding severity (22.4%
n=329/1,466), product not available (3.4% n=50/1,466), clinician not
trained (3.3% n=49/1,466), patient choice, (0.5% n=8/1,466), suspected
COVID-19 (0.1% n=1/1,466) and ‘other’ (not otherwise specified)
(24.3%, n=356/1,466).
Bilateral packs were used in 7.9% of patients (n=186/2,356) and
posterior packs in 1.5% (n=36/2,356).
Silver nitrate cautery was performed in 38.4% of ED patients at some
point (n=891/2,319) and was declared successful in 73.4% of cases
(n=654/891). It was the only intranasal management by ENT in 17.7%
(n=417/2,351) and was classed as the definitive treatment administered
in 11.9% (n=277/2,319).
Tranexamic acid was given intravenously (IV) to 16.4% of patients
(n=350/2,131), orally to 5.0% (n=106), and applied topically to 3.8%
(n=81).
A minority of patients were managed remotely with telephone advice only
(6.8%, n=160/2,355). When seen face to face (n=2,195), the majority of
patients were reviewed by pre-specialty grade junior doctors (48.3%,
n=1,060) followed by specialty grade junior doctors (42.2%, n=926),
consultants (7.9%, n=174) and then nurse practitioners (1.6%, n=35).
Admission to hospital from
ED
Table 1 shows the discharge rates for patients presenting to the ED. The
overall discharge rate was 54.6% (n=1,267/2,322). These data are
visualised in Figure 2, stratified by intranasal management type.
Discharge rates were highest in the cautery only group, and lowest in
the non-dissolvable pack group.
If admitted to hospital from the ED, length of stay data were available
for 99.2% (n=1,047/1,055). The majority of patients stayed ≥1 day
(61.6%, n=645), with 28.8% (n=302) staying ≥2 days and 12.3% (n=129)
staying ≥3 days. 15.5% (n=163) of admissions were for social, rather
than clinical reasons.
Planned follow-up for ED
discharges
No follow-up was arranged in 61.7% of patients (n=780/1,264) with
28.9% having face-to-face (n=365/1,264) and 8.5% having telephone
appointments scheduled (n=107/1,264) (12 listed as ‘other’).
Unscheduled re-presentation of ED patients within 10
days
The re-presentation rates for ED discharges, related to management and
relevant patient factors, are shown in table 1. The overall
re-presentation rate was 19.5% for ED discharges (n=245/1,259) and
9.9% for ED admissions (n=104/1,046). 6.8% of ED discharges and 5.7%
of ED admissions were admitted following their re-presentations (n=86
and 60 respectively). The outcomes following re-presentation, stratified
by intranasal management, are shown in table 3.
Univariable logistic regression showed not being packed by the ED, being
on antiplatelet medication, having unsuccessful cautery performed and
having had recent epistaxis treatment were significant predictors of
re-presentation within 10 days (table 1).