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\title{Admission avoidance in acute epistaxis: a prospective national audit
during the initial peak of the COVID-19 pandemic}



\author[1]{John Hardman}%
\affil[1]{The Royal Marsden Hospital}%


\vspace{-1em}



  
  \date{April 25, 2026}


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\selectlanguage{english}
\begin{abstract}
\textbf{Objectives:} To report changes in practice brought about by
COVID-19 and the implementation of new guidelines, and to explore
factors relating to unscheduled re-presentations for patients discharged
from the emergency department (ED).

\textbf{Design:} Prospective multicentre national audit over 12 weeks
from 6th April 2020.

\textbf{Setting:} UK secondary care ENT departments.

\textbf{Participants:} Adult patients with acute epistaxis Main outcome
measures Re-presentation within 10 days for patients discharged from the
ED.

\textbf{Results:} 83 centres from all four UK nations submitted 2,631
valid cases. The majority of cases were ED referrals (89.7\%,
n=2,358/2,631). 54.6\% were discharged from the ED following ENT review
(n=1,267/2,322), of whom 19.5\% re-presented within 10 days
(n=245/1,259) and 6.8\% were ultimately admitted (n=86/1,259). 46.7\% of
patients had a non-dissolvable pack inserted by ED prior to referral to
ENT (n=1,099/2,355). The discharge rates for ED patients and their
subsequent re-presentation rates were as follows: non-dissolvable packs,
29.5\% discharged (n=332/1125), 18.2\% re-presented (n=60/330);
dissolvable products, 71.1\% discharged (n=488/686), 21.8\% re-presented
(n=106/486); cautery only, 89.2\% discharged (n=247/277), 20.0\%
re-presented (n=49/245); and no intranasal intervention, 85.5\%
discharged (n=200/234), 15.2\% re-presented (n=30/198). Univariable
logistic regression showed that not being packed by ED, antiplatelet
medications, failed cautery and recent epistaxis treatment were
significant predictors of re-presentation within 10 days.

\textbf{Conclusions:} Management of acute epistaxis was notably affected
during the initial peak of the pandemic, with a shift towards reduced
admissions. This national audit highlights that many patients who may
previously have been admitted to hospital may be safely discharged from
the ED following acute epistaxis.%
\end{abstract}%



\sloppy


\section*{Introduction}

{\label{introduction}}

The SARS-CoV-2 (COVID-19) pandemic led to necessary changes in the
management of common ENT emergency presentations internationally.
Epistaxis is the most common emergency presentation to
ENT,\textsuperscript{1} with a patient presenting to UK in-hospital ENT
teams every other day on average.\textsuperscript{2} Several aspects of
epistaxis management were considered to pose a risk of COVID-19 spread.
Firstly, COVID-19 resides principally in the
airway,\textsuperscript{3,4} and so instrumentation of the upper
aerodigestive tract (as indicated in the management of epistaxis) is a
known risk factor for droplet formation and aerosol
generation.\textsuperscript{5,6} Secondly, non-dissolvable intranasal
packs have traditionally been associated with hospital admission which,
at the height of the initial peak of the pandemic, would have meant
exposure to an environment with a higher prevalence than found in the
community.\textsuperscript{7,8}

In March 2020, new UK guidelines were issued for the management of
epistaxis presenting to emergency departments (ED), in light of
COVID-19.\textsuperscript{9} The major shifts in practice proposed were:
the use of dissolvable intranasal products (in particular by the ED),
the avoidance of non-dissolvable packs; and the discharge of suitable
patients once bleeding cessation is achieved. These changes presumably
aimed to: minimise the personnel involved in managing the acute
presentation; reduce intranasal instrumentation; reduce admission rates,
with the ultimate goal of preserving hospital bed capacity for the
anticipated COVID-19 demand; and avoid unnecessary interactions with
healthcare services.

The implementation of these guidelines resulted in inevitable changes to
established practices, shown to be safe over many years of epistaxis
care. However, the safety of these new practices has not been assessed.

This article aims to:

\begin{enumerate}
\item
  Report the findings of a 12-week prospective audit of acute epistaxis
  care, conducted during the initial peak of COVID-19 in the UK.
\item
  Explore factors relating to unscheduled re-presentation to hospital in
  epistaxis patients discharged from the ED.
\item
\end{enumerate}

\section*{Methods}

{\label{methods}}

The protocol for this study was published in advance
at\emph{https://entintegrate.co.uk}. This manuscript has been prepared
with reference to the STROBE~checklist for cohort
studies.\textsuperscript{10}

\subsection*{Ethical considerations}

{\label{ethical-considerations}}

The Health Research Authority decision tool determined the study design
to fall under the remit of audit, and so no ethical approval was
required (available
at:\emph{http://www.hra-decisiontools.org.uk/research/}).

\subsection*{Study design and setting}

{\label{study-design-and-setting}}

A national prospective audit of the hospital management of acute
epistaxis by UK secondary care ENT departments was conducted, in
parallel to an audit of tonsillitis and peritonsillar abscess emergency
care.\textsuperscript{11} The audit was developed and run by INTEGRATE,
the UK ENT Trainee Research Network. All UK ENT departments were invited
to participate via advertisement, and registration with local audit and
Clinical Governance Departments was required. Sites could open at any
point during the prospective data collection period.

\subsection*{Participants}

{\label{participants-1}}

Consecutive patients with acute epistaxis, aged 18 years and older, and
referred to ENT secondary care were eligible for inclusion, whether
managed by telephone advice or face-to-face review. Traumatic epistaxis
was excluded.

\subsection*{Data collection}

{\label{data-collection}}

Eligible cases were identified over a 12 week period, between 6th April
and 29th June 2020. Each case was followed-up for 10 days. A
standardised electronic case report form was created using Excel
software (Microsoft Corporation, Washington, USA) and made available
online (Supplementary material), incorporating data validation to
encourage valid data entry and completeness. Data were initially held
offline at each centre, and patient identifiable data were removed prior
to submission to the project management team. Data were collected on:
patient demographics; COVID-19 status; referring and reviewing
clinicians; relevant comorbidities, medications history and
administration; and intranasal management strategies.

\subsection*{Interim reports}

{\label{interim-reports}}

The 12 week audit was divided into three 4-week periods. Two interim
reports were produced (after periods 1 and 2) allowing for rapid
feedback of management and preliminary outcomes to the UK ENT community.
Both interim reports were disseminated electronically via ENTUK mailouts
within 10 days of data submission and hosted online
at\emph{https://entuk.org} and\emph{https://entintegrate.co.uk}.

\subsection*{Data analysis}

{\label{data-analysis}}

The primary outcome was unscheduled re-presentation to hospital within
10 days for ED discharges. This intended to assess the safety of the
lower rates of admission anticipated.

Univariable binary logistic regression analysis was used to identify
significant determinants of the primary outcome measure. The level of
significance was set at \textless{}0.05 with Bonferroni corrections
applied, where applicable. Analysis was performed using R statistical
software (R Foundation, Vienna, Austria).

\section*{Results}

{\label{results-1}}

\subsection*{Centres}

{\label{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.

\subsection*{Submissions}

{\label{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\%).

\subsection*{COVID-19}

{\label{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.

\subsection*{Acute management of ED
patients}

{\label{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).

\subsection*{Admission to hospital from
ED}

{\label{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.

\subsection*{Planned follow-up for ED
discharges}

{\label{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').

\subsection*{Unscheduled re-presentation of ED patients within 10
days}

{\label{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).

\par\null

\section*{Discussion}

{\label{discussion}}

COVID-19 led to significant disruption of well-established standards of
care, but it is increasingly recognised that these changes may have
unveiled positive developments in our management of certain conditions.
This discussion focuses on the lessons that can be learned from the
collective national experience regarding the management of acute
epistaxis.

The 2016 UK epistaxis audit, also delivered by INTEGRATE, provides a
pre-COVID-19 baseline for comparison.\textsuperscript{2} The two audit
cohorts appear similar in age and sex ratio, and the median number of
cases treated by ENT per unit per month was relatively unchanged at 14
in 2016, and 12 in the COVID-19 dataset. This finding contrasts with the
greatly reduced rates of ED presentation seen for other
conditions,\textsuperscript{12,13} possibly as patients are unable to
defer management of acute haemorrhage.

\subsection*{COVID-19 and epistaxis}

{\label{covid-19-and-epistaxis}}

Period 1 data showed the highest prevalence of COVID-19 infection over
the test periods. However, testing rates were initially lower, and
perhaps targeted at those with symptoms suggestive of COVID-19, thus
providing a strong pre-test selection bias. As a greater proportion of
patients were tested, the proportion of positive test results reduced.

\subsection*{Dissolvable intranasal
products}

{\label{dissolvable-intranasal-products}}

The use of dissolvable products was notably higher in the present study
than seen in the 2016 audit, likely as a result of the recommendation
for their first-line use in the COVID-19 guidelines. More than a third
of patients had a dissolvable agent used at some point compared to only
4.7\% in 2016. ED use of dissolvable products was very low (2.0\%,
n=47/2,355). Moreover, where an intranasal product/pack was used by ENT,
a dissolvable agent was used more commonly than a non-dissolvable device
(61.1\% n=816/1,336, table 2). The main barrier to the further use of
dissolvable products was reported as the presence of a non-dissolvable
pack by the time of ENT review. Re-presentations for patients in whom a
dissolvable product was the definitive intranasal management were not
significantly higher (table 1) and subsequent rates of admission and
packing were comparable to other strategies (table 3).

\subsection*{Non-dissolvable packs}

{\label{non-dissolvable-packs}}

BRS guidelines have previously recommended discharge as routine for
dissolvable products, and this practice was largely followed during the
audit period (figure 2, table 1).\textsuperscript{14} COVID-19 era
guidance for non-dissolvable packs also recommended discharge in
suitable patients.\textsuperscript{9} Although discharge rates were
considerably higher than in the 2016 audit (where not one of the 520
patients was discharged from the ED with a non-dissolvable pack), the
rates were still lower than for other groups (table
1).\textsuperscript{2} Patient factors and clinical concern may account
for some of this difference, reflective of the time it can take for
practice to evolve in the absence of evidence of safety to reassure the
managing clinicians. In this study, the re-presentation rate for those
with non-dissolvable packs was not significantly different to other
groups, suggesting the practice observed was safe.

It is known that patients find the insertion and presence of
non-dissolvable intranasal packs painful, and they are reluctant to have
them disturbed once in situ.\textsuperscript{7} However, unless the pack
is removed during the initial ENT review, the rates of cautery and the
preferential use of dissolvable intranasal products will be severely
restricted. Nearly half the patients presenting via the ED had a
non-dissolvable pack inserted prior to ENT review (table 2), a finding
similar to 2016. Perhaps unsurprisingly, dissolvable products were
barely used by EDs, despite the new guidelines. Acknowledging the
prominent role ED clinicians play in the management of acute
epistaxis,\textsuperscript{15} and engaging them in future practice
recommendations, will be crucial to any further shifts in clinical
practice.

\subsection*{Implications for clinical
practice}

{\label{implications-for-clinical-practice}}

COVID-19 will persist within the community for some
time,\textsuperscript{16} but there appears to be no reason to return to
pre-COVID-19 epistaxis management practices. The avoidance of admission
may be of benefit to patients and the health service alike: fewer
interactions at healthcare facilities will reduce opportunities for
viral transmission, may be more convenient to patients and is less
resource intensive.

However, this must be weighed against the risk of adverse events. The
10-day re-presentation rate was taken as the primary outcome for this
study. This makes direct comparison between the admitted and discharged
cohorts challenging as factors prompting early re-presentation in the
discharged group may have occurred during the inpatient stay for the
admitted group. This may go some way to explain the higher
re-presentation rate seen in the ED discharged group at 19.5\%, nearly
double that of the admitted group. This rate was also higher than the
13.9\% 30-day re-presentation rate seen in 2016 (though this figure is
for the combined admitted and discharged cohorts). Importantly, most
individuals re-representing could continue to be managed as outpatients,
with only 6.8\% initially discharged from ED eventually being admitted
for inpatient care. Additionally, no adverse events were reported in the
community. Given the observational nature of this study, it is not
possible to reliably generalise the findings to other groups, but it has
been shown that a greater proportion of patients with acute epistaxis
can be safely managed at home than has traditionally been the case.

\subsection*{Strengths and limitations of the
study}

{\label{strengths-and-limitations-of-the-study}}

This large prospective national study gives a comprehensive view of
acute epistaxis management and is uniquely placed to learn from the
changes in practice brought about by the initial peak of the COVID-19
pandemic in the UK. Despite the pandemic disruptions, extremely high
levels of data completeness were seen.

This work is limited by its observational nature. Bleeding severity is
the most important variable not accounted for, omitted due to the
complexity in objectively assigning a grade. It is likely that cautery,
dissolvable packs and outpatient care are all associated with less
severe cases, potentially enhancing their apparent success.

\section*{Conclusion}

{\label{conclusion}}

Presentations with epistaxis during the initial peak of the COVID-19
pandemic were comparable to past data. The management of these cases,
however, was notably affected, with a shift towards reduced admissions.
This national study highlights that many patients who may previously
have been admitted to hospital, with a variety of presentation and
management factors, may be safely discharged from the ED following acute
epistaxis.

\par\null

\section*{References}

{\label{references}}

1 NHS Digital (2017) NHS Hospital Episode Statistics in England and
Wales. .

2 INTEGRATE (The National ENT Trainee Research Network) (2017) Epistaxis
2016: national audit of management. \emph{J Laryngol Otol} \textbf{131}
, 1131--1141.

3 Harcourt J., Tamin A., Lu X., \emph{et al.} (2020) Severe Acute
Respiratory Syndrome Coronavirus 2 from Patient with Coronavirus
Disease, United States. \emph{Emerging Infect. Dis.} \textbf{26} ,
1266--1273.

4 Zou L., Ruan F., Huang M., \emph{et al.} (2020) SARS-CoV-2 Viral Load
in Upper Respiratory Specimens of Infected Patients. \emph{N. Engl. J.
Med.} \textbf{382} , 1177--1179.

5 Thamboo A., Lea J., Sommer D.D., \emph{et al.} (2020) Clinical
evidence based review and recommendations of aerosol generating medical
procedures in otolaryngology - head and neck surgery during the COVID-19
pandemic. \emph{J Otolaryngol Head Neck Surg} \textbf{49} , 28.

6 Workman A.D., Welling D.B., Carter B.S., \emph{et al.} (2020)
Endonasal instrumentation and aerosolization risk in the era of
COVID-19: simulation, literature review, and proposed mitigation
strategies. \emph{Int Forum Allergy Rhinol} \textbf{10} , 798--805.

7 INTEGRATE (The UK ENT Trainee Research Network) (2020) Nasal Packs for
Epistaxis: Predictors of Success. \emph{Clin Otolaryngol} \textbf{ePub
ahead of print} .

8 Tysome J.R. \& Bhutta M.F. (2020) COVID-19: protecting our ENT
workforce. \emph{Clinical Otolaryngology} .

9 Davies E., Hopkins C., Harries P., \emph{et al.} (2020) COVID-19
Epistaxis Management. .

10 von Elm E., Altman D.G., Egger M., \emph{et al.} (2008) The
Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) statement: guidelines for reporting observational
studies.\emph{J Clin Epidemiol} \textbf{61} , 344--349.

11 INTEGRATE (The UK ENT research trainee network) (2020) Admission
avoidance in tonsillitis and peritonsillar abscess: a prospective
national audit during the initial peak of the COVID-19
pandemic.\emph{Clin Otolaryngol} \textbf{Submitted} .

12 Hartnett K.P., Kite-Powell A., DeVies J., \emph{et al.} (2020) Impact
of the COVID-19 Pandemic on Emergency Department Visits - United States,
January 1, 2019-May 30, 2020. \emph{MMWR Morb. Mortal. Wkly.
Rep.}\textbf{69} , 699--704.

13 The Nuffield Trust (2020) Where are the patients? The factors
affecting the use of emergency care during Covid-19. \emph{The Nuffield
Trust} .

14 INTEGRATE (The National ENT Trainee Research Network) (2017) The
British Rhinological Society multidisciplinary consensus recommendations
on the hospital management of epistaxis. \emph{J Laryngol
Otol}\textbf{131} , 1142--1156.

15 Newton E., Lasso A., Petrcich W., \emph{et al.} (2016) An outcomes
analysis of anterior epistaxis management in the emergency
department.\emph{J Otolaryngol Head Neck Surg} \textbf{45} , 24.

16 Anderson R.M., Hollingsworth T.D., Baggaley R.F., \emph{et al.}(2020)
COVID-19 spread in the UK: the end of the beginning? \emph{The Lancet}
\textbf{396} , 587--590.



\section*{Tables and figures}

{\label{tables-and-figures}}

\textbf{Table 1:} Characteristics of study populations, with proportions
admitted/discharged and re-presentation rates for ED discharges (with
univariable regression analysis).

\textbf{Table 2:} Intranasal management strategies for ED patients.

\textbf{Table 3:} Outcomes following re-presentation by intranasal
management

\textbf{Figure 1:} Combination graphic to communicate trends in data
over 12-week audit period: 1) The bar chart forming the background shows
sequential opening of centres across the UK as the audit period
progressed, 2) The box and whisker plots show the median, range and
interquartile range of epistaxis patients presenting per centre per week
for each of the three 4-week audit periods, 3) The scatter plot and
error bars are COVID-19 swab rates (\%) (diamonds) and positive swab
rates (\%) (crosses) with 95\% confidence intervals, 4) The grey line
chart is the 7-day rolling average of UK cases from 1st March to 31st
July (available at:\emph{https://coronavirus.data.gov.uk/cases}).

\textbf{Figure 2:} Sankey chart visualising proportions of patients
being admitted or discharged from the ED, with rates of subsequent
re-presentation, stratified by definitive intranasal management.

\textbf{Table 1:} Characteristics of study populations, with proportions
admitted/discharged and re-presentation rates for ED discharges (with
univariable regression analysis).

\textbf{Variable}

\textbf{Status}

\textbf{All epistaxis patients}

\% (n)

\textbf{ED admissions}

\% (n)

\textbf{ED discharges}

\% (n)

\textbf{Re-presentation rates of}

ED discharges

\% (n)

\textbf{Univariable logistic regression}

p value

Overall

-

(2631)

45.4 (1055/2322)

54.6 (1267/2322)

19.5 (245/1259)

-

Sex

Female

45.7 (1201)

46.1 (494/1071)

53.9 (577/1071)

17.4 (100/574)

0.111

Male

54.3 (1425)

44.8 (559/1249)

55.2 (690/1249)

21.2 (145/685)

Age in years

Cohort Median (Range) (Interquartile range)

74 (18 to 102) (63 to 83)

76 (19 to 99) (66 to 84)

73 (18 to 102) (61 to 82)

Re-presented vs no 73 vs 73 (18 to 99) vs (18 to 102) (61 to 82) vs (61
to 82)

0.799

Intranasal management

No intranasal intervention

13.5 (350)

14.5 (34/234)

85.5 (200/234)

15.2 (30/198)

-

Cautery only

14.2 (369)

10.8 (30/277)

89.2 (247/277)

20.0 (49/245)

0.172

Non-dissolvable packs

45.6 (1183)

70.5 (793/1125)

29.5 (332/1125)

18.2 (60/330)

0.438

Rapid Rhino

40.3 (1046)

72.4 (724/1000)

27.6 (276/1000)

20.0 (55/275)

0.192

Merocel

3.0 (78)

72.1 (49/68)

27.9 (19/68)

5.3 (1/19)

0.968

Other non-dissolvable

2.3 (59)

35.1 (20/57)

64.9 (37/57)

11.1 (4/36)

0.538

Dissolvable products

26.7 (692)

28.9 (198/686)

71.1 (488/686)

21.8 (106/486)

0.074

NasoPore

18.6 (483)

25.3 (121/479)

74.7 (358/479)

21.8 (78/357)

0.096

Floseal

5.9 (152)

38.4 (58/151)

61.6 (93/151)

24.7 (23/93)

0.060

Other dissolvable

2.2 (57)

33.9 (19/56)

66.1 (37/56)

13.9 (5/36)

0.910

Non-dissolvable pack by ED

No

55.9 (1470)

28.0 (345/1233)

72.0 (888/1233)

21.3 (187/880)

0.024*

Yes

44.1 (1158)

65.2 (709/1087)

34.8 (378/1087)

15.3 (58/378)

Silver nitrate cautery at any time

No

61.2 (1607)

53.2 (760/1428)

46.8 (668/1428)

18.1 (120/664)

-

Yes (any)

38.8 (1019)

32.8 (292/891)

67.2 (599/891)

21.0 (125/595)

0.203

Successful

28.5 (747)

26.8 (175/654)

73.2 (479/654)

18.4 (88/477)

0.885

Unsuccessful

10.3 (269)

49.2 (116/236)

50.8 (120/236)

31.4 (37/118)

0.001*

Recent epistaxis treatment

No

80.0 (2102)

44.2 (826/1868)

55.8 (1042/1868)

17.0 (176/1035)

\textless{}0.001*

Yes

20.0 (525)

50.4 (227/450)

49.6 (223/450)

31.1 (69/222)

Hypertension

No

41.3 (1071)

39.5 (365/924)

60.5 (559/924)

18.4 (102/554)

0.459

Yes

58.7 (1521)

49.4 (672/1361)

50.6 (689/1361)

20.1 (138/686)

Ischaemic heart disease

No

65.9 (1709)

40.2 (607/1511)

59.8 (904/1511)

18.8 (169/898)

0.416

Yes

34.1 (883)

55.6 (430/774)

44.4 (344/774)

20.8 (71/342)

Diabetes

No

87.3 (2263)

44.0 (877/1992)

56.0 (1115/1992)

19.3 (214/1109)

0.882

Yes

12.7 (329)

54.6 (160/293)

45.4 (133/293)

19.8 (26/131)

Anticoagulation

None

56.8 (1488)

39.3 (512/1304)

60.7 (792/1304)

19.5 (153/786)

-

Yes (any)

43.2 (1130)

53.6 (539/1005)

46.4 (466/1005)

19.8 (92/464)

0.997

Yes (in range, no treatment)

31.1 (815)

43.8 (317/724)

56.2 (407/724)

20.2 (82/405)

0.906

Yes (in range, lowered)

7.8 (203)

79.7 (145/182)

20.3 (37/182)

18.9 (7/37)

0.943

Yes (above range, no treatment)

1.1 (29)

60.0 (15/25)

40.0 (10/25)

20.0 (2/10)

0.969

Yes (above range, lowered)

3.2 (83)

83.8 (62/74)

16.2 (12/74)

8.3 (1/12)

0.349

Antiplatelets

None

75.5 (1974)

44.8 (777/1734)

55.2 (957/1734)

18.4 (175/950)

-

Yes (any)

24.5 (641)

48.1 (276/574)

51.9 (298/574)

23.6 (70/297)

0.043*

Aspirin (only)

13.2 (345)

46.3 (144/311)

53.7 (167/311)

24.0 (40/167)

0.084

Clopidogrel (only)

8.1 (213)

51.1 (97/190)

48.9 (93/190)

22.6 (21/93)

0.304

Aspirin \& Clopidogrel

3.2 (83)

47.9 (35/73)

52.1 (38/73)

24.3 (9/37)

0.350

IV Tranexamic acid

No

77.4 (2029)

43.1 (768/1781)

56.9 (1013/1781)

20.5 (206/1006)

0.328

Yes

22.6 (591)

62.0 (217/350)

38.0 (133/350)

16.7 (22/132)

*denotes statistical significance with p value \textless{}0.05

\textbf{Table 2:} Intranasal management strategies for ED patients.

\textbf{Intranasal management}

\textbf{ED Mx}

(Can be more than 1)

\% (n)

\textbf{Subsequent ENT Mx}

(Can be more than 1)

\% (n)

\textbf{Final status following ENT review}

(Definitive intranasal management)

\% (n)

Overall

(2355)

(2351)

(2322)

\textbf{No intranasal intervention}

\textbf{52.3 (1232)}

\textbf{32.0 (752)}

\textbf{10.1 (234)}

\textbf{Cautery only}

\textbf{Data not collected}

\textbf{17.7 (417)}

\textbf{11.9 (277)}

\textbf{Non-dissolvable packs}

\textbf{46.7 (1099)}

\textbf{22.1 (520)}

\textbf{48.4 (1125)}

Rapid Rhino

40.2 (946)

18.9 (445)

43.1 (1000)

Merocel

5.4 (127)

0.6 (14)

2.9 (68)

Other

1.1 (26)

2.6 (61)

2.5 (57)

\textbf{Dissolvable products}

\textbf{2.0 (47)}

\textbf{34.7 (816)}

\textbf{29.5 (686)}

NasoPore

1.7 (39)

24.4 (573)

20.6 (479)

Floseal

0.1 (3)

7.7 (182)

6.5 (151)

Other

0.2 (5)

2.6 (61)

2.4 (56)

\textbf{Table 3:} Outcomes following re-presentation by intranasal
management

\textbf{Intranasal management}

\textbf{Admission rate}

after re-presentation

\% (n)

\textbf{Packing rate}

after re-presentation

\% (n)

Overall

35.1 (86/245)

42.9 (105/245)

\textbf{No intranasal intervention}

\textbf{23.3 (7/30)}

\textbf{30 (9/30)}

\textbf{Cautery only}

\textbf{28.6 (14/49)}

\textbf{36.7 (18/49)}

\textbf{Non-dissolvable packs}

\textbf{40 (24/60)}

\textbf{66.7 (40/60)}

Rapid Rhino

36.4 (20/55)

63.6 (35/55)

Merocel

100 (1/1)

100 (1/1)

Other non-dissolvable

75 (3/4)

100 (4/4)

\textbf{Dissolvable products}

\textbf{38.7 (41/106)}

\textbf{35.8 (38/106)}

NasoPore

32.1 (25/78)

30.8 (24/78)

Floseal

60.9 (14/23)

47.8 (11/23)

Other dissolvable

40 (2/5)

60 (3/5)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1:} Combination graphic to communicate trends in data
over 12-week audit period: 1) The bar chart forming the background shows
sequential opening of centres across the UK as the audit period
progressed, 2) The box and whisker plots show the median, range and
interquartile range of epistaxis patients presenting per centre per week
for each of the three 4-week audit periods, 3) The scatter plot and
error bars are COVID-19 swab rates (\%) (diamonds) and positive swab
rates (\%) (crosses) with 95\% confidence intervals, 4) The grey line
chart is the 7-day rolling average of UK cases from 1st March to 31st
July (available at:\emph{https://coronavirus.data.gov.uk/cases}).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2:} Sankey chart visualising proportions of patients
being admitted or discharged from the ED, with rates of subsequent
re-presentation, stratified by definitive intranasal management.

\textbf{Hosted file}

\verb`Table 1.docx`  available at \url{https://authorea.com/users/356692/articles/479540-admission-avoidance-in-acute-epistaxis-a-prospective-national-audit-during-the-initial-peak-of-the-covid-19-pandemic}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/356692/articles/479540-admission-avoidance-in-acute-epistaxis-a-prospective-national-audit-during-the-initial-peak-of-the-covid-19-pandemic}

\textbf{Hosted file}

\verb`Table 3.docx`  available at \url{https://authorea.com/users/356692/articles/479540-admission-avoidance-in-acute-epistaxis-a-prospective-national-audit-during-the-initial-peak-of-the-covid-19-pandemic}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Epistaxis-Figure-1/Epistaxis-Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Epistaxis-Figure-2/Epistaxis-Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{CJK}\end{document}

