# 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.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,12,13 possibly as patients are unable to defer management of acute haemorrhage.

## 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.

## 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).

## 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).14 COVID-19 era guidance for non-dissolvable packs also recommended discharge in suitable patients.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).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.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,15 and engaging them in future practice recommendations, will be crucial to any further shifts in clinical practice.

## Implications for clinical practice

COVID-19 will persist within the community for some time,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.

## 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.