# 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).