Discussion
The introduction of dissolvable nasal packing in the A&E epistaxis treatment algorithm was successful in reducing epistaxis admissions locally. The main strengths of this project were ease of use by the A&E team, the initial collaboration between A&E and ENT teams in the planning of the project and the capacity to continue the intervention over time.
The utilisation of dissolvable nasal packs in A&E departments has been demonstrated to be drastically lower than the use by otolaryngology doctors in both the UK and the USA1,10. The average length of stay for an epistaxis admission is reported as 3.2 days11,12. In the United States of America (USA), the estimated cost per epistaxis admission is almost $700012.
Not only are hospital admissions costly, they can also be detrimental to the patient. Patients in hospital are at risk of venous thromboembolism, falls, physical and cognitive deconditioning and contraction of nosocomial infections 13–16. In addition, during the covid-19 pandemic, admissions to hospital increased patient risk of contracting covid-19. In December 2020, 1 in 4 new covid-19 cases were estimated to have been contracted in hospitals17. As such, it is of the utmost importance that medical specialties consider methods to reduce the number of hospital admissions in their patients.
Considerations of introducing NasoPore® to the epistaxis treatment pathway include cost and availability of NasoPore®. There is a paucity of research comparing cost-effectiveness of NasoPore® with non-dissolvable packs, this analysis would be useful to help emergency departments decide whether to include NasoPore® in their epistaxis pathway.
NasoPore® has been found to be superior to non-dissolvable Merocel® nasal packs with regard to in-situ pain, pain of removal and re-bleeding rate18. However, there is limited evidence comparing Rapid-Rhino® to NasoPore®, although Rapid-Rhino® is typically better tolerated than Merocel®19.
There were several limitations to this study. Firstly, it is noted that 33.7% of epistaxis patients were packed with dissolvable or non-dissolvable packs post-intervention vs 17% pre-intervention. It is possible that A&E clinicians are more comfortable inserting NasoPore® than non-dissolvable packs, thereby reducing the threshold to pack. It is also possible that conservative measures were applied less effectively (e.g. pinching nose for a shorter period) as NasoPore® could be used, without requiring admission as non-dissolvable packing does.
Secondly, the rate of attendance to A&E with epistaxis was much lower in the post-implementation period, with a reduction seen of almost 12 per month. The post-implementation period was during the second wave of the covid-19 pandemic, when reductions in non-covid A&E attendances were seen across the world, for example in the UK, Italy and the USA20–22. It is possible that fear of attending A&E meant that patients only attended when epistaxis was severe. This could offer further explanation as to the increase in the percentage of patients in the post-implementation group requiring more than conservative measures. If this is the case, the use of TXA-soaked NasoPore® is further supported as we saw an decrease in epistaxis admissions, despite the potentially increased severity presenting to A&E.
The covid-19 pandemic in itself may have skewed the admission rates seen in the study compared to non-covid times, due to enhanced admission avoidance during this time period. It would be helpful to repeat data collection in a time period with low covid-19 hospital attendance rates, in order to confirm long term validity of the intervention.
Increasing use of dissolvable nasal packs in A&E can reduce the number of admissions to hospital. Introduction of a formal pathway is a helpful way to encourage this. This intervention is sustainable if the pathway is taught to incoming A&E clinicians and if the stock of NasoPore® is maintained. There is scope to trial this pathway across multiple centres and assess whether admissions are reduced on a larger scale. In addition, TXA-soaked NasoPore® could be introduced in pre-hospital settings, for example by paramedics, to reduce the number of initial A&E attendances with epistaxis in the first place.