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.