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.