Development of a Clinical Care Pathway for Severe Epistaxis at a Tertiary‐Care Medical Center

Abstract

Objectives: (1) Describe the treatment patterns for the management of severe epistaxis at a tertiary-care center. (2) Develop a clinical care pathway (CCP) for system-wide management of severe epistaxis. Methods: A review of patients admitted for epistaxis from August 2012 to December 2013 was performed using: (1) CPT codes and (2) a digital archive of all medical records. Severe epistaxis was defined as persistent bleeding not controlled using local pressure, vasoconstrictive medication, and anterior packing. A root cause analysis identified factors contributing to the morbidity and mortality of patients with severe epistaxis. Results: Of 332 cases of epistaxis, 48 met criteria for severe epistaxis. Of these, 64.6% (31/48) presented via the Emergency Department and 35.4% (17/48) as an inpatient. All were packed initially. Average duration of packing was 3.02 ± 1.88 days. Nearly half (45.8%) failed packing and had either sphenopalatine artery ligation (37.5%) or embolization (8.3%). Intubation was required in 16.7% (8/48) for airway protection. Nearly half (48.9%) were inappropriately admitted to a location where key resources (operating room and interventional radiology) were unavailable after hours. A CCP was then devised in conjunction with emergency medicine that minimizes the duration of nasal packing and length of hospitalization and reduces the total cost of care. Implementation of the pathway required changes in the electronic medical record and educational programs. Conclusions: Implementation of a CCP requires evaluation of current practices and the standard of care followed by input from institutional decision makers. Quantifying improvement requires retrospective normative data with ongoing review of compliance with the CCP.