Adult ENT Research Articles

894 An Audit of Venous Thromboembolism Prophylaxis in A Busy ENT Department

Abstract Aim Venous thromboembolisms (VTEs) are a common and preventable cause of in-hospital morbidity and mortality. Assessment of risk factors (RFs) on admission and appropriate prescription of mechanical (e.g., TEDS) and/or pharmacological prophylaxis (e.g., low-molecular-weight heparin (LMWH)) is crucial. This is especially true in ENT where the variety of patient cohorts make a one-size-fits-all approach unsatisfactory. Guidelines from ENT UK reflect this. Method Electronic medical records were retrospectively reviewed for all emergency and pre-operative admissions (n = 173) to an adult ENT ward over 8 weeks. Adherence to the ENT UK guideline was assessed. Results 58% of patients had VTE RFs, 27% had bleeding RFs, 2% had mechanical thromboprophylaxis contraindications. VTE risk assessment was clearly carried out for 39% of admissions. 63 patients (36%) met the criteria for LMWH prescription. 22 (35%) received it. 5 received LMWH without meeting the criteria. 96 patients (55%) met the criteria for TEDS prescription. 5 (5%) received it. 1 received TEDS without meeting the criteria. Overall, 45% of admissions had both prescribed according to the guideline. Using a pro-forma (n = 148) significantly improved risk assessment rates (43% vs. 12%), but not correct prescription rates (45% vs 40%) compared to freehand clerking (n = 25). No patients developed a VTE or unexpected bleeding. Conclusions Risk assessment and prescription of pharmacological and, especially, mechanical thromboprophylaxis for those who met the relevant criteria has significant room for improvement. However, no apparent harm occurred because of this. Further work will focus on developing a departmental policy and educating staff on its application.

883 A Closed-Loop Audit to Improve Admissions Documentation in A Busy ENT Department

Abstract Aim Accurate and thorough admissions documentation is crucial for patient safety and effective care. We amended the admissions pro-forma used on a busy adult ENT ward to improve adherence to a modified version of Royal College of Surgeons of England guidelines. Method Baseline documentation of the 25 parameters of interest was assessed using electronic medical records for all emergency and pre-operative admissions over a 4-week period (n = 75). A new pro-forma was introduced, and the documentation over the following 4 weeks (n = 75) was assessed in the same way. Statistical analysis was done using Excel and RStudio (z-test for two proportions, p-value ≤ 0.05). Results The two groups were similar in age, gender, length of stay, and presenting complaint. The new pro-forma was completed for more admissions than the prior version (91% vs 77%) and resulted in documentation improvements in 19 out of 25 parameters. 9 of these were statistically significant, including initial vital signs and differential diagnosis. Parameters that improved, but not significantly, include admission source, medication history, and cognitive assessment. Across the 8 weeks, using a pro-forma (n = 126) significantly improved documentation of 11 parameters compared to freehand clerking (n = 24). Conclusions Adequate documentation at admission can help with immediate patient care, and act as a point of reference during extended stays. We were able to increase use of a pro-forma and produce meaningful documentation improvements quickly. Further work is required to assess why certain parameters are infrequently completed, and how future pro-forma iterations can become more user-friendly.

Impact of the COVID-19 epidemic on ENT surgical volume

PurposeThe purpose of this study was to assess the impact of the COVID-19 pandemic on the surgical volume of three ENT departments in Ile-de-France, a region severely affected by the epidemic. Materials and methodsThe number and nature of surgeries was collected from three university hospital ENT departments from 17/03/2020 to 17/04/2020 and from 18/03/2019 to 18/04/2019. Centre 1 is a general adult ENT department specialized in otology, centre 2 is a general adult ENT department specialized in cancer and centre 3 is a paediatric ENT department. Comparative analysis of the decreased surgical volume was conducted between 2019 and 2020. ObjectiveTo analyse the reduction of ENT surgical volume. ResultsThe three centres operated on 540 patients in 2019, versus 89 in 2020, i.e. an 84% decrease: 89% in Centre 1, 61% in Centre 2, and 95% in the paediatric centre. Otological surgery decreased by 97%, endonasal surgery decreased by 91%, head and neck surgery decreased by 54%, plastic surgery decreased by 82%, and transoral surgery decreased by 85%. The number of surgical operations for skin cancer decreased (24 vs. 9), while the total number of head and neck cancer surgeries remained stable (18 vs. 22). The number of planned tracheostomies increased from 8 to 22. ConclusionThe number of ENT surgeries decreased by 84% during the first month of the COVID-19 epidemic. This decreased surgical volume mainly concerned functional surgery, while the level of cancer surgery remained stable. Hospital units will need to absorb a marked excess surgical volume after the epidemic.

972 Managing Ent Emergencies Needing Transfer to Picu: the Extended Transport Team

BackgroundPaediatric ENT emergencies are rare but can be life-threatening and challenging to manage. In UK paediatric ENT services are centralised, and adult ENT surgeons and anaesthetist provide cover in local...

The use of diode laser in adult ENT procedures

The use of diode laser in adult ENT procedures

Retrospective analysis of use and distribution of resources in otolaryngology wards in Romanian hospitals between 2003 and 2008 to improve provision and financial performance of healthcare services.

To analyze use and distribution of resources by otolaryngology (ENT) hospital wards in Romania between 2003 and 2008, in order to plan the improvement of patient access to health care services and health care services' financial performance. Clinical electronic records were searched for all patients discharged from all public hospitals funded on a per-case basis by the government between January 2003 and September 2008. Adult and pediatric ENT wards, as well as ENT wards from different counties, were compared. The number of ENT hospital beds and the number of specialists decreased from 2003 to 2004, the number of specialists declined, and specialists were distributed unevenly among the hospitals and counties. The total number of ENT wards was over 100 for almost the entire study period, but there were only about 15 pediatric ENT wards in all 42 counties. ENT wards recorded more cases and hospitalization days than oral-maxillofacial surgery and neurosurgery wards, but fewer cases than general surgery or obstetrics wards. ENT wards had the lowest mortality rates. Until the second half of 2007, adult ENT wards had a lower surgical index, higher complexity of cases, and longer average length of stay than pediatric ENT wards (P<0.001, t-test). After 2007, pediatric ENT wards treated more complex cases (P=0.004, t -test) that were less surgical in nature; this result was due to the shift from the Health Care Finance Administration classification diagnostic-related group (DRG) system to the Australian Refined DGR system, as well as to improper use of codes. ENT wards in different counties differed in the number of cases, average length of stay, and case mix index. Statistics and case mix clinical data may be a good starting point for informing hospital management to assess ENT service coverage, but they should be supplemented with data on hospitalization costs.

Hoarse voice in adults: an evidence‐based approach to the 12 minute consultation

The hoarse voice is a common presentation in the adult ENT clinic. It is estimated that otolaryngology/voice clinics receive over 50 000 patients with dysphonia each year. Good vocal function is estimated to be required for around 1/3 of the labour force to fulfil their job requirements. The assessment and management of the patient with a hoarse voice is potentially a complex and protracted process as the aetiology is often multi-factorial. This article provides a guide for the clinician in the general ENT clinic to make a concise, thorough assessment of the hoarse patient and engage in an evidence based approach to investigation and management. Literature search performed on 4 October 2008 using EMBASE, MEDLINE, Cochrane databases using subject headings hoarse voice or dysphonia in combination with diagnosis, management, investigation, treatment, intervention and surgery. General vocal hygiene is beneficial for non organic dysphonia but the evidence base for individual components is poor. There is a good evidence base for the use of voice therapy as first line treatment of organic dysphonia such as vocal fold nodules and polyps. There is little evidence for surgical intervention as first line therapy for most common benign vocal fold lesions. Surgery is, however, the treatment of choice for hoarseness due to papillomatosis. Both CO(2) laser and microdissection are equally acceptable modalities for surgical resection of common benign vocal fold lesions. Laryngopharyngeal reflux is commonly cited as a cause of hoarseness but the evidence base for treatment with gastric acid suppression is poor. Despite the widespread use of proton pump inhibitors for treating laryngopharyngeal reflux, there is high quality evidence to suggest that they are no more effective than placebo. A concise and thorough approach to assessment in the general ENT clinic will provide the diagnosis and facilitate the management of the hoarse voice in the majority of cases. Voice therapy is an important tool that should be utilised in the general ENT clinic and should not be restricted to the specialist voice clinic. If there is no improvement after initial measures, the larynx appears normal and/or the patient has failed initial speech & language therapy, referral to a specialist voice clinic may be helpful. More research is still required particularly with regard to laryngopharyngeal reflux which is often cited as an important cause of hoarseness but is still poorly understood.

Nurse‐led adult ENT pre‐operative assessment

Pre-operative assessment in some ENT departments is now nurse-led rather than doctor-led. Appropriately trained nursing staff can perform medical aspects of pre-operative assessment to the same or a better standard than a doctor. Almost all patients are satisfied with a nurse-led pre-operative assessment, and in some cases they prefer it.

Nasal septal deformities in ear, nose, and throat patients: An international study

Purpose The purpose of this study was to investigate the incidence and characteristics of nasal septum deformities in ear, nose, and throat (ENT) patients in various geographic regions in the world. Materials and methods Anterior rhinoscopy without nasal decongestion was performed in 17 ENT centers in 14 countries. The septal deformities were classified according to the classification system proposed by Mladina. Results A total of 2589 adult ENT patients (1500 males and 1089 females) were examined. Septal deformities were found in 89.2% of subjects. Left-sided deformities were slightly more prevalent than right-sided deformities (51.6% and 48.4%, respectively). The most frequent type of deformity was type 3 (20.4%). Straight septum was found in 15.4% of females and 7.5% of males. Conclusions Almost 90% of the subjects showed 1 of the 7 types of septal deformity. There were no statistically significant differences in the incidence of their appearance among particular geographic regions. Type 3 was the most frequent type. Straight septum was twice as frequent in females than in males.

Adult ENT day surgery: a case for expansion of services

Day case surgery is acknowledged to have many advantages over inpatient surgery, including greater efficiency, reduced risk of infection, reduced waiting lists and lower costs. 1 Although in the past two decades day surgery has experienced a gradual expansion of services in the UK, the 2001 Audit Commission report on day surgery showed that there was still far more potential for expansion 2 and the Department of Health launched the 'day surgery strategy' in January 2002 with the specific aim of increasing and improving day surgery in the NHS.

Is a doctor needed in the adult ENT pre–admission clinic?

Pre-admission clinics are traditionally run jointly by nurses and doctors. Within an adult ENT pre-admission clinic, we wished to assess what doctors added to nurses' pre-clerking, to determine whether doctors were actually needed in the clinic. Prospective study, looking at how often doctors, seeing patients after ward-based nurses, changed or added to clerking or tests as organized by nurses. Out of 184 patients, doctors changed or added to nurses' clerking or planned investigations in 47 patients (26 per cent), making 64 different changes. The commonest reasons for changes were ordering blood tests (22 changes), chest X-rays (eight), cancelling due to hypertension (seven), altering drug history (five) and requesting electrocardiograms (five changes). Most changes made by doctors could be eliminated by designing a pre-admission clinic protocol that could easily be used by nurses. We recommend that all ENT departments consider implementing nurse-led pre-admission clinics.

For mild-to-moderate losses, rapport with parents and child is essential

Susan M. Fowler, MEd, CCC-A, and Bridgette A. Fowler, MEd, CCC-A, are both Audiologists with Pediatric and Adult ENT Associates in Richmond, VA.