Implementing criteria-led discharge for acute admissions to facilitate the elective recovery from COVID-19: an example in acute tonsillitis.

BACKGROUND: Healthcare systems face unprecedented numbers of patients waiting for elective treatments in the wake of the COVID-19 pandemic. Hospitals must urgently optimise patient pathways and build capacity to meet the populations health needs. Criteria-led discharge (CLD) is frequently used to optimise elective care pathways but may hold potential in discharging patients at the end of an acute hospital admission. METHODS: We conducted a quality improvement project to design and introduce a novel inpatient pathway using CLD for patients with severe acute tonsillitis. Our analysis compared the standardisation of treatment, length of stay, discharge time and readmission rate between those treated on the novel pathway compared with standard treatment. RESULTS: The study population included 137 patients admitted to a tertiary centre with acute tonsillitis. Introduction of the tonsillitis pathway using CLD resulted in a significant reduction in median length of stay from 24 hours to 18 hours. Of those treated on the tonsillitis pathway, 52.2% were discharged prior to midday compared with 29.1% who received standard treatment. No patient discharged using CLD required readmission. CONCLUSION: CLD is safe and effective at reducing length of stay in patients requiring acute hospital admission for acute tonsillitis. CLD should be used and evaluated in further novel patient pathways across different areas of medicine to optimise care and build capacity for provision of elective healthcare services. Further research is required to investigate safe and optimal criteria which indicate patients are fit for discharge.

One year on: assessing the impact of coronavirus disease 2019 on demand for semi-urgent ENT services.

OBJECTIVE: This study investigated how the coronavirus disease 2019 pandemic has impacted on presentations to ENT first-on-call services. METHODS: All appointments to a rapid access triage clinic from 1 June to 31 August in 2019 and 2020 were reviewed retrospectively and their reasons for consultation classified. A binomial proportion test was used to determine whether the proportions of consultations per presentation differed significantly between years. This analysis was repeated with the number of unique patients per presenting complaint. RESULTS: The proportions of nine reasons for consultation differed significantly between 2019 and 2020, including an increase in otitis media and nasal trauma presentations, and a decrease in otitis externa and tonsillitis presentations. Reattendances caused some variation in the frequency of certain diagnoses. CONCLUSION: Our data suggest a shift in the presentations to first-on-call services, which may be a result of changes in patient behaviour and access to healthcare services.

Improving the management of suspected tonsillitis and peritonsillar abscess referred to ENT - a coronavirus disease 2019 service improvement.

BACKGROUND: The impact of coronavirus disease 2019 on healthcare has led to rapid changes in otolaryngology service provisions. As such, new standard operating procedures for the management of suspected tonsillitis or quinsy were implemented in our centre. METHODS: A retrospective audit was performed of acute referrals to ENT of patients with suspected tonsillitis, peritonsillar cellulitis or quinsy, during the 10 weeks before (group 1) and 10 weeks after (group 2) implementation of the new standard operating procedures. RESULTS: Group 2 received fewer referrals. Fewer nasendoscopies were performed and corticosteroid use was reduced. The frequency of quinsy drainage performed under local anaesthetic increased, although the difference was not statistically significant. Hospital admission rates decreased from 56.1 to 20.4 per cent, and mean length of stay increased from 1.13 to 1.5 days. Face-to-face follow up decreased from 15.0 to 8.2 per cent, whilst virtual follow up increased from 4.7 to 16.3 per cent. There were no significant differences in re-presentation or re-admission rates. CONCLUSION: Management of suspected tonsillitis or quinsy using the new standard operating procedures appears to be safe and effective. This management should now be applied to an out-patient setting in otherwise systemically well patients.

ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines: translating guidance into practice.

OBJECTIVES: This study examined the uptake of ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines at our tertiary centre, and assessed perceived barriers to uptake. METHODS: A retrospective case series of tonsillitis and quinsy patients was analysed in two arms: before and after the introduction of new ENT UK management guidelines. A survey assessed perceptions and practice differences between ENT and emergency department doctors. RESULTS: Each study arm examined 82 patients. Following the introduction of new ENT UK guidelines, ENT clinicians demonstrated significant changes in practice, unlike their emergency department counterparts. Survey results from emergency department doctors highlighted a lack of appreciation of guideline change and identified barriers to guideline uptake. CONCLUSION: The introduction of new management guidelines for tonsillitis and quinsy patients during the pandemic resulted in disparate uptake within ENT and emergency department departments at the tertiary centre. Clearer dissemination to all affected clinicians is paramount for future rapidly introduced changes to practice, to ensure clinician safety.

Ambulatory management of common ENT emergencies - what's the evidence?

OBJECTIVES: The global pandemic of coronavirus disease 2019 has necessitated changes to 'usual' ways of practice in otolaryngology, with a view towards out-patient or ambulatory management of appropriate conditions. This paper reviews the available evidence for out-patient management of three of the most common causes for emergency referral to the otolaryngology team: tonsillitis, peri-tonsillar abscess and epistaxis. METHODS: A literature review was performed, searching all available online databases and resources. The Medical Subject Headings 'tonsillitis', 'pharyngotonsillitis', 'quinsy', 'peritonsillar abscess' and 'epistaxis' were used. Papers discussing out-patient management were reviewed by the authors. RESULTS: Out-patient and ambulatory pathways for tonsillitis and peritonsillar abscess are well described for patients meeting appropriate criteria. Safe discharge of select patients is safe and should be encouraged in the current clinical climate. Safe discharge of patients with epistaxis who have bleeding controlled is also well described. CONCLUSION: In select cases, tonsillitis, quinsy and epistaxis patients can be safely managed out of hospital, with low re-admission rates.

Management of ENT emergencies during the coronavirus disease 2019 pandemic.

BACKGROUND: Coronavirus disease 2019 imposed dramatic changes on ENT service delivery. Pre-pandemic, such changes would have been considered potentially unsafe. This study outlines the impact of lockdown on the incidence and management of ENT emergencies at a large UK centre. METHODS: After modification of pre-pandemic guidelines, ENT emergency referrals data during the UK lockdown were prospectively captured. A comparative analysis was performed with retrospective data from a corresponding period in 2019. RESULTS: An overall reduction (p < 0.001) in emergency referrals (n = 119) and admissions (n = 18) occurred during the lockdown period compared to the 2019 period (432 referrals and 290 admissions). Specifically, there were reduced admission rates for epistaxis (p < 0.0001) and tonsillar infection (p < 0.005) in the lockdown period. During lockdown, 90 per cent of patients requiring non-dissolvable nasal packing were managed as out-patients. CONCLUSIONS: Coronavirus disease 2019 compelled modifications to pre-pandemic ENT guidelines. The enforced changes to emergency care appear to be safe and successfully adopted. Arguably, the measures have both economic and patient-related implications post-coronavirus disease 2019 and during future similar pandemics and lockdowns.

Admission avoidance in tonsillitis and peritonsillar abscess: A prospective national audit during the initial peak of the COVID-19 pandemic.

OBJECTIVES: To report changes in practice brought about by COVID-19 and the implementation of new guidelines for the management of tonsillitis and peritonsillar abscess (PTA), and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). DESIGN: Prospective multicentre national audit over 12 weeks from 6 April 2020. SETTING: UK secondary care ENT departments. PARTICIPANTS: Adult patients with acute tonsillitis or PTA. MAIN OUTCOME MEASURES: Re-presentation within 10 days for patients discharged from the ED. RESULTS: 83 centres submitted 765 tonsillitis and 416 PTA cases. 54.4% (n = 410) of tonsillitis and 45.3% (187/413) of PTAs were discharged from ED. 9.6% (39/408) of tonsillitis and 10.3% (19/184) of PTA discharges re-presented within 10 days, compared to 9.7% (33/341) and 10.6% (24/224) for those admitted from ED. The subsequent admission rate of those initially discharged from ED was 4.7% for tonsillitis and 3.3% for PTAs. IV steroids and antibiotics increased the percentage of patients able to swallow from 35.8% to 72.5% for tonsillitis (n = 270/754 and 441/608) and from 22.3% to 71.0% for PTA (n = 92/413 and 265/373). 77.2% of PTAs underwent drainage (n = 319/413), with no significant difference in re-presentations in those drained vs not-drained (10.6% vs 9.5%, n = 15/142 vs 4/42, P = .846). Univariable logistic regression showed no significant predictors of re-presentation within 10 days. CONCLUSIONS: Management of tonsillitis and PTA changed during the initial peak of the pandemic, shifting towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.