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Improving the Quality of Assessment and Management of Nasal Trauma in a Major Trauma Centre (MTC): Queen Elizabeth Hospital, Birmingham

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Improving the Quality of Assessment and Management of Nasal Trauma in a Major Trauma Centre (MTC): Queen Elizabeth Hospital, Birmingham Open access Quality improvement report BMJ Open Qual: first published as 10.1136/bmjoq-2019-000632 on 27 November 2019. Downloaded from Improving the quality of assessment and management of nasal trauma in a major trauma centre (MTC): Queen Elizabeth Hospital, Birmingham Apoorva Khajuria ,1 Max Sallis Osborne ,1 Lisha McClleland,1 Sandip Ghosh2 To cite: Khajuria A, Osborne MS, ABSTRACT no specific guidelines to provide a standard McClleland L, et al. Improving Background Nasal fractures present in 39% of patients of care for nasal fracture patients. Therefore, the quality of assessment and with facial trauma. These patients are assessed in the management of nasal trauma junior doctors with little prior ENT experi- emergency department followed by outpatient review in a major trauma centre (MTC): ence may find themselves perplexed when Queen Elizabeth Hospital, in the senior house officer- led emergency ear, nose and assessing such injuries. Birmingham. BMJ Open Quality throat (ENT) clinic. Inadequate treatment of nasal trauma Violent crime and antisocial behaviour in can result in debilitating functional and aesthetic problems. 2019;8:e000632. doi:10.1136/ Birmingham is on the rise; we found assault bmjoq-2019-000632 Inexperienced junior doctors may be apprehensive in and violence the most common causes of assessing nasal trauma resulting in time pressured clinics 1 ► Additional material is and suboptimal management. nasal injuries in our patient cohort. The ENT published online only. To view Measures A retrospective review of clinical noting over senior house officer (SHO) on-call would please visit the journal online 3 months was carried out to gauge the extent of the book nasal trauma patients into the SHO- (http:// dx. doi. org/ 10. 1136/ bmjoq- 2019- 000632). problem. Three baseline measurements for satisfactory led emergency clinic for further assessment quality of assessments included: (1) 3/5 key symptoms or management; these clinics occurred daily elicited by the clinician (epistaxis, rhinorrhoea, nasal and each appointment lasted 30 minutes. Received 10 January 2019 airway obstruction, dental malocclusion and diplopia). SHOs found nasal trauma patients difficult copyright. Revised 5 November 2019 (2) Presence/absence of ‘septal haematoma’ (SH) and to assess as they were unsure of what consti- Accepted 9 November 2019 ‘deviated nasal septum’ (DNS) documented. (3) Patient tutes ‘comprehensive’ assessment and if follow-up within 2 weeks after the initial injury. Three Plan-Do- Stud y-Act (PDSA) cycles were conducted with management such as a manipulation under implementation of interventions (proforma, clinic poster, anaesthesia (MUA) was required which patient information leaflet and training) as visualised in our would then require senior input thus adding ‘driver diagram’. time- pressure to an already busy clinic. Care http://bmjopenquality.bmj.com/ Results The quality of nasal trauma assessments was not standardised, thus, the project team improved following each intervention. There was an designed assessment tools to enable junior increase from 86% to 100% patients being seen within 2 doctors to carry out more robust assessments weeks of the injury. There was an improvement in quality of nasal injuries and standardise care. of assessments following the teaching as two- thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) of clinical documentation included ‘rhinorrhoea’ and 83% (PDSA cycle 2) to 100% (PDSA cycle 3) included ‘nasal airway BACKGROUND obstruction’. Similarly, two thirds (PDSA cycle 2) followed Nasal fractures are the most common type © Author(s) (or their by 100% (PDSA cycle 3) examined and documented the of facial fractures and frequently present to employer(s)) 2019. Re- use presence/absence of SH and DNS. A 100% improvement in the emergency department (ED).2–5 They can on September 26, 2021 by guest. Protected permitted under CC BY-NC. No trainee confidence was reported. We are now conducting be part of more serious facial injuries or an commercial re- use. See rights more comprehensive assessments of nasal trauma isolated injury following physical altercations. and permissions. Published by patients. BMJ. Conclusion The need to provide relevant training Regardless of the nature of the injury, correct 1 Ear, Nose & Throat (ENT) and support to ENT junior doctors is crucial in their assessment and management must be carried Department, Queen Elizabeth development, as well as to ensure delivery of high- quality out for all patients to avoid complications and Hospital Birmingham, 6 7 patient- centred care. provide good aesthetic outcomes. Key issues Birmingham, UK 2Diabetes and Endocrinology surrounding inexperienced junior doctors Department, Queen Elizabeth assessing this patient cohort are: unnecessary Hospital Birmigham, PROBLEM DESCRIPTION investigations, inadequate documentation Birmingham, UK This improvement activity took place in a busy and inappropriate acute management or Correspondence to Ear, Nose and Throat (ENT) department follow-up arrangements. Another example of Dr Apoorva Khajuria; within a 1213- bed major trauma centre in the insufficient assessment includes overlooking ap. khajuria@ gmail. com UK. Presently, there is limited evidence and the need to differentiate an acute deformity Khajuria A, et al. BMJ Open Quality 2019;8:e000632. doi:10.1136/bmjoq-2019-000632 1 Open access BMJ Open Qual: first published as 10.1136/bmjoq-2019-000632 on 27 November 2019. Downloaded from from a pre- existing chronic deformity as this will make a of a hard copy which is then scanned into ‘clinical portal’ MUA difficult thereby altering management.8 (our local patients’ electronic records system) or as a There are presently no robust, user- friendly tools that framework to document consultations in the traditional exist to allow standardised and efficient assessment and clinical noting system; this made it a simple and sustain- management of nasal trauma patients thus presenting a able tool. challenge for junior doctors in deciding how to approach the patient. In our hospital, this resulted in a registrar Context being contacted to assist in clinic. If registrars were readily The patient group was selected by identifying patients available, then it became a possible training opportunity with suspected nasal fracture who had been booked into as per Kolb’s experiential learning cycle, although the the SHO- led emergency clinic between June and August value of experiential learning is limited without appro- 2017. Patients were booked into this clinic following: priate reflection and conceptualisation.9 It is important i. Direct review by the ENT on- call SHO in ED or to note that due to time pressures and the need to prior- ii. Direct review by an ED doctor who contacts the ENT itise patient safety, Halsted’s ‘see one, do one, teach one’ SHO over the phone to request an emergency ENT model may no longer be an appropriate method for prac- clinic appointment. tical skills training.9 10 If registrars were not immediately Initial data collection involved retrospective review of available to assist in clinic then this caused clinic delays emergency ENT clinic noting of nasal trauma patients and patient frustration. to gauge the extent of the problem. A data spread- There is limited evidence to suggest an accurate time sheet was created to capture objective related baseline for nasal trauma patient follow- up, however, the general measurements. Over the 3 months period, 58 nasal consensus among experts is reassessment within 7–10 trauma patients were identified. Out of 58 patients, one days (ideally within a 2- week window) from the day of was seen in Maxillo-facial (MaxFacs) clinic due to extent injury.11–13- The reason for the delay in re- reviewing of injuries. 14 patients did not attend their appointments patients is to allow oedema to subside, at which point and so a total of 43 clinic notes were reviewed to estab- nasal deformities are easier to assess and closed reduc- lish baseline measurements. The implementation of the tion can be considered.14 Finally, clinician training and tools (see below) developed from this project, specifi- patient education may be essential tools to optimise clinic cally the proforma, was monitored. During the project, appointments.15 For example, predesigned proformas aid new junior doctors joined the team, they were educated copyright. in diminishing errors due to human factors in time pres- and signposted to the proforma and other tools by senior sured situations.16 members of the team. Additionally, the project was presenting again, 6 months following the initial work. DESIGN Interventions The need for a sustainable assessment tool was apparent Proforma to enable junior doctors to better assess patients and so a A driver diagram (figure 1) was used to develop addi- http://bmjopenquality.bmj.com/ proforma was developed by a team consisting of a SHO, tional ideas for our improvement strategy, including the Registrar and an ENT consultant. We aimed to improve assessment proforma. The proforma documents the date, the quality of care for nasal trauma patients in the ENT specific time the clinic appointment started and patient SHO- led emergency clinic to ensure timely management, demographics. The time aspect was important as we accurate assessment and documentation of key symptoms postulated that nasal trauma patients, due to the nature and examination findings during all nasal trauma consul- of their injury, would be more time consuming especially tations. The proforma
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