title: Successful Implementation of a Clinical Care Pathway for Management of Epistaxis at a Tertiary Care Center.
abstract: We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost.
  
  
  
  Single prospective analysis with historical control.
  
  
  
  Tertiary academic hospital.
  
  
  
  Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing.
  
  
  
  Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P < .001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented.
  
  
  
  Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA peter.vosler@gmail.com.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Vosler
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Boston University, Boston, Massachusetts, USA.
authors.forename: Jason I
authors.initials: JI
authors.lastname: Kass
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Eric W
authors.initials: EW
authors.lastname: Wang
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Carl H
authors.initials: CH
authors.lastname: Snyderman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways; D004844:Epistaxis / Q000191:economics / Q000628:therapy*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D016896:Treatment Outcome
keywords: clinical care pathway; costs; embolization; epistaxis; nasal packing; sphenopalatine artery ligation; surgery