Rapid access rather than open access leads to improved effectiveness of an ENT emergency clinic

Abstract

An Ear, Nose and Throat (ENT) emergency clinic provides important access to specialist care for patients referred by General Practitioners (GPs), Emergency Departments and doctors on non-ENT hospital wards. The aim is to enable the prompt diagnosis and management of acute conditions, within an optimum environment containing appropriate clinical and staff resources.Amid concerns that an open access ENT casualty service had become overburdened we performed a four week audit of all attendances. We identified 45% of patients presenting to the clinic without having evidence of first accessing primary care assessment or treatment. Waiting times were unpredictable, averaging 75 minutes and clinic numbers above those recommended to be safe in national guidelines. 60% of attendances to the department were judged to be inappropriate.Subsequently the ENT emergency service was changed to an appointment based Rapid Access Clinic, with an easily accessible and prompt triage facility provided by a trained triage nurse. Concurrently the opportunity was taken to improve record keeping and formalise post consultation communication.Re-audit confirmed a 43% reduction in the number of patients accessing the ENT emergency clinic facility, allowing individual clinic numbers to fall to safe levels. Average patient waiting times fell by 70% to 22 minutes. The number of referrals judged to be inappropriate was halved.The transformation of our service has enabled time and resources to be more effectively directed towards a smaller number of patients, whose needs are more urgent.

In the face of increasing subspecialisation, how does the specialty ensure that the management of ENT emergencies is timely, appropriate and safe?

“…In 2013, there were a total of 68 788 emergency admissions to ENT units in England; this represents an increase of 8711 admissions from 10 years previously in 2003, in which 60 077 admissions were reported 16 . Common emergencies within ENT include acute otitis externa, epistaxis, nasal injury and foreign body (ENT), 17 as well as acute upper airway obstruction. It is vital for these presentations to be recognised quickly and the appropriate management to be put in place, as there is the potential for rapid deterioration with life-threatening consequences.…”

“…The systems in place to deal with ENT emergencies vary across hospitals, 20 with many employing the use of ENT emergency clinics, 17 , 21 which enable access to specialist care (for referring general practitioners), accident and emergency departments, and other specialties across hospitals. These clinics are designed to ensure that ENT specialist care is maximally and efficiently used, as appropriate resources and equipment within the clinic treatment room enable rapid diagnosis and management of ENT emergencies, 22 with the additional benefit of minimising unnecessary admissions 23…”

“…However, there is significant variability in the ENT emergency clinical service across trusts, with no standardisation of design 24 . ‘Rapid access’ rather than ‘open access’ clinics have been shown to improve the effectiveness of an ENT emergency clinic, as recently demonstrated by Smyth et al 17 . The difficulties of an ‘open access’ clinic, which patients can attend without referral, include varying numbers of attendees and waiting times, with the potential of over-burdening.…”

“…The difficulties of an ‘open access’ clinic, which patients can attend without referral, include varying numbers of attendees and waiting times, with the potential of over-burdening. It was found that a ‘rapid access’ clinic, with formal nurse triaging to assess whether it would be more appropriate for the patient to be seen in a consultant out-patient appointment, could efficiently identify more urgent presentations and thus streamline management towards a smaller number of patients with acute ENT presentations 17 …”

A multifaceted approach to improving the quality of ENT Emergency Clinic referrals

“…3 The time-sensitive nature of rapid access clinics requires effective communication between GPs, ED and ENT to provide an effective and patient-centred service. Poor communication when referring a patient to a rapid access clinic is an important quality and safety issue 4.…”