Introduction
The ENT emergency clinic in St George's Hospital, London, provides an important service to the local community. It runs every weekday and is staffed by year one and two core surgical trainee or foundation year two doctors. It is designed as a rapid access clinic for patients requiring urgent ENT assessment and management. Patients are referred from their general practitioners, from St George's Hospital wards, and from other local hospitals without ENT services. It is a busy clinic which sees over 180 patients a month. Similar emergency clinics are run in other UK ENT departments.Reference Ali Raza, Denholm and Wong1–Reference Wasson, Pearce and Alun-Jones4
It was noticed that a number of patients were being seen multiple times in the ENT emergency clinic, despite departmental guidelines recommending that no patient be seen more than twice in this clinic in a single out-patient episode. By the end of a patient's second ENT emergency clinic appointment, a plan should have been made for their further care, the options being: discharge from the ENT emergency clinic, with or without general practitioner follow-up; referral to a named ENT consultant clinic; referral to another specialty; or, rarely, a third ENT emergency clinic follow up appointment (e.g. for further aural toilet in cases of acute otitis externa).
To establish the number of patients who were attending the ENT emergency clinic more than twice in a single clinical episode, a retrospective audit was undertaken. Data from this audit were reviewed and presented, and interventions decided upon. These interventions were implemented and the audit loop was completed with a re-audit after six months.
Methods
The criteria for this audit were developed from the departmental guideline stating that no patient should be seen more than twice in the ENT emergency clinic in a single out-patient episode. The inclusion criterion for the initial, retrospective arm of the audit was all patients who had attended the ENT emergency clinic more than twice in the same out-patient episode between 1 September to 30 November 2007. The data sources were the case notes of these patients. A data collection form was designed in collaboration with the St George's Hospital audit department. The clinical entries for third ENT emergency clinic attendances were reviewed and the relevant findings entered in the data collection form. The data were analysed and presented at a departmental audit meeting.
After departmental discussion, two recommendations were made, in an attempt to improve the process of clinical care offered by the ENT emergency clinic.
The first recommendation stated that, if a patient was being considered for a third ENT emergency clinic appointment in the same out-patient episode, then approval should be sought from an ENT consultant or specialist registrar.
The second recommendation was made in light of the finding that acute otitis externa was the diagnosis most commonly seen in frequent attendees to the ENT emergency clinic. Thus, the second recommendation stated that a departmentally approved management guideline should be implemented for the diagnosis of acute otitis externa.
A management guideline was discussed, developed and approved at a subsequent departmental meeting (Figure 1).Reference Rosenfeld, Brown, Ron Cannon, Dolor, Ganiats and Hannley5
Fig. 1 Management guideline for diagnosis and treatment of acute otitis externa. Reproduced with permission.5 y = years; AOE = acute otitis externa
Implementation methods were discussed and agreed upon; these were as follows. (1) The recommendations should be explained at all subsequent ENT junior doctor induction meetings. (2) The ENT emergency clinic coordinator should be informed of the recommendations. (3) The first recommendation should be the screen saver on the ENT emergency clinic desktop computer terminal. (4) A laminated copy of the departmentally approved guidelines for the management of acute otitis externa should be prominently displayed in the ENT emergency clinic.
The second data collection was performed six months after the interventions had been made. The inclusion criterion for this re-audit was all patients who had attended the ENT emergency clinic more than twice in the same out-patient episode between 1 March to 31 May 2008. The data sources were the patients' case notes. The clinical entries for third ENT emergency clinic attendances were reviewed and the relevant findings entered in the data collection form.
Results
Between 1 September to 30 November 2007, there were 555 ENT emergency clinic consultations. Thirty-eight patients were seen more than twice in this time period, giving rise to 81 ‘excess’ clinic appointments (an excess clinic visit being any in addition to the two recommended for a single clinical episode) (Table I and Figure 2).
Fig. 2 Number of visits to the ENT emergency clinic in a single clinical episode (if >2).
Table I ENT emergency clinic visits
* Patient attending more than twice in a single clinical episode. Sep = September; Nov = November; Mar = March
The case notes of 35 of the 38 frequent attendees to the ENT emergency clinic were reviewed (three sets of notes contained insufficient information). Acute otitis externa was the diagnosis in 28 of these 35. Other diagnoses included tympanic membrane perforation, wax impaction, neck lump, facial cellulitis, globus pharyngeus, pinna haematoma and aural foreign body.
After the described interventions were implemented, the ENT emergency clinic was re-audited. Between 1 March to 31 May 2008, there were 435 ENT emergency clinic consultations. Nineteen patients were seen more than twice in this time period, giving rise to 24 excess clinic appointments (Table I and Figure 2). The fall in both the number of ENT emergency clinic consultations and the excess clinic appointments was statistically significant (p ≤ 0.01).
The case notes of 18 of the 19 frequent attendees to the ENT emergency clinic were reviewed (one set of notes contained insufficient information). Acute otitis externa was the diagnosis in 11 of these 18 case notes. Other diagnoses included tympanic membrane perforation, wax impaction, epistaxis, human bite to the pinna and post-operative reviews.
Discussion
It was noticed that a number of patients were being seen in the ENT emergency clinic more than twice in the same clinical episode, in contradiction to departmental guidelines. This suspicion was confirmed by the retrospective arm of the audit, which identified 38 patients who had been seen more than twice in the ENT emergency clinic in the same clinical episode between September 2007 and November 2007 (Figure 2). These patients were responsible for 81 excess clinic visits in the initial audit period (Table I). This meant that 15 per cent of the total ENT emergency clinic visits in the initial audit period were excess visits. Any increase in the number of follow-up appointments leads to an extra burden on the ENT emergency clinic and greater pressure on the ENT junior doctors who run it. Further analysis of the findings demonstrated that acute otitis externa was the most common clinical condition seen more than twice in a single clinical episode, accounting for 80 per cent of such cases. The high prevalence of acute otitis externa cases in ENT emergency clinics has been previously noted.Reference Ali Raza, Denholm and Wong1
Two interventions were decided upon, in an attempt to decrease the number of frequent attendees.
Firstly, the junior doctors who ran the clinic were requested to discuss all patients thought to need a third ENT emergency clinic appointment with an ENT consultant or specialist registrar. Although senior clinicians had always been available to review patients, it seemed that use of this key communication pathway had waned insidiously. It was hoped that highlighting this issue would encourage more regular senior review of potential frequent attendees.
• Many British ENT departments run an ENT emergency clinic usually staffed by the most junior members of the department
• The commonest condition seen in the ENT emergency clinic is acute otitis externa
• A significant number of patients attending the authors' ENT emergency clinic were seen multiple times without senior review
• Insisting upon a senior clinician review of any patient attending the ENT emergency clinic more than twice, and the implementation of treatment guidelines for acute otitis externa, reduced the number of frequent attendees by 50 per cent
Secondly, the disproportionate number of frequent attendees suffering a single clinical condition, acute otitis externa, stimulated a review of management. A departmentally approved guideline was agreed for this condition (Figure 1). A number of methods were used to advertise these recommendations (see Methods), in the hope that they would inform not only the department's current set of junior doctors but also future rotations of ENT juniors.
The re-audit showed that the implementation of the two key recommendations had had a significant effect on the number of frequent attendees to the ENT emergency clinic. There had been a 50 per cent reduction in the number of frequent attendees (Table II), a 70 per cent reduction in the number of excess clinic appointments involving frequent attendees, and a 22 per cent reduction in the total number of ENT emergency clinic visits (Table I). Although the reduction in the total number of ENT emergency clinic visits between the retrospective and prospective arms of the audit could not be entirely explained by the reduction in the number of excess clinic appointments, it certainly helped to reduce the burden.
Table II Total number of ‘frequent attendees’ to the ENT emergency clinic
Conclusions
The recommendation that patients being considered for a third ENT emergency clinic review be discussed with a more senior ENT surgeon, combined with the implementation of a departmentally approved guideline for acute otitis externa management, significantly reduced the number of excess emergency clinic appointments. These interventions were simple, cheap and effective, and resulted in reduced clinic workload and, hopefully, improved patient care.
