Implementation of a Suspected Nasal Bone Fracture Pathway in a Major Trauma Centre

Introduction: Nasal trauma is a common facial injury worldwide and a frequent cause of presentation in the emergency department. At the largest trauma center in Khartoum, Sudan, there was no formalised pathway for the management of patients suspected to have this injury, leading to late referrals to ENT and suboptimal management. This audit assessed whether implementing a standard protocol could improve documentation quality, clarify referral criteria and reduce inappropriate imaging requests and subsequent ENT clinic utilization.
Methods: The first QIP cycle was completed over a four-month period from January to April 2023, and the second loop was done between August and November 2024. Adult patients (>= 16 years old) presenting to A&E with suspected nasal fracture or nasal trauma were included. In the second loop, a nasal trauma protocol was introduced, emphasizing a pathway for exclusion of red flags, reinforcement that isolated nasal bone fractures do not require plain radiographs and appropriate triage to ENT services.
Results: A total of 48 patients were included (Cycle 1: n = 21; Cycle 2: n = 27). Nasal exam documentation improved considerably following protocol implementation, increasing from 41% to 79% (p=0.018), with red-flag documentation increasing from 29% (6/21) in Cycle 1 to 85% (23/27) in Cycle 2 (p<0.001). Requests for inappropriate scans (x-rays not fitting criteria) reduced from 95% to 11% (p<0.001). 
Conclusion: Implementation of a standardised nasal fracture protocol considerably improved accuracy of clerking documentation, reduced unnecessary imaging and radiation exposure and enhanced overall pathway adherence for follow-up and definite management. The improvements supported a more efficient utilization of the ENT fracture clinic and reduced unnecessary exposure to radiation. Continuous auditing, staff education due to high turnover and overall monitoring are prudent to maintain this level of adherence, and evaluation of the long-term effect on ENT clinic utilization and manipulation success rate is recommended.