Legislative Update

Case Report: Juvenile Nasopharyngeal Angiofibroma and a Call for Communication

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report confirmed nasopharyngeal angiofibroma. He is 18 months postsurgery without complications or signs of recurrence.

Discussion

Diagnosis of rare entities such as this will depend on thorough history and physical examination and consideration of a broad differential. After the initial examination, partnering with our subspecialty colleagues becomes imperative for ongoing patient discussion and education. In our case, the patient was referred to otolaryngology as a precaution with low initial clinical suspicion for JNA. Communication requires participation by all parties; therefore, subspecialists must welcome patients sent as a precaution. Once a diagnosis is confirmed, successful management will depend upon the ability between providers to coordinate and optimize an individualized treatment plan to reduce operative blood loss and minimize the chances of recurrence.

The mean time from initial symptom(s) to diagnosis has been estimated to be 14 months, a significant amount of time for the rapidly evolving adolescent4. The mental, physical, and social impact of 14 months of potentially embarrassing symptoms and uncertainty cannot be understated. The diagnosis of a tumor, although benign, is likely to add stress at an often-insecure age. In conclusion, JNA is a diagnostic challenge that requires scrutinization of a complete history and physical examination to determine when further investigation of epistaxis is warranted. The position and nature of the tumor as well as the literature suggest that the optimal method for management requires an interdisciplinary approach.

Reference List

1. Martins MBB, de Lima FVF,

Mendonça CA, de Jesus EPF,

Santos ACG, Barreto VMP, et al.

Nasopharyngeal angiofibroma: Our experience and literature review.

Int Arch Otorhinolaryngol. 2013

Jan;17(1):14–9. 2. McInerny TK, Adam HM, Campbell

DE, DeWitt TG, Foy JM, Kamat DM.

American Academy of Pediatrics textbook of pediatric care. 2nd ed.

Washington: American Academy Of

Pediatrics; 2017. 3. Shaw KN, Bachur RG. Fleisher & Ludwigs textbook of pediatric emergency medicine. 7th ed.

Philadelphia: Wolters Kluwer; 2016. 4. Paris J, Guelfucci B, Moulin G,

Zanaret M, Triglia JM. Diagnosis and treatment of juvenile nasopharyngeal angiofibroma.

Eur Arch Otorhinolaryngol. 2001

Mar;258(3):120–4.

Neerav Goyal, MD, MPH; Ellen S Deutsch, MD, MS On behalf of the PAO-HNS Patient Safety Committee

Introduction

A hack is a "simple and clever tip or technique for accomplishing some familiar task more easily and efficiently."1 In healthcare, we often use the term "workaround," to describe actions that bypass standard processes in order to solve problems in the moment. The intent of a workaround is to achieve a healthcare delivery goal more readily or efficiently by circumventing real or perceived workflow obstacles.2 We discuss the advantages and disadvantages of workarounds and conclude with areas of agreement.

PRO

No matter how carefully we plan our work each day, it is likely that we will have to make adjustments as the day proceeds. A resource that we need may be unavailable: equipment may be broken, supplies may have run out, staff may be committed other tasks. Or each of those resources may be available and functioning well, but there are just too few of them. Because the need to provide care for our patients never stops, we frequently figure out ways to bypass system constraints - we develop workarounds that accomplish patient care despite system limitations.

The need for workarounds is most evident during a crisis, such as a mass casualty incident, in which providers and institutions are unable to adhere to conventional standards of care3 and improvisation is needed.4,5

Investigation of responses to mass casualty incidents, such as the Beirut Port explosion in 2020 and the Formosa Fun Coast Dust Explosion in Taiwan in 2015, revealed that modifications of standard processes were implemented by administrators, patient care teams, and individual clinicians.4,6 Examples of ad hoc adaptations included using non-traditional spaces for patient care, simplifying documentation processes, spontaneously reorganizing clinical teams, and “liberating” supplies from other patient care units.4,6

Workarounds are ubiquitous but less visible in daily work when there is no crisis but there are still persistent pressures to optimize efficiency and minimize workload7 despite poorly performing work systems.8 In fact, healthcare workers are often so good at workarounds that the magnitude of underlying system problems remains hidden.8

CON

Workarounds, or methods which circumvent established processes, can lead to significant patient safety concerns. Standardized processes designed to support efficient systems can sometimes impose barriers to day-to-day efficiency or the ability of an individual in the health system to complete their work. It is easy in these situations to identify a workaround that allows for more efficient care delivery in the immediate setting, however this may also create hazards. In 2018, ECRI Institute listed workarounds among the top 10 patient safety concerns for healthcare organizations.9

One example of the problems that workarounds can create relates to patient flow through a health system for appointments, referrals, and diagnostic tests. Many of us in our day-to-day work strive to maximize patient satisfaction, and in the setting of a diagnosis necessitating urgent care, try our best to get patients treated quickly. We may call other offices directly, “phone a friend,” or use other backchannels to get the earliest possible appointment. While this achieves the immediate goal for the patient, by not using an established process, the inefficiency of that process is never identified on a systems level. Instead of developing and implementing a standardized process to address urgent consults or orders, the use of workarounds will make the system appear to be functioning effectively and will force the continued use of the workaround as opposed to stimulating an improvement in the standardized process. Attempts to improve efficiency can also be taken to an extreme. A 2019 NYT article reported that nurses were hiding medications on their units because the pharmacy was taking too long to deliver medications needed by patients.10 As an isolated example,