Implementation of an Acute Tonsillitis Protocol in a District General Hospital: A Two-Cycle Audit

Background Acute tonsillitis is a common presentation in ear, nose, and throat (ENT), placing a considerable burden on emergency and inpatient services due to the high volume of admissions and resource use. At our district general hospital, the absence of a formalised pathway contributed to inconsistent reassessment practices and prolonged admissions. This audit evaluated whether implementing a standardised acute tonsillitis protocol could improve the timeliness of clinical review and support more efficient inpatient management. Methods A two-cycle audit was conducted over identical three-month periods (September to November 2023 and 2024). Adult patients (≥18 years) referred to ENT with a clinical diagnosis of tonsillitis were included. A structured protocol was introduced, emphasising reassessment within six hours to identify suitability for discharge on oral therapy. Implementation included departmental teaching, protocol dissemination, and the use of visual prompts. Data were collected retrospectively in Cycle 1 and prospectively in Cycle 2. Outcomes included time to second review, length of stay (LOS), and two-week readmission rates. Analyses were performed using Mann-Whitney U, Fisher's exact test, and linear regression. Results A total of 49 patients were included in Cycle 1 and 54 in Cycle 2. The median time to second review decreased by 3.25 hours (9.0 to 5.75 hours, p = 0.031) following protocol implementation. The median LOS reduced by six hours (24.0 to 18.0 hours), though not statistically significant (p = 0.083). Among patients with a recorded second review, no significant association was found between review timing and LOS (Cycle 1: β = 0.89, p = 0.24, Cycle 2: β = -0.38, p = 0.55). The two-week readmission rate increased from 6.1% to 11.1%, though this was not statistically significant (p = 0.49). Conclusion Implementation of a standardised tonsillitis protocol improved the consistency and timeliness of inpatient reassessment and showed a clinically meaningful trend toward reduced LOS. While not statistically significant, the observed operational gains may support more efficient bed use in resource-constrained services. Based on the observed reduction in length of stay and typical monthly admission volumes, this corresponds to an estimated four to five bed-days released per month. Ongoing monitoring, staff education, and re-audit are required to ensure safe, sustained adoption and to further evaluate the pathway's longer-term clinical and service impact.