LMC Guide to Ear Care
As I am sure you are aware, ear irrigation is not stipulated within the GMS contract. The GP registered nurse/health care professional has a duty under contract to assess the patient, undertake the appropriate examination and decide whether ear irrigation is the best course of action. Never refusing appointments for those patients where ear wax may be contributing to hearing loss or other symptoms or where the wax needs to be removed to facilitate examination of the ear (NICE 2018). Ear irrigation is not always essential, if the patient has been clinically assessed as per the Rotherham care pathway.
Diagnoses, delegation & training
Practices are advised to take into consideration their resources, competency of staff, their training needs, patient safety and possible risk of litigation. In some circumstances the patient may need to be referred to an alternative service or make arrangements for an audiological assessment or an additional diagnostic assessment if needed.
The recommendation from the RCN, NHS Digital and the GMC is that the GP and or registered nurse/health care professional remains responsible for any task such as ear irrigation delegated to another including an unregistered practitioner e.g. HCA. The NMC requires that when a registered nurse delegates a task to another person then they are adequately supervised, have ongoing support and access to a clinician.
The role of an unregistered practitioner e.g., HCA, is not to diagnose but to work within guidelines and protocols, it is therefore not appropriate for an HCA to make the initial assessment. Medical Protection Society would support ‘reasonable delegation’ within the field of the HCA’s expertise ensuring that they are fully trained, competent and follow a robust protocol. “The degree of risk must have been assessed because ultimately the patient has a right to the same standard of care, whoever delivers it “(CQC Mythbusters Health Care Assistants in General Practice. Oct 2015).
It is essential to ensure that the person undertaking the procedure can provide evidence that they have received training are competent and capable. The person undertaking the procedure may consider (if trained and competent) using a Jobson–Horne probe to remove the wax under direct vision. (Rotherham NHS Trust - Aural instrumentation guidelines.) Fundamentally it is important that if anything untoward happened in your practice, the Partners could stand in front of a Coroner or Judge and justify that the training they had provided for their staff was sufficient to ensure they were competent, and confident to undertake the task given to them.
Patient education & advice
Before accessing an initial appointment with a registered nurse/health care professional patients should be encouraged to oil their ears for an agreed period prior to having them re-assessed for ear irrigation. The NICE guidelines on the management of earwax published in June 2018 suggest that the use of drops for 3-5 days prior to irrigation can work well for a significant number of patients. The research available suggests that there are some advantages of using softening agents prior to ear irrigation but there is no evidence that one type is superior to another (Cochrane study 2018).
It is essential to ensure there are no contraindications prior to undertaking the procedure and this is documented in the patient’s notes. (CKS/NICE March 2021). Many practices in attempting to reduce demand for appointments have produced a leaflet encouraging self-care (Rotherham Ear Care Centre – patient leaflets)
Impact of Covid – restarting ear irrigation.
Due to Covid most if not all practices have ceased offering face to face appointments for ear irrigation some are now starting to consider whether to reintroduce this procedure. Practices are advised to encourage their patients to self-manage the problem where possible, however impacted ear wax can be debilitating for some people.
There have been discussions about whether ear microsuction or irrigation are aerosol generating procedures. We are following NHS England’s guidance and it does not list either microsuction or irrigation as an aerosol procedure.
As an organisation we want to ensure that we provide you with the relevant advice the information above may help your practice in deciding if you want to re-introduce this procedure. Some practices and PCNs are now considering offering micro suction as an alternative to ear irrigation. Given the specialist nature of this we would suggest that this needs to be commissioned as a Locally Commissioned Service.
The following are useful websites to refer to for further advice:
http://www.earcarecentre.com/ (The Rotherham Ear Care Centre)