LMC Guide to Ear Care
As I’m sure you are aware, ear irrigation is not stipulated within the GMS contract. The GP and or qualified nurse 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) Practices are advised to take into consideration their resources, competency of staff, training needs, safety and risk of litigation. In some circumstances the patient may need to be referred to an alternative service, make arrangements for an audiological assessment or for an additional diagnostic assessment if needed.
The recommendation from the RCN, The Rotherham NHS Foundation Trust, Medical Defence Organisations and the BMA is that the GP and or registered nurse remains responsible for any task such as ear irrigation delegated to an unregistered practitioner (HCA). The NMC (2015) requires that any registered nurse that delegates a task to another person is adequately supervised and has ongoing support and access to a clinician (1)
The role of an unregistered practitioner (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) (2)
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 following extract is taken from the guidelines.
"Prescribe ear drops for 3–5 days initially, to soften wax and aid removal.
Olive oil, or almond oil drops can be used 3-4 times daily for 3-5 days (do not prescribe almond oil ear
drops to anyone who is allergic to almonds).
Sodium bicarbonate 5%, sodium chloride 0.9% - Sodium chloride 0.9% is not available as a proprietary
ear drop product. However, sodium chloride 0.9% nasal drops can be prescribed for use in the ear (off-label use).
Do not prescribe drops if you suspect the person has a perforated tympanic membrane.
Warn the person that instilling ear drops may cause transient hearing loss, discomfort, dizziness and irritation
of the skin.
If symptoms persist, consider ear irrigation, providing that there are no contraindications.
If irrigation is unsuccessful, there are three options:
- Advise the person to use ear drops for a further 3–5 days and then return for further irrigation.
- Instill water into the ear. After 15 minutes irrigate the ear again.
- Refer to an Ear Nose and Throat specialist for removal of wax.
Advise anyone who has had earwax removed to return if they develop otalgia, or significant itching of the ear, discharge from the ear (otorrhoea), or swelling of the external auditory meatus, as this may indicate infection"
Before accessing an appointment for with the nurse, patients should be encouraged to oil their ears for an agreed period prior to having them re-assessed for ear irrigation. It is essential to ensure there are no contraindications prior to undertaking the procedure and this is documented in the patient’s notes. The person undertaking the task may consider (if trained and competent) using a Jobson–Horne probe to remove the wax under direct vision.
Many practices in attempting to reduce demand for appointments have produced a leaflet encouraging self-care. At the LMC we have produced a leaflet based on advice and recommendations from The Rotherham Ear Care Centre, NICE Guidelines 2018 and that produced by Twyford Surgery who have kindly agreed for us to share this information. This updated leaflet can be amended by practices depending on their own policy. Please click here to access the leaflet - Earwax - an LMC guide
The following are useful websites to refer to for further advice:
http://www.earcarecentre.com/ (The Rotherham Ear Care Centre)