Policy Number LCH-51

This document has been reviewed in line with the Policy Alignment Process for Liverpool Community

Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational

change this FRONT COVER has been added so the reader is aware of any changes to their role or to

terminology which has now been superseded. When reading this document please take account

of the changes highlighted in Part B and C of this form.

Part A – Information about this Document

Policy Name Ear irrigation Policy

Policy Type Board Approved (Trust-wide) ☐ Trust-wide ☐ Divisional / Team / Locality ☒

Action No Change ☐

Minor Change ☐

Major Change ☐

New Policy ☒

No Longer Needed ☐

Approval

As Mersey Care’s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements

Signature: Date:

Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document New terminology when reading this Document

Part C – Additional Information Added (to be used with ‘Major Changes’ only)

Section /

Paragraph No Outline of the information that has been added to this document – especially where it may

change what staff need to do

Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)

Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)

Accountable Director

Recommending Committee

Approving Committee

Next Review Date

LCH Policy Alignment Process – Form 1

Policy Number LCH-1

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SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and

promote the welfare of children and adults, including:

being alert to the possibility of child / adult abuse and neglect through their observation of

abuse, or by professional judgement made as a result of information gathered about the

child / adult;

knowing how to deal with a disclosure or allegation of child / adult abuse;

undertaking training as appropriate for their role and keeping themselves updated;

being aware of and following the local policies and procedures they need to follow if they

have a child / adult concern;

ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team;

participating in multi-agency working to safeguard the child or adult (if appropriate to your

role);

ensuring contemporaneous records are kept at all times and record keeping is in strict

adherence to Mersey Care NHS Foundation Trust policy and procedures and professional

guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you

hold within the organisation;

ensuring that all staff and their managers discuss and record any safeguarding issues that

arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience

prejudice and discrimination. The Equality Act 2010 specifically recognises the protected

characteristics of age, disability, gender, race, religion or belief, sexual orientation and

transgender. The Equality Act also requires regard to socio-economic factors including

pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the

provision of services and in our role as a major employer. The trust believes that all people

have the right to be treated with dignity and respect and is committed to the elimination of

unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights

Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and

promote Human Rights in everything they do. It is unlawful for a public authority to perform any

act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service

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delivery in line the with a Human Rights based approach and the FREDA principles of

Fairness, Respect, Equality Dignity, and Autonomy

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Liverpool Community Health Trust

Ear Irrigation Policy

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Title Policy for use of a Propulse 2/3 Irrigator within the Treatment Rooms and LCH Community services

Guideline 5

Aim and Purpose

of Guideline To provide guidance for all LCH staff within

Liverpool Community Health who perform ear

irrigation

Author Ear Syringing Lead LCH Trust Team Leader LCH Treatment Room Service Service Lead Ambulatory Care and Diagnostics

Type Reviewed Document

Review Date

September 2018

Person/Group

accountable for

review

Service Manager for Walk in Centres and Treatment Room

Type of evidence

based used

C: Evidence which includes published and/or unpublished

studies and expert opinions

Issue Date August 2016

Authorised by

Clinical Policy

Group

23rd August 2016

Equality Analysis Yes Yes

Date when Undertaken Evidence Collated 02/04/2013

X

X X

X

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Version Control

Version Number 2

Ratified by: Clinical Policies Group

Date of Approval: 23rd August 2016

Name of Originator/Author: Ear Irrigation Lead – Treatment Rooms

Margaret Carran / Joyce Collier

Nurse Clinician Ambulatory Care

Approving Body/Committee: Clinical Policies Group

Date Issued: September 2016

Review Date August 2018

Target Audience: Practitioners undertaking ear irrigation

using Propulse 2/3 irrigator

Name of Lead Director / Managing

Director:

Director of Nursing

Changes / Alterations made to Previous

Version:

Front page included

Change in referral criteria

Patient information leaflet updated

and link included in the policy

Appendix amended and links

added

This Document was circulated to the Following Individuals for Consultation

Name Designation

Ann Lamkin Service Manager: WIC & Treatment

Rooms

Louise Hornby Team Leader Treatment Room Service

Kate Byrom Part Time Team Leader Treatment Room

Service

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Contents Page

1. Introduction 5

1.1 Background Information 5

2. Purpose 5

3. Scope 4

4. Definitions 5

5. Duties and Responsibilities 5

6. Referral Criteria 5

7. Training 6

8. Equipment 6

8.1 Equipment required for irrigation 6

9. Ear Irrigation Process 7

9.1 Documentation 7

9.2 Clinic Procedure 7

10. Linked areas / Information 8 11. References 8

List of Appendices 8

1. Competency Frameworks

2. Declaration of Competency

3. Treatment Room Referrals

4. Ear irrigation Procedure – Video

5. Ear Wax Flowchart

6. Ear Irrigation Objectives

7. Patient Information Leaflet s for Liverpool + Sefton

8. Letter template for Clinic M at BGH

9. M Clinic Opening Times + Telephone Number

10. Ear Irrigation Audit

11. – 15. Links for Other Relevant Information

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1. Introduction

Assessment of patients for irrigation of the ear/s is a procedure frequently

undertaken within Liverpool Community Health (LCH).

This policy is designed to give clarity and support to all LCH staff

on the assessment, management, treatment and ongoing care of

all patients requiring ear irrigation.

Ear irrigation is undertaken for the purpose of removing wax from the

external auditory meatus (ear canal) for a variety of reasons e.g.

• Ear wax which can block the ear canal causing hearing loss/pain/tinnitus

• A hearing aid mold is required

• Earwax is causing a problem to the hearing aid

1.1 Background Information

Ear wax also known as cerumen is a normal bodily secretion (made up of oils,

sweat, keratin, debris, and foreign bodies) which forms a protective coating over the

skin of the ear canal and drum. It is the body’s natural way of protecting the ear from

damaging substances due to its anti-fungal and anti-bacterial properties, itvaries in

form and appearance and should only be removed if necessary.

Although the ear has natural mechanisms for the removal of ear wax, it is

recognised that due to contributory factors certain people do experience

problems with the accumulated wax that necessitates ear irrigation. Ideally,

excessive wax should be removed before it becomes impacted, giving rise to

tinnitus, hearing loss, vertigo, pain and discharge (Harkin 2000).

Ear irrigation is an invasive procedure with the potential to cause discomfort

or injury (Cook 1998) and therefore must only be considered when other

conservative methods of wax removal have failed (e.g. use of softeners).

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2. Purpose

This Policy is designed to ensure quality and consistency in the care of

people requiring ear irrigation using the propulse 2/3 irrigator from practitioners

working within LCH Trust.

3. Scope

This policy applies to all staff who are employed by LCH Trust who have

completed the competency framework and training (Appendix 1).

This policy applies only for ear irrigation of patients over the age of 16.

Anyone under the age of 16 should be referred to Alder Hey Childrens

Hospital for assessment.

4. Definitions

Ear Irrigation – The process used to remove wax from the ear canal using a

controlled

jet stream of water via a machine.

Tympanic Membrane – The eardrum.

Perforation of the Tympanic Membrane – A hole in the eardrum caused by some

kind of trauma or infection.

Otitis Externa – Infection of the outer ear/ear canal.

Otitis Media – Infection of the middle ear (area behind the tympanic membrane).

Tinnitus – a ringing/buzzing noise in the ears.

Noot – A disposable trough used to catch water/debris.

5. Duties and Responsibilities

All personnel undertaking ear irrigation will be expected to comply with the

Trust training and complete the ear irrigation competency framework

(Appendix 1).

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Those staff undertaking this procedure will also be required to complete a

competency declaration prior to their yearly PDR (Appendix 2).

LCH staff who are competent in ear irrigation also have a responsibility

for cleaning equipment prior to use as outlined in section 8 of this policy.

Equipment Services are responsible for the 12 monthly maintenance of the

equipment and staff are expected to ensure that the equipment they are using

has been appropriately serviced within the last 12 months.

6. Referral Criteria

Treatment Room Service: This as an adult only service(over 16yrs old), patients

can either self-refer into the service or they can be referred by another Health Care

Professional (HCP) as we now have designated Ear Irrigation Clinics across the city

(Liverpool and Sefton). These clinics run on an appointment only system therefore

the wait is dependent on individual clinic appointment availability whether it be a self-

referral or a referral by other means e.g. fax, all appointments have to be made by

telephoning the Central Booking Line Service.

District Nursing Service: This as an adult only service (over 16yrs old), for those

patients that are housebound and are unable to attend a clinic setting. Patients can

either self-refer into the service or they can be referred by another Health Care

Professional (HCP). Whether it is a self-referral or a referral by other Health Care

Professional this is either through Single Point of Care (Monday to Friday) or the

District Nursing Team direct (weekends and bank holidays).

7. Training Requirements

All LCH staff will be required to complete a training program in order to

develop the appropriate knowledge and skills to fulfill the required

competencies and safely perform the procedure. Please see the Training

Needs Analysis (Appendix 13).

8. Equipment - Cleaning and maintenance

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Equipment used is the Propulse 2 or 3 Irrigator.

The irrigator has a maintenance check on a yearly basis by Equipment

Services as per LCH Policy (see Infection Control Policy Appendix10).

Prior to using the Propulse 2/3 irrigator it must have been cleaned using

chlorine releasing cleaning tablets;

• Fill the tank to 500ml with warm tap water

• Dissolve a chlorine releasing table in the water.

• Run the irrigator for a few seconds to allow solution to fill pump and

flexible tubing, then leave to stand for 10 minutes.

• Run the chlorine water through the irrigator until the tank is empty.

• Rinse the water tank with warm water, then refill the tank with warm water and

run through the irrigator again until the tank is empty.

• The tank is then dried and the irrigator base turned upside down

and is ready for use.

After every patient – the disposable jet tip should be changed along with

the tip (speculum) of the auroscope, as they are all individual use only.

When changing the tips the auroscope and jet tip handles should be

wiped with a detergent wipe such as tuffy wipes.

Equipment required for irrigation

• Waterproof material to protect patient

• Auroscope with white halogen light and disposable speculum

• Propulse 2/3 machine foot or hand control

• Disposable jet tip applicators for propulse machine

• Disposable noots for collecting water and debris

• Tissues

• Tap water at body temperature (37 degrees)

• Apron and Gloves and protective goggles (PPE)

• Headlight

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9. Ear Irrigation Process

9.1 Documentation

Documentation should be completed in accordance with NMC

guidelines for record keeping and in accordance with local record

keeping policy. This can be in Electronic or Paper Form

(Appendix 12 Record Keeping Policy link).

9.2 Clinical Procedure

The step by step procedure for ear assessment and irrigation is

discussed and demonstrated in (Appendix 4 the Video link.) and at the

LCH training day.

A full and relevant history should be obtained from the patient prior to

irrigation in order to ensure an informed consent for the procedure.

The information obtained should include the following and should be

clearly documented in accordance with record keeping policies.

Staff should take a detailed history and record the following;

• History of previous ear irrigation

• Hearing loss / Hearing aids

• Tinnitus

• Ear Pain

• Previous ear surgery

• History of perforation

• Recent ear infection

• History of Grommets or T Tubes

• Complications following previous ear irrigation

• Have they used a softener and for how long

Once satisfied that there are no contraindications and the procedure is

appropriate and necessary, they should visualise the ear canal and ensure that

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wax is occluding a healthy ear drum and appears soft enough to irrigate. They

should then explain the risks of irrigation and document this in the notes. If the

patient is happy with the information given regarding the procedure they can

then proceed to irrigate. Once the procedure is completed staff should visualise

the Tympanic Membrane and document what they see. Post irrigation advice

should be given to the patient and the LCH Patient Information Leaflet offered.

All used equipment should be safely disposed of in accordance with LCH local

infection control policy.

The list of contraindications and precautions to irrigation is discussed in detail on the

training day and is by no means exhaustive and should be used in conjunction with

the staffs own clinical judgment which are as follows;

Precautions

Irrigation can be performed on a low setting if the patient has

A history of a healed perforation (confirmed by a GP, Consultant or other

Professional person).

Suffers with tinnitus.

A history of vertigo or Meniere’s disease and is not currently having an

episode of dizziness or was triggered on a previous irrigation.

Patient is taking anticoagulants.

Contraindications

Irrigation should NOT be performed if;

1. The patient has a history of a complication post procedure in the past, eg

vasovagal attack, chronic infections, MI, extreme dizziness or nausea etc.

2. There is a history of ear infection that has been treated in the last 6 weeks

(they can be rebooked for irrigation 6 weeks post completion of treatment if no

other contraindication reported)

3. The patient has had any ear surgery (except grommets that have extruded

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more than 18 months ago)

4. The patient was born with a cleft palate regardless of whether it has been

repaired or not

5. There is any evidence of otitis externa with any pain or tenderness to the

pinna

6. The patient has a perforation that has not been diagnosed as healed.

7. There is a history of mucous discharge.

8. Sudden acute undiagnosed unilateral hearing loss.

If irrigation is contraindicated or unsuccessful the patient can be referred to M Clinic

at Broadgreen Hospital. They will need to be given a letter (Appendix 8) detailing the

reason for review at ENT along with the list of opening times and contact details

(Appendix 9). If the patient experiences any complications post irrigation procedure,

they should be sign posted either to their GP, M Clinic or nearest WIC or A+E for

medical advice/review in regards with the clinical judgement of the practitioner at the

time.

10. Audit

The monitoring of the use of this guideline should be undertaken by individual

services and localities where ear irrigation is performed as part of their local audit

plan. (Appendix 10, audit used by the Treatment Room Service).

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Appendix

1. Competency Frameworks

EAR IRRIGATION COMPETENCY FRAMEWORK.docx

2. Declaration of Competency

THE DECLARATION OF EAR COMPETENCY RECORD.docx

3. Treatment Room Referral

Treatment Room Referral Form Sefton Feb 2015.doc

Treatment Room Referral Form Liverpool Feb 2015.doc

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4. Ear irrigation Procedure

http://www.nwyhelearning.nhs.uk/elearning/northwest/liverpool/healtheclips/in

dex.html

5. Ear Wax Flowchart

Ear Wax Flowchart.docx

6. Ear Irrigation Objectives

3502_LCH_Treatment_A5_v3 leaflet for reconfiguration.pdf

7. Patient Information Leaflets for Liverpool and Sefton

LCH Ear Leaflet Liverpool.pdf

LCH Ear Leaflet Sefton.pdf

3502_LCH_Treatment_A5_v3 leaflet for reconfiguration.pdf

8. Template M Clinic letter with editing rights

New Patient Letter 1.rtf

9. M Clinic Opening Times and Contact Number

New ENT Opening Times.doc

10. Ear Irrigation Audit – including report

Ear Syringing Audit Report 2016.docx

Linked areas / information

This policy should be read in conjunction with;

11. Infection control

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http://opera.liverpoolch.nhs.uk/SIRS/Policies-and-Procedures/Clinical%20Policies/Standard%20Precuations%20Policy.PDF

12. Consent

http://opera.liverpoolch.nhs.uk/SIRS/Policies-and-Procedures/Clinical%20Policies/Consent%20to%20Treatment%20Policy.pdf

13. Record Keeping

http://nww.liverpoolch.nhs.uk/service-directory/corporate-

services/clinical-record-keeping.htm

14. TNA

http://nww.liverpoolch.nhs.uk/Downloads/LDB/Mandatory-

TNA/Mandatory%20TNA%20Version%206%20%2001.07.15.docx

15. Customer Service / Pals

http://nww.liverpoolch.nhs.uk/service-directory/corporate-

services/customer-services-department.htm

16. References

• DOH (2001) Reference Guide for Consent. HMSO.London

• Harkin, H (2002) Guidance Document in Ear Care endorsed by the

Royal College of General Practitioners, Royal College of Nursing,

Primary Ear Care Centre, and the Medical Devices Agency.

www.entnursing.com

• Kaufman G (1998) Ear problems, Care and Prevention.

Practice Nurse Vol 15 p338-342 NMC (2008) Code of

Professional Practice.

• Primary Ear Care Centre website: www.earcarecentre.com

• Rogers R (2000) Understanding the legalities of ear syringing.

Practice Nurse 19 (4) p166-169 Rogers R (2001) The National

Diploma of the Primary Ear Care Centre Booklet.

• Sharp JF, W ilson JA, Ross L, Barr- Hamilton RM (1990) Earwax removal; a

survey of current practice.

• British Medical Journal. Vol 301, p1251-1252

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