ear irrigation guidelines.doc · web viewnhs grampian ear irrigation guidelines author murrap last...

Author & Co-ordinator: Paul E Murray

Reviewer: Sheila Wheeler

Approver: Lead Nurse group GP Sub-Committee

Identifier: Review Date: May 2006 Date: May 2005

UNCONTROLLED WHEN PRINTED

Version 3

Policy and Procedure forEar Irrigation Using the Propulse II and

Propulse III Universal Electronic Irrigator

Signature SignatureSignature

NHS Grampian Ear Irrigation Guidelines

Table of Contents

Guidance Document ………………………………………..………….. 3

Cerumen Management ………………………………………..………….. 4

Guidance for Ear Examination ………………………………………..………….. 4

Guidance on Patient Ear Care ………………………………………………….... 6

Guidance on the Use of Wax Softeners – Olive Oil

……………….…….. 6

Guidance on the Use of Syringes in the Ear

………………………………… 8

Reasons for Carrying Out Ear Irrigation Using the Propulse II

………….. 9

Reasons When Irrigation Should Not be Carried Out

………………………. 9

Equipment Requirements ………………………………………..………….. 9

Ear Irrigation Procedure ………………………………………..………….. 10

Guidance Notes for Aural Toilet

………………………………………..………….. 13

Guidance Notes for Removal of Excessive Wax Using Instrumentation ..

14

Decontamination Guidelines(as approved by

………………………………………..………….. 15

FAQs ………………………………………..………….. 17

Useful Links Relating to Ear Care ……………………………………………. 18

Bibliography ………………………………………..………….. 19

Appendix 1: 3C Checklist for Ear Irrigation ……………………….. 20

Appendix 2: Suggested Ear irrigation Consent Form

……………….. 24

Appendix 3: Additional Information on the Propulse III Universal

…………

25

An ear care website has been developed to support staff in Grampian. As well as information and downloads, there is also a discussion forum, an area for sharing good practice and an opportunity to ask questions.

The website can be found via the NHS Grampian Intranet NHS Grampian Ear Irrigation Guidelines - PEM 2

homepage, click on microsites, then ear irrigation.


Guidance Document

This guidance document has been produced to support all disciplines of staff working within NHS Grampian who undertake otoscopy, ear irrigation, aural toilet and manual wax removal. The experienced practitioner should always use their clinical judgement to select the most appropriate procedure and method for ear examination and wax removal.

These recommendations do not replace the need for education, training and supervision in order to develop confidence and competence when performing these procedures safely. If staff are undertaking ear irrigation as a new skill, then they are encouraged to use the 3C Ear Irrigation Observation Checklist [see Appendix 1].

It is no longer acceptable practice to use a chrome, metal, plastic syringe or the Propulse I for ear irrigation in Grampian. Please refer to ‘Guidance on the Use of Syringes in the Ear’ (page 8) for further information.

These guidelines endorse the use of both the Propulse II and Propulse III Universal for ear irrigation in Grampian. Where these guidelines refer to the Propulse II only, it is assumed that the Propulse III Universal is also included. Please refer to ‘Appendix 3’ for further information on the Propulse III Universal.

Thanks to everyone who have contributed and given feedback during the development of these guidelines. Acknowledgement also to the Primary Ear Care Centre (Rotherham Health Authority) for their guidance in preparing this document.

This document supercedes and replaces all previous Ear Irrigation Guidelines in Grampian.

This document has been compiled by Paul E Murray, Clinical Training Officer, NHS Grampian with input and approval from Clinical Staff, the Lead Nurse Group, the GP Sub-Committee, Infection Control, Risk Management and Mirage Health Group.

This document shall not be copied in part or whole without the express permission of the author or the author’s

NHS Grampian Ear Irrigation Guidelines - PEM 3

representative.


Cerumen Management

Wax or cerumen is a normal secretion of the ceruminous glands in the outer meatus and is slightly acidic, providing bactericidal qualities. A small amount of wax is normally found in the ear canal and its absence may be a sign that dry skin conditions, infection or excessive cleaning has interfered with the normal production of wax. It is only when there is an accumulation of wax that removal may be necessary.

A build-up of wax is more likely to occur in people who insert implements into the ear (frequent users of cotton buds, etc) have narrow ear canals, hearing aids, older adults and patients with learning difficulties. A build-up of wax may also occur as a result of anxiety, stress and dietary or hereditary factors.

Wax should only be removed if it is causing symptoms such as dulled hearing, itch, or discomfort.

If wax is removed due to a complaint of hearing loss, ascertain whether good hearing is restored after treatment or if the patient would benefit from a formal assessment by ENT or Audiology.

Guidance for Ear Examination

1. Prior to the physical examination of the ear, listen to the patient, elicit symptoms and take a careful history. Thorough hand hygiene (soap & water) should be undertaken before the physical examination starts.

2. ConsentExplain each step of any procedure or examination and ensure that the patient understands and gives consent. Consent may be given verbally or written depending on local preference [refer to appendix 2 for a suggested ear irrigation consent form]. If verbal consent is given, then it is important for the Health Professional to record that this has been asked and given in the patient’s notes.

3. Ensure that both you and the patient have privacy and are seated comfortably at the same level. Examine the pinna, outer meatus and adjacent scalp. Check for previous surgery incision scars, infection, discharge, swelling and signs of skin lesions or defects. Decide on the most appropriate size of speculum that will fit comfortably into the ear and place it on the auriscope.


NHS Grampian Ear Irrigation Guidelines Guidelines

Guidance for Ear Examination/ continued

4. Gently pull the pinna upwards and outwards to straighten the ear canal (directly down and back in children). Localised infection or inflammation will cause this procedure to be painful, so if this is present do not continue!

5. Hold the auriscope like a pen and rest your small finger on the patient's head as a trigger against any unexpected head movement. Use the light to observe the direction of the ear canal and the tympanic membrane.

6. There is improved visualisation of the ear drum by using the left hand for the left ear

and the right hand for the right ear, but clinical judgement must be used to assess your own ability. Insert the speculum gently into the meatus to pass through the hairs at the entrance to the canal.

7. Looking through the auriscope, check the ear canal and tympanic membrane. The ear cannot be judged to be normal until all the areas of the membrane are viewed. If the ability to view all of the tympanic membrane is hampered by the presence of wax, then wax removal will have to be carried out.

8. If the patient has had canal wall mastoid surgery, methodically inspect all parts of the cavity and tympanic membrane by adjusting your head and the auriscope. The mastoid cavity cannot be judged to be completely free of ear disease until the entire cavity and tympanic membrane has been seen.

9. The normal appearance of the membrane or mastoid cavity varies and can only be learned by practice. Practice will lead to recognition of any abnormalities.

10. Carefully check the condition of the skin in the ear canal as you withdraw the auriscope. If there is any doubt about the patient's hearing an audiological assessment should be made. Thorough hand hygiene (soap & water) should again be undertaken before going to complete any documentation.

11. Document what was seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus and any treatment given.

12. Findings should be documented, following your Professional Body’s recommendations on record keeping and accountability. If any abnormality is found, a referral should be made to the ENT Outpatient Department following local procedures.



Guidance on Patient Ear Care

Earwax forms a protective coating of the skin in the ear canal. Small amounts are made all the time and the quantity of earwax produced varies greatly from person to person.

The ear canal is usually self-cleaning. Patients should be discouraged from putting any implement into their ear as this can damage the delicate ear lining and increase the likelihood of ear infection, itchiness and problems with the build-up of wax.

Remember wax is not formed in the deep part of the ear canal near the eardrum, but only in the outer part of the canal. When a patient has wax blocked up against the eardrum it is often because they have been probing their ears with cotton buds, pen tops, match sticks, paper clips, Kirby grips or the end of their pencil! Patients shouldn’t put anything into their ears!

Patients should also be encouraged to maintain the health and well-being of their ears by keeping their ears dry during showering or bathing, as it may be their shampoo or soap that is irritating the skin. Patients should also ensure that they dry their ears using a towel or dry tissue afterwards.

Guidance on the Use of Wax Softeners – Olive Oil

Despite there being a vast array of wax softeners available, olive oil is the current oil of choice. These NHS Grampian guidelines recommend the use of olive oil as it is effective, cheap and readily available from Pharmacists in a glass dropper bottle that has been specifically designed for applying into the ear.

Maintenance UseEvidence and practical experience show that where patients suffer from excessive wax, the insertion of 1 to 2 drops of olive oil on a regular basis (e.g. weekly, depending on the Health Professional’s clinical judgement and the hardness of the wax) may help the ear clean itself, thus reducing or eliminating the need for regular ear irrigation.



Guidance on the Use of Wax Softeners – Olive Oil/ continued

Other Oils In UseIt is impossible to give a complete and definitive guide to all the ear softening oils available to patients, however some of the more commonly used oils include:

Almond Oil – should be avoided due to the risk of anaphylaxis caused by nut allergy. Sodium Bicarbonate – can be effective, but tends to dry the ear, which is unhelpful in older patients. ‘Over-the-counter’ products such as Cerumol or Otex are also not recommended routinely as they are generally more expensive and have no clear clinical advantage over olive oil. Their side-effects can also include local irritation to the ear lining which can further compound the patient’s ear problems.For further information on these drugs visit the BNF website at: http://www.bnf.org/bnf

Patient Advice Prior To Ear Irrigation Insert 1 to 2 drops of olive oil into the ear(s) requiring wax softening, every morning and evening commencing at least 3-7 days prior to treatment. The olive oil should be administered at 370. Patients can heat the oil to this temperature by placing the closed glass dropper bottle containing the oil into a cup of warm water for two minutes or by allowing it to come up to room temperature.

The patient should always test a drop of the oil on their hand to ensure that it is not too hot, before placing it in their ear and it may be easier for someone else to put the oil drops in.

Patient Advice Following Ear IrrigationThe ear canal may be vulnerable to ear infection after irrigation. This is caused by removal of all the wax, which has inherent protective properties for the ear canal. Until the ear produces more wax to protect the canal, patients should be encouraged to keep the ear(s) that have been irrigated dry from the entry of water for a minimum of four or five days after the procedure. This would include activities such as showering, bathing or swimming.

In the unlikely event that patients develop pain, dizziness, reduced hearing or discharge from the ear after the procedure, then they should be encouraged to return and consult with their nurse or doctor.



Guidance on the Use of Syringes in the Ear

Metal and plastic syringes are now obsolete for use in the ear canal.

Manual syringes are inherently dangerous due to a combination of the design, the pressure of water it creates within the ear canal and the difficulty of disinfecting the syringe after each use.

The Medicines and Healthcare Products Regulatory Agency (formerly the Medical Devices Agency) also has reservations about the use of the metal syringe for wax removal. They expressed concerns around the poor manufacture of some syringes allowing them to break and cause injury during use and the pressure of water that can be exerted manually on the tympanic membrane. More information can be found at their website: http://www.medical-devices.gov.uk

Electronic irrigators such as the "Propulse” allow irrigation of the ear canal rather then wax removal under pressure. The Medicines and Healthcare Products Regulatory Agency issued Safety Notice SN 9807 in February 1998, which advised users that the original Propulse electronic irrigator required an isolation transformer for electrical safety.

Subsequently the manufacturer designed and marketed the Propulse II to replace the original Propulse and from February 2005, the Propulse III Universal. This guidance document recommends that practitioners use an electronic ear irrigator rather than the manual syringe and refers to the procedure as ear irrigation. The Propulse II and III irrigators have variable pressure control of minimum-maximum, allowing the flow of water to be easily controlled by commencing irrigation on the minimum setting.

The use of the Propulse II or Propulse III Universal are the preferred irrigation methods for all staff in NHS Grampian.

Mirage will offer a part exchange to staff when upgrading from a Propulse I. For more information telephone: 0845 130 5440.

It is also recommended that only disposable ‘one use’ jet tips should be used. On no account should ‘one use’ items be reused or reprocessed. These disposable one use jet tips can be ordered directly from Central Stores.

Product Code: FP00389

Description: Tip Jet Disposal for Propulse II (Pack = 100)

Price: £42.00

A complete range of accessories and replacement parts are also available from Mirage by contacting 0845 130 5440 or go to www.miragehealthgroup.com and click on ‘Medical’.

Immediate queries can be sent to: [email protected] NHS Grampian Ear Irrigation Guidelines - PEM 9


Reasons for Carrying Out Ear Irrigation Using the Propulse II

This procedure is only to be carried out by a competent doctor, registered nurse, audiologist or by a learner who is being closely supervised by one of the above.

Irrigating the ear is carried out to facilitate the removal of cerumen and foreign bodies which are not hygroscopic*, from the external auditory meatus.

*Hygroscopic matter such as peas and lentils will absorb the water and expand, thus making removal more difficult. Remove discharge, keratin or debris from the external auditory meatus. Correctly treat otitis externa where the meatus is obscured by debris.

An individual assessment should be made of every patient to ensure that it is appropriate for ear irrigation to be carried out.

Reasons When Irrigation Should Not be Carried Out

The patient has previously experienced complications following this procedure. Six-week history of middle ear infection. The patient has undergone any form of ear surgery (apart from grommets that have

extruded at least 18 months previously and the patient has been discharged from the ENT Department).

Twelve month history of perforation or mucous discharge. The patient has a cleft palate (repaired or not). In the presence of acute otitis externa with pain and tenderness of the pinna.

Equipment Requirements

Auriscope Disposable ‘one use’ jet tip Noots trough Non-sterile/ non-powdered gloves

Jobson Horne probe Cotton wool Head mirror and light or head light Disposable waterproof cape or towel

Propulse II or Propulse III Universal electronic irrigator with water heated to 40°C Staff may also wish to wear safety glasses during the procedure

This procedure should be carried out with both participants seated and under direct vision, using a headlight or head mirror and light source throughout the procedure.



Ear Irrigation Procedure 1 of 3

Procedure Rationale

1.Check reason and source for referral. Ideally, medical staff or another suitably qualified professional should make the initial referral. Although in reality, patients tend to self-refer!

2.Check whether the patient has had their ears irrigated previously, or if there are any contraindications why irrigation should not be performed.

Explain the procedure to the patient and seek verbal or written consent [refer to guidance notes on consent, page 4].

A careful history and listening to the patient will ensure no patient with contraindications has their ears irrigated.

Consent and information are legal requirements and ensures the practitioner and patient understands the procedure fully.

3.Thorough hand hygiene (soap & water) should be undertaken before the physical examination starts then put on non-sterile/ non-powdered gloves.

Ask the patient to sit in an examination chair with the head tilted towards the affected ear.

A child could sit on an adult’s knee with the child’s head held steady.

Refer to the ‘Guidelines for Hand Hygiene’ document issued by the Infection Control Committee (2002) for further information.

The patients ear should be in the practitioner’s direct line of vision with the practitioner as close to the ear as possible. A sudden movement by the patient (particularly when it’s a child) could cause injury to the ear.

4.Examine both ears with the auriscope and record findings. These findings will determine whether the patient does or does not require ear irrigation. If the clinical decision is not to irrigate, then this should be explained to the patient and documented.

An examination of both ears offers an opportunity for comparison. A written record of findings should be made in accordance with Professional for Record Keeping Standards (e.g. NMC).

5.Place the protective cape and towel (to be disposed of in orange bag later) on the patient's shoulder and under the ear to be irrigated. Ask the patient to hold the receiver under the same ear.

The procedure should be as comfortable as possible for the patient and the receiver should catch the water from the ear.

6.Check that the headlight is in place and the light is directed down the ear canal.

The headlight ensures a well-lit area to work safely. This is especially important when irrigating in patient’s homes.

7.Check that the temperature of the water is approximately 40°C and fill the reservoir of the irrigator.

Too cold water may cause the patient to jump increasing the risk of perforation and too hot water may burn or damage the ear canal.



Procedure Rationale8. Set the pressure to minimum. Too strong a pressure, too early in the

procedure may cause the patient to feel dizzy. If this does occur, stop irrigating and ask the patient to fix their gaze on some object for approximately 5 minutes until the dizziness has passed.

9. Connect disposable ‘one use’ jet tip to tubing of machine with a firm push/ twist action, pushing until a ‘click’ is feIt.

This ensures that the applicator is connected correctly.It is recommended that the jet tips used are disposable, one use only.

10. Always use a clean speculum and probe for each patient.

11. Direct the irrigator tip into the Noots receiver and switch on the machine for 10-20 seconds, circulating the water through the system, discarding the initial flow of water.

This enables the noise of the machine to be more easily accepted by the patient and to remove any static water remaining in the tube.

12. Ensure the light from the headlight is shining over the ear throughout the entire procedure.

To practice safely you must at all times be in direct vision of the patients’ ear. If anything untoward does occur, you will be in a position to act immediately.

13. Twist the disposable ‘one use’ jet tip so that the water can be aimed along the posterior wall of the ear canal (towards the back of the patient's head).

This ensures the safest position for irrigating.

14. Advise patient you are about to commence, then gently pull the pinna upward and backward or directly backward in children.

To straighten the meatus.

15. Warn the patient that you are about to start irrigating and that the procedure will be stopped if they feel dizzy or experience any pain.

This will ensure that the patient is ready to proceed and any problems can be identified.

16. Place the tip of the nozzle into the ear canal entrance and using the foot control*, direct the stream of water along the roof of the ear canal, towards the posterior canal wall.

If you consider the entrance to the ear canal as a clock face, you would direct the water at 11 o'clock in the right ear and 1 o'clock in the left ear.

The tip is the only part the manufactures recommend to be placed at the opening of the ear as damage may be caused by inserting the tip into the ear.

*The manufacture recommends the use of the foot pump. A direct water stream hitting the tympanic membrane may cause a perforation.



Procedure Rationale

17. Increase the pressure control gradually, if there is difficulty removing the wax.

Gradual increase of pressure is usually successful in moving earwax.

18. It is advisable that a maximum of two reservoirs of water are used in any one irrigating procedure. An increase in pressure would not be recommended.

If wax does not move after the maximum water is used the patient needs to instil olive oil for a further 3-7 days.

19. Irrigation should never cause pain. If the patient complains of pain - stop immediately!

20. If you have not managed to remove the wax within five minutes of irrigating, it may be worthwhile moving on to the other ear.

The introduction of water via the irrigating procedure will soften the wax and it may be worth retrying irrigation after about 15 minutes.

21. Periodically inspect the meatus with the auriscope and inspect the solution running into the receiver.

If the meatus becomes red or inflamed or show any signs of bleeding, the procedure must stop!

22. After removal of wax or debris, dry mop excess water from the meatus under direct vision using best quality cotton wool and the Jobson Home probe (if available) [refer to guidance notes on Aural Toilet].

Stagnation of water and any abrasion of skin during the procedure, predispose to infection. Removing the water with the cotton wool tipped probe reduces the risk of infection.

23. Examine ear, both meatus and tympanic membrane and treat as required, following specific guidelines or refer to doctor if necessary.

If any abnormality is found a referral should be made back to the doctor or to the ENT Outpatient department. Remove gloves and dispose in clinical waste (orange bag).

A careful examination establishes accurate treatment. The whole ear starting on the outside working in, must be examined and any treatment outwith the practitioners expertise should be referred to the doctor.

24. Give advice regarding ear care and any relevant information.

Thorough hand hygiene (soap & water) should again be undertaken before going to complete any documentation.

Patient education is essential to empower patients to take control of their own ear health and reduce ear problems.

25. Document what was seen in both ears including the condition of the tympanic membrane and external auditory meatus

- the procedure carried out and any treatment given- the condition of both ears and any hearing changes prior to leaving the patient.

This will ensure there is an accurate record of what was seen prior to commencing, what action was taken and the condition of the ears prior to the patient leaving.Records should be completed following Professional Guidelines.



Guidance Notes for Aural Toilet

Aural toilet is used to clear the aural meatus of debris, discharge, soft wax or excess fluid following irrigation. This procedure is only to be carried out by a competent doctor, registered nurse, audiologist or by a learner who is being closely supervised by one of the above.

1. An individual assessment should be made of every patient to ensure that it is appropriate for aural toilet to be carried out.

2. Thorough hand hygiene (soap & water) should be undertaken before the Aural Toilet starts and staff should put on non-sterile/ non-powdered gloves. Examine the ear and dry mop using a Jobson Horne probe and a small piece of fluffed up cotton wool (the size of a postage stamp) applied to the probe. Under direct vision (with headlight or head mirror and light), pull the pinna to straighten the canal and clean the ear with a gentle rotary action of the probe. Do not touch the tympanic membrane.

3. Replace the cotton wool as soon as it becomes soiled. Soiled cotton wool should be disposed of in the clinical waste (orange bag). Pay particular attention to the anterior-inferior recess, which can harbour debris.

4. Re-examine the meatus using the auriscope intermittently during cleaning to check for any debris, discharge or crusts, which may remain in the meatus at awkward angles.

5. Patients who have mastoid cavities should be followed up in the ENT department unless the nurse, doctor or audiologist has been specifically trained in this area. The frequency of cleaning required by the cavity will depend on the individual patient. If the cavity gets repeatedly infected the patient should be considered for revision surgery.

6. If an infection is present treatment should follow patient group directives and referral guidelines or as dictated by the result of a swab culture and sensitivities following the failure of first line management. If the patient has repeated problems with the ear, an ENT Surgeon should review the patient.

7. Give advice regarding ear care and any relevant information. Gloves should be removed and hand hygiene (soap & water) should again be undertaken before going to complete any documentation.


8. Document what was seen in both ears including the condition of the tympanic membrane, the procedure carried out and any treatment given. Also record the condition of both ears and any hearing changes prior to leaving the patient. If any abnormality is found a referral should be made to the ENT Outpatient Department following local policy.


Guidance Notes for Removal of Excessive Wax Using Instrumentation

This procedure is only to be carried out by a competent doctor, registered nurse, audiologist or by a learner who is being closely supervised by one of the above.

These notes are for guidance only and the practitioner should use their clinical judgement on the most appropriate method to remove wax.

1. Thorough hand hygiene (soap & water) should be undertaken before the examination takes place and staff should put on non-sterile/ non-powdered gloves. Examine the ear to discern the type of wax to be removed. Ask yourself if it is healthy wax or may it be bacterial debris of wax-like appearance? Is it dry crumbly wax related to Dermatitis or soft and beige wax in both ears which can be associated with high cholesterol?

2. Hard, crusty wax can often be gently manoeuvred out of the meatus with a ring probe, using a head mirror or light for illumination. If this treatment becomes painful, do not continue as the meatal lining quickly becomes traumatised, risking infection.

3. Instruct the patient according to your clinical judgement – they may be required to go and use olive oil for a further week. The patient can then return for irrigation or further instrumentation. Excessive soft wax or crumbly wax and debris can be wiped out with cotton wool wound onto a Jobson Horne probe (see Aural Toilet guidance on previous page) or irrigation. Gloves are removed and hand hygiene (soap & water) should again be undertaken before going to complete any documentation.

4. If a perforation is suspected behind the wax, advise the patient to use olive oil in very small amounts, but to stop using it if they experience any pain.

5. Give advice regarding ear care and any relevant information.

6. Document what was seen in both ears including the condition of the tympanic membrane and external auditory meatus, the procedure carried out and any treatment given. Also record the condition of both ears and any hearing changes prior to leaving the patient. If any abnormality is found a referral should be made to the ENT Outpatient Department following local policy.



Decontamination Guidelines

Aural care and ear irrigation are clean not sterile procedures and staff have two options when decontaminating their non ‘single use’ equipment.

Mirage only recommend the use of their own Propulse Cleaning Tablets. They are provided in an easy-to-use formula, removing the need for clinicians to mix batches of cleaning solution. This also eliminates unnecessary wastage.

The second option is to use NaDCC (Sodium Dichloroisocyanurate 0.1%) available in Grampian as HAZ tablets. These tablets should be stored in a cool, dry place away from sunlight. COSHH regulations must be observed when using NaDCC.

Non-sterile gloves and a disposable apron should be worn when carrying out any decontamination procedure. This procedure should be undertaken in a designated deep sink and not in a 'hand wash’ sink, as these basins should be used for hand hygiene only.

Propulse Electronic Ear Irrigator

Stage 1: Each day before use, the electronic ear irrigator must be disinfected.

Using the Propulse Cleaning Tablets :

1. Place one Propulse cleaning tablet into the reservoir, fill with warm water to the 500ml mark on the reservoir and wait for the tablet to completely dissolve.

2. Run the Propulse Electronic Ear Irrigator for a few seconds to fill the pump and hose.3. Leave to stand for 10 minutes. DO NOT leave the solution in the unit for longer. 4. Empty the reservoir of the solution, then fill the reservoir with cool boiled water and

flush through the whole system to ensure no cleaning solution is left.

Using NaDCC Tablets :

1. Follow the manufacturer's instructions to get a solution which provides 1000 parts (NaDCC) per million (0.1%).

2. Fill the water tank with the NaDCC solution.3. Run the irrigator for a few seconds to allow the solution to fill the pump and flexible

tubing.4. Leave to stand for 10 minutes. 5. Empty the water tank then rinse the system through with tap water before use.



Decontamination Guidelines/ continued

Stage 2: At the end of the day (or at the end of the ear irrigation session), the irrigator should again be decontaminated.

Using the Propulse Cleaning Tablets :

1. Place one Propulse cleaning tablet into the reservoir, fill with warm water to the 500ml mark on the reservoir and wait for the tablet to completely dissolve.

2. Run the Propulse Electronic Ear Irrigator for a few, then leave to stand for 10 minutes. DO NOT leave the solution in the unit for longer.

3. Empty the reservoir of the solution, then fill with cool boiled water and flush the whole system to ensure no cleaning solution is left.

Using NaDCC Tablets :

1. Follow the manufacturer's instructions to get a solution which provides 1000 parts (NaDCC) per million (0.1%).

2. Fill the water tank with the NaDCC solution.3. Run the irrigator for a few seconds to allow the solution to fill the pump and flexible

tubing, then leave to stand for 10 minutes. 4. Empty the water tank then rinse the system through with cool boiled water. 5. Any NaDCC solution must be discarded at the end of each session/ day.

Following decontamination, all equipment must be stored dry, preferably in a container that will ensure safe storage and prevent the accumulation of dust or debris on the equipment.

Note: The water does not have to be of 'injection quality' as this would be too expensive and impractical for irrigation or rinsing purposes. Similarly tap water is not acceptable and must not be used for the final rinse.

Only disposable ‘one use’ jet tips should be used. On no account should ‘one use’ items be reused or reprocessed.

After each individual patient treatment, items of equipment should also be disinfected: Jobson Horne Probe - send to Central Sterilising Services or use an instrument

washer/ disinfector followed by an autoclave. Instruments must be allowed to cool completely before further use.

Speculum for Otoscope – as above, although some practitioners may find it more appropriate to use disposable speculae.



Nootes Ear Tank – as above.

FAQs

CAN I STILL USE THE OLD CHROME OR PLASTIC SYRINGES?

No. The NHS Grampian Ear Irrigation Guidelines are based on the National Ear Care Guidance Document (endorsed by the Royal College of Practitioners, the Royal College of Nursing, the Primary Ear Care Centre and the Medicines and Healthcare Products Regulatory Agency). These guidelines state that the chrome/ plastic syringe is now obsolete. Continued use of these manual syringes endangers patient safety and undermines the integrity of the Health Professional. Remember 90% of litigation concerning ear irrigation involves the chrome syringe!

MY WORKPLACE STILL USES THE PROPULSE I, IS THIS ACCEPTABLE?

No. The Medicines and Healthcare Products Regulatory Agency issued Safety Notice SN 9807 in February 1998, which advised users that the original Propulse electronic irrigator required an isolation transformer for electrical safety. (More information can be found at: http://www.medical-devices.gov.uk)

In the majority of areas a ‘circuit-breaker’ was not being used and the Propulse was withdrawn. The Propulse II and Propulse III Universal now have in-built isolation transformers, making ear irrigation much safer. There is a general consensus in Grampian that the Propulse I is now antiquated and staff are advised to only use the Propulse II or Propulse II Universal.

Mirage will offer a part exchange to staff when upgrading from a Propulse I and for more information telephone: 0845 130 5440.

HOW LONG SHOULD THE PATIENT USE OLIVE OIL DROPS BEFORE HAVING EAR IRRIGATION?

It is dependent on the Health Professional's clinical judgement, however practitioners in Grampian generally agree that 3 – 7 days work best. [See page 6 of these guidelines for more details]

CAN I IRRIGATE A CHILD'S EARS?

This again depends on the Health Professional's clinical judgement and skill. If irrigation is indicated, then most clinical areas in Grampian will refer the child to Sick Children’s A&E or ENT. However, if you do proceed then ask yourself, is the irrigation



really necessary, will the child co-operate, does the parent consent and is the person carrying out the irrigation fully trained and competent to do so?


Useful Links Relating to Ear Care

NHS Grampian Ear Care Website NHS Grampian Intranet homepage microsites ear irrigation

This website has been developed to support all staff in Grampian. As well as information and downloads, there is also a discussion forum, an area for sharing good practice and an opportunity to ask questions.

Primary Ear Care Centre www.earcarecentre.com

The Primary Ear Care Centre is a unique pioneering organisation providing and promoting effective ear care for people with ear and hearing problems in the primary care setting.

Mirage Health Group http://miragehealthgroup.com

Manufacturers of ear irrigation products including the Propulse II and Propulse III Universal Electric Ear Irrigator.

Royal College of Nursing www.rcn.org.uk

Website representing nurses and nursing, promoting excellence in practice and shaping health policy.

Nursing Midwifery Council www.nmcuk.org

The Nursing and Midwifery Council website providing guidelines for standards of care to patients and clients.

Royal College of General Practitioners

www.rcgp.org.uk

Website run by the Royal College of General Practitioners for GPs.

Department of Health www.doh.gov.uk

Department of Health website highlighting current issues in the NHS

ENT Nursing www.entnursing.com

A website providing a national approach to ENT Nursing development, sharing good practice, and enhancing professional and personal development.



Bibliography

Aung,T. ; Mulley.G.P. (2002) Removal of ear wax. British Medical Journal. 325:27

Eckhof J A H, de Beck G h. Le Cessie S. Springer M P. (2001) A quasi-randomised controlled trial of water as a quick softening agent of persistent earwax in general practice. British Journal of General Practice August: 635-637

Fisher,E.W.;Pfleiderer,A.G. (1992) Assessment of the otoscopic skills of general practitioners and medical students: is there room for improvement?. British Journal of General Practice. Vol. 42:65-67.

Price, J. (1997) Problems of ear syringing. Practice Nurse. 14:126-8

Ney, D.F. (1993) Cerumen impaction, ear hygiene practices and hearing acuity. Geriatric Nursing. Mar/ Apr.:70-73.

Nursing Midwifery Council (2002) Code of Professional Conduct: Standards for Conduct, Performance and Ethics.

. Nursing Midwifery Council (2004) Guidelines for Records and Record Keeping.. Rodgers, R. (2001) The National Diploma of the Primary Ear Care Centre

booklet

Rodgers R.W. (2002) Continued education: preventive ear care. Nursing in Practice. March: 71-73

Rodgers R. (2000) Understanding the legalities of ear syringing. Practice Nurse 19(4)166-169

Roesser, R.J.; Ballanchanda, B.B. (1997) Physiology, pathophysiology, and anthropology/ epidemiology of human ear canal secretions. Journal of American Academy of Audiology. Vol. 8:391-400.

Rotherham Primary Ear Care Centre.

Sharp, J.F.; Wilson, J.A.; Ross, L.; Barr-Hamilton, R.M. (1990) Ear wax removal: a survey of current practice. British Medical Journal. Vol. 301:1251:1252.

Spiro, S. (1997) A cost-effective analysis of ear wax softeners. Nurse Practitioner. Vol. 22(8): 28,30-31.

+ Appendix 1 (3C Checklist), Appendix 2 (Consent Form) and Appendix 3 (Propulse III Universal Information)



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