Recommendations for clinical care guidelines on the management of Otitis Media in Aboriginal and Torres Strait Islander Populations

Section F-1: Practical Considerations in Health Care Delivery

Address implementation issues and barriers to ensure effective, high quality care for all clients

Page last updated: 14 October 2011

Address implementation issues and barriers to ensure effective, high quality care for all clients

StrategyRelevant Information
Effective PreventionSevere OM is usually a disease of poverty. Improved living standards, maternal education, breast feeding, provision of a smoke free environment and pneumococcal vaccination will decrease rates of acute perforation and CSOM.
Awareness among families and teachers for early identification of language, learning and behavioural problems, early hearing assessment and appropriate management is very important for the prevention of OM related hearing loss and its consequences.
Interpreters should be used whenever possible if English is not the first language of the family.
A video otoscope can assist in helping patients and families to understand ear disease. This may lead to greater engagement in its prevention and management.
Aboriginal Health Workers are the main workforce delivering primary care services in remote communities. Training and support should be provided for all health staff to increase adherence to the strategies for improve prevention, diagnosis and management of OM.
Additional community-based ear workers may be required to sustain hearing health education programs.
Effective DiagnosisTraining is required for staff (including all health workers, nurses and GPs) in the following diagnostic instruments. Training should also cover the appropriate interpretations of results.
A tympanometer or a wall mounted pneumatic otoscope is essential equipment for all Community Health Centres. Specific instruction on how to examine young children should be provided. This equipment can help to assess middle ear aeration. It supports the accurate diagnosis of OME.
A video otoscope is useful for informing family members about ear problems, for recording changes in the eardrum over time, and for transmitting images for diagnostic review (tele-otology).
Effective Diagnosis
Continued
A ‘LumiView’ (or similar instrument for hands-free illumination of the ear canal) allows thorough cleaning of the canal under direct vision. This can greatly improve the visualisation of the TM.
A pure-tone audiometer enables trained staff (ear health workers, Aboriginal Health Workers and remote nurses) to perform hearing tests.

Diagnostic hearing assessments should only be performed by qualified, trained audiologists or audiometrists.
Standardised, calibrated audiometers and a quiet environment are required for pure tone audiometry. Do not perform hearing tests if a very quiet room is not available (e.g. heavy rain outside).
Referral to a major regional hearing centre is required to determine level of hearing loss in children <3 years of age.

Referral to a major regional hearing centre is also required for all children with hearing loss >25dB.
Telehealth strategies may results in better diagnosis and management as well as opportunities for ongoing training and support.
Effective ManagementEarly intervention for detection of OM (and related hearing loss and its consequences) should be made a priority for infant and early childhood health and education programs. Formal collaboration between local health clinics and education services is recommended.
Compliance with treatment is essential to achieve expected outcomes. Combinations of appropriate patient instruction, reminders, close follow-up, supervised self-monitoring and rewards for success are recommended.
Refrigeration of antibiotics may represent a problem for some families. This issue should be addressed at the time of initial treatment and options proposed e.g. supervised dosing, use of intramuscular antibiotics, single dose azithromycin or use of antibiotic sachets to be made up by families.
A strategic plan for the management of OM and hearing loss in individual communities should be developed by local health and education staff. This should be supported by regional and visiting specialist staff. Ideally, this should be evaluated regularly using the available process and outcome indicators.
Additional process indicators (e.g. frequency of assessment, detection, treatment, and referral) should be considered in order to monitor the level of service. Each indicator should be defined to ensure that they can influence continuous quality improvement without being a burden. Health Centre record reviews can help in monitoring levels of activity.
Effective Management
Continued
Disease registers (clinic-based recall and reminder systems) are recommended for all chronic illnesses that improve with adherence to a structured treatment plan. Health practitioners should consider putting all children with CSOM and persistent hearing loss on disease registers (local clinic-based recall and reminder systems). This can be used to ensure regular review and to follow clinical progression or resolution of the disease.

Disease registers may also include clear information on all diagnostic findings, results of hearing assessment and other tests; treatments given, referral notes and findings. They should support two way communication between primary care and audiology/ENT/speech services.

There should be a written ENT management plan available after each ENT procedure. The visiting ENT surgeon should be available via phone/email for post operative concerns.
Access to specialist services (Audiology and ENT) is essential in the provision of comprehensive care. When referral to an audiologist for full hearing assessment is necessary (and if they cannot be seen locally), the family should be given the option of travelling to a major centre. Where referral is indicated, the hearing test should occur within 3 months, and review by an ENT surgeon should occur as soon as possible and within 6 months.
Access to speech therapy is essential for those children who suffer from speech and language problems. The primary care workers should be given information about the ‘Education Services’ and ‘Disability Support Units’, and how to access other relevant services in their region.
Schools and other educational services should be aware of educational resources that are locally available. This would include the access to Health Centres, ‘Teachers of the Deaf’, ‘Advisory Visiting Teachers’, and sound field amplification systems.
Hearing assessments in regional centres may need to be booked in conjunction with a medical appointment to ensure that travel assistance is available.
ENT surgeons are responsible for ensuring that a post-operative management plan is available for each individual who has surgery. Written recommendations should be discussed with the appropriate health care providers.

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