Specifying a service for the surgical management of otitis media with effusion in children

Service components

The key components of a service for the surgical management of otitis media with effusion (OME) in children are:

• ensuring accurate assessment and diagnosis of OME in children
• ensuring appropriate specialist referral and management of children with OME
• developing a high-quality service for the surgical management of OME in children.

Ensuring accurate assessment and diagnosis of OME in children

The diagnosis and general management of OME in children is described in detail in NICE clinical guideline CG60 on surgical management of OME. Ensuring that children with features suggestive of OME are accurately assessed, have the diagnosis confirmed and, where appropriate, are offered surgical management is important both in terms of good clinical management and in managing service demand.

OME may be overlooked because of the insidious nature of the condition, and suspicion of hearing loss in children must be acted upon effectively. Therefore, concerns from parents, carers or professionals about features suggestive of OME should lead to an initial assessment and subsequent formal assessment for confirmation of diagnosis if considered necessary. See the NICE clinical guideline CG60 quick reference guide for further information on care pathways, including initial and formal assessment. Commissioners should ensure that services provide a formal assessment, some of which may be provided in primary care or community settings.

NICE clinical guideline CG60 on surgical management of OME recommends that persistent bilateral OME and hearing loss should be confirmed over a period of 3 months before intervention is considered and that a child's hearing loss should be re-tested at the end of this time. Commissioners will need to ensure there is timely access to, and sufficient service capacity for, hearing tests suitable for the developmental stage of children presenting with OME. Children may be placed on multiple waiting lists (for example, ear, nose and throat (ENT) as well as audiology) as GPs attempt to gain access to the service for their patients in the quickest possible way^[1]. The Department of Health report on Improving access to audiology services in England states that commissioners should carry out a rigorous needs assessment of the local population and review existing provision of audiology services to identify gaps and the potential for improvements. This may also provide the opportunity to review current practice and develop an integrated care pathway with clinicians and other health and social care professionals, for example, community paediatricians, health visitors, school nurses and teachers. The pathway should identify clear criteria for referral and support consistent thresholds for surgical management of OME in line with NICE clinical guideline CG60 on surgical management of OME.

The topic-specific advisory group identified that it is useful for diagnostic reports from audiology to include the interpretation of results and an indication of whether onward referral is thought necessary. This can help to reduce the length of time on the patient pathway.

Transforming services for children with hearing difficulty and their families: a good practice guide advises that where possible initial hearing assessment should be carried out in a local hearing service with multidisciplinary and cross-sector working. Until local hearing services are fully developed, this may require collaboration with ENT services for access to expertise and facilities.

Ensuring appropriate specialist referral and management of children with OME

NICE clinical guideline CG60 on surgical management of OME states that persistence of hearing loss with adverse affects on the child will require further action, which may include surgery. Once a decision has been taken to offer surgery, it is important that there is a minimum of delay. Therefore commissioners will need to ensure that referral, assessment and access to surgery are timely. Adjuvant adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms.

Hearing aids should be offered to children with persistent bilateral OME and hearing loss as an alternative to surgical intervention where surgery is contraindicated or not acceptable. This may include children who have Down's syndrome and OME with hearing loss.

It is anticipated that the implementation of NICE clinical guideline CG60 on surgical management of OME should not require a major change in what is already current practice in many areas. However, commissioners may need to consider that the management of children with OME can be complex and long term and requires specialist resources. There may also be resource implications in the non-surgical management of OME, particularly if a hearing aid is fitted.

Developing a high-quality service for the surgical management of OME in children

NICE clinical guideline CG60 on surgical management of OME recommends.

• Treatment and care should take into account children's needs and preferences together with those of their parents or carers.
• Good communication between healthcare professionals and the parents or carers of children with OME is essential. This should be supported by evidence-based written information tailored to the particular patient's needs.
• During the active observation period, advice on educational and behavioural strategies to minimise the effects of the hearing loss should be offered.
• Hearing testing should be carried out by trained staff using tests suitable for the development stage of the child, and calibrated equipment.
• The care of children with Down's syndrome who are suspected of having OME should be undertaken by a multidisciplinary team with expertise in assessing and treating these children.
• Hearing aids should normally be offered to children with Down's syndrome and OME with hearing loss.
• The care of children with cleft palate who are suspected of having OME should be undertaken by the local otological and audiological services with expertise in assessing and treating these children in liaison with the regional multidisciplinary cleft lip and palate team.

Commissioners may wish to consider delivering a service for the management of OME in children in a number of different ways, and mixed models of provision may be appropriate across a local health economy. Examples include:

• joint clinics with paediatric audiology (this could be a community paediatric audiology service) and a consultant ENT surgeon or a paediatrician with expertise in developmental paediatrics and a special interest in audiology
• one-stop consultant-led primary care clinics
• direct surgical listing from paediatric audiology services.

The Shifting care closer to home: care closer to home demonstration site - report of the speciality subgroups identifies a hospital-based one-stop hearing and assessment service, where children no longer have to shuttle between hospital-based and community-based services. However, some care closer to home demonstration sites triage children aged under 5 years directly to secondary care, partly because of the need for more complex audiological testing and enhanced room facilities when assessing younger children. For further information on the requirements of audiology services, see also the quality assurance section for further information.

Surgical treatment of OME can be provided as day case surgery, but should meet the standards identified in the Healthcare Commission report Improving services for children in hospital, which emphasises the standards needed for children's services, including anaesthesia. Surgery for children: delivering a first class service contains recommendations aimed at improving the quality of service, training, individual and team performance in children's surgery.

Commissioners should ensure that the standards of care are in place for children with OME, who are often of pre-school age, and their parents or carers. The environment must comply with the requirements of the National service framework for children, young people and maternity services and in particular Getting the right start: National service framework for children, young people and maternity services: Standard for hospital services. Clinics that are known to be family-friendly will have higher attendance rates, thus maximising efficiency of the service and reducing waiting times^[2].

Local stakeholders, including service users, should be involved in determining what is needed from a service for the surgical management of OME in order to meet local needs. The service needs to be child-centered and integrated with other elements of health and social care.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service
• the expected number of children (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access, including access to interpreting services for audiology services and service location; commissioners should engage with parents and carers and other relevant individuals and organisations locally
• care and referral pathways, including audiology for GPs and other health and social care professionals, and by direct access as prents should be able to refer their own child if they have concerns about his or her hearing^[2]
• information and audit requirements, including high quality information systems that enable children's progress to be tracked across agencies; this is crucial in ensuring a seamless journey across complex pathways
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
• service monitoring criteria.

Useful sources of information may include:

• Delivering the 18 week patient pathway: audiology commissioning pathways - glue ear in children.
• Transforming services for children with hearing difficulty and their families: a good practice guide provides advice for commissioners and service providers on changing the way services for children with hearing difficulties and their families are commissioned and delivered, and on reducing waiting times.
• The Map of medicine provides an information resource that visually organises the latest evidence and best practice guidelines.

References

1. House of Commons Health Committee (2007) Audiology services: Fifth report of session 2006-07. London: The Stationery Office.

2. Department of Health (2008) Transforming services for children with hearing difficulty and their families: a good practice guide. London: Department of Health.