Community Audiology Clinic Service (Children)

Standards and Guidelines

Reference Number:

NHSCT/09/226

Responsible Directorate: Children’s Services

Replaces (if appropriate): Legacy Trust Speech and Language Therapy Audiological Services Standards and Guidelines

Policy Author/Team: Lynn Ashcroft, Speech and Language Therapy Team Manager Teresa Degnan, Head of Educational Audiology, NEELB

Type of document: Inter Agency Standards and Guidelines between NEELB and NHSCT

Approved by: Brenda McConville Assistant Director Paediatrics and Neonatology Date Approved: October 2009

Date Policy disseminated by the Policy Unit: 16 November 2009

NHSCT Mission Statement To provide for all the quality of services we would expect for our families

and ourselves

COMMUNITY AUDIOLOGY CLINIC SERVICE (Children)

STANDARDS AND GUIDELINES

SEPTEMBER 2007

Date of Implementation: September 2007 Date of 1st Review: April 2009 Date of 2nd Review: April 2011

Contributors: Lynn Ashcroft Teresa Degnan

This guidance should be read in conjunction with:- � Newborn Hearing Screening Programme Guidelines for Surveillance and Audiological

Monitoring of Infants and Children following the newborn hearing screen version 3.1 - June 2006.

� Northern Ireland Newborn Hearing Screening programme Professional Guidance for NHSSB

Community Audiology Staff - September 2005. � Guidance for Staff providing Community Audiology Services within the NHSSB area: The

Child Health System and the 8 month Hearing Assessment - April 2007. � Audiological Guidelines for Health Visitors � Community Audiology Administrative Guidelines

CONTENTS 1. INTRODUCTION

1.1 Purpose of Community Audiology Service 1.2 Principles of Service Delivery 1.3 Definitions

2. PROCESS CHART 3. REFERRALS 4. AUDIOLOGICAL ASSESSMENT 5. TEST RESULTS 6. REVIEW 7. REFERRAL 8. DISCHARGE 9. EQUIPMENT

APPENDICES Appendix 1 NHSP Risk Factors Appendix 2 Clerical Support Staff contact details Appendix 3 Community Audiology Referral Form Appendix 3(i) & (ii) Test Result Forms Appendix 4 Guidance on Writing Hearing Test Outcomes

Appendix 5 Summary of Test Results table

Appendix 6 Procedures for Referral to ENT / Letters Appendix 7 Guidance on Completion of Audiology Clinic List Appendix 8 Alert to HV re Decline / Non Attendance

ABBREVIATIONS

NHSP Newborn Hearing Screening Programme

PCHR Personal Child Health Record

HV Health Visitor

GP General Practitioner

SLT Speech and Language Therapist

CHS Child Health System

CMV Cytomegalovirus

NNU Neonatal Unit

IPPV Intermittent Positive Pressure Ventilation

AABR Automated Auditory Brainstem Response (screening test)

AOAE Automated Oto Acoustic Emissions ENT Ear Nose and Throat PCHI Permanent Childhood Hearing Impairment

1. INTRODUCTION 1.1 PURPOSE

The purpose of the Community Audiology Service is to assess the hearing level of children, with a specific focus on pre-school children from 6 months of age. Following assessment, information regarding test results will be shared and onward referral made, as appropriate. The Community Audiology Service is unable to offer a service to any child: • already known to ENT • unable to move their head to locate sound • whose vision is severely impaired • unable to sit unsupported • who is over-sensitive to sound, with no concerns about hearing

1.2 PRINCIPLES OF SERVICE DELIVERY

1. To provide a timely and efficient multi-disciplinary service. 2. To provide age appropriate hearing tests of children for whom there is parental or

professional concern.

3. To support the Newborn Hearing Screening Programme (NHSP) by offering follow up or further assessment to identified children at 8 months.

4. To screen out inappropriate referrals to hospital ENT/Audiology departments.

1.3 DEFINITIONS

Age at Testing: Ages in this document refer to corrected ages i.e. age adjusted for prematurity (based on 40 week term). Age of testing may be interpreted with some flexibility i.e. 8 months may be 7-12 months.

2. COMMUNITY AUDIOLOGY PROCESS

REFERRALS Health Visitors, Community Paediatric Staff,

Parents, GP, SLTs, Child Health System - NHSP Educational Psychology

Hearing same q or deteriorated

GP/HV will be alerted if child has never had a clear response to hearing testing and has failed to attend.

3. REFERRALS

1. An open referral system is in operation.

Audiological Assessment

DNA Hearing Normal

Mild / Moderate Loss

Significant Loss

Discharge

Discharge

2-3 month recall

Audiological Assessment

Refer to ENT urgent/routine

Results: � Recorded in PCHR � Sent to Referrer / HV / GP � Recorded on CHS

2. Appointments are offered within 8 weeks of referral. 3. Criteria for referral: Any child

� for whom there is parental or professional concern regarding hearing � for whom there is general concern regarding development who does not have recent

hearing test results

� who has recurrent ear infections

� who has delayed speech or language development

� who has failed hearing testing by Health Visitor Babies requiring further assessment following NHSP referred by CHS for testing at 8 months as � they have one or more risk factors for newborn hearing screening (Appendix 1) � they have failed to attend both appointments offered for newborn hearing screening

� their parents have withdrawn consent to newborn hearing screening

� they have no record of completed newborn hearing screening on CHS

4. Referrals will be received in writing by the Clerical Staff supporting the Community

Audiology Service, using the Community Audiology Referral Form (Appendix 3). (Contact details are listed in Appendix 2.)

Telephone referrals will only be accepted from parents.

4. AUDIOLOGICAL ASSESSMENT

1. The Community Audiology Service is provided by a multi-disciplinary team which may

include:-

� Speech and Language Therapist/Audiologist � Audiologist � Teacher of the Deaf � Community Paediatricians � Speech and Language Therapist � Speech and Language Therapy Assistant

2. The principal assessor will hold a qualification in Audiology (or have significant clinical expertise in paediatric hearing testing)

3. The second assessor must have attended in-service training in paediatric hearing

testing 4. Both assessors will wear name badges and will introduce selves to parents 5. Parents/carers will be asked if they have any concerns regarding their child’s hearing 6. Children with a chronological or developmental age 6 months - 4.06 years will be

assessed using free field audiological tests 7. All tests used will be age-appropriate and use frequency specific stimuli across

the frequency range e.g. 6-18 months The Distraction Test 1.06 - 2.06 years The Co-Operative Test 2.06 - 4.06 years The Performance Test 8. Stimuli will be measured for volume, using a sound level meter 9. Visual Response Audiometry will be used for children aged 6-18 months, where available 10. The McCormick Toy Test of Speech Discrimination will be used for children aged

2.06 - 4.06 years, as part of the test battery 11. Pure Tone Audiometry will be used for children with a chronological or

developmental age over 4.06 years 12. Tympanometry will be used when children fail their hearing test

5. OUTCOME OF ASSESSMENT

1. Results of audiological assessment will be explained to the parent/carer at the time

of the assessment

2. Results will be recorded in the PCHR and on the test result forms (Appendix 3(i) or

3(ii)) using terminology provided in Guidance (Appendix 4 & Appendix 5) NDCS leaflet ‘Glue Ear’ will be offered to parents, if appropriate

3. Results will be supplied to the referring agent / GP/ HV within 15 working days 4. Results will be recorded on the Child Health System using SPOTRN indicators

NON-ATTENDANCE 1. When parents fail to attend the Community Audiology appointment, a second

appointment will be offered. (See 8. Discharge) CANCELLATION 2. Patients who cancel their first appointment will automatically be offered a second

appointment. If a second appointment is cancelled, the patient will not normally be offered a third opportunity and will be referred back to the referring agent. (See 8. Discharge)

6. REVIEW

1. Children failing audiological testing will be reviewed and re-tested in 2-3 months 2. Children with Down’s Syndrome will be offered annual review until 5 years and

thereafter bi-annually in Community Audiology clinics or in Special School (ref: DSMIG 2000)

7. REFERRAL

1. Children with a mild hearing loss < 40 dBHL will be referred to their GP if there is concern

regarding build up of ear wax, and discharged 2. Children with a hearing loss > 40 dBHL who fail hearing testing on 2 occasions,

will be referred to ENT. The referral will be made by Head of Service, NEELB or SLT/Audiologist Northern Health & Social Care Trust, following agreed procedures (Appendix 6)

8. DISCHARGE

1. Children who have passed their hearing test will be discharged 2. Children who have been referred to ENT will be discharged 3. Non-Attendance

Parents will be informed in writing if they have failed to attend or cancelled two appointments and how to request a further appointment. A copy will be sent to HV, GP, CHS and referring agent.

The HV and GP will be alerted to children referred by CHS following NHSP, who fail to attend Community Audiology and who have never had a clear response to hearing screening. (Appendix 8) A re-referral will only be accepted if the carer/holder of parental responsibility contacts the Community Audiology clinic clerical support staff.

4. All parents will be informed of how to request a re-test if they have further concerns.

9. EQUIPMENT 1. All audiological equipment will be calibrated annually * 2. Equipment used in Community Audiology clinic will include:

� Sound Level Meter *

� Manchester high frequency rattle

� G Chime bar approximately 1500 Hz

� C Chime bar approximately 500 Hz

� Warble Tone *

� McCormick Toy Test

� Pure Tone Audiometer *

� Tympanometer *

� Play materials - for distraction - for repetitive games used in

Co-operative and Performance testing

REFERENCES McCormick B (1993) Paediatric Audiology 0-5 years Whurr Publishers, London McCormick B (2001) Neonatal Hearing Screening and Assessment The Distraction Test as a procedure for Hearing Screening A Recommended Test protocol www.nhsp.info

Wood S (2003) Neonatal Hearing Screening and Assessment Protocol for the Distraction Test of Hearing www.nhsp.info McCormick B (1994) Screening for Hearing Impairment in Young Children Whurr Publishers, London Day J (2002) Neonatal Hearing Screening and Assessment Visual Response Audiometry Testing of infants A recommended Test Protocol www.nhsp.info

McCormick B (2000) Screening and Surveillance for Hearing Impairment in Young Children prof.bmc@onetel.com NDCS (2000) Quality Standards in Paediatric Audiology Volume 4 National Deaf Children’s Society, London Down Syndrome Medical Interest Group (2000) (DSMIG) Basic Medical Surveillance essential for People with Down’s Syndrome - hearing impairment www.dsmig.org.uk British Journal of Audiology (1988) 22 123

APPENDIX 1

Newborn Hearing Screening Programme Risk Factors

These risk factors are listed in PCHR reverse of page 17

Risk Factor Risk Factor Description 1. Congenital infection Proven or possible congenital infection

due to toxoplasmosis, rubella, CMV or herpes as determined by TORCH screen, and notified at any age

2. Craniofacial anomalies A (noticeable) craniofacial anomaly

(excluding minor pits and ear tags) at any age, e.g. cleft palate

3. High levels of ototoxic Child who has had high levels of drugs administered ototoxic drugs (outside therapeutic range) including aminoglycoside e.g. gentamicin and frusemide 4. Bacterial meningitis Confirmed or suspected bacterial

meningitis or meningococcal disease 5. Family history of hearing loss Hearing loss in baby’s parents or

(parents/siblings only) siblings; should be permanent (i.e. not glue ear) and present from childhood, irrespective of degree of loss

6. IPPV > 5 days NNU child who had IPPV > 5 days 7. Jaundice at exchange Jaundice where bilirubin (normally

transfusion level unconjugated) reached a level indicating the need for exchange transfusion, taking into consideration other factors such as hypoxia, acidaemia and prematurity

8. Neurodegenerative or e.g. microcephaly, cerebral palsy neurodevelopmental disorders 9. Syndrome Confirmed syndrome related to hearing

loss, e.g. Down’s syndrome 10. NNU protocol results Bilateral clear response at AABR and

the infant has not acquired a clear response in at least one ear at AOAE

An infant with one or more risk factors will be offered an audiological assessment at 8 months

APPENDIX 2

Community Audiology Clinic

Clerical Support Staff contact details LARNE BALLYMENA & ANTRIM Audiology Appointments Audiology Appointments Larne Health Centre Ballymena Health Centre Gloucester Avenue Cushendall Road Larne BT40 1PB Ballymena BT43 6HQ Tel: 028 2827 5331 Tel: 028 2531 3162 Fax: 028 2827 9560 Fax: 028 2564 9051

MAGHERAFELT BALLYMONEY Audiology Appointments Audiology Appointments Community Health Office Community Information Service 44 King Street Child Health Magherafelt BT45 6AH Armour Site Tel: 028 7963 4831 Newal Road Fax: 028 7930 0401 Ballymoney BT53 6HD Tel: 028 2766 1825

CARNMONEY & WHITEABBEY COLERAINE Audiology Appointments Audiology Appointments Health Office Community Information Service 40 Carnmoney Road Child Health Newtownabbey Armour Site Tel: 028 9083 1423 Newal Road Fax: 028 9083 1414 Ballymoney BT43 6HD Tel: 028 2766 1823

CARRICKFERGUS & BALLYCLARE Audiology Appointments Community Health Office Carrickfergus Health Centre Taylors Avenue Carrickfergus BT38 7HT Tel: 028 9331 5823 Fax: 028 9336 7173

APPENDIX 3

COMMUNITY AUDIOLOGY REFERRAL FORM

____________________________________________________________________________ Name: _______________________________________ DOB: ______________________ Address: _____________________________________ Ref by: _____________________ Telephone: ___________________________________ H+C No: ___________________ GP: __________________________________________ HV: _______________________ Address: _____________________________________ School: ____________________ ____________________________________________________________________________ Reason for concern regarding Hearing Comment where relevant on:- Family History, Birth History, Perinatal History, Medical History, Developmental History, Speech and Language Development. History of Hearing Results including, most recent HV hearing test results. Social Services involvement etc.

____________________________________________________________________________ History of Hearing Test Results: • Results of NHSP, and date • Results of McCormick Toy Test, and date ____________________________________________________________________________ Signed: _____________________________________ Date: ______________________

APPENDIX 3 (i)

COMMUNITY AUDIOLOGY RESULTS FORM

NAME: __________________________________________________ LOCATION: ______________________ ADDRESS: _______________________________________________ DATE OF TEST: ___________________ DATE OF BIRTH: __________________________________________ AGE: ____________________________ GP/SCHOOL MEDICAL OFFICER: ____________________________ REFERRED BY: ___________________ SCHOOL/CENTRE: ________________________________________ DATE OF REFERRAL: ______________ or NHSP printout date + 2 months HEALTH + CARE NUMBER: ________________________________ IS THIS APPT A RECALL? Yes / No HISTORY: SPEECH AND UNDERSTANDING OF LANGUAGE:

RESULTS / TESTS USED:

DISTRACTION (6-18 months) STIMULUS LEFT RIGHT PASS WARBLE LEFT RIGHT PASS

High Frequency Rattle

4000 Hz 30 dBA

S

2000 Hz 30 dBA

G Chime

30 dBA

1000 Hz 30 dBA

C Chime

500 Hz 30 dBA

Voice, eg hum

CO-OPERATIVE (18 months - 2 ½ years) TYMPANOMETRY::::

LEFT RIGHT PASS

LEFT RIGHT

Following spoken command 40 dBA

HFR 30 dBA

S 30 dBA

COMMENTS:

2K / G Chime

PERFORMANCE (2 ½ years +)

LEFT RIGHT PASS

Go 30 dBA S 30 dBA Other eg warble 500 Hz 30 dBA

4000 Hz ACTION:

SPEECH DISCRIMINATION TEST:

LEFT RIGHT PASS

McCormick Toy Test 40 dBA

RESULT: Pass

Fail

S P O T R N

Copies to: CHS Central/Ballymoney Office

TESTED BY: _____________________________________________________ Referring Agent HV GP

APPENDIX 3 (ii)

COMMUNITY AUDIOLOGY RESULTS FORM

PURE TONE AUDIOMETRY

NAME: _____________________________________________ LOCATION: _____________________________ ADDRESS: _________________________________________ DATE OF TEST: _________________________ DATE OF BIRTH: ____________________________________ AGE: __________________________________ GP/SCHOOL MEDICAL OFFICER: ______________________ REFERRED BY: _________________________ SCHOOL/CENTRE: __________________________________ DATE OF REFERRAL: ____________________ or NHSP printout date + 2 months HEALTH + CARE NUMBER: ___________________________ IS THIS APPT A RECALL? Yes / No HISTORY:

SPEECH AND UNDERSTANDING OF LANGUAGE:

Pure Tone Audiogram in dBHL 250 500 1000 2000 4000 8000

L

Air: R

Comments:

250 500 1000 2000 4000 8000

Bone: L

R Comments:

Speech Discrimination Test Free Field Left Right Pass Level

40 dBA

Tympanograms Left Right

Comments: Action:

RESULT: Pass

Fail S P O T R N

Copies to: CHS Central/Ballymoney Office

TESTED BY: _____________________________________________________ Referring Agent GP

APPENDIX 4

Guidance on Writing Hearing Test Outcomes on Results Form

1. Ensure all child’s details are completed on results form. 2. Ensure date and location of test is complete and indicate referring agent, date of referral

or NHSP printout date plus 2 months, and if test is a recall.

3. Essential to complete details re Understanding of speech and language -

because this is used for prioritisation by ENT. 4. Results - indicate by � which test carried out and complete result details.

Indicate all tests attempted

Record by � if Pass or Fail Record S P O T R N results by � in correct box Most commonly used:

S = Satisfactory (includes those for whom no action is required as they are deemed to be functioning normally)

O = Observe - recall R = Referral 5. Comments - include summary of test results (see table in Appendix 5)

� normal / functioning as normal � mild hearing loss, mild/moderate � moderate, uni/bilateral, moderate/severe etc

6. Tympanometry - record results e.g. normal peak, negative middle ear pressure, reduced

compliance, flat. 7. Action - Essential to indicate actions to be taken e.g.

� Discharge No Further Action � Recall in X months � Refer to ENT (urgent referral for children with suspected sensori-neural loss)

� GP Action required (concern re build up of ear wax)

8. Referral letters (Appendix 6)

APPENDIX 5

Guidance on Writing Hearing Test Outcomes

in PCHR and on Results Form

These guidelines are written in the context of the environment of the Community Audiology Clinic.

A brief summary of the test results should be written onto form and into PCHR

Options: Pure Tone dBHL

Free Field dBA

� Hearing normal No further action

< 25

< 35

� Hearing test results essentially normal Parent advised to contact if concerned

20 - 30

< 40

� Mild hearing loss Retest or Refer On

31 - 40

40 - 50

� Moderate Retest or Refer On

41 - 70

51 - 70

� Severe Retest or Refer On

71 - 95 > 71

Adapted from reference. (BJA 1988)

APPENDIX 6

Agreed Procedures regarding Referral to ENT (Mr Adams and Ms Scally) 1. Referral will be made by Head of Educational Audiology, SLT/Audiologist, or

Paediatrician, if present at clinic. 2. Age appropriate testing will be attempted and, in most cases, results from 2 tests

undertaken 2-3 months apart will be attached to the referral. 3. Tympanometry results will be included. 4. Parental concern will be indicated. 5. Impact on speech and language development will be recorded. 6. Where there is great concern regarding the possibility of sensori-neural hearing loss, the

referral will be marked as urgent. 7. GP, referring agent and HV will be informed of the referral to ENT. 8. Once referred to ENT, children will be discharged from Community Audiology Service.

APPENDIX 6 (i)

Mr D Adams ENT Consultant RBHSC Falls Road Belfast Date: Dear Mr Adams

Re: Name: Address: DOB: I would like to refer this child to you. She/he recently attended Community Audiology on: and on: Unfortunately s/he failed the hearing test and the results are consistent with a possible diagnosis of ______________________________________ (results attached) I would be grateful if you would assess this child and provide me with information on the outcome of your assessment. Yours sincerely _____________________________ Ms L Ashcroft SLT/Audiologist Copy to GP

File

Carrickfergus Health Centre, Taylors Avenue, Carrickfergus, BT38 7HT Tel: 028 9331 5823 - Fax: 028 9336 7173 - Email: linda.manson@northerntrust.hscni.net

APPENDIX 6 (ii)

Ms C Scally ENT Consultant Antrim Area Hospital Bush Road Antrim Date: Dear Ms Scally Re: Name: Address: DOB:

I would like to refer this child to you. She/he recently attended Community Audiology on: and on:

Unfortunately s/he failed the hearing test and the results are consistent with a possible diagnosis of ______________________________________ (results attached) I would be grateful if you would assess this child and provide me with information on the outcome of your assessment. Yours sincerely _____________________________ Ms L Ashcroft SLT/Audiologist

Copy to GP

File

Carrickfergus Health Centre, Taylors Avenue, Carrickfergus, BT38 7HT

Tel: 028 9331 5823 - Fax: 028 9336 7173 - Email: linda.manson@northerntrust.hscni.net

APPENDIX 7

Guidance on Completion of Community Audiology Clinic List

1. The clerical staff will complete all the information on the clinic list prior to the clinic. 2. Professional staff will complete the Outcome and Action Taken sections. (a) Outcome: Indicate by � if:

� pass � fail

� DNA

(b) Action: Indicate in writing if:

� discharge � recall (indicating when to be recalled/month of recall)

� refer to ENT (name of Consultant)

� refer to GP

COMMUNITY AUDIOLOGY CLINIC LOCATION: _________________________________

STAFF: ____________________________________ DATE: _____________________________________

Outcome Action Taken

Time of Appt

Patient’s Name & Address DOB Age Referring Agent Date

Referral Received

Date First Appt

Offered

Wait Time in Weeks

Init

ial

Asse

ssm

en

t

Revie

w

PA

SS

FA

IL

DN

A

DIS

CH

AR

GE

RE

CA

LL

RE

FE

R

APPENDIX 8

Date: Name: Address: Postcode: DOB:

ALERT TO HEALTH VISITOR

Following Newborn Hearing Screening protocol, an appointment was offered on _______________________________ but was:- � declined � not kept or cancelled According to our records, this child has never had a clear response to hearing screening and you may wish to act upon this. No further appointments will be offered unless a further request is made by holder of parental responsibility. ________________________________ On behalf of: Teresa Degnan, Educational Audiology, NEELB Lynn Ashcroft, SLT/Audiology, NHSCT Copy to: GP Referring Agent CHS

Carrickfergus Health Centre, Taylors Avenue, Carrickfergus, BT38 7HT Tel: 028 9331 5823 - Fax: 028 9336 7173 - Email: linda.manson@northerntrust.hscni.net