COACHing to improve NHS

Outcomes:

Coalition of Ohio Audiologists and

Childrens’ Hospitals

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Who we are, how we got here…

• Gina Hounam, Ph.D. - Program Manager of Audiology 2

• Lisa Hunter, Ph.D. - Scientific Director, Audiology and Professor of

Otolaryngology 1

• Reena Kothari, Au.D - Public Health Audiology Consultant and Newborn Hearing

Screening contact 3

• Wendy Steuerwald, Au.D . - Clinical Manager of Audiology1

1)Cincinnati Children’s Medical Center, Cincinnati, Oh 2)Nationwide Children’s Hospital, Columbus, Oh

3)Ohio Department of Health, Columbus, Oh

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Who we are, how we got here…

2014 EHDI Meeting – Jacksonville, Fl

Recurring themes:

� Building connections within the community

� Concept of the Medical Home

� Partnerships with state stakeholders

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Perrin, James M. (2014) Expanding the Medical Home: From Concept to Care Delivery (PowerPoint Slides). Retrieved from

http://www.infanthearing.org/meeting/ehdi2014/docs/1430JamesPerrin_WEB_ONLY.pdf

Meeting of the minds

� Various attendees from Ohio at the EHDI

conference(s)

� Stakeholder commitment and desire for

improved outcomes

� Further growth and improvement

within state EHDI system

� Importance and value placed on early

identification of hearing loss

� Communication opportunities/options and

availability of services

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O-hi-O� 39th state to pass UNHS legislation in 2002

� Implementation 2004

� Birth rate: 139,000

� 129 Hospitals; 8 Children’s hospitals; 5 Birthing centers

� Large urban, large rural

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Data on Babies with Follow-up

65% w/normal hearing*

5.8% Diagnosed hearing loss*

23% Lost to follow up* (LTF)

*2013 Published CDC Hearing Screening Data cdc.gov/ehdi

Prevalence

1.62 out of

1,000

221 Babies

with Hearing

Loss

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Audiology Diagnostic sites

Screening sites: 56

Diagnostic sites (age group):

� Birth to 6 months: 64

� 7 months to 1 year: 67

� 2 to 3 years: 69

� 4 to 5 years: 70

� Newly designed

directory of services

� Separates screening

sites from diagnostic

sites

� Numbers are

decreased from

previous directories

� Improved locations

with proper FU

testing to identify

HL

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Why are Guidelines needed in Ohio?

� To achieve best outcomes for infants with P H L

� National guidelines and many studies (JCIH) have

shown that early, accurate, high quality,

integrated audiologic care is critical.

� Audiologic practice and evidence evolves rapidly -

difficult to keep current

� Audiologic practices are highly variable from one

setting to another

� Specific, helpful guidelines can improve

consistency and outcomes

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Opportunities for Ohio

to move the Needle

� Loss to Follow-up from Screening to

Diagnosis

� Loss to Follow-up from Diagnosis to

Habilitation

� Outpatient Rescreening

� Middle ear diagnosis and management

� New techniques (Chirps, ASSR,

Wideband Reflectance)

� Improved diagnostic accuracy9

Change and Growth

As novelist Leo

Tolstoy said,

"Everyone thinks of

changing the world,

but no one thinks of

changing himself."

Growth is optional and

it is a mindset. Most

people agree that

growth is a good thing,

but few people

practice growth

mindset.

Without change, growing and

learning is impossible.

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What Guidelines are available?

� Ohio does not have to reinvent the wheel!

� 21 states have guidelines for E H D I diagnostic

and/or habilitative process

� 10 state guidelines are comprehensive

� Many are 2-4 pages, general

� Available at: www.infanthearing.org

� 3 countries have comprehensive guidelines

(Canada, Australia, UK)

� AAA (comprehensive), J C I H (brief outline)

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Elements of Guidelines (JCIH)

� Child and Family History

� Frequency-specific ABR

� Click ABR (risk for ANSD)

� D P O A E or TE OAE

� Tympanometry (1 kHz)

� Behavioral cross-check

� Medical evaluation

� Medical home

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How can we develop Guidelines?

� Representative Task Force to review other

states and countries

� Develop draft

� Send out for comment

� Discuss input

� Consider training and implementation

� Submit for consideration to O D H N H S

Advisory Committee

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When?

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Process 2014

Initial Collaboration

meeting

June 2014

Creation of Call to Action

letter

September 2014

First Collaborative meeting with

Children’s Hospital

Audiologists

October 2014

Abstracts for Ohio Academy of Audiology

Conference

Ohio Speech Language Hearing

Association

November 2014

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Process 2015

COACH Presentation

For the Infant Hearing Screening Subcommittee/Advisory Board

August

Second collaborative meeting

Pediatric audiologists and Children's hospitals

June

Ohio Speech Language Hearing Association Conference

Audiologists and speech pathologists share vision of standardized testing to identify hearing loss sooner

March

Ohio Academy of Audiology

Open forum/round table with 30+ audiologists attended, voiced need for earlier identification of HL within EHDI system

February

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Recurrent Themes

� Standardized Protocols

� Screening/Re-screening Protocols

� Training, Licensure, Certification

� Messaging

� Lost to Follow-up

� Audiology Directory of providers

� Resources

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Process 2015����2016

Facilitators Meetings:September ‘15- create EHDI abstract and submit, draft

of standardized testing protocols

November ‘15-refine testing protocols

December ‘15- revisions to process

January ‘16- review final draft

February ‘16- identify stakeholders and sent for peer

reviews

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COACH PartnersAkron Children's Hospital

Cleveland Clinic Special Maternal Unit

Columbus Speech & Hearing Center

Cincinnati Children’s Hospital Medical Center

Cleveland Hearing & Speech Center

Dayton Children's Hospital

Galion Community Hospital

Knox Community

MD School for the Deaf

Nationwide Children's

ODH- Infant Hearing Supervisor

Ohio Board of Speech Language Pathology and Audiology

OSU AuD student

St. Elizabeth Boardman Hospital

Summa Health Systems

Summit County ESC

The Christ Hospital

Toledo Hospital and Toledo Children’s Hospital

UC AuD student

University Hospitals Case Medical Center-Rainbow Babies and

Children

Wright Patterson Air Force Base

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Overview of Protocol

I. Introduction

II. Acronyms

III. Qualified Personnel

IV. Safety and Health Precautions

V. Test Environment

VI. Procedures

VII. Equipment

VIII. Important Points and Tips

IX. Case History

X. Otoscopic examination

XI. Immittance

XII. Diagnostic OAE Evaluation

XIII. Diagnostic Threshold Auditory Brainstem Response (ABR) Protocol

XIV. Follow-up and Intervention protocol

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Follow-up and Intervention protocol

1. Complete Diagnostic Assessment

2. Initiation of Intervention

3. Counseling

4. Follow-up recommendations for newly identified children with sensorineural

hearing loss or ANSD

5. Follow-up recommendations for conductive hearing loss

6. Follow-up recommendations for normal ABR with risk factors (JCIH, 2007

7. Documentation

8. Confirmation of Hearing Loss

9. Periodicity Schedule for Evaluation

10. Referrals

11. Sharing information with Families

12. Diagnostic follow up reporting

13. Acknowledgements

14. Peer review

15. References

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Process Flow Chart

Case History, External ear exam and Otoscopy:

Risk for delayed/progressive HL: Make note for appropriate follow-up

months regardless of test outcome.

1000-Hz Tympanometry and

DPOAE or TEOAE

Click - Air

Bilateral 70 dB and 30 dB nHL

Alternating split-sweep

Air-Conduction Tone bursts

* 1000 Hz, 4000 Hz, 500 Hz, 2000 Hz

Tip: After obtaining reliable results in

2 frequencies, switch to the opposite

ear. Then complete additional

frequencies in each ear if needed.

Limited Test Protocol

Complete

If OAEs or Click-Air

Abnormal

If OAEs and Click-

Air is WNL

If AC tonebursts

WNL

Diagnostic Test Protocol

Complete

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Process Flow Chart, continued

Discuss results with parent and make

appropriate recommendations, report to

parents, PCP and ODH

Interpret Results – Confirm with another audiologist if questionable

Tip: Questionable = Poor morphology/repeatability, present CM, abnormal

latencies, or tests do not agree with each other (eg. abnormal ABR + normal

OAEs, abnormal OAEs + normal ABR)

Bone-Conduction Tone bursts

Complete at one or more abnormal frequencies.

Tip: If all frequencies are abnormal,

start with 1000 Hz.

Refer to otolaryngologist if abnormal

results, either to monitor ME condition, or

evaluate for permanent HL

If AC tonebursts

Abnormal

Diagnostic Test Protocol

Complete

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Stakeholder and Peer review process

� Feedback solicited from stakeholders

� Survey design on survey monkey

-specific questions

-specific feedback

-open text field for additional comments

� Sent via email with links to PDF document,

link to survey

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Survey Questions

1. Name

2. Professional role

3. Years in role

4. Familiarity with EHDI

5. Follow up services for newborns

6. Familiarity with follow up protocols post UNHS

7. Benefit of having statewide protocol

8. Follow the protocol shared

9. Ability to use in current setting

10. Reduce age of identification

11. Open text for reducing age of identification

12. Additions or deletions

13. Appropriate equipment in clinic

14. Appropriate training to follow protocol

15. Barriers to using protocol

16. More education on this topic

17. Additional education needs for other professionals

18. Open text field for feedback and comments25

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Protocol

FeedbackImplementation

may be difficult

How can we get How can we get

all facilities who

do this testing

on the same

page?

Consider offering 2 Consider offering 2

forms of

documentation for

diagnostic testing: one

for abnormal and one

for normal so that the

PCP is alerted

Make the

protocol easily

accessible and

include links to

forms

When is a

limited

protocol

needed?

Training is

key

Having a Having a

protocol

gives ODH a

consistent

voice

Is there a point

sedated ABR?

Is there a point

where you

suggest just

biting the bullet

and doing a

sedated ABR?

This needs

counseling.

This needs

more

expansion

on

counseling.Great work

and very

comprehensive

Sound

Protocol Can you

for families?

Can you

include a

process map

for families?

Very nice

document!

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Here we are…

EHDI Conference 2016

� Revised document

� Continuation of peer/stakeholder input

� Updates and changes

� Acknowledgements

� Approval from Infant Hearing Screening

Subcommittee

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More thoughts“A statewide model is something that creates continuity no matter where a

child is born in Ohio. Making the protocol easily accessible with links to the

forms is also important. Training is also key. Having a protocol also gives ODH

a consistent "voice" when providing training and consultation to audiologists

and others who are screening and providing

diagnostic follow up.”

“I think this looks like a very thorough protocol for follow up UNHS diagnostic testing and I would like to see it implemented state wide.”

“Thanks for taking the time to get this on paper and make adifference for Ohio's newborns!”

“By the way, I love that Ohio is doing this.”

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Planned activity

1. Informal group conversation/discussion

2. Advantages and disadvantages

3. Solutions

4. Other ideas for implementation, buy

in/support

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Discussion Topics

1. Should infants receive a re-screening instead of a full

evaluation?

2. Limited protocol: Should we have one, when should we

use it?

3. Do infants with risk factors need different follow up or

considerations?

4. Does the order of tests and steps in the flow chart make

sense to you? Why or why not?

5. How important is it to always do otoscopy prior to

testing?

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Additional considerations…

� Should repeat testing be done before referring for middle

ear issues? What if pediatric ENT is unavailable?

� Do we need additional ABRs to confirm results before HA

fitting? Or does this lead to a delay in intervention?

� Several parts of the protocol could result in delay, such as

referral for medical clearance, referral to various

providers and multiple tests to confirm diagnosis. How we

can move through the steps quickly? Do we need a

timeline for each phase?

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…Additional considerations� Should normal and abnormal results be communicated

differently to providers? Do we need a way for the

abnormal results to stand out? Would this result in greater

urgency? What if all abnormal results throughout Ohio

were distributed with a bright red logo and a large font

saying ‘Possible Hearing Loss’ or ‘Newly Identified Hearing

Loss’? Would this change culture and improve outcomes?

� What is the most effective method for implementation,

training and enforcement? What can we learn from other

states?

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Next steps

� Continued partnerships with ODH, other

stakeholders, groups

� Distribution

� Implementation• Training (mixed platforms) for Ohio audiologists

� Continued development of protocol,

expansion of services to include behavioral

testing, amplification, cochlear implants,

family support, etc

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Stakeholders

Partnerships

Collaboration

Commitment

Coordination

Hours

Increased

Outcomes

37

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Contact us

Lisa L. Hunter, Ph.D. Scientific Director and Professor,

Audiology and Otolaryngology

Cincinnati Children’s Hospital

Medical Center

240 Albert Sabin Way| ML 15008 |

Cincinnati, OH 45229-3039

Phone: 513-803-0532

Email: lisa.hunter@cchmc.org

Wendy Steuerwald, Au.D. Clinical Manager of Audiology

Cincinnati Children’s Hospital Medical

Center

3333 Burnet Avenue

Cincinnati, OH 45229

Phone: 513-636-3035

Email: Wendy.Steuerwald@cchmc.org

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Contact us

Gina Hounam, Ph.D. Program Manager of Audiology

Nationwide Children's Hospital

700 Children’s Drive

Columbus, OH 43205

Phone: 614-722-5868

Email:

Gina.Hounam@nationwidechildrens.org

Reena Kothari, Au.D. Public Health Audiology Consultant

and Newborn Hearing Screening

Ohio Department of Health

Infant Hearing Services-EHDI

246 North High Street | 5th Floor

Columbus, OH 43215

Phone: 614-387-0135

Email: reena.kothari@odh.ohio.gov

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