Audiometric Baseline Revision Written by A. Gregg Moore, CCC-A

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1 WHITE PAPER Audiometric Baseline Revision Written by A. Gregg Moore, CCC-A A Bit about Baseline Audiograms in General Hearing tests done in general industry are best thought of as screening audiograms. Where testing conducted in clinical environments (hospitals, physician s offices, Audiology clinics) often probe hearing ability using quite sophisticated methods, industrial hearing tests are simple and quick assessments of a person s basic ability to hear. When an industrial hearing test is evaluated, two basic questions are asked: A. Gregg Moore, CCC-A Senior Occupational Audiologist 1. What does the person s hearing look like currently?, and 2. Has this person s hearing changed over time? Leaving aside the first question for now, let us recognize the importance of the second. Changes in hearing over time can be caused by many factors including: 1. Earwax impaction 2. Upper respiratory issues (cold, flu, allergies) 3. Occupational noise exposure 4. Recreational noise exposure 5. Middle ear disease 6. A tumor on the Auditory Nerve 7. Chemical-induced hearing damage, including medicines and work-related chemicals While the above is not a comprehensive list, it will be observed that the causes of hearing loss range from the not-dangerous to the potentially deadly; from biological to chemical to noise and any combination thereof. Because of the medical seriousness of some of these factors, it is imperative that the Occupational Hearing Conservationist conducting hearing tests have a systematic means of screening for hearing change as well as hearing loss. Enter the OSHA Noise Standard which specifies that current hearing tests are compared to earlier hearing tests in order to detect change. Hopefully, the detection of change then leads to appropriate follow-up such that medical referrals are made, earplugs are refit, engineering controls are implemented to reduce noise exposure, and training is conducted to mitigate against further hearing loss. Please note that reviewing audiograms for potential medical conditions is far more complex than simply looking for Standard Threshold Shifts (STS). There are a whole range of criteria which may be used for

2 that purpose, but that is a topic for another day. The purpose of the present paper is to consider Standard Threshold Shifts and the role of the STS in baseline revision. This is the purpose of the baseline hearing test: to serve as the reference test against which future tests will be compared to look for change. Because of its importance, OSHA specifies that the baseline test is to be preceded by 14 hours of quiet. The idea is to obtain a baseline test uncontaminated by noise exposure so that it will serve as a sensitive reference for future comparisons. In terms of hearing change, OSHA s red flag in the Noise Standard is the Standard Threshold Shift. This is defined as an average change of at least 10 db at 2000, 3000 and 4000Hz in either ear. Here is an example of an STS. In order to keep things simple, age adjustments as allowed by OSHA are not included in this example. Current Test (2014) Baseline Test (1996) In this simple example, we subtract the sum of the Baseline thresholds (15) from the sum of the Current thresholds (75) and divide by = 60 db of total change. 60 divided by 3 = 20, thus this person has experienced an average change of 20 db easily meeting the 10 db trigger for an STS. Assuming the test is accurate we conclude that this person s hearing has changed substantially between the years 1996 and This test will most certainly be reviewed by an Audiologist or Physician who may probe further to ascertain when and why, leading to recommended follow-up. This follow-up could save this person s life. Baseline Revision Suppose that ABC Company hired a person 30 years ago obtaining a baseline hearing test at that time. When would it be appropriate to revise that baseline? Should it be revised just because the person s hearing worsened over time even though there is no STS? Audiologists and physicians reviewing hearing tests are familiar with this question as we address it frequently. The short answer is, probably not. Why, you ask? Because a person s hearing is expected to change over time to one degree or another simply due to aging. Losing hearing as we age is inevitable; it is just a matter of how much and when. Those genetically predisposed to hearing loss will begin losing their hearing at an earlier age while others keep excellent hearing into their 70s. The OSHA Noise Standard recognizes the role of aging in hearing loss providing age-correction charts to use when calculating STSs. Hopefully, a person s hearing never changes so much during their working years that a baseline revision is necessary. The OSHA Noise Standard states that baseline revision is at the discretion of the Audiologist or Physician who may revise the baseline in the presence of a persistent STS. Because baselines are so important to evaluation of the hearing health of individuals, the decision to revise baselines rests with healthcare professionals well versed in the medical implications of doing so. Note also the use of the word persistent. What does persistence mean? It obviously means, more than one STS but beyond this the

3 term is undefined in the Noise Standard. OSHA wisely leaves it to healthcare professionals to decide when to revise baselines. The downside of this non-specific language is lack of consistency among those professionally reviewing audiograms. Suppose a person has an earwax impaction (unbeknownst to the reviewer), has an STS, and the next day s retest also shows an STS. Has the definition of persistence been met? If the professional reviewer s definition of persistence is two consecutive STSs then, yes, the definition is met and the baseline may be revised. But is it really wise to revise a baseline based upon a temporary condition? After all, when the earwax impaction is removed it is quite likely that the STS will go away. This and other baseline revision scenarios created significant concern among professional reviewers seeking a consistent guideline for baseline revision, a definition of persistence less likely to lead to unwarranted baseline revisions. Due to this concern, the National Hearing Conservation Association (NHCA) established a 16-member committee to address this issue resulting in the 1996 issuance of the NHCA Professional Guide for Audiometric Baseline Revision. While this document is not a regulatory requirement, it has essentially become the gold standard for use by reviewing audiologists and physicians, and audiometric testing service providers. The guideline provides two rules: Rule 1: Revision for Improvement Those conducting hearing tests, and the professionals who review them, with some frequency note that a person s hearing may appear to improve when compared to the baseline. There are numerous reasons why a baseline audiogram may not be accurate, a few of which are listed below: Noise exposure contamination Upper respiratory conditions or earwax impactions Unfamiliarity with audiometric testing (test results can improve with practice, the learning curve effect) Fatigue Too much background noise in the audiometric testing room So it does make sense that the baseline should be revised for improved results in order to provide a more sensitive reference for future change. The NHCA guideline is to revise the baseline when the average change at 2000, 3000 and 4000Hz improves by at least 5 db on one test, and that change persists on the next test. Age correction factors are not typically used when looking for improved hearing. Here is an example: Annual Test 01/18/ Baseline Test Average improvement is 6.7 db.

4 Retest 01/19/ Baseline Test Average improvement is 8.3 db. In this case, there are consecutive tests each showing at least an average 5 db improvement compared to the existing baseline. Per the guideline, the baseline would revise but which current test becomes the new baseline? The guideline states that the baseline for that ear should be revised to the improved test which shows the lower (more sensitive) value unless the audiologist or physician determines and documents specific reasons for not revising. So as long as the audiologist or physician agrees to revise, the second test showing the average improvement of 8.3 db becomes the new baseline in this example. Rule 2: Revision for Persistent OSHA Standard Threshold Shift While revision for improvement does occur, the unfortunately far more common case is to revise for worsening hearing i.e. the presence of a persistent Standard Threshold Shift. When to revise hinges on the definition of persistence. The NHCA guideline specifies that the baseline should be revised for worsening hearing, unless the reviewing audiologist or physician notes specific reasons for not doing so, when two criteria are met: Consecutive Standard Threshold Shifts, and Separated in time by at least six months. Why the six-month time period between consecutive STSs? Ideally, baselines should be revised for permanent changes in hearing, not temporary conditions such as upper respiratory issues, transient middle ear disease, and earwax impactions, among others. The likelihood of revising a baseline due to a temporary condition is greatly reduced over a six-month time period. Earwax can be removed; earaches can be medically treated; cold and flu resolve quickly (though never quickly enough!). In the example below age corrections will not be used though such are commonly used in STS calculation except where it is legally impermissible to do so (the states of Washington and Oregon). Retest 01/30/ Annual Test 01/08/ Baseline Test The average change is 15 db on the 01/08/2013 and 18.3 db on the 01/30/2013 retest, thus there is an STS on both 2013 tests. Should the audiologist or physician revise the baseline? In this case, there are

5 consecutive STSs, but separated in time by only a few days, not six months. No, the baseline should not revise per the NHCA guideline. Now consider what happens on the next test: Annual Test 01/26/ Retest 01/30/ Annual Test 01/08/ Baseline Test Compared to the original baseline, there are STSs on 01/08/2013, 01/30/2013 and 01/26/2014. Note that there is now at least a six-month separation between the consecutive STSs on 01/30/2013 and 01/26/2014. Should the baseline revise? Yes, according to the NHCA guideline, as long as the reviewing audiologist or physician agrees. The 01/08/2013 test becomes the new baseline because of the three consecutive STSs this is the test with the least average hearing loss. What about this example? Annual Test 01/26/ Retest 01/30/ Annual Test 01/08/ Baseline Test In this case, the STS did not persist on the 01/26/2014 test so there is no need to revise the baseline. The temporary condition causing the STS on both 2013 tests later resolved. Are there times when a baseline should be revised apart from the NHCA Guideline? Albeit a very good guideline, the NHCA guideline is just a guideline and nothing more. Audiologists and Physicians are given latitude to revise baselines based on professional judgment. Each case is unique and can be considered on its own merit. In general, the NHCA guideline should be adhered to unless there is a strong reason to do otherwise, and this reason should be well documented.

6 Is there a Relationship between Baseline Revision and OSHA 300 Log Recordability? There is considerable misunderstanding of the relationship between recordability and baseline revision. The short answer is, no. 29 CFR Recording criteria for cases involving occupational hearing loss makes no mention of it. Baseline revision is governed entirely by 29 CFR , the OSHA Noise Exposure Standard which does not discuss recordability at all. OSHA 300 Log recordability and baseline revision are two entirely different subjects governed by two different though related regulations. What this means is that the fact an STS is recordable on the OSHA 300 Log has no bearing on baseline revision. Put another way, a baseline does not revise because an STS is recorded on the OSHA 300 Log. Baseline revision is based on STS persistence, not recordability.

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