Hearing Screening Protocol for School Aged Children

This is an official Northern Trust policy and should not be edited in any way Hearing Screening Protocol for School Aged Children Reference Number: NHSCT/12/577 Target audience: This policy is directed to School Nursing staff. Sources of advice in relation to this document: Loraine Calvert, Nurse Manager Lynn Ashcroft, SLT Service Lead Dr Clare Bailey, Associate Specialist Replaces (if appropriate): NHSCT Protocol for Hearing Screening for School Aged Children (NHSCT/09/141) Type of Document: Directorate Specific Approved by: Policy, Standards and Guidelines Committee Date Approved: 30 July 2012 Date Issued by Policy Unit: 22 August 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves

Hearing Screening Protocol for School Aged Children July 2012

Hearing Screening Protocol for School Aged Children Introduction to Policy Hearing screening of school aged children is undertaken by the school nursing service primarily in P1 pupils as part of the school entrant health appraisal process. This protocol sets out the procedure for hearing testing in children and what should be done in the event of the child failing a hearing test or being uncooperative for testing. This document was first written in 2005 in order to ensure consistency of approach, across the Northern Health and Social Care Trust (NHSCT) and has been reviewed regularly since that time. Purpose of Policy To ensure consistency in approach to hearing testing by the school nursing service across Northern Health and Social Care Trust. Target Audience This policy is directed to school nursing staff. Responsibilities Director and Assistant Director are responsible for the dissemination and implementation of this guidance within the directorate. Service managers are responsible for ensuring that staff have a working knowledge of and adhere to the guidance. All relevant are responsible for familiarising themselves with and adhering to this guidance. Equality, Human Rights and DDA The policy is purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 1

Policy Statement Protocol for Hearing Screening for School Aged Children Equipment 1. Pure tone audiometer which has been calibrated annually 1. 2. CHS18R. 3. Parent information letters. Preparation 1. Ensure the room used has as few distractions as possible. i.e. low background noise and minimal visual stimulators. 2. Ensure the audiometer is functioning adequately at all frequencies. 3. Ensure that consent has been obtained for hearing screening. Procedure for Sweep Test 1. Explain the procedure to the pupil. 2. Allow the pupil to hear all four frequencies in the free field situation before putting on the earphones. 3. The attenuator should be set at its loudest volume setting to enable the lower frequencies to be heard. 4. Demonstrate the required response to the sound e.g. raise hand, clap or tap the table, still in the free field. 5. Turn the volume down to 50dB. Place the earphones over the ears of the pupil with the red phone to the right ear. 6. Sit behind the pupil, ensuring that he/she does not see the controls of the audiometer or the hands of the tester. 7. Commence the test with the right ear or if there is a known hearing impairment test the good ear first. 8. The pupil should respond every time he /she hears the sound through the earphones. 9. Practice at 50dB at 4000Hz. 10. Reduce the intensity to 25dB (pass level at all frequencies with the exception of 500Hz). 11. Check that the pupil is hearing at the pass level across the frequencies i.e. 1000Hz, 2000Hz and 4000Hz. 12. Increase the volume to 30dB at 500Hz (pass level). 13. Transfer to left ear at 30dB at 500Hz. Reduce the volume to 25dB for remaining frequencies i.e. 1000 Hz, 2000 Hz and 4000 Hz. 14. The pupil is required to respond to one stimulus only at each frequency, unless the tester feels that a response may not be genuine. 15. The sweep test should not take more than two or three minutes. 16. Where a pupil fails to respond to pass levels, pure tone audiometry should be performed. 1 Refer to NHSCT Medical Devices Management Policy (Interim) 2

Procedure Flow Chart Start with Right Ear 500Hz at 30dB Change to Left Ear 1000Hz 2000Hz at 25dB at 25dB 4000Hz at 50dB 4000Hz at 25dB 500Hz at 30dB 1000Hz 2000Hz at 25dB at 25dB 4000Hz at 25dB Ensuring Test Validity 1. Vary the intervals between stimuli. 2. Ensure that the pupil is given no clue as to when the test tone is being switched on. 3. Do not look up at the pupil every time the stimulus is presented. Recording Results 1. Record result as pass or fail (P/F) on sweep test column of CHS18R. 2. Where a pupil fails the sweep test the results should be recorded under each frequency on CHS18R. 3. Where the parent 2 is not present a letter detailing result of screening should be sent home. Procedure for Pure Tone Audiometry This test is usually used if a pupil has failed the Sweep Test. 1. Start with 50dB at 1000Hz, or produce a signal estimated to be above the pupil s threshold. Check that the required response is given, if necessary repeat the signal two or three times. Test the better ear first (if known). 2. When clear responses are obtained, reduce the intensity by 10dB 3. If the pupil responds, reduce the intensity by a further 10dB. 4. Continue to reduce the sound level in steps of 10dB until the pupil ceases to respond. 2 Parent is used to refer to parent or carer 3

5. Increase the sound level in steps of 5dB until the pupil again responds. The signal should now be at or above the pupil s threshold. The threshold of hearing is defined as the level of consistent response as one carries out step 5 i.e. as one increases the sound level in steps of 5dB from below threshold. Consistent response is in practice taken to be two times out of three. 6. Reduce the sound level by 10dB and repeat step 5. Procedure if pupil does not respond to first signal: 1. If the pupil does not respond to the first signal, check that pupil understands what he has to do. Then follow procedure outlined in points 3-5 above. 2. If pupil fails to respond, increase sound level in steps of 10dB up to 90dB. Example: Dial setting (db) 60 60 50 40 30 20 25 30 35 25 30 20 25 30 Response + + + + + - - - + - + - - + Step 1 Steps 2 3 4 Step 5 Step 6 Step 6 There was no response at 25dB. There was response twice out of three times at 30dB, hence threshold at this frequency = 30 db. 3. The usual order of testing the frequencies in a full test is 1000Hz, 2000Hz, 4000Hz, 8000Hz, 500Hz. If for any reason a shortened test is used, then test 500Hz, 1000Hz, 4000Hz. The audiogram for these three frequencies usually gives a good picture of the hearing loss. 4. If the pupil s responses become unreliable, increase the signal level by about 40dB and give one or two signals at that level to remind them of what they are listening for. 5. If the responses are still unreliable, re-conditioning is necessary. Recalls All pupils who fail their hearing screening will be re-tested by the nurse in 6-8 weeks 2 follow care pathway on page 7. When a pupil has been referred to ENT no routine recall audio is necessary. All subsequent requests for hearing screening/testing should be managed as if a new referral. 2 ENT Guidance allows for retest up to 3 months (accommodates those pupils whose first test occurs in May or June) 4

Special Requests for Hearing Testing of Pupil of any age Requests for hearing test may be received from parents, health visitors, GPs, paediatricians, speech and language therapists, MAST service, Education Audiology Service, second tier audiology services etc. It is incumbent on the referring agent to provide adequate details in the referral letter as to when the pupil needs to be seen especially if this is a second or subsequent hearing test. o Where the request has originated from the parent, consent is obtained verbally and documented in the child s health record. o Where the request has originated from the GP or paediatrician it is assumed that consent has been obtained. o Where the request has originated from the Educational Audiology Service, the results of the first hearing test will be attached and therefore the first test of hearing conducted by the school nursing service amounts to the second test for the child and direct referrals can be made to ENT provided the criteria are met. o All other requests for hearing testing should be supported by evidence of consent having been obtained. However, if this is not clearly documented the nurse should seek consent from the person with parental responsibility. Pupils with Down s syndrome or other named condition(s) Pupils with Down s syndrome will continue to be reviewed at community audiology clinics until such times as they are proficient with pure tone audiometry. Pupils with Down s syndrome require to have their hearing reviewed every two years while they remain at school. Recall should be by Nurse recall using code N7 (biannual hearing). Those children in special schools will be reviewed by Educational Audiology Service and those in mainstream schools will be reviewed by the school nursing service. Pupils with other named conditions may require regular review of their hearing. This is most likely to be requested by the child s paediatrician and in accordance with condition specific guidance. Recall should be by Nurse recall. Pupils with Hearing Aids/Cochlear Implants Currently pupils with hearing aids/cochlear implants have their audiological needs met by the Education Audiology Service and do not require to be selected for hearing testing by the school nursing service. This service: o o o o Checks and maintains hearing aids; Undertakes aided threshold testing; Liaises with education staff regarding hearing aid use and Reviews hearing levels. 5

Criteria for Referral to Community Audiology Clinics Pupils who are uncooperative for, or unable to undertake, pure tone audiometry should be referred to the community audiology clinic closest to their home unless the parent has indicated otherwise. Consent to referral is required. Larne Antrim & Ballymena Audiology Appointments Audiology Appointments Larne Health Centre Health Centre Gloucester Avenue Cushendall Road Larne Ballymena BT40 1PB 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 Services 44 King Street Pupil Health Magherafelt Armour Site BT45 6AH Newal Road Tel: 028 7963 4831 Ballymoney Fax 028 7930 0401 BT43 6HD Tel: 028 2766 1825 Glengormley & Whiteabbey Coleraine Audiology Appointments Audiology Appointments Health Office Community Information Services 40 Carnmoney Road Pupil Health Newtownabbey Armour Site Tel: 028 9083 1423 Newal Road Fax: 028 9083 1414 Ballymoney BT53 6HD Tel: 028 2766 1823 Carrickfergus & Ballyclare Audiology Appointments Community Health Office Carrickfergus Health Centre Taylors Ave Carrickfergus BT38 7HT Tel: 028 9332 5823 Fax: 028 93367173 6

Care Pathway Following Hearing Test Screening Result 500 Hz 30 db 1000 Hz 25 db 2000 Hz 25 db 4000 Hz 25 db 500 Hz 30 db 1000 Hz 25 db 2000 Hz 25 db 4000 Hz 25 db First hearing test Hearing other than 500 Hz 30 db 1000 Hz 25 db 2000 Hz 25 db 4000 Hz 25 db Failed repeat hearing test 2 or more responses at, or greater than, 40dB Repeat hearing test Less than 2 responses at, or greater than, 40dB Uncooperative pupil or pupil unable to undertake test Comment No concern With concern With or without concern With or without concern With or without concern With or without concern Action No further action P1/new entrant: Where no parent present issue regional health appraisal results letter Specific request or retest: Issue Appendix 1. In the event of a specific request for hearing test, Appendix 2 must be forwarded to any health professional making a referral and copied to the GP Advise parent to contact GP P1/new entrant: Where no parent present issue regional health appraisal results letter) and include a hand written comment as follows Your child s hearing test was normal but in view of the concerns expressed about your child s hearing, I must advise you to contact your GP if the concerns remain Specific request or retest: Issue Appendix 1 and include a hand written comment as follows Your child s hearing test was normal but in view of the concerns expressed about your child s hearing, I must advise you to contact your GP if the concerns remain and issue Appendix 2 (with copy to GP). Offer repeat hearing test in 6-8 weeks 3. P1/new entrant: Where no parent present issue regional health appraisal results letter Specific request or retest: Issue Appendix 1. In the event of a specific request for hearing test, Appendix 2 must be forwarded to the referring agent and copied to the GP Refer to ENT Complete Appendix 3 (direct referral to ENT) copy to be sent to GP and retained on child s record Where no parent present issue Appendix 4 to inform of referral Functionally Normal Hearing Issue Appendix 1 to the parent and Appendix 2 to the Referring agent/gp No further action Attempt to test without parent in the room (with parental consent) Refer to a community audiology clinic using Appendix 5, with parental consent 3 ENT Guidance allows for retest up to 3 months (accommodates those pupils whose first test occurs in May or June) 7

Procedure for School Nursing Service to Make Direct Referrals to ENT (Northern Health & Social Care Trust only) Agreement has been reached which allows the School Nursing Service to make referrals directly to ENT in Northern Health & Social Care Trust, providing the following criteria are met: 1. The pupil must have had two hearing tests (Pure Tone Audiometry) undertaken at least 6-8 weeks 4 apart 2. Referrals to ENT will be made if there are 2 or more responses at different frequencies at, or greater than, 40dB 3. Referrals to ENT will be made on standard letter (Appendix 5) and must include: a. All available results b. Reference to concerns, if any, in relation to i. Speech and language development ii. Family history of hearing loss iii. Past history of infections including ear infections, meningitis, measles etc iv. Perinatal complications eg intensive care, jaundice requiring phototherapy, etc 4. Referral to ENT can only be made when consent has been obtained from the person with parental responsibility 5. Copies of referral letters will be shared with GP and retained in the pupil s health record 6. Pupils whose results are still not a pass but do not reach the threshold for a referral to ENT will be discharged as functionally normal. Re-referrals can be made to the school nursing service at any time 7. Referrals will be forwarded as follows: a. Mr Delap at Braid Valley Hospital, Ballymena b. Dr Gallagher at Moyle Hospital and Whiteabbey Hospital c. Ms Scally at Causeway Hospital and Antrim Area Hospital d. Ms Stewart at Mid Ulster Hospital 4 ENT Guidance allows for retest up to 3 months (accommodates those pupils whose first test occurs in May or June) 8

References Ballantyne (1993) Deafness Hall (1996) Health for all Children 3 rd Edition Hall (2002) Health for all Children 4 th Edition McCracken & Laoide-Kemp (1997) Audiology in Education McCormick (1993) Paediatric Audiology 0-5 years Original Authors Dr Clare Bailey, Associate Specialist Mrs Loraine Calvert, Team Leader, School Nursing Mrs Rosaleen Devlin, Team Leader, School Nursing Ms Lynn Ashcroft, Team Manager, Speech & Language Therapy (Special Needs/Audiologist) Dates Originally written: August 2005 First Review: July 2007 Second Review: May 2009 Third Review: July 2011 9

Appendix 1: Letter to parent - results letter Ref: SN4/11 Date: To the Person with Parental Responsibility for: Name: D.O.B.: Address: School: In response to a recent request to check your child s hearing, I am pleased to advise that the test has been carried out. The results are as follows: (tick appropriate box) Your child s hearing was tested today and found to be within normal limits His/her hearing will not be routinely rechecked. However, should you have any concerns in the future please contact your school nurse and arrangements will be made for the hearing to be rechecked. Your child's hearing found to be slightly reduced and will be retested in approximately 6-8 weeks you will be informed of the result. Should you have any queries please contact your school nurse at the address below or alternatively your child s GP who has been sent a copy of the results. Yours sincerely SCHOOL NURSE School Nursing, Northern Health & Social Care Trust, «Company», «Address1», «Address2», «PostalCode», «TelNumber». 10

Appendix 2: Letter to referring agent - results letter Ref: SN7/11 Date: To: Name: Referral Agent D.O.B.: Address: School: Please find below the audiogram results recorded in decibels (db) in respect of the above-named pupil. Date of Test Frequency (Hz) 500 1000 2000 4000 8000 Right Ear (db) Left Ear (db) Date of Test Frequency (Hz) 500 1000 2000 4000 8000 Right Ear (db) Left Ear (db) Comments: Yours sincerely SCHOOL NURSE cc GP School Nursing, Northern Health & Social Care Trust, «Company», «Address1», «Address2», «PostalCode», «TelNumber». 11

Appendix 3: Referral to ENT Ref: SN7a/11 Date: To: Name: Mr Delap/Dr Gallagher/Ms Cate Scally/Ms Stewart D.O.B.: Address: Ph: School: GP Name & Address: I would be very grateful if you would accept this referral, in accordance with previously agreed procedures. Results of hearing tests are detailed below. Date of Test: Right Ear (db) Left Ear (db) Frequency (Hz) 500 1000 2000 4000 8000 Date of Test: Right Ear (db) Left Ear (db) Frequency (Hz) 500 1000 2000 4000 8000 Comments: Detail any difficulties with speech & language development: Detail any relevant family history of hearing loss: Detail any relevant history of infections: Detail any relevant history eg perinatal complications: Yours sincerely SCHOOL NURSE cc: GP Pupil s Health Record School Nursing, Northern Health & Social Care Trust, «Company», «Address1», «Address2», «PostalCode», «TelNumber». 12

Appendix 4: Consent to refer Ref: SN7b/11 Date: To the Person with Parental Responsibility for: Name: D.O.B.: Address: School: Your child's hearing was re-checked today and remains slightly reduced. It is recommended that your child should now be referred to an Ear Nose and Throat (ENT) Consultant. A referral has been made and you will receive a letter to invite you to make an appointment. Should you have any queries please contact your school nurse at the address below or alternatively your child s GP who has been sent a copy of the results. Yours sincerely SCHOOL NURSE School Nursing, Northern Health & Social Care Trust, «Company», «Address1», «Address2», «PostalCode», «TelNumber». 13

Ref: SN7c/11 Appendix 5: Referral to Community Audiology Clinic Date: To: Name: Community Audiology Clinic D.O.B.: Address: Ph: School: GP Name & Address: I would be very grateful if you would accept this referral, in accordance with previously agreed procedures. Unfortunately, the above named child has been uncooperative for assessment. Parental concerns are as detailed below together with additional information: Comments: Detail any parental concerns: Detail any difficulties with speech & language development: Detail any relevant family history of hearing loss: Detail any relevant history of infections: Detail any relevant history eg perinatal complications: Yours sincerely SCHOOL NURSE cc: GP Pupil s Health Record School Nursing, Northern Health & Social Care Trust, «Company», «Address1», «Address2», «PostalCode», «TelNumber». 14