What happens when you refer a patient to Audiology? Modernising patient pathways and services
Paediatrics Adult Rehab RBFT AUDIOLOGY Balance Hearing Therapy To provide high quality services for people with hearing loss, tinnitus and balance disorder across the UK
Some stats One in seven of the UK population (8 million people) have hearing loss 2 million currently have a hearing aid although 1.4 million people use them regularly 80% have NHS hearing aids 60% of hearing aid users are in the age range 71-80 years..thus significant unmet need
Why are pathways important? Almost a decade after NHS Modernising Hearing Aid Services (MHAS), demand for digital hearing aids continues to rise
Appointment demand No. of Direct referrals 3000 2500 2000 1500 1000 05-06 06-07 07-08 08-09 09-10
Why are pathways important? Almost a decade after NHS Modernising Hearing Aid Services (MHAS), demand for digital hearing aids continues to rise More tests
Pure tone audiometry Speech Audiometry VideoNystagmography Calorics Cortical auditory evoked potentials Play audiometry Distraction testing Performance testing Visual reinforcement Audiometry Tympanometry TESTS NOW AVAILABLE! Acoustic reflexes Auditory Steady-State Response Otoacoustic Emissions Vestibular Evoked Myogenic Potentials Central Auditory Processing Disorder Auditory Brainstem Response
Why are pathways important? Almost a decade after NHS Modernising Hearing Aid Services (MHAS), demand for digital hearing aids continues to rise More tests More treatments
Assistive Listening Devices Vestibular Rehabilitation Tinnitus Counselling Adult hearing aids TREATMENT Bone anchored hearing aids Neonatal hearing aids BPPV Central auditory processing disorder
Why are pathways important? Almost a decade after NHS Modernising Hearing Aid Services (MHAS), demand for digital hearing aids continues to rise More tests More treatments Waiting times
Why are pathways important? Almost a decade after NHS Modernising Hearing Aid Services (MHAS), demand for digital hearing aids continues to rise More tests More Waiting times Cost
Make sure that every referral follows an agreed pathway which optimises both their outcome and the use of resources Data from the Action On and Collaborative pilot sites suggest that some 10-40% of new referrals from GPs do not require a surgical opinion. The benefits of putting the patient on the right pathway from the outset are considerable.
BPPV treatment the long way round BPPV treated GP refers re. dizziness Elderly Care ENT Audiology Neck physio Vestibular rehabilitation 36 weeks! Nationally, balance service audits show an average of 4-5 specialists before patient receives a diagnosis
Improving pathways? BPPV treated GP refers re. dizziness Elderly Care ENT Audiology Neck physio Vestibular rehabilitation
Good practice guidelines
Process mapping reduce number of steps Consider telephone and email referrals only (use of template) Referrals received from GP,hospital,SALT,SHA, CDT, Parent,Hounslow By letter, phone call,template or shared email Cancellation sheet passed to person updating spreadsheet Phone pts to remind re appt Consider txt msg reminders from bookings staff Audiology (paediatric admin +clinical) Process Map Post /emails triaged into referrals for <3yrs + >3yrs date stamp applied Details of cancellation added to admin sheet Cancellations rebooked, electronic diary adjusted Pt called to confirm attendance by clinician Database checked for previous referral. Database updated. Clinic lists compiled Notes collected for clinic Admin staff to do If previously referred, put aside for admin person to find notes Interpreters booked by fax with citas if required Clinic details checked on database/ electronic diary Referrals reported on demand + capacity form Pt phoned to make appt or sent letter with appt on. Appt added to excel database Test undertaken File discharged and DNA pts Cover sheet printed, and attached with clinic sheet to referrals New pts added to registration folder. And entered on database Liaise with audiologists to see when they are free for clinics Report written (paper) and referral if needed Copy and post letters (inc any DNA letters) Diary checked for clinic spaces Notes filed Database updated Clinic outcomes sheet completed Letters typed and given to clinicians to sign Complete reports in clinic? Value steps that will benefit the patient are highlighted in pink. A ll other processes need to be reviewed and elim inated where possible Cancellation messages collected and added to cancellation slip and passed to bookings person Clinic sheet updated with cancellations +electronic diary Dx patients moved onto Dx spreadsheet Onward referrals placed in tray
Paediatrics Neurology Radiography Speech and Language Therapy AUDIOLOGY Physiotherapy Clinical Psychology ENT Elderly Care (Falls)
Community-based care
and further afield
Provision of community-based care 80 RBH Community 70 % activity 60 50 40 30 20 10 0 05-06 06-07 07-08 08-09 09-10
Referral criteria British Academy of Audiology Guidelines for Referral to Audiology of Adults with Hearing Difficulty (2009) based on Based on Guidelines of the Liaison Group of Technicians, Therapists and Scientists in Audiology (TTSA), 1989
Direct referral red flags Persistent pain affecting either ear (defined as earache lasting more than 7 days in the past 90 days before appointment); History of discharge other than wax from either ear within the last 90 days Sudden loss or sudden deterioration of hearing (sudden=within 1 week, in which case send to A&E or Urgent Care ENT clinic) Rapid loss or rapid deterioration of hearing (rapid=90 days or less) Fluctuating hearing loss, other than associated with colds Unilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5 minutes at a time Troublesome, tinnitus which may lead to sleep disturbance or be associated with symptoms of anxiety or depression Abnormal auditory perceptions (dysacuses) Vertigo (defined as hallucination of movement, but here includes dizziness, swaying or floating sensations (frequently associated with unsteadiness) that may indicate otological, neurological or medical conditions). Normal peripheral hearing but with abnormal difficulty hearing in noisy backgrounds; possibly having problems with sound localization, or difficulty following complex auditory directions.
Direct referral red flags On examination: Complete or partial obstruction of the external auditory canal preventing proper examination of the eardrum and/or proper taking of an aural impression. Abnormal appearance of the outer ear and/or the eardrum (e.g., inflammation of the external auditory canal, perforated eardrum active discharge). Audiometry: Conductive hearing loss, defined as 25 db or greater air-bone gap present at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz. Unilateral or asymmetrical sensorineural hearing loss, defined as a difference between the left and right bone conduction thresholds of 20 db or greater at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz. Evidence of deterioration of hearing by comparison with an audiogram taken in the last 24 months, defined as a deterioration of 15 db or more in air conduction threshold readings at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.
Choose and Book OP Appt or Advice and Guidance Request + Priority selections SNOMED search these are set by RBFT Specialty and Clinic Type search these are set by the Royal Colleges Named Clinician search these are set on PMS. Can only be smartcard registered consultants Patient s postcode (this test patient is based at RBFT) Distance limit of search will show services based on distance from the entered postcode Indicative wait time is approx. 3rd next available appt on CaB Age and Gender Appropriate services many services are specific to either paeds or adult and this option ensures only appropriate services are returned. These are set by CaB Team with the department Search Primary or Secondary care all Audiology services are secondary.
Choose and Book Adult hearing Location RBH Service name Specialty Clinic type Diagnostic Physiological Measurement Audiology - Hearing Aid Assess and Fit Audiology - Hearing Aid Review Audiology - Hearing Assess / Reassess RBFT - Adult Audiology Hearing Aid Assessment & Rehab - West Berkshire Community Hospital - RHW Diagnostic Physiological Measurement Audiology - Hearing Aid Assess and Fit Audiology - Hearing Aid Review Audiology - Hearing Assess / Reassess Wallingford RBFT - Adult Audiology Hearing Aid Assessment & Rehab - Wallingford Community Hospital - RHW Diagnostic Physiological Measurement Audiology - Hearing Aid Assess and Fit Audiology - Hearing Aid Review Audiology - Hearing Assess / Reassess Wokingham RBFT - Adult Audiology Hearing Aid Assessment & Rehabilitation Wokingham Hospital - RHW Diagnostic Physiological Measurement Audiology - Hearing Aid Assess and Fit Audiology - Hearing Aid Review Audiology - Hearing Assess / Reassess Skimped Hill RBFT - Adult Audiology Hearing Aid Assessment & Rehabilitation - Skimped Hill Surgery - RHW Diagnostic Physiological Measurement Audiology - Hearing Aid Assess and Fit Audiology - Hearing Aid Review Audiology - Hearing Assess / Reassess RBFT - Adult Audiology Hearing Aid Assessment & Rehabilitation Townlands Hospital - RHW Diagnostic Physiological Measurement Audiology - Hearing Aid Assess and Fit Audiology - Hearing Aid Review Audiology - Hearing Assess / Reassess WBCH Townlands RBFT - Adult Audiology Hearing Aid Assessment & Rehabilitation - Royal Berkshire Hospital RHW
Choose and Book Tier 2 Preschool Assessment Clinic (PSAC) Community clinics for children presenting WITHOUT clear risk factors Parental and professional concerns with hearing 30 minute appointments Location RBH Service name Specialty Clinic type Diagnostic Physiological Measurement Audiology - Hearing Assess / Reassess Children's & Adolescent Services Audiology Diagnostic Physiological Measurement Audiology - Hearing Assess / Reassess Children's & Adolescent Services Audiology RBFT - Audiology Pre-School Assessment West Berkshire Community Hospital - RHW Children's & Adolescent Services Audiology Wokingham RBFT - Audiology Pre-School Assessment Wokingham Hospital - RHW Children's & Adolescent Services Audiology RBH WBCH RBFT - Audiology Pre-School Assessment for Under 3s - Royal Berkshire Hospital - RHW RBFT - Audiology Pre-School Assessment (35yrs) - Royal Berkshire Hospital - RHW
Choose and Book Tier 3 Children s Hearing Assessment Clinic (CHAC) For children presenting with a risk factor e.g. family history, developmental delay, autism Clinics held at RBH due to specialised test environment and senior clinician support 45 minute appointments Location RBH Service name RBFT - Paediatric Audiology Hearing Assessment for Under 3s - Royal Berkshire Hospital - RHW Specialty Diagnostic Physiological Measurement Children's & Adolescent Services RBH RBFT - Paediatric Audiology Hearing Assessment for Over 3s - Royal Berkshire Hospital - RHW Diagnostic Physiological Measurement Children's & Adolescent Services Clinic type Audiology - Hearing Assess / Reassess Audiology Audiology - Hearing Assess / Reassess Audiology
Choose and Book Tinnitus and Balance Clinics Location Service name Specialty Clinic type RBH RBFT - Audiology Balance Service with Audiologist Royal Berkshire Hospital - RHW Ear, Nose & Throat Ear Balance / Dizziness RBH RBFT - Audiology Tinnitus Clinics with Audiologist Royal Berkshire Hospital - RHW Ear, Nose & Throat Tinnitus WBCH RBFT - Audiology Tinnitus Clinics with Audiologist West Berkshire Community Hospital - RHW Ear, Nose & Throat Tinnitus Skimped Hill RBFT - Audiology Tinnitus Clinics with Audiologist Skimped Hill Surgery - RHW Ear, Nose & Throat Tinnitus
Further streamlining Triaging in surgeries allowing selection of either fast-track assess and fit or regular review via: Use of hearing screening devices Use of more enhanced referral criteria re. dexterity, vision etc. Wax removal if required Or even: One-stop direct access Audiology and Balance clinics in your surgery?pilot project
From: Provision of Adult Balance Services A Good Practice Guide
Helping you choose the right path Better information about which referral pathway is best Facilitate direct access to appropriate care pathway Share information and knowledge of advances in audiological testing and treatments
A hearing loss is more obvious than a hearing aid. Smiling and nodding your head when you don't understand what's being said, makes your condition more apparent than the largest hearing aid.
Thank you!