COACHingto improve NHS Outcomes: Coalition of Ohio Audiologists and Childrens Hospitals

Transcription

1 COACHingto improve NHS Outcomes: Coalition of Ohio Audiologists and Childrens Hospitals 1

2 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 Audiology 1 1)Cincinnati Children s Medical Center, Cincinnati, Oh 2)Nationwide Children s Hospital, Columbus, Oh 3)Ohio Department of Health, Columbus, Oh 2

3 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 Perrin, James M. (2014) Expanding the Medical Home: From Concept to Care Delivery (PowerPoint Slides). Retrieved from 3

4 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 4

5 O-hi-O 39 th state to pass UNHS legislation in 2002 Implementation 2004 Birth rate: 139, Hospitals; 8 Children s hospitals; 5 Birthing centers Large urban, large rural 5

6 Data on Babies with Follow-up 65% w/normal hearing* 5.8% Diagnosed hearing loss* 23% Lost to follow up* (LTF) Prevalence 1.62 out of 1, Babies with Hearing Loss *2013 Published CDC Hearing Screening Data cdc.gov/ehdi 6

7 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 7

8 Why are Guidelines needed in Ohio? To achieve best outcomes for infants with PHL 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 8

9 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 accuracy 9

10 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. 10

11 What Guidelines are available? Ohio doesnot have to reinvent thewheel! 21 states have guidelines for EHDI diagnostic and/or habilitative process 10 state guidelines are comprehensive Many are 2-4 pages, general Available at: 3 countries have comprehensive guidelines (Canada, Australia, UK) AAA (comprehensive), JCIH (briefoutline) 11

12 Elements of Guidelines (JCIH) Child and Family History Frequency-specific ABR Click ABR (risk foransd) DPOAE orteoae Tympanometry (1 khz) Behavioral cross-check Medical evaluation Medical home 12

13 How can we develop Guidelines? Representative Task Force to review other states and countries Develop draft Send out forcomment Discuss input Consider training and implementation Submit for consideration to ODH NHS Advisory Committee 13

14 When? 14

15 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

16 Process 2015 February March June August Ohio Academy of Audiology Open forum/round table with 30+ audiologists attended, voiced need for earlier identification of HL within EHDI system Ohio Speech Language Hearing Association Conference Audiologists and speech pathologists share vision of standardized testing to identify hearing loss sooner Second collaborative meeting Pediatric audiologists and Children's hospitals COACH Presentation For the Infant Hearing Screening Subcommittee/ Advisory Board 16

17 Recurrent Themes Standardized Protocols Screening/Re-screening Protocols Training, Licensure, Certification Messaging Lost to Follow-up Audiology Directory of providers Resources 17

18 Process 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 18

19 COACH Partners Akron 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 19

20 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 20

21 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, 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 21

22 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 Hz Tympanometry and DPOAE or TEOAE 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. If OAEs or Click-Air Abnormal If AC tonebursts WNL Click -Air Bilateral 70 db and 30 db nhl Alternating split-sweep If OAEs and Click- Air is WNL Limited Test Protocol Complete Diagnostic Test Protocol Complete 22

23 Process Flow Chart, continued If AC tonebursts Abnormal Bone-Conduction Tone bursts Complete at one or more abnormal frequencies. Tip: If all frequencies are abnormal, start with 1000 Hz. Diagnostic Test Protocol Complete 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) Discuss results with parent and make appropriate recommendations, report to parents, PCP and ODH Refer to otolaryngologist if abnormal results, either to monitor ME condition, or evaluate for permanent HL 23

24 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 with links to PDF document, link to survey 24

25 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 comments 25

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29 Protocol Feedback Training is key Consider offering 2 forms of documentation for diagnostic testing: one for abnormal and one for normal so that the PCP is alerted Having a protocol gives ODH a consistent voice Great work and very comprehensive Implementation may be difficult Is there a point where you suggest just biting the bullet and doing a sedated ABR? Sound Protocol Make the protocol easily accessible and include links to forms How can we get all facilities who do this testing on the same page? This needs more expansion on counseling. Can you include a process map for families? When is a limited protocol needed? Very nice document! 29

30 Here we are EHDI Conference 2016 Revised document Continuation of peer/stakeholder input Updates and changes Acknowledgements Approval from Infant Hearing Screening Subcommittee 30

31 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 a difference for Ohio's newborns! By the way, I love that Ohio is doing this. 31

32 Planned activity 1. Informal group conversation/discussion 2. Advantages and disadvantages 3. Solutions 4. Other ideas for implementation, buy in/support 32

33 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? 33

34 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? 34

35 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? 35

36 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 36

37 Stakeholders Hours Partnerships Increased Outcomes Coordination Collaboration Commitment 37

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39 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 Cincinnati, OH Phone: lisa.hunter@cchmc.org Wendy Steuerwald, Au.D. Clinical Manager of Audiology Cincinnati Children s Hospital Medical Center 3333 Burnet Avenue Cincinnati, OH Phone: Wendy.Steuerwald@cchmc.org 39

40 Contact us Gina Hounam, Ph.D. Program Manager of Audiology Nationwide Children's Hospital 700 Children s Drive Columbus, OH Phone: 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 Phone: reena.kothari@odh.ohio.gov 40