Quality Standards for Paediatric Audiology Services

Appendices

APPENDIX 1: References and Evidence Base

Introduction

Public Health Institute of Scotland ( PHIS) Needs Assessment Report on NHS Audiology Services in Scotland 1993

Quality Improvement Scotland, www.nhshealthquality.org

Development of the Quality standards for Paediatric Audiology Services

Fortnum H, Summerfield Q, Marshall D, Davis A, Bamford J . Prevalence of permanent childhood hearing impairment in the United Kingdom and implications for universal neonatal hearing screening: questionnaire based ascertainment study. British Medical Journal 2001;323: 536

Casselbrant ML, Mandel EM. Epidemiology. In: Rosenfeld RM, Bluestone CD, eds. Evidence-based otitis media. Hamilton, British Columbia, Canada: Decker, Inc, 1999:117-37

Conrad R. The deaf schoolchild: language and cognitive function. London: Harper and Row, 1979

Wood D, Wood H, Griffiths A, Howarth I. Teaching and talking with deaf children. Chichester: Wiley 1996

Bennett KE, Haggard MP. Behaviour and cognitive outcomes from middle ear disease. Arch Dis Chil 1999;80:28-35

Paradise JL, Dollaghan CA, Campbell TF, Feldman HM, Bernard BS, Colborn DK, et al. Language, speech sound production, and cognition in 3-year-old children in relation to otitis media in their first 3 years of life. Pediatrics 2000;105:1119-30

Vernon-Feagans L. Impact of otitis media on speech, language, cognition, and behavior. In: Rosenfeld RM, Bluestone CD, eds. Evidence-based otitis media. Hamilton: British Columbia, Canada: Decker, Inc, 1999:353-73

Standard 1

Yoshinaga-Itano C. Sedey A. Coutter D. Mehl A. (1998) Language of early and later deafened children with hearing loss, Peadiatrics, 102, 1161-1171

Moeller MP.(2000) Early Intervention and language development in children who are deaf and hard of hearing. Pediatrics, 106(3) 1-9

Hind S. Davis A. Outcomes for children with permanent hearing impairment. In Seewald R, ed A sound foundation through early amplification. Procedings of the international conference sponsored by Phonak Oct 1998, Chicago, Illinois USA. Staefa Switzerland: Phonak AG 2000: 199-212

NDCS Quality Standards in Paediatric Audiology: vol IV ( 2000) Guidelines for the Early Identification and the Audiological Management of Children with Hearing Loss

Vernon-Feagans L. Impact of otitis media on speech, language, cognition, and behaviour. In: Rosenfeld RM, Bluestone CD, eds. Evidence-based otitis media. Hamilton: British Columbia, Canada: Decker, Inc, 1999:353-73

Jonathan Parsons. Redesigning Audiology/ ENT Patient Pathway (RD&E/Devon PCT),www.swirl.nhs.uk/resource/115

Standard 2

Transforming Services for Children with Hearing Difficulty and their Families (Department of Health, August 2008)

Modernising Childrens' Hearing Aid Services

http://www.psych-sci.manchester.ac.uk/mchas/

NHS Newborn Hearing Screening Programme. Tympanometry in babies under 6 months : a recommended test protocol 2008 http://hearing.screening.nhs.uk/getdata.php?id=135

NHS Newborn Hearing Screening Programme. Visual reinforcement audiometry testing of infants : a recommended test protocol. Anonymous. Anonymous. 2008.

http://hearing.screening.nhs.uk/getdata.php?id=10490

Do Once and Share: http://www.mrchear.info/cms/Resources.aspx?Action=Folder&ResourceID=177

British Society of Audiology ( BSA) Procedure:Pure tone air and bone conductionthreshold audiometrywith and without maskinand determination of uncomfortable loudness levels (2004)

Acoustics. Audiometric test methods - Part 1: Basic pure tone air and bone conduction threshold audiometry, BSENISO 8253-1:1998

Standard 3

Getting it right for every child, www.scotland.gov.uk/gettingitright/publications

Moeller MP.(2000) Early Intervention and language development in children who are deaf and hard of hearing. Pediatrics, 106(3) 1-9

Calderon R Journal of deaf studies and deaf education 2000, vol. 5, no2, pp. 140-155 (1 p.1/4), Parental involvement in deaf children's education programs as a predictor of child's language, early reading, and social-emotional development

Early years support programme http://www.earlysupport.org.uk

Together from the start practical guidance for professionals working with disabled children (birth to third birthday) and their families, Department of Health publications

National Deaf Children's Society ( NDCS) (2000) Quality Standards in Paediatric Audiology - Guidelines for the early identification and the audiological

management of children with hearing loss, Volume IV. NDCS.

Standard 4

MCHAS Guidline; Guidelines for the Fitting, Verification and Evaluation of digital signal processing hearing aids within a Children's Hearing Aid Service,

www.psych-sci.manchester.ac.uk/mchas/guidelines

Strauss S, Van DC. Hearing instrument fittings of pre-school children: Do we meet the prescription goals? International Journal of Audiology. 2008;47:S62-S71.

National Services Framework for Children, Young People and Maternity Services in Wales (2006). Welsh Assembly Government

National service framework for children, young people and maternity services 2004, Department of Health

Getting it right for every child (2008), Scottish Government

Standard 5

MCHAS Guidline; Guidelines for the Fitting, Verification and Evaluation of digital signal processing hearing aids within a Children's Hearing Aid Service,
www.psych-sci.manchester.ac.uk/mchas/guidelines

Rotteveel LJ. Snik AF. Vermeulen AM. Cremers CW. Mylanus EA. Speech perception in congenitally, pre-lingually and post-lingually deaf children expressed in an equivalent hearing loss value. Clinical Otolaryngology. 33(6):560-9, 2008 Dec.

Nikolopoulos TP. Archbold SM. Gregory S. Young deaf children with hearing aids or cochlear implants: early assessment package for monitoring progress. International Journal of Pediatric Otorhinolaryngology. 69(2):175-86, 2005 Feb

Ching TY, Hill M, Dillon H. Effect of variations in hearing-aid frequency response on real-life functional performance of children with severe or profound hearing loss. International Journal of Audiology. 2008;47:461-475.

Vohr B, Jodoin-Krauzyk J, Tucker R, Johnson MJ, Topol D, Ahlgren M. Early language outcomes of early-identified infants with permanent hearing loss at 12 to 16 months of age. Pediatrics. 2008;122:535-545.

Aetiological Investigations into severe and profound hearing loss in children, British Association of Audiovestibular Physicians, British association of Paediatricians in Audiology, October 2008

Medical management of infants with significant congenital hearing loss identified through the national newborn hearing screening programme. Best Practice Guidelines, http://hearing.screening.nhs.uk/standards

Standard 6

HPC -Standards of proficiency of registered practitioners - http://www.hpc-uk.org/publications/standards/index.asp?id=42

Department of Health (2004) The NHS Knowledge and Skills Framework and the Development review Process. Department of Health Publications

Role of the doctor in the NHSP team, British Association of Audiolgoical Physicians ( BAAP)

National Deaf Children's Society ( NDCS) (2000) Quality Standards in Paediatric Audiology - Guidelines for the early identification and the audiological

management of children with hearing loss, Volume IV. NDCS.

Transforming Services for Children with Hearing Difficulty and their Families (Department of Health, August 2008)

Standard 7

Clinical Standards Board for Scotland. 2002. Clinical Standards: Generic. Edinburgh: Clinical Standards Board for Scotland. www.clinicalstandards.org/pdf/finalstand/generic.pdf [access to full document]

Greenberg PB, Walker C, Buchbinder R. Optimisong communication between consumers and clinicians. Medical Journal of Australia. 2006 Vol 185(5) 246-247

National Deaf Children's Society ( NDCS) website; http://www.ndcs.org.uk

Baguley D, Davis A & Bamford J (2000) Principles of family-friendly hearing services

for children. BSA News 29, 35-39.

Mitchell W & Sloper P (2000) User-friendly information for families with disabled

children: a guide to good practice. Joseph Rowntree Foundation.

Standard 8

Eleweke CJ, Gilbert S, Bays D, Austin E. Information about support services for families of young children with hearing loss: A review of some useful outcomes and challenges. Deafness & Education International. 2008;10:190-213.

Fitzpatrick E, Angus D, Durieux-Smith A, Graham ID, Coyle D. Parents' needs following identification of childhood hearing loss. American Journal of Audiology. 2008;17:38-50.

MCHAS Guidline : Guidelines for professional links between audiology and education services within a children's hearing aid service, www.psych-sci.manchester.ac.uk/mchas/guidelines

Quality standards and good practice guidelines: transition from paediatric to adult audiology services 2005, NDCS

Department for Children, Schools and Families ( DCSF) and Department of Health ( DH). A Transition Guide for all Services. Key Information for Professionals about the Transition Process for Disabled Young People. 2007

Early Years and Early Intervention: A joint Scottish Government and COSLA policy statement (2008) Scottish Government

Appendix 2 - Range of Audiological Assessments

Staff must have the appropriate knowledge, practical skills, competencies and experience to perform and interpret the results of all the assessments they undertake.

It is expected that services should provide, or have arrangements in place to access the following assessments:

Auditory Brainstem Response test ( ABR)

• click, tone pip,
• air conduction / bone conduction
• cochlear microphonics
• conducted under sedation or anaesthetic if required

Auditory Steady State Response

Cortical evoked potentials

Transient evoked oto-acoustic emissions

Distortion products oto-acoustic emissions

Tympanometry, including high frequency tympanometry

Stapedial reflexes

Visual reinforced audiometry

• soundfield
• inserts
• bone conduction

Performance testing

Play audiometry

Toy tests, several modalities

Speech testing, using several modalities

Pure tone audiometry

• air conduction
• bone conduction
• with masking as required

Tertiary centres will also provide

Specific tests for further investigation of auditory neuropathy / dyssynchrony

Specific tests for further investigation into auditory processing difficulties

Assessments for the "difficult to test child"

Paediatric vestibular assessments

Paediatric tinnitus assessment

Appendix 3 - Examples of Good Practice Guidance, Standards and Protocols

Modernising Children's Hearing Aid Services
( http://www.psych-sci.manchester.ac.uk/mchas/guidelines)

1. Guidelines for the taking of impressions and provision of ear moulds within a children's hearing aid service

2. Guidelines for professional links between audiology and education services within a children's hearing aid service

3. Guidelines for testing digital signal processing hearing aids"in the field" within an integrated children's hearing aid service

4. Guidelines for fitting, verification and evaluation of digital signal processing hearing aids within a children's hearing aid service

5. Transition from paediatric to adult audiology services: Guidelines for professionals working with deaf children and young people

6. Procedures for setting up of fm radio systems for use with hearing aids

British Society of Audiology Recommended Procedures (http://www.thebsa.org.uk)

1. Pure tone air and bone conductionthreshold audiometry with and without masking and determination of uncomfortable loudness levels

2. Tympanometry

3. Taking an aural impression

British Society of Audiology and British Academy of Audiology

( http://www.thebsa.org.uk/docs/RecPro/REM.pdf)

1. Guidance on the use of real ear measurements to verify the fitting of digital signal processing hearing aids

NHS Newborn Hearing Screening Programme

( http://hearing.screening.nhs.uk/standards)

1. Medical management of infants with significant congenital hearing loss identified through the national newborn hearing screening programme - Best practice guidelines

2. Audiology protocols for children referred for audiology assessment from the newborn hearing screen

a. Guidelines for the early audiological management and assessment of babies referred from the newborn hearing screen

b. ABR bone conduction testing in babies

c. ABR tone pip testing in babies

d. Air conduction ABR testing in babies using clicks

e. TEOAE testing in babies

f. Tympanometry in babies under 6 months

g. Behavioural observation audiometry testing in babies

h. Distraction diagnostic test protocol

i. Visual reinforcement audiometry testing in infants

3. Audiological Calibration

a. SLM target values for pure tones and ABR stimuli

b. Routine (stage A) checks for ABR systems

c. ABR calibration specification

4. Auditory Neuropathy/Auditory Dys-synchrony policy documents

5. Guidelines for surveillance following the newborn hearing screen

National Deaf Children's Society

( http://ndcs.org.uk/)

1. Quality Standards in Paediatric Audiology - Guidelines for the early identification and audiological management of children with hearing loss

2. Quality Standards in the Early years: Guidelines on working with deaf children under two and their families

3. Quality Standards and Good practice Guidelines: Transition from Child to Adult Services

Appendix 4 - Audiology Individual Management Plan ( AIMP)

AN EXPLANATION OF THE AUDIOLOGY INDIVIDUAL MANAGEMENT PLAN

What is an Audiology Individual Management Plan?

Individual Management Plans are a set of agreed needs and actions that are developed with the child and family.

The initial plan may simply note the date and time of appointment and any special requirements, and actions taken if appropriate, that have been identified from the referral information (e.g. arranging an interpreter).

At the first appointment a history, appropriate examination and audiological assessment will be undertaken. Information and results from these are documented in a format agreed locally, and will inform ongoing development of the management plan.

As for some children the assessment period may be lengthy, this is included within the Paediatric AIMP.

Who has an Audiology Individual Management Plan?

All children referred to the service will have an AIMP.

Who develops the Audiology Individual Management Plan?

The audiologist, child and family will develop the AIMP together using the information gathered during the assessment and following explanation and discussion about possible care options. When children are being seen within a combined clinic setting, for example with ENT or Paediatric colleagues, then information from the medical clinician must also be considered when developing the plan.

A list of agreed needs and actions will be recorded, a copy of which should be given to the child and family. The format of this information may vary depending on local arrangements. It may be in the form of a letter or completed template sent to the child and family, or a printout from the patient management system for example.

What do Audiology Individual Management Plans look like?

AIMPs will vary greatly depending on the individual child. They will record assessment information, needs and planned actions. When plans are updated the outcomes of actions undertaken will also be recorded.

The AIMP for a child referred to a Community Audiology clinic for a hearing assessment due to speech and language delay who is found to have normal hearing may be very simple. An AIMP for a pre-term baby referred from the hearing screen with additional needs and subsequently found to have a bilateral sensorineural deafness will be more complicated.

Initial AIMPs will be composed mainly of agreed needs and actions. These will be added to through time and the AIMP will also include completed actions and outcomes, detailing a summary of the effect of actions take.

What is meant by 'agreed needs'?

Agreed needs are whatever the audiologist and the family have agreed needs to be addressed or managed to ensure that the child has the best possible chance of fulfilling his or her potential. These initial needs will be based on the history, examination, assessment and full discussion with the parent.

What is meant by 'actions'?

Actions are what the audiologist is going to do, or ask someone else to do, to actually attempt to meet the identified needs. Actions will be specific and directive, probably written in the future tense and attached or relevant to one or more of the needs.

What is meant by 'completed actions'?

These are actions that the audiologist (or other audiologists / agencies) actually do at each stage (as opposed to plan to do). They will be directly linked to actions and probably written in the past tense.

What is meant by 'outcomes'?

These will be a summary of the effects of actions and will enable the audiologist to evaluate whether or not the actions have met the needs. Ideally these will be supported by more formal outcome measures.

Outcomes will be linked to needs and may often reference specific actions, They will probably be written in the present tense.

When is a management plan completed?

The management plan is complete when there are no outstanding actions and when outcomes indicate that needs have been met.

Consideration needs to be given as to how you include outcomes or effects of referral to external agencies that may not have been delivered at final follow up appointment.

For children with permanent child hood hearing impairment Paediatric AIMPs will be required until transition to adult services. At that time the adult services will take over the plan.

Information in the Paediatric AIMP will be used to inform the Multi-Agency Support Plan, where one exists.

Audiology Individual Management Plans are not intended to create more work for audiology, but to encourage closer partnership working with children and their families and to provide a means of recording, reviewing, evaluating and updating the agreed needs and actions.

Example 1:	4 year old child with speech and language delay
Referral:	Referred by Speech and Language due to speech delay. Wishes to exclude any underlying hearing problem.
History:	Family have no concerns about hearing. Born at term, good weight, no health problems as a baby or since. No concerns about general development other than speech. No family history of hearing problems.
Assessment:	Tympanic membranes normal PTA - responses at normal levels right and left (Audiogram on Auditbase) Tympanograms normal Automated Kendal Toy Test - 100% at 40dB (minimum presentation) NORMAL HEARING
Agreed Needs and Actions:	Notify results to referrer, GP and Community Child Health. Copy to family No further follow up required. Discharge.

Example 2:	3 month old baby referred from the hearing screen
Referral:	Referred by hearing screening. Refer response on otoacoustic emissions and automated auditory brainstem response bilaterally.
History:	Family unsure about hearing. Born at 28 weeks, ventilated for 3 weeks, jaundice requiring phototherapy. Discharged home at 8 weeks of age. Reported to be making good general progress.
Assessment:	Tympanic membranes normal but not clearly visualised High frequency tympanograms, good peak Transient evoked otoacoustic emissions absent both ears Click evoked auditory brainstem response - repeatable wave forms at 90dBnHL right and left ear Tone pip ABR, Repeatable responses at 55dBnHL at 500Hz, 70dBnHL at 2000Hz and 95dBnHL at 4000Hz in both ears. Responses repeated on 2 separate occasions 1 week apart. Results explained to family, (paediatrician also present).
Agreed Needs:	Information about hearing loss Support Fitting of hearing aids
Agreed Actions:	Family to be given UNHS information leaflet and NDCS Understanding booklet Education Services and Health Visitor to be notified of outcome of assessment by phone Referral letters to be sent to education, speech and language therapy and social work for the deaf Family to be given information about NDCS Paediatrician to arrange urgent home visit. Impressions to be taken for ear moulds Appontment to be given for hearing aid issue.
Completed Actions	Family given NDCS information booklets and contact telephone numbers and emails for the paediatric audiology team Educational Audiologist and Health Visitor notified by phone Referral letters sent to Education S&LT Social Work for the deaf Local branch of NDCS Home visit arranged for .............. Impressions for ear moulds taken Appointment given for hearing aid issue on .........................

Local Children's Hearing

Service Specialist Centre Supra-Specialist Centre

Appendix 5 - Examples of Outcome Measures and Resources for Evaluating Children's Hearing Aids

1. Speech Test Resources

• Ling Speech Sounds ( http://www.bionicear.com/UserFiles/File/Ling_Six_Sound_Check-6.pdf)
• McCormick Toy Test
• Parrot (Recorded versions of the McCormick toy test, including English as an additional language ( EAL) toytest, Manchester picture test and AB word lists ( http://www.soundbytesolutions.co.uk/products.htm)
• Phoenix - Automated McCormick toy test with algorithm for establishing thresholds for speech in quiet and speech in noise
• Consonant confusion task ( http://www.chears.co.uk/downloads/sptestinfo.pdf)
• Auditory Performance test ( http://www.chears.co.uk/downloads/sptestinfo.pdf)
• AB word lists ( http://www.ihr.mrc.ac.uk/products/index.php?products=15)
• BKB Sentence lists( http://www.ihr.mrc.ac.uk/products/index.php?products=15)
• FAAF test ( http://www.ihr.mrc.ac.uk/products/index.php?products=15)

2. Questionnaires

• LIFE - to help evaluate a child's hearing aids in the classroom
• Listening Situations Questionnaire - developed in the UK to provide a means to evaluate a child's benefit from hearing aids in the real world ( http://www.psych-sci.manchester.ac.uk/mchas/eval/quest/LSQ.pdf)
• PEACH and TEACH - The NAL website has additional information on these tools ( http://www.nal.gov.au/nal_products%20front%20page.htm) PEACH booklet, questionnaire and score sheet can be accessed via http://www.psych-sci.manchester.ac.uk/mchas/eval/quest

Appendix 6 - Children's Hearing Services Working Groups

What are Children's Hearing Services Working Groups ( CHSWGs)?

(from http://hearing.screening.nhs.uk)

• A CHSWG is a multi-disciplinary group, including service users, which takes the lead in integrated service delivery for deaf children and their families.
• The main focus of the group is both to monitor and to develop and improve the services delivered to deaf children and their parents and other family members through the processes of ongoing support.
• A CHSWG should operate on both strategic and practical levels.
• The group should be represented by all organisations that are involved in the services delivered to children and their families, and should include Children's Services (with health, education and social service input), appropriate Voluntary Sector representation and parents and carers who are service-users.
• The group should be formally organised with a recognised chair. All members of the group, their views and opinions, should be equally respected by all.
• The CHSWG is a formal group which:-
  • functions properly and in harmony with other groups to succeed in its goals and objectives
  • ensures that each member of the group conforms to shared values, attitudes and norms
  • expects it members to be fully committed to the aims of the group
  • is allowed to make decisions on behalf of the services represented; and direct the strategic developments of the services offered to deaf children
• The group should work as a team, all members should have mutual respect for individual roles and the contribution each can make whether that is from professional or user perspectives.
• CHSWGs need to continue to plan and be clear in their purpose in order to meet the changing expectations from national initiatives and work closely with service providers to continue to deliver high quality children's hearing services.
• The underlying principle of CHSWGs is that working closer with parents as well as across organisations will lead to improved services for deaf children and their families. Effective recruitment of parents to CHSWGs will ensure appropriate representation for the child and family, and demonstrates a truly inclusive approach.
• A key role of the group is to ensure that children's hearing services remain high on the agenda of those responsible for planning and delivering services at a strategic level. It should offer advice, guidance and, where necessary, pressure, to ensure high quality services are available.

What a CHSWG is not:

• A part of other services (e.g. adult audiology, paediatrics, ENT, disability services). The group should aim to maintain a separate identity to improve the profile of Children's Hearing Services and to promote the requirements of the service as well as any successes to all of the relevant stakeholders.
• A 'talking shop'. By being clear about the aims and objectives of the group and by ensuring the best representation of local services the CHSWG should be a forum where services work closely together to continually monitor and improve services offered to deaf children and their families.
• A group that can operate in isolation from service providers, nor can it be managed as a group with no real purpose and no accountability. Therefore a CHSWG needs to have the authority to act with the full knowledge and support from all service providers, at a practitioner, managerial and strategic level.
• A group where one person, irrespective of who they are representing, can use the group for their own or their services' purposes alone. Nor should the group be wholly dominated by any one (or a small number of members) to such an extent where other group members feel they are not included in the group's direction or are unable to have an input to any decisions made. The aim of the group is to address all pertinent issues in a collaborative manner.

Further more detailed information about Children's Hearing Services Working Groups is available at http://hearing.screening.nhs.uk/cms.php?folder=1955

Appendix 7 - Example of a Multi-Agency Support Plan

Appendix 8 - Patient Satisfaction Questionnaire

Paediatric Audiology Service Satisfaction Questionnaire

Please complete the questionnaire below to help us improve Audiology services.

Indicate your level of satisfaction for each item with a tick. Please base your responses on all of the appointments you have received over the last few months, and on your and your child's experience.

Overall, how satisfied are you with:

	Verysatisfied	Satisfied Somewhat	Dissatisfied	Verydissatisfied
Accessibility
Your experience communicating with the Audiology Service?
The time you waited for your child's appointments?
The time you waited at your appointments?
The location of your appointments? (How accessible from your home)
The hearing aid repair and battery replacement service?
Surroundings
The signage directing you to the Audiology department?
Your welcome at reception?
The child-friendliness of the waiting room?
The child-friendliness of the clinic rooms?
The comfort of the clinic rooms?
Information
The information you received with the appointment letters?
The written information you received at the appointments?
The information in the waiting room?
Staff
The professionalism of the reception staff?
The professionalism of the audiologist?
Care & Treatment
The opportunities to discuss any problems or difficulties?
Any explanations you were given?
The assessment and management of your child's hearing needs?
The appropriate involvement of other services?
Overall
The audiology service you received?
Please state below one improvement you would make to the Audiology Service or please add any comments?

Section below for completion by Audiology staff:

Clinic ________________________________________________

Date ______________

Type of Appointment

_________________________________________________________

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