Overcoming barriers to following guidelines.

1. Overcoming barriers to following guidelines. Greg Nassar South Manchester University Hospitals Paediatric Audiology: Balancing Protocols with Reality

2. Introduction • Review of MCHAS guidelines • Including troubleshooting • Influence on local service protocols • Good practice • Personal barriers • http://www.psych-sci.manchester.ac.uk/mchas Paediatric Audiology: Balancing Protocols with Reality

3. Guidelines • Impression taking and earmoulds • Testing aids in the field • Fitting verification and evaluation • FM Advantage • Child to Adult transition • Links between Health and Education Paediatric Audiology: Balancing Protocols with Reality

4. No. 2 Testing aids in the field • Gain curves at 50, 65, 80 dBSPL • Gain vs. Output • Pure tone or broadband stimulus • Modulated • Blooming effects • Total Harmonic Distortion (THD) measures at 65 dBSPL • Pure tone sweep, less than 10%, Can be legitimately higher • “Like for Like” Paediatric Audiology: Balancing Protocols with Reality

5. LISTEN! • Subjective listening check • Use stetoclip (take care with power aids) • If it sounds bust…..it probably is bust Paediatric Audiology: Balancing Protocols with Reality

6. Gain curves showing WDRC Paediatric Audiology: Balancing Protocols with Reality

7. What do gain curves tell us? • Hearing aid set-up • First wave evaluation found some aids set up linearly or with high knee point instead of WDRC • Compression ratios • 3:1 or under (?evidence) Paediatric Audiology: Balancing Protocols with Reality

8. Output curves. Same signal level, different input signals Paediatric Audiology: Balancing Protocols with Reality

9. Gain curves. Same signal level, different input signals Paediatric Audiology: Balancing Protocols with Reality

10. Factors to look out for • Directional microphones • Programs • Feedback management • Noise algorithms Paediatric Audiology: Balancing Protocols with Reality

11. Same stimulus, same program setting, directional mic effects Directional mic off Directional mic on Paediatric Audiology: Balancing Protocols with Reality

12. Position A directional mic off PositionB DM on Position A directional mic on Paediatric Audiology: Balancing Protocols with Reality

13. Repeat baseline curves • If the hearing aid is replaced • If the hearing aid goes for repair • A change in programming e.g. 2nd programme is activated, noise reduction, feedback management, etc. • If the hearing aid is re-tuned Paediatric Audiology: Balancing Protocols with Reality

14. Comparison to baseline curves • Alert Health colleagues if • Gain curves differ by +/- 3 dB • THD levels alter • It sounds bust Paediatric Audiology: Balancing Protocols with Reality

15. No. 5 Transition to adult services • Performed poorly • Young adults tend to appear at service desk • Good links required between Child and adult services (if separate) Paediatric Audiology: Balancing Protocols with Reality

16. First presentation to adult service • Often present at hearing aid service desk (broken aids, requiring new earmoulds, batteries etc) • Service provision may change from at least annual reviews to a “drop in” • School → higher education or work setting. May need assistive devices (access to work?) • Role of education, parents and hearing aid user. Empower the user to enquire about helpful agencies Paediatric Audiology: Balancing Protocols with Reality

17. Flow of information • Details about patient • Audiological history • Hearing aid history (including prescription history) • Etc.. • Helps ensure smooth transition • Hearing aids and settings • Verification using REAR (or REIG!) • DSL i/o or NAL NL1 Paediatric Audiology: Balancing Protocols with Reality

18. Examples of good transition • Written policy • Information for hearing aid user • About 6 months prior to transition • Transition support worker • ?hearing therapist • Pre-transition appointment with adult service Paediatric Audiology: Balancing Protocols with Reality

19. No. 6 Links between Health and Education • Work together • MCHAS trained you together • Efficient bi-directional flow of information Paediatric Audiology: Balancing Protocols with Reality

20. Health to education • Letters • Detailed hearing aid information including earmould details. • FM use. Is default FM+M in the software really default? • Frequency response curves Paediatric Audiology: Balancing Protocols with Reality

21. Education to Health • Feedback from ToD, parents, child • Summary report on outcome measures used • Speech test results • Changes in hearing • FM use or problems Paediatric Audiology: Balancing Protocols with Reality

22. How to share? • Usual methods • Phone, secure fax, letters, email (security issues) • By hand • Can information be shared at appointments or meetings Paediatric Audiology: Balancing Protocols with Reality

23. Common communications • Hearing aid (earmould) breakdown or loss • There’s no shelf anymore! • Quick turnaround • Meetings and other CPD events • CHSWG Paediatric Audiology: Balancing Protocols with Reality

24. Good practice • Self assessment tool on MCHAS website • Contact: • christine.cameron@manchester.ac.uk • Written protocols • Looking for good practice from departments and individuals to be a “Champion” • BAA “do once and share” Paediatric Audiology: Balancing Protocols with Reality

25. Barriers in my local service • Youngest child with PCHI • Born 15th August 2005 • Consanguinity (parents are first cousins) • No other FH • Fallots tetralogy, other problems with colon • Within hours sent to Leeds no hearing screen performed. Paediatric Audiology: Balancing Protocols with Reality

26. Returned October 2005 • OAE and AABR on 10th October. NCR bilaterally • Diagnostic ABR 18th October. No reliable responses. CNA one appointment. • Repeated 15th November. TP ABR >95 dBHL on right, around 90 dBHL on left. Impressions taken. • 3 Cancelled appointments • First hearing aid fitting appointment attended 13th December 2005. Paediatric Audiology: Balancing Protocols with Reality

27. Seen • 23rd December 2005 • 7th February 2006 • 21st February 2006 • DNA and CNA until • 2nd May 2006 Paediatric Audiology: Balancing Protocols with Reality

28. Fitting screen shots • First RECD Paediatric Audiology: Balancing Protocols with Reality

29. Second RECD • Only one occasion were FRQ recorded!! • Crashing system Paediatric Audiology: Balancing Protocols with Reality

30. Problems encountered and solutions • Frequency DNA and CNA appointments • Education went to child’s home • Gave an weekly appointment at preferred venue • Hearing not high on his parent’s agenda • Still undergoing major surgery • We were unaware of hospital inpatient • 24 journal entries since October 2005, (7 months) • Doing well with binaural hearing aids other teams have been notified Paediatric Audiology: Balancing Protocols with Reality

31. Overall • Run frequency response curves • Huge benefits to you, your child, service • Communicate with colleagues • Just flow your information Paediatric Audiology: Balancing Protocols with Reality

32. Thank you Paediatric Audiology: Balancing Protocols with Reality