Pennsylvania Department of Health Out-of-Hospital Birth Newborn Hearing Screening Initiative National EHDI Conference Washington, D.C. February 2 -3, 2006 Arthur A. Florio, DOH EHDI Program Administrator Patti Matlock, R.N., DOH Nursing Services Consultant Lynn Shay, R.N., BSHS, CPM
Presenter Disclosure Information In the past 12 months, we have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in our presentation. This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA or will be discussing unapproved or “off-label” uses of pharmaceuticals or devices.
Pennsylvania Facts • Population 12,406,292 • 44,817 square miles • 67 Counties and 2,567 municipalities • 48 of 67 counties are rural • 1/3 of the population lives in a rural area
1999 – began demonstration program in 26 birthing hospitals • IHEARRAct passed in November of 2001 • Statewide program implemented July 1, 2002 • Universal EHDI inall125 birthing hospitals • ~ 142,000 hospital births per year • Approx. 3,400 out-of-hospital births per year Pennsylvania’s Early Hearing Detection & Intervention Program
Why undertake a special effort to screen Out-of-Hospital Births? • IHEARR Act specifically mentions the need to screen out-of-hospital births within 30 days. • HRSA UNHSI grant has a requirement to assure broadest possible representation of culturally distinct groups in programs sponsored by MCHB. • Pennsylvania has historically concentrated cultural communities where out-of-hospital birthing is preferred. These communities have continued to grow.
Out-of-Hospital (OOH) Births • Pennsylvania had a total of 3,390 out-of-hospital births in 2003. • 1,066 OOH births (32%) occurred at Freestanding Birthing Centers (FBCs); 120 FBC births were to out-of-state residents. • 2,324 OOH births (68%) occurred in residences, midwives’ homes or other locations (the majority were home births).
Geographic Concentrations • 5 of the 15 FBCs accounted for 64% of the 1066 births that took place in FBCs during 2003. • 5 counties accounted for 62% of all OOH births in the residence, physician’s office & other location category (i.e., places other than FBCs).
2003 OOH Births – Top 20 Counties of Occurrence (all types included) Erie Warren 112 McKean Bradford Tioga Susquehanna Potter Wayne Crawford 43 Forest Wyoming Cameron Lackawanna Sullivan Venango Elk Mercer 97 Pike Lycoming Clinton Luzerne Clarion Jefferson Columbia Monroe Lawrence Clearfield Union 211 Montour Carbon Centre 33 Butler Armstrong Northumberland Snyder Northampton Mifflin 104 Schuylkill Beaver Indiana 120 Lehigh Juniata -- 162 Dauphin Allegheny 135 Cambria Blair Berks 215 Perry Lebanon 38 Bucks Westmoreland Montgomery 187 Huntingdon Washington Cumberland 86 Lancaster 1047 Bedford Somerset Philadelphia 88 Fayette Chester 124 York 38 Fulton Franklin 99 Greene Adams Delaware 78 1,000 + 50 – 100 100 - 200 40 - 80
2003 OOH Births – Areas of Concentration • Red – Areas with concentrated home births (townships/boroughs with at least 5 and as many as 104 home births – residence of mother) • Colored Dots with surrounding shading – Locations of FBCs and the twps./boroughs where mothers who gave birth in those FBCs reside.
MIDWIVES DOING OOH BIRTHS • Certified Nurse Midwife (CNM) • Certified Professional Midwife (CPM) • Direct Entry Midwife (DEM) • Traditional Midwife Some RNs and midwife apprentices also do newborn hearing screening for OOH births.
Overcoming Barriers in Getting OOH Birth Hearing Screening Started . . . • Lack of interest among midwives • Midwives not convinced of its importance – viewed hearing screening as an additional unnecessary procedure • Patients not interested • Hospitals hesitant to allow hands-on in-service training for midwives doing OOH births
Getting Started. . . • Contact midwives in the counties with the largest concentrations of OOH births • Contact DOH district office community health nurses • Finding midwives interested in performing newborn hearing screening • FBCs are a good venue for hands-on training
Traveling Midwife Networks Freestanding Birthing Facilities Establishing OOH Birth Screening Networks . . .
Advisory Committee helped formulate equipment specifications Bid Procurement -- bid specification is issued and vendors submit bids The lowest bid that meets all requirements of the bid specification gets the sale How Machines are Purchased
Bid Specification Highlights . . . • Must be Portable • Auditory Brainstem Response (ABR) • Battery-powered (5-hour operating capability on charge) • Pass/Not-pass result indication • Consumables for 500 screenings/unit • 3-year service agreement & warranty • Vendor Training
Mailing reports and information Faxes and e-mail Telephones and cell phones Communication is Important
CURRENT PLACEMENT OF PORTABLE ABR SCREENING UNITS • Pennsylvania’s EHDI program has purchased 15 portable ABR units • The units are currently deployed at the above locations • Upcoming prospective placement at Pittsburgh FBC • Another bid purchase is in process for 5 additional units
Preparing for Hearing Screening • Quiet environment • Make sure infant is tired and fed • Identify and prepare sensor sites • Connect Sensors • Fit ear-tip on the probe • Prepare the machine • View results and record results
Maintaining the Networks • 15 portable ABR screening units in use • 6 traveling midwives share 3 machines • 12 units are at FBCs • Maintaining equipment - 5 machines need yearly replacement cables - knowledge of warranties • Budgeting for and ordering supplies
Reports OOH Birth Filter Paper
Success of Program • Diagnosed 2 newborn infants with hearing loss • Both infants have amplification • Awareness among the Lancaster County about hearing screening and the outcome • More interest among the midwives in screening
Challenges • Fluctuating birthing volumes • Generating interest among clientele • Equipment recalls • Cooperation among midwives sharing screening units • Submission of data and referrals
Goals for 2006 • Purchase 5 ABR hearing machines • Screen 50-60% of OOH births • Provide educational updates for midwives • Initiate feedback newsletter for midwifes
Serving special sub-groups of the population in Pennsylvania The Plain People Agrarian communities Rural residents Complementary healthcare seekers
The Old Order Amish and Mennonites • Cost of test and subsequent treatment • Transportation and access
The Old Order Amish and Mennonites • Educational level • Reliance on non-allopathic healthcare • Community belief systems • Routine preventive care devalued • Technology • Avoid being unique • Advice from grandparents • Government aid
Other Plain Groups, Farmers, Rural Dwellers and Complementary healthcare groups • Cost • Transportation • Ease of accessibility • Distrust of government programs • Distrust of allopathic healthcare/technology
Removing the Barriers • Personal relationship with the provider • Patient education • Free testing • Portable process • Incorporation into routine care • Viewing hearing screening as a standard of care • Relating early treatment to adult productivity
Cultural Competence:The chameleon effect • Home visits • “Hitching posts” • Personal relationship • The teachable moment • Informing multiple generations
Net results for outreach screening services: • Decreasing disparity in healthcare services to population sub-groups (Healthy People 2010 goal) • Increased screening to children at risk • Increased awareness of importance of prevention, screening and early intervention among often marginalized groups
Screening and Intervention Linked • Screening followed by intervention in all subgroups • Intervention amenable
Summary and Lessons Learned • Research is Key • Identify and Overcome Barriers • Recognize Cultural Diversities • Program Requires Investment of Staff Time and Effort • Develop Relationships Based on Trust • Communications