ROUGH EDITED COPY
CONSUMER: CASEY JUDD
EDHI
QUALITY IMPROVEMENT STRATEGIES FOR AUDIOLOGISTS (3:20 PM – 3:50 PM, TIKI PAVILION)
MARCH 14, 2015
CART CAPTIONINGPROVIDED BY: SHERRIN PATTI
ALTERNATIVE COMMUNICATION SERVICES, LLC
PO BOX 278
LOMBARD, IL 60148
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This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings
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> Hello, everybody. It's time to get started. We want to share the audience around what you're doing with QI for audiologist. My name is Vickie. I served in Colorado for twenty years and now I work through the University of Colorado, Denver, and I am lucky to have as an audiology regional coordinator and a colleague Stacy who has been really been instrumental in helping us think of ideas around pediatric audiology because what we're finding is that one of the biggest gaps in the system are audiologists.
We're getting lost to documentation. We're not getting quality audiology across the states. Just all sorts of issues that we really want to address in a serious more aggressive way. So I'm going to let Stacy talk about some of the cases she's had and I'll turn it over to you, Stace.
> All right. Good afternoon, everyone our presentation, we kind of apologize for the lighting in here there's nothing we can do to adjust. So if it's difficult to see please raise a hand and ask for extra explanation. I feel really fortunate to work in the position that I'm at. I work in a state, you know, that has instrumental in newborn hearing screening and early intervention and I really kind of work at a legacy institution and so really some of the thoughts and ideas of Mary have been passed down and I'm just really grateful for the opportunity to work with the people that I work with. So the case that I'm presenting today was one that really struck me and this is a case that came across my desk. I am not the managing audiologist but I was the person reporting this child to the state.
And as I input the child's information the age of the child is presented in days of life. So 895 days. And this is this child's story of late identification. So stepping back I'm going to go back through this in reverse order. This was, again, not my clinic but this was the initial institution that saw this child after the refer on newborn hearing screening. So this infant was likely exposed to a number of elicit drugs in utero. Was admitted to the NICU and to a foster family. Otherwise this child was generally healthy and referred on any born hearing screening bilaterally. So on 21 days things are on target and they come in for the outpatient assessment. The tympanology was recorded as normal. And they did normal screens but they have a small collection window 10 milliseconds.
And they noted that 30 DB click where they have marked as normal and they have noted the other ear as being slight in terms of degree of hearing loss with a recommendation of recalling the child back in two weeks. So in 25 days this child comes back for the initial diagnostic.
The things that I note on this is for the left ear that we don't have wave forms that are actually marked. For the right ear we have some atypical collections and all that they note are the OAE findings for one of the ears. And when I look at these OAE findings I note them to be pretty similar in their presentation. Or having similar qualities and so they were just noting however that the issues with the right ear. So this is the third assessment that takes place at 76 days. Again, it's a click and we are only looking at the right ear this time. And I think as we look at this waveform it's marked at the 30 DB NHL and it's marked as being normal and I think of ABRs as something that should be really prominent when you're marking waves and easy to find and there's just nothing that I can see there that's worth marking. And additionally there isn't any other assessment that's been obtained on this child for information. So this audiologist remarks that the testing is consistent with normal hearing for the right ear and normal hearing that was previously notated for the left ear and it's just kind of general in the recall information. So essentially this child was let go free and clear. So fast forward to 782 days. This is when the child is first seen as part of child find due to the foster now adopted family's concerns of this child's speech and language development. And we found out a bit more information the bold points are those points that weren't initially noted on the intake form of the previous audiology clinic. So this child was born a little bit early. About five weeks early and actually had a sixteen day NICU admission which puts them in a risk group. They performed some screening on the child. The questionnaire came out generally normal but they referred out on OAEs. The recommendation was made for audio logic assessment and days later. Again 866 days old the child returns for child find evaluation where they obtain some child field testing. Again, we have that refer result on OAEs with normal tympanometry and no more specific information except for some limited speech information.
But we finally really made a recommendation to a pediatric specification facility to get more information on what's happening which at 895 days is when this child presents to my institution. And we finally have a confirmed hearing loss. So this child was fast tracked then into going through the hearing aid consult process and we scheduled the hearing aid fitting and a speechlanguage consult at the next opportunity which in this family's case, it was a rural family, so we're talking about a fourfive hour drive in order to get back to our center and they're also coordinating care with two additional siblings. But we got your specific information that we are able to obtain. We have bone conduction information that allowed us to confirm the hearing loss in a more appropriate way and finally at 917 days, we get to the hearing aid fitting and, you know, as part of audiology pediatric practice I think a lot about the validation of the work that we do and so, of course, we're verifying all of our findings and when we look at our speech intelligibility index we see a massive difference between what this child has access to unaided versus aided. And then going through some speechlanguage work at that same visit to provide some validation for what this child now has access to in terms of sound and how can they move forward in expanding this child's speech and language abilities. So to recap I just want to kind of want to do through this child's process and what went right and, you know, what went wrong. You know, the newborn hearing screening was completed prior to hospital discharge. They return for that outpatient evaluation as recommended with that foster and adoptive family and that child was recalled for additional assessment. But in terms of what went wrong, I think that there were some pretty significant mistakes. It was a very limited case history that was obtained. They had this short time window for their ABR collection that didn't allow them to get perhaps as much information as they could have potentially needed. There was a normal interpretation for an ABR which in my experience was in general disagreement of what I would call normal and then finally they didn't report any of these findings to the state so this child isn't being tracked in an appropriate way. At three months the things the list of things that went right is considerably shorter. The family, again, they returned for further assessment. But in terms of things that went wrong, there was no frequency specific information that was attempted. There was no evaluation of the left ear. It kind of got left out of this process. There was some really poor agreement between the raw data and the actual test interpretation that somebody with more experience might have had. The family wasn't firmly recalled for future assessment and none of these findings were reported to the state. Which then leaves us at the six month mark and we got nothing in that category of things that went right and we have a huge miss in terms of what went wrong. So I'm going to turn it over to Vickie to talk a little bit about some future QI work.
> Thanks, Stacy. So actually in the last two weeks what has happened with this case is that our audiology or EHDI coordinator met with this clinic and basically what we have done in Colorado over the last six months is taken our audiology guidelines, looked at the AAA guidelines and made them more specific to Colorado. We call it the roadmap for families. We have customized the roadmap for families. You can go to Hands & Voices website and we customized it to every hospital in Colorado and on the back is a list of resources. We're now going to work with audiologist to say you got to meet this strict criteria to be able to be on this roadmap for referral source for infants. And so our EHDI coordinator met with this audiology group that had misdiagnosed this child and they've misdiagnosed many others over the years.
And basically having it come from her she said we are going to take you off the roadmap immediately and that includes teleaudiology with someone who knows what they're doing. They have agreed to do that.
This is the first time in my twenty years of working with this agency that we've made any headway, so I am optimistic that we might finally make some headway with this group so in this community we can start to see some really good diagnostics come out of there because it is very hard for these families on the other side of the state to travel six hour to Denver to be able to get evaluated for hearing aid fittings. We'd like families to stay in their community. We believe in community based systems that whatever a family receives in Denver they should be able to receive in Aspen, Colorado or down in Durango so maybe next year we'll be able to report on what's happening with this.
So that's what I call audiology tough love and we're going to monitor the reports closely. We're going to work with the audiology clinics in a number of ways. One thing that did happen that I think really caught the eye of this audiology clinic is this family has reported this audiologist to DORA and that's potential for losing their license. So I think they're finally willing to step up to the plate and learn what they need to learn. So we're going to start doing audiology report cards. Even in some of our better audiology clinics, they're saying, oh, we get infants in in two to three weeks, but the actual audiologist will say, no, it's six. It's eight weeks before we can get a family in. Well, we don't want that. Because what happens is it's a week to get in. By the time they're two to three months and they often have to have a second appointment to get the full spectrum of frequencies.
And another six weeks to get in. We're seeing our age of diagnosis from two and a half months to four and a half to five months so we really have to work on getting these audiologists to make sure they have slots in their appointment calendars to be able to see these babies.
Stacy does an amazing job and maybe it's because of her flexibility with her schedule but she can actually work to get infants in. I remember when I was a real audiologist at Boulder Community twenty years ago I too would make an appointment. I would see the parents in the evening to get these infants in and get them diagnosed.
So one PSA that we did many years ago was we looked at that time it took with the scheduler for when a family called to when their first appointment was available that they could fit in or that the audiologist was available. And it was about four weeks out. And with some work we were able to help the audiology team and Sandy was there at the time, schedule appointments sooner so they would have open slots to be able to see infants now they're asking the diagnostic center to schedule two appointments at the same time.
Just so that you know that you could have the one appointment for the diagnostic fitting and if you need that second appointment you already got it scheduled. Also using some fax back forms we need to work with our primary care physician so they're in the loop.
I don't know what's happened in clinical audiology lately now that I've been a bureaucrat but after I diagnosed a baby it was common courtesy to sent the information to the primary care physician.
Apparently that's not happening as regularly as it should be. So we're going to look at our integrated data system through our CDC work to printout reports for both the audiologist so they can print out an easy report from the data they've entered into our data system but also for our early intervention providers so they can share these reports that are readable, easy to understand, with their providers. We want to provide technical assistance to encourage best practices and reporting to the state. We have had so much lost documentation. We recently were presenting at the AAP and we were working with our chapter champion Dr.Maureen Cunningham and she was actually calling physician offices to find out results. We did a little PDSA at quality improvement to see if she could put some closure on infants that had been both inpatient and outpatient.
Those, typically are the ones that often have hearing loss and even though we didn't get a great turnaround response 50% of the ones that she did get information from were that the babies had been followed but the audiologist hadn't reported so that's one of the areas lost to documentation that we are really going to work on and, again, looking at being able to provide teleaudiology with our funding so that we can have more audiologists out in the field that can have regular training and support so families don't have to go a long ways.
Reducing the time to diagnosis. We know that significantly reduces the name for se dated ABRs. We had as a diagnostic center in southern Colorado that was waiting three months purposefully or four months so they could only do sedated ABRs. Took some education.
They're no longer seeing infants at all thank goodness but another reason we want to get those infants in sooner we don't want have to do unnecessary sedated ABRs. We also know that this increases parent satisfaction we just know that for a fact. We did some parent questionnaires. We know it's very anxious for families to wait six, seven weeks for a diagnostic appointment and this just causes more stress for the family and it also we can decrease that age of diagnosis to closer to two months. We have wonderful research that's always coming out from the University of Colorado and what the doctor is starting to find which I know is a little scary and we want to make sure we put the family first but is that oftentimes she's seeing in her research that it may not be 1, 3, 6, model anymore. It may be like 1, 2, 3. Getting that diagnosis done by two months and that early intervention started and these children are showing better outcomes. I'm not saying that's the way it should be or that all families want to move through the system that fast but if we're starting to see better outcomes there may be more opportunities to improve our system so that families that do want to move that quickly will have that opportunity. So we'd like to hear from all of you as well what maybe you've been doing to help improve your QI with your audiologist. Does anybody havegreat.
> So I am the audiology consultant for Maine's newborn hearing program which is our EHDI and we see a lot of the same things in terms of lost to follow up, lost documentation but also pretty inappropriate testing being completed by audiologists. So one thing that we have recently started is a quarterly meeting with pediatric audiologists but really inviting everybody for continuing education purposes but also just to discuss case studies like this to make sure everybody is aware that this is really happening. We have babies that have referred on newborn hearing screenings? The in the hospital and they're popping up at two, two and a half with speech and language delays being diagnosed with mildtomoderate hearing loss.
There's lots of cases out there so our big push right now is really education for audiologists and continuing education because we are in a really rural area where that isn't always available for our audiologists.
> Great. Anybody else?
> So I'm in Idaho and one of the things that we've been really fortunate the last, I guess last ten years, Idaho's own beginnings, your EHDI program has been able to use some of their funding to bring the workshop every two years and we have done that in different sections of the state and we're getting ready we're actually in the middle of one right now or it's going to be in the southern part of the state. We always reserve slots for Idaho audiologists and invite all of the Idaho audiologists, not just the pediatric audiologists to attend and pay for them to attend and that has been pretty amazing at helping with the collaboration among the audiology community and actually decreasing some of the audiology shaming that was going on.