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States See Improvement in Infant Hearing Screening and Follow-Up

October 16, 2012
By Kristina Grifantini

  Louisiana, New Mexico, and Kentucky
  Louisiana, New Mexico, and Kentucky have made great progress through their IHSIS collaborative work.


States across the country are improving diagnosis, early intervention (EI) services and support for families with infants who have hearing loss. In the U.S., approximately 63,000 newborns out of 4 million born each year fail their hearing test. In 2009, approximately half of these newborns had no record of receiving a follow-up test or treatment (see a NICHQ graphic).

Through NICHQ’s Improving Hearing Screening and Intervention Systems (IHSIS) program and past collaborative efforts, teams in nearly every state are using quality improvement methods to provide better care to infants and families at three stages: the time that the initial hearing screening results are delivered at the birthing hospital; at a follow-up appointment with an audiologist to confirm or rule out hearing loss; and when the child is enrolled in EI services, which provide assistance and options in developing language abilities. If hearing loss is confirmed, it is crucial that infants begin EI services as soon as possible so they don’t fall behind in communication skills.

Coordinators from Early Hearing Detection and Intervention (EHDI) state offices, as well as audiologists, interventionists, other practitioners and parents of children with hearing loss, make up the IHSIS quality improvement teams. Funded by the Human Resources and Service Administration (HRSA), the IHSIS program has helped teams to improve documentation and information sharing processes between hospitals, pediatricians, families, EHDI offices and audiologists since September 2011. Teams have also increased the role of families at all steps in the process.

By the project’s end in 2013, 31 states will have made services for children with hearing loss better through their participation in the IHSIS program. Three states that have made great progress through their collaborative work are Louisiana, New Mexico and Kentucky.

Overcoming the language barrier to reduce gaps

At the beginning of the project, 38 percent of babies in Louisiana who didn’t pass the initial hearing screening at the hospital had no records of having a second screening to confirm that they did or did not have hearing loss.

To find out what happened to the missing babies and to close the gap in records, the Louisiana team tested and implemented two improvements. They sent a fax-back form to pediatricians to determine whether or not their patients had confirmation of hearing loss. They also sent a letter to parents who had missed appointments with an audiologist.

“What we found overall, both between the parent letters and the fax-back forms, was that many babies were having follow-up that was not being reported by audiologists,” says Jeanette Webb, the follow-up coordinator for the EHDI program in Louisiana. Getting these reports is important, says Webb, so that EHDI offices can make sure all babies are getting the assistance they need if they did fail a hearing screen.

By clarifying these records through the IHSIS program, the Louisiana team found that a small percentage of babies were not getting follow-up confirmation and treatment. They discovered several Spanish-speaking families who, despite having signed paperwork at the hospitals, did not understand that their children had failed a hearing screening test and missed the follow-up appointments. To address the problem, the team’s Spanish-speaking parent partner assisted parents through the process, and the team created a letter with English on one side and Spanish on the other to send to parents. They also created several bilingual hearing screening informational forms for hospitals and doctors to pass out.

“Before this improvement project, we didn’t have checks and balances in place. NICHQ has helped us with doing things in a more timely way and making sure all babies are accounted for,” says Webb.

Increasing resources in a vast landscape

New Mexico is large, rural and has only a few pediatric audiologists, so families experience long travel distances and wait times to get a follow-up appointment if their child did not pass the initial hospital screening.

“In New Mexico, it’s extremely important to follow-up with an audiologist as soon as possible,” says Tammy Voisine, team lead and New Mexico’s EHDI coordinator. “We only have nine pediatric audiology offices serving the entire state so families typically need to wait for services.”

To address this issue, the New Mexico team needed to facilitate better understanding about hearing loss as well as to increase the resources available to parents. They did this by educating pediatricians and parents, training audiologists and providing screening equipment.

Drawing inspiration from the Colorado team and with their parent partners’ input, the team created a family “roadmap” that outlines guidelines for ensuring hearing loss confirmation by three months of age and starting early intervention by six months. Using quality improvement techniques to refine the roadmap, they also created a version for primary care physicians, some of whom might not have experience with patients with hearing loss.

Click here to see a larger version of the roadmap.

“We got a lot of positive response from the primary care physicians,” says Voisine. “We have since made the roadmap into a poster to send out to more doctors.”

With the parent and physician roadmaps conveying the importance of follow-up after an infant did not pass a hearing screening, the team then needed to make sure parents could get the appropriate testing to confirm or rule out hearing loss for their babies. In addition to calling families to help them set up appointments and make sure they kept those appointments, the team set up trainings for 40 adult audiologists to learn how to test babies. The team also helped local midwives and pediatricians obtain hearing screening equipment.

Collaborating across departments to provide care


The Kentucky EHDI office already had an impressive 98%-99% rate of receiving results from initial screening tests from hospitals at the beginning of the project. However, staff did not have solid information on whether those children who did not pass their initial screening went to audiologists for follow-up confirmation or EI services.

The Kentucky team tested about a dozen possible changes to address this concern. The team sent immediate feedback to the hospitals when entries were delayed, as well as when entries were missing primary care physician information or notice of a follow-up appointment. Since sending the feedback to hospitals (now once a month), the EHDI office has seen a decrease in the number of hearing screen reports submitted with incomplete information.

The team is also currently working on sending an alert letter to a child’s primary care physician if the hospital reports a failed hearing screening, as well as a second alert letter if the child is then confirmed by an audiologist to have hearing loss. Additionally, the team is making individual contact with families to facilitate the referral process.

Another barrier the team faced is receiving child-specific information from EI services. “Our data showed that we needed the most work in coordinating with EI,” says Kelly Daniel, the EHDI coordinator and team lead. “We knew kids were getting EI that we weren’t documenting.”

Because of patient privacy regulations, the EI service only shared aggregate data, so the EHDI department could not be sure which specific children were receiving assistance. To remedy this, the team encouraged the EI services to change their policies so that every child could have a release signed by a parent that would allow sharing of information with the EHDI office.

“Through IHSIS, we’ve been able to open up lines of communication between the EHDI office and EI services and improve contact between the two agencies,” says Daniel. “EI and pediatricians now understand more about our program and we understand more about their procedures.”

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