- Published on 07 August 2012
Two Danish audio and speech therapists with master in arts, Christina Degn and Maria Baltzer Gormsen, have studied how the guidelines for screening of new-borns are followed in Denmark, and whether the goals for the screening process are complied. They found that there was a potential for improvement. In this article they describe the study and their conclusions.
Lack of liability positioning is a hinder to optimal hearing screening in Denmark
-Key results of audiologic logopeadia candidate special at Syddansk University
International studies have showed that it is very important to identify and take action at an early stage with hearing loss, in order to make possible the normal development of language, cognitive and social competences. Neonatal screening was therefore developed in 2005 as a national service in Denmark. The goals of the screening were the following:
- That min. 90% of all new-borns should be screened
- That the screening procedure, for healthy new-borns, should be completed within 30 days of the child’s birth
- That children with permanent hearing loss should be fully diagnosed within 3 months
The National board of health in Denmark found out, after 2 evaluations, that even though a higher number of children with congenital hearing loss were diagnosed earlier than before 2005, the screening efforts do not reach the mentioned goals, see figure 1.
The goal of this study was therefore to contribute with possible explanations of the causes of the lacking results and to identify specific procedures in practice that can influence the goals.
The empiric data from the study was found through quantitative and qualitative study methods, by observations and questionnaires around the screening practice in 5 audiological departments specialized in paediatrics and 10 screening units that are evenly divided in each of the Danish regions. In addition, we used an interview with the National Health Board, as the highest responsible authority for hearing screening. The study did thus include several user surveys, that support each other, and valid results, see figure 2.
A short screening process is important, as this optimizes the possibility of an early diagnosis and the following intervention on the children born with hearing loss. At the same time this ensures a quick discovery of false positive test results , which otherwise would could create unnecessary worry among the parents.
The National Health Board recommend therefore that the screening process itself should not exceed the child’s 30th day of life, and that children with hearing loss should be examined and fully diagnosed within the age of 3 months, see figure 3. However, results from this study show that the recommendations are not followed, as only 20% of the contributing screening units have guidelines stating that the primary screening (1st screening) should be performed before 10 days after birth. A part from this, only 50% have a goal of maximum one week between the primary screening and an eventual re-screening follow-up screening (2nd screening). In addition there is a wide ranging misunderstanding about re-screening (3rd screening) not being a part of the complete screening process, and that it should not be performed in the child’s first month of life, as opposed to what is described in the National Health Board’s guidelines. Concerning the measure methods that are employed, most of the departments that were looked at also differ from the guidelines. The National Health Board recommends that no matter which test method is used for the primary screening, that is it should always be followed by an Automated Auditory Brainstem Response (AABR), if the child is referred to re-screening, a follow-up screening see figure 3.
In the National Health Board it is also pointed out that AABR should be employed in an eventual re-screening. However only 20% of the screening units that were asked follow these guidelines, as they only use Transient Evoked Oto Acoustic Emissions (TEOAE) for both tests. In a similar way, only 20% of the audiological departments use AABR as a standard for re-screening of children. As you can see in figure 1, 93% of the screening processes ended at the right time in 2006, which the National Health Board were pleased with. Since then the tendency has been that fewer children have completed the screening within one month, which must be considered as highly unsatisfactory. At the same time there is a fall of 44% of the rate of children with hearing loss who are diagnosed within three months. Therefore, in 2009 only 45%, less than half, were diagnosed at the right time. This is especially alarming, as it could mean that the children who are concerned do not experience the optimal intervention with auditory input until after they are 6 months old, which is considered as the critical period of time for optimal development of language and speech, and the reason for starting with hearing screening (JCIH 2007; Sundhedsstyrelsen 2004). It has not been possible for the screening units nor the audiological departments who specializes in small children to come up with a precise explanation as to what caused the negative development at the time of the screening and diagnosis. One of the causes for this is that none of the participants perform quality controls of their performance. Problems with cancellations or parents who do not show up for appointments, children who are readmitted to the hospital and cannot complete the screening before they are discharged, delays in registrations to the national patient register, these are among the possible explanations that are mentioned. The impact of them in reality is impossible to determine based on the available information.
The screening density is the explanatory factor for how many children are examined. In other words, it is a goal for making it possible to identify all children with hearing loss. To insure a high screening density it is important that the parents are informed about the screening service. The National Health Board has therefore set up when, how and what kind of information the parents should receive. According to the guidelines, the first information should be given to the future parents at least 1 month before the due date. However, the study found that not all the screening units followed these guidelines, as 50% answered that this information was given at the time of, or after, birth. All soon-to-be/new parents should have received information, but did not receive it at the right time. According to the Board, the written information should also be translated to the most common immigrant languages. The study does point out that 30% of the units do not have information material in other languages than Danish, which exposes children of immigrants to a higher risk. All screening units were therefore asked if they were especially vigilant about screening children of parents who do not speak Danish, to what 70 % answered no. The 30% of the units who did not have information in other languages than Danish, were among these.
The study did not find any guidelines for how the screening units should call new-born children in for screening. But the study did find that 50% of the units make an appointment for screening before the parents leave the hospital. The others hand out a telephone number where the parents can call to make an appointment. The study did not decide which method is the best in practice, when it comes to work and resources, but did find that with the latter there is no control of whether the parents actually make an appointment. If the parents don’t show up to their appointment, whether the appointment is ordered by the parents or by the staff, 40% of the units do not contact the parents to make a new appointment, because the screening is not mandatory. The other 60% vary as to what they do to make a new appointment with the parents.
The organisation of the neonatal hearing screening is an important element for the optimal functioning of the screening in practice. According to the Board it seems appropriate that the screening units are attached to one audiological department in each region in order to maintain the knowledge and the guidelines. When the hearing screening was introduced the previous counties all got one medical coordinator, but these were not transferred to the regions of today. Still, two regions employed a screening coordinator who has a similar position. The rest of the regions had one or more persons in charge of this area. The study also looked at the how the screening units are affected by the fact that most of the regions have no clear placing of responsibility. The National Health Board’s guidelines give specific demands to education and continuing education of the screening staff. This study shows that 80% of the audiological departments confirmed that all their staff received education. 60% of the screening units said they did not receive education at the audiological department with new employees. There is a lack of communication between the departments, which we also can also see in the fact that only 60% of both the audiological departments and the screening units feel that the communication between the two is “good” or “very good”. The other 40% were neutral or feel that the communication was “poor” or “very poor”. More than half (60%) of the audiological departments considered their own initiative to organising meetings with the screening staff as to be “poor” or “very poor”.
The lack of placing of responsibility is the main problem when it comes to the Danish hearing screening effort. There is lacking a precise and well-defined description of what areas concern who of the involved parties in the screening process, and whose responsibility it is that the performance lives up to the goals. The conclusion is that the overall responsibility should be centred to the audiological departments that specialize in small children, as they hold the specialized knowledge and at the same time receive the children that are identified through hearing screening. However, for an optimal screening process it is necessary to improve the communication between the audiological departments and the screening units. For example when it comes to the education of the screening staff, to make sure the staff are familiar with the correct guidelines and that they are aware of the importance of an early identification of children with hearing loss. A lack of focus on the motivation among the screening staff is an issue where Denmark stands out compared to other countries such as USA and Australia. Due to this fact there should be organised meetings regularly where the screening staff is updated on new knowledge and on the quality of their performance compared to the goals. This can only be possible if the regions perform quality controls locally by using the results of the journal systems. The audiological departments that specialize in small children should point out one coordinator that would take on the responsibility for their region/area respectively. The screening effort has an urgent need for higher focus as well as new procedures, if not we will end up letting down the same children that the screening was set out to help.
- JCIH (2007) Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs, Joint Commitee on Infant Hearing, gentryk af Pediatrics, Vol. 120, s. 898-921
- Sundhedsstyrelsen (2010): Opfølgende evaluering af den neonatale hørescreeningsindsats
- Sundhedsstyrelsen (2007): Evaluering af den neonatale hørescreeningsindsats
- Sundhedsstyrelsen (2004): Sundhedsstyrelsens retningslinjer af 12. august for neonatal hørescreening