hearing equipment protocol · childhood detection of hearing, vision and dental problems for...

Hearing Equipment Protocol

Prepared by the BCEHP Hearing Equipment Advisory Group

Version August 2006

PROTOCOL HE100 - HE700

TABLE OF CONTENTS Hearing Equipment Protocol Manual

Acknowledgements ........................................................................................ 3 Introduction ...................................................................................................4 Summary and Scope .......................................................................................5 HE 100 Competencies and Facility Requirements ..............................................6

101 Assessment Personnel...............................................................6 102 Test Environment......................................................................6 103 Test Equipment, Calibration and Supplies ...................................7

HE 200 Flow Chart .........................................................................................9 Referral from diagnostics with 2 or more confirmed thresholds HE 300 Data and Documentation.....................................................................10

301 Data ...................................................................................10 301 Documentation....................................................................10

HE 400 Hearing Instruments and Earmolds .....................................................13

401 Criteria for Amplification............................................................13 402 Special Populations ...................................................................14 403 Pre-selection Criteria for Hearing Instrument Selection................14

404 Earmolds ..................................................................................18 405 Selection and Verification of Electroacoustic Characteristics .........19

406 Verification of Aided Auditory Function .......................................20

HE 500 FM .....................................................................................................23 501 Recommendations Regarding FM Use With Infants and ...............23 Young Children 502 FM Matching Protocol ................................................................23 503 Cochlear Implant and Bone Anchored Instruments......................24

HE 600 Follow up Guidelines: Hearing Instruments and FM ...............................25

601 Rationale ............................................................................25 602 Follow Up Schedule .............................................................25 603 Follow Up Procedures ..........................................................25

HE 700 Counseling..........................................................................................27

C:\Documents and Settings\rjanssen\Desktop\Hearing equipment manual\Hearing Equipment Protocol.doc

ACKNOWLEDGEMENTS The BC Early Hearing Program would like to thank the members of the BCEHP Hearing Devices Protocol Advisory Group for their hard work developing this document.

BCEHP Hearing Devices Advisory Group

Monika Bernauer

Anne Caulfield

Roger Floyd

Lorienne Jenstad

Lesley Lee Backup Chair

Susan Nelson–Oxford

Chair

Brad Orr

Helga Rode

Laurie Usher


INTRODUCTION Announced by the BC government in March 2005, the BC Early Hearing Program (BCEHP) – A Sound Start is one component of a provincial screening program for early childhood detection of hearing, vision and dental problems for children in the province under age six. BCEHP is accountable for ensuring that the program’s services are accessible to all BC families. The program’s goal is to reduce the age of identification of hearing loss to age 3 months and the age of enrollment in intervention to 6 months of age. This provincial program focuses on early identification through screening (refer to Screening Protocol) and diagnostic services (refer to Diagnostic Protocol). Early intervention including Hearing Equipment and Infant development support services through both provincial and local resources are included to allow young children and their families to access the services of support required for communication and development, so that children and families will acquire the communication skills critical for positive social development, educational achievement and personal independence. The program is administered through the Provincial Health Services Authority (PHSA) and is a collaborative effort of Health Authorities, PHSA, provincial ministries, physicians, educators and other service providers. The program is currently in development and will be delivered by health care professionals in BC’s six Health Authorities. Provincial standards and protocols such as this document are being established to ensure all infants receive the same level of consistent, high quality care. This document is the result of work by the BCEHP Hearing Equipment Advisory Group (formerly Hearing Devices Advisory Group); this version is in effect until further notice.


SUMMARY AND SCOPE This protocol is intended to provide direction to audiologists and designates on how to evaluate, fit and verify hearing devices (hearing instruments and FM) for BCEHP infants and young children. It also includes information on data reporting to BCEHP. This protocol includes the process and criteria for referring families to cochlear implant services, but does not include post referral guidelines for cochlear implants. All BC BCEHP protocols are evidence-based and gathered from best practice material, where such evidence is available. The protocols that follow identify mandatory procedures for audiologists and designates in the fitting and verification of hearing devices for BCEHP clients. The Training/ Resource manual includes detailed procedures and resources for mandatory and optional procedures.


HE 100 Competencies and Facility Requirements 101 ASSESSMENT PERSONNEL

101.1 AUDIOLOGIST

An audiologist is the professional singularly qualified to select and fit all forms of amplification for children, including personal hearing aids, FM systems, cochlear implants and other assistive listening devices. An audiologist working with young children must have experience with the assessment and management of infants and children with hearing loss and the knowledge necessary for procedures and equipment used with current pediatric hearing assessment methods, hearing aid and FM selection and verification procedures. All procedures funded by the BCEHP will be conducted by audiologists who are approved through the BCEHP as having completed competency requirements in various procedures used in pediatric aural habilitation. BCEHP designates audiologists through training and support to provide services for children identified through screening (See BCEHP Protocols: Designation - to be developed).

101.2 PEER MENTORS

BCEHP will establish experienced peer mentors within the Health Authority or provincially with referral to external expert support if needed. The role of the peer mentor is to act as a resource for other clinicians. Support could be in the form of phone calls, emails, or possibly in-person visits. Mentors do NOT evaluate the competency.

APPENDIX 1: PEER MENTOR LISTING

101.3 AUDIOMETRIC TECHNICIANS

BCEHP Audiologists may designate some work to audiometric technicians. BCEHP training and support is available for audiometric technicians. Working under supervision of a BCEHP audiologist, a technician may: take earmold impressions and make approved earmold modifications, provide hearing aid orientation, hearing aid repairs, and assist audiologists in evaluations and real ear measures.

102 TEST ENVIRONMENT

102.1 ACOUSTICS

Assessments will be done in an audiometric environment that satisfies the current ANSI standards for hearing aid fitting and verification. APPENDIX 2: ANSI STANDARDS ENVIRONMENT


Testing in any other environment will not qualify for BCEHP support unless the environment has been specifically and previously approved by the BCEHP representative. Contact the Regional Coordinator for further clarification. APPENDIX 3: REGIONAL COORDINATOR CONTACT INFORMATION

102.2 INFECTION CONTROL Personnel must follow Health Authority and BCEHP Infection Control procedures. Including but not limited to:

Hand washing before and after client contact, Client hearing aids must not be handled with bare hands.

All hearing aids must be disinfected when: • they are received from clients • before dispensing back to client • before they are attached to the stethoscope or hearing aid

analyzer • prior to being sent to repair

Detailed procedures are included in the Training/Resource manual and APPENDIX 6: HEARING CLINIC INFECTION CONTROL PROCEDURES

103 TEST EQUIPMENT, CALIBRATION AND SUPPLIES

103.1 HARDWARE REQUIRMENTS Clinics must have:

• Recommended hearing aid verification equipment (Audioscan Verifit or RM500SL including all accessories)

• HiPro box for programming hearing devices • All relevant cables • Printer • Computer capable of running software. (Reference NOAH software

manual for details.) • FM Programming Interface (a.k.a. toaster) for programming transmitter

and cable for programming receivers • FM cable to speaker jack (for programming transmitters) • Otoscope

103.2 SOFTWARE Clinics must have current versions of the following software:

• NOAH 3 hearing aid programming software • All relevant hearing aid manufacturer software • Current FM programming software

103.3 CALIBRATION Equipment used in providing BCEHP services must be maintained and calibrated to ANSI standards (ANSI/ASA S3.6-2004) American National Standard Specification for Audiometers and installed by qualified/certified audiometric instrument specialist, authorized (and trained) by the equipment manufacturer. Contact Regional Coordinator for information. APPENDIX 3: REGIONAL COORDINATOR CONTACT INFORMATION


103.4 CONSUMABLES/SUPPLIES

Clinics must have:

• probe tubes • foam ear tips • otocream • disinfectant wipes • batteries • pediatric ear hooks • plastic film (to cover foam tip) • ear tips for otoscope


HE 200 FLOW CHARTS Referral from diagnostics with two or more confirmed thresholds.


HE 300 DATA, DOCUMENTATION AND FORMS 301 DATA Under development. An interim database is in place for tracking hearing equipment, using information provided on the BCEHP Enrollment Form, BCEHP Authorization to Invoice, and BCEHP FM Equipment Request Form. 302 DOCUMENTATION and FORMS

302.1 INTRODUCTION There are a number of required forms in BCEHP. The purpose of forms is to standardize the data that is collected, how it is reported and to ensure that all BC families receive comparable information and service. The forms and notifications listed in this section are all required/mandatory. There may be additional information that your Health Authority requires.

The following information must be complete and in the client file for audit upon request by BCEHP.

302.2 DOCUMENTATION CONTENT

• Date • Client Name • File number • Make and model of instrument(s) • Serial number of instrument(s) • Which ear the instrument is being used on • Earmold and tubing type

302.3 INFORMATION

302.3.1 GENERAL

• Frequency specific and ear specific thresholds (behavioural or frequency specific ABR)

• Medical clearance for fitting of hearing aid • Middle ear function results

302.3.2 HEARING AID RELATED

• RECD measure printout (NOTE: obtaining new RECD is strongly recommended for each new set of earmolds)

• Indication of use of an appropriate prescription method • Hearing instrument verification data • Current hearing instrument settings printout • Documentation of successful fit


302.3.3 FM RELATED • FM verification data • Default channel of transmitter and receiver and listing of

additional channels programmed into the equipment, if applicable.

302.4 FORMS

302.4.1 GENERAL • The BCEHP Enrollment Form may be filled in by either the

diagnostic centre audiologist or by the dispensing audiologist. Complete all sections of the form, including details of type and degree of hearing loss; hearing aid recommended (if known).

• FORM 1: ENROLLMENT FORM • The BCEHP Tracking Report is used to track the baby's progress

through BCEHP. This is an interim form to be used until the provincial information system is available. Dispensing audiologist will complete the "Amplification" section of this form.

• FORM 4: BCEHP TRACKING REPORT

302.4.2 HEARING AID RELATED • Hearing Aid/FM Fitting Client Agreement to be signed by the

family FORM 5: HEARING INSTRUMENT/FM FITTING CLIENT AGREEMENT

• Functional Assessment Tool which is to be completed within two months post initial fitting and again at one year as follow up. APPENDIX 7: FUCNTIONAL ASSESSMENT TOOLS

• All invoicing/confirmation forms required as per Hearing Equipment Plan Protocol and Procedures Document Section BCEHP Hearing Equipment Plan: Hearing Equipment Plan Protocol and Procedures Document

302.4.3 FM RELATED

• FM enrollment FORM 3: BCEHP FM EQUIPMENT REQUEST • FM orientation checklist FORM 5: HEARING AID/FM FITTING

CLIENT AGREEMENT/PLAN • Functional assessment tool APPENDIX 7: FUNCTIONAL

ASSESSMENT TOOLS • All invoicing/confirmation forms required as per Hearing

Equipment Plan Protocol and Procedures Document. SECTION BCEHP Hearing Equipment Plan: Hearing Equipment Plan Protocol and Procedures Document

302.5 FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY All personal information collected by BCEHP is gathered under the authority of the province's Freedom of Information and Protection of Privacy Act, section 26. The information will help BCEHP determine how well it is meeting families' needs and how it can improve services. Information relating to Hearing Equipment is also to determine eligibility for funding, and to confirm accuracy of invoicing.


Information about individual children may be shared with other professionals who provide services to families as part of the program. These professionals may include other hearing clinics, hospitals, health units, child development centres, early intervention programs or education centres.


HE 400 HEARING INSTRUMENTS AND EARMOLDS 401 CRITERIA FOR AMPLIFICATION

401.1 HEARING LOSS Target hearing loss for amplification is not the same as the BCEHP screening target. Some lesser degrees of hearing loss that the screening target identifies may be fit with amplification. Consideration for amplification includes any hearing loss for which there is reasonable evidence that it will compromise auditory development and speech perception, in the absence of intervention.

The decision for amplification should be based on the child’s audiological data, the speech and language development, the home performance, the family preferences and the existence of other medical conditions or special needs.

401.2 MEDICAL CLEARANCE Medical clearance is required prior to earmold impression taking and subsequent hearing aid fitting (See BCEHP Medical Protocols - to be developed). A copy of indication of medical clearance is to be kept on file. (SEE HE 302.3.1 Documentation Information General) 401.3 AGE The provision of amplification to infants age less than 3 months is at the discretion of the audiologist, but is not generally recommended by the BCEHP. The BCEHP fully endorses the provision and verification of amplification by 6 months of age, as recommended by the Canadian Working Group on Childhood Hearing (CWGCH) http://www.phac-aspc.gc.ca/rhs-ssg/cwgch-gtcae/index.html.

401.4 THRESHOLD INFORMATION Infants should be fit to the “best estimate” audiogram based on ABR results where behavioural results are not yet available. Where there is no response on ABR, amplification should still be considered as an option to determine if there is any residual hearing and may be required as part of cochlear implant candidacy. Fitting of amplification for a loss with less than 2 confirmed thresholds per ear (2000Hz and 500Hz) is not advised/not supported. A minimum of 4 (500, 1000, 2000, 4000 Hz) and ideally, 5/6 frequencies (250, 500, 1000, 2000, 4000, 6000Hz) per ear must be established to enable appropriate fitting. Amplification can be fit conservatively if only 2 thresholds are known (or no response on the ABR) until such time as the other thresholds are established. ABR threshold information will be reported in eHLs (estimated Hearing Levels refer to DX837). The eHLs will be used in the hearing aid fitting protocol (e.g. DSL™).

401.5 RECD RECD must be measured unless there is a valid indication of why the procedure could not be performed. If RECDs could not be obtained, age appropriate and transducer specific values should be used. Although values are available in the current Audioscan Verifit or RM500SL Software, very broad age ranges for the RECD averages starting at 13 months are used (see Audioscan Verifit or


http://www.phac-aspc.gc.ca/rhs-ssg/cwgch-gtcae/index.html

RM500SL manual section 15.2). DSL™ V.5 has much more detailed values based on each month of age from one month to 36 months (http://www.dslio.com). See APPENDIX 8: RECD TABLES. These values should be inserted in the audiometric data when using the Audioscan Verifit or RM500SL.

402 SPECIAL POPULATIONS

402.1 CONDUCTIVE HEARING LOSS While BTE hearing instruments may be the device of choice for infants with hearing loss, some infants may have a conductive hearing impairment caused by a structural issue (i.e. atresia, middle ear malformation). Since children under the age of 5 years are not candidates for surgically-implanted bone-anchored hearing instruments, bone-conduction hearing instruments shall be considered. 402.2 AUDITORY NEUROPATHY/ DYS-SYNCHRONY No consensus or evidence exists on a single appropriate management strategy for infants and children diagnosed with AN/AD (e.g., Berlin, Morlet, & Hood, 2003; Berlin, Hood, Morlet, Li, Brashears, Tedesco, et al., 2003). Some children receive benefit from amplification, but as yet, no predictors exist to determine which child will receive benefit. Infants who have been identified as having AD based on ABR findings should be evaluated behaviourally before amplification is considered. Individuals with AD have been shown to have variable thresholds (i.e. range from normal to profound), which cannot be determined by ABR alone (see Diagnostic Protocol for details on AN/AD diagnosis).

Once behavioural thresholds have been obtained, these thresholds can be used to generate targets for the hearing aid fitting, using a pediatric-specific hearing aid prescription, such as DSL™. Infants may be fitted with amplification at the discretion of the audiologist, should the family elect amplification, and the infant’s auditory progress carefully monitored. If amplification is considered, a trial period should be used to determine whether the individual infant shows improved auditory awareness with amplification. (See also Intervention Protocol for more detail on AN/AD management options other than amplification)

403 PRE-SELECTION CRITERIA FOR HEARING INSTRUMENT SELECTION Hearing instruments chosen for inclusion in the BCEHP have a number of features that are mandatory. For example (i.e. including but not limited to): BTEs, FM compatible, low distortion, and flexible. Following is a listing pertaining to mandatory and/or desirable features for pediatric fitting.

403.1 NON-ELECTROACOUSTIC CHARACTERISTICS


http://www.dslio.com/

403.1.1 BTE HEARING INSTRUMENTS Behind the Ear hearing instruments are the style of choice for most infants/children due to the following considerations:

• Rapid growth of a child’s ear necessitates the need for frequent remakes of the earmold. A custom fitted hearing instrument would require frequent remakes and therefore, the child would be without their amplification far more than with the use of a BTE hearing instrument.

• Custom products do not allow for FM use. • Custom products are more prone to feedback issues due to the

close proximity of the microphone to the receiver. • BCEHP only supplies BTE loaners.

403.1.2 BILATERAL HEARING INSTRUMENTS Infants with confirmed hearing loss in both ears shall be fitted with bilateral hearing instruments unless contraindicated. Many studies have demonstrated the benefits of bilateral hearing (Hawkins & Yacullo, 1984; Valente, 1982a, 1982b). Additionally, auditory deprivation in children with unilateral amplification has been reported (Boothroyd, 1992; Hattori, 1993). Therefore, binaural amplification should always be provided to young children with bilateral hearing loss unless there is behavioural evidence that a hearing aid fitted to the poorer ear is detrimental to performance.

403.1.3 FM COMPATIBILITY/ DIRECT AUDIO INPUT (DAI) This is the system of choice to improve signal to noise ratio. FM may also be used for severe feedback problems. Note: it has been well documented that the use of FM technology by children in educational settings is an effective strategy for improving listening in environments with poor signal to noise ratios, great distance between listener and talker, and highly reverberant rooms (Crandell, 1993). While an FM system may not be used in the first few months of life, when the infant becomes a toddler, more difficult listening situations will develop. The child may be at a distance from the primary caregiver or talker and in highly reverberant environments. In addition, use of this technology may increase the rate of language acquisition (Moeller et al., 1996). For these reasons, it is recommended that FM systems be discussed with the family during amplification appointments and provided when appropriate.

403.1.4 TAMPER RESISTANT BATTERY DOORS 403.1.5 VOLUME CONTROL LOCK/VOLUME CONTROL COVERS A system for locking the volume control (or disabling it in programming) or covering the volume wheel is desirable. Volume controls are highly recommended for younger children to manage feedback on short-term


basis (e.g. in car seat or when waiting for new earmolds). Volume control covers are recommended to prevent accidental changes in volume. 403.1.6 PEDIATRIC-SIZED EAR HOOK Unless otherwise instructed, manufacturers will send adult-sized unfiltered earhooks when hearing instruments are ordered. A pediatric earhook will allow the BTE to stay situated on the infant’s ear. Therma-plastic material is desired.

403.1.7 FILTER IN EAR HOOK A filtered earhook must provide a minimum of 6 dB attenuation at 1000 Hz. Unfiltered earhooks will add resonant peaks to the output response of the hearing instrument, possibly causing feedback and making adjustment to MPO targets difficult. A filtered earhook will smooth the response and allow for a better match to targets with less chance of feedback (Scollie & Seewald, 2002). Therefore, prescriptions should specify filtered pediatric earhooks unless contraindicated. (NOTE: Non-filtered earhooks may be used for certain fitting situations at audiologist's discretion.)

403.1.8 WATER RESISTANT An instrument that is water resistant is a highly desirable feature for this population. However, availability is limited. It is possible for the manufacturer to provide a moisture resistant coating to the inner components of the hearing aid.

403.1.9 RETENTION DEVICES Retention devices assist in keeping the hearing instruments in place as well as assisting in loss prevention (e.g. Huggie Aids, Huggie Catchar, wig tape). See Training and Resource Manual Section 2.2 for more information.

403.1.10 REMOTE CONTROL Should be considered for parental control of multi-memories and/or volume control, e.g. for fluctuating hearing loss, management of feedback.

403.1.11 VISUAL INDICATION OR SWITCH TO INDICATE M, T, FM, OR OFF MODE

403.2 ELECTROACOUSTIC CHARACTERISTICS

403.2.1 BACKGROUND Because amplification must be chosen on the basis of gain and output targets individually-calculated from the infant’s hearing thresholds, it is not possible to specify electroacoustic characteristics that will match targets for all individual infants. The role of BCEHP is to establish general guidelines for target generation and hearing instrument selection.


The role of the audiologist is to select amplification that will meet the prescribed targets. When prescribing amplification for an infant, the selection of electroacoustic characteristics shall include the following: • A systematic, evidence-based prescriptive process that takes into

account the unique acoustic properties of each infant’s ear. The prescription should ensure speech audibility at a comfortable level over as broad a frequency range as possible, and should avoid tolerance problems. It should incorporate age-dependent variables, where necessary.

• Individual ear characteristics (either measured or predicted) incorporated into the prescription.

• Frequency-gain and output limiting characteristics of the hearing

instrument determined using prescription-based calculations.

Therefore, the hearing instruments selected will have the following electroacoustic features to meet these goals.

403.2.2 LOW DISTORTION • Meets ANSI specifications for Total Harmonic Distortion (refer to

manufacturer specifications for values and ANSI S3.22-2003 for tolerances)

• “Clean” output limiting, such as compression limiting or soft peak-clipping

• Wide-dynamic-range compression with slow or adaptive release times until evidence exists to suggest otherwise. (For infants with profound hearing loss, targets may not be met using WDRC. In this case, linear processing with output compression or soft peak-clipping is preferred.)

403.2.3 FLEXIBILITY The hearing aid should have sufficient flexibility in frequency/output shaping to provide audibility across a wide input range and frequency range; e.g. frequency-gain characteristics, compression characteristics across the frequency range, gain at more than one input level, compression threshold, output compression limiting.

403.2.4 ABILITY TO DISABLE EXTRA PROGRAMS AND/OR

TELECOIL

403.2.5 ABILITY TO DISABLE ADVANCED FEATURES SUCH AS DIRECTIONAL MICROPHONES, NOISE REDUCTION, AND FEEDBACK MANAGER


403.2.6 TYPE OF SIGNAL PROCESSING Either digital or analog, is left up to the discretion of the BCEHP audiologist until evidence is available to suggest that one type is superior to the other.

403.2.7 ADVANCED FEATURES OPTIONS Advanced features such as feedback reduction, multimemories, etc., are viable options until there is evidence to suggest otherwise.

404 EARMOLDS

404.1 STYLES A shell style with no vent is often recommended for infants, for best retention and feedback-prevention. However the choice of style is at the audiologist’s discretion. The most important consideration is to obtain a good-fitting canal. A helix-lock may help if retention is a problem, but parents should be carefully instructed on inserting earmolds correctly to prevent irritation or feedback from a helix-lock that is not placed properly. 404.2 MATERIAL Although earmold labs have a variety of brand names for their products, 2 main choices of pliable earmold material should be considered for infants: PVC (vinyl) or Silicone. In the rare event of an allergic reaction (itching, swelling, blistering, sore spots, lesions, or very rarely breathing difficulties or wheezing), an allergic coating is available (“photocoating”). Another soft material, UV-Soft, may also be tried, either if there is an allergic reaction to skinflex or if the canal portion bends over when inserted into the ear.

404.3 TUBING For very young children (<12 months), the size of the ear canal may limit the diameter of the sound bore and how completely the earmold can be tubed. If the earmold material is too pliable, a small ear canal could constrict or close off the un-tubed portion of the sound bore. Silicone materials do not accept glue and usually require the use of a tube lock or tubing retention ring to hold tubing in place. This can distort the shape of the earmold in small ear canals, causing irritation or even feedback. PVC (vinyl) material accepts tubing glue and is somewhat stiffer in shape than silicone; therefore, it is preferable for children under 6 months of age, or for children with unusually small ear canals. In case of changing tubing that has been glued in, leave mold in warm tap water for a few minutes. This softens the glue, then the tube can be removed more easily by pulling out using a circular motion.


405 SELECTION AND VERIFICATION OF ELECTROACOUSTIC CHARACTERISTICS

405.1 PRESCRIPTIVE METHOD RATIONALE A systematic, evidence-based prescriptive process must be used that takes into account the unique acoustic properties of each infant’s ears. The prescription should ensure speech audibility at a comfortable level over as broad a frequency range as possible, and should avoid tolerance problems. It should incorporate age-dependent variables such as ear canal size, where necessary. The Desired Sensation Level Method (DSL™) is the approach of choice for BCEHP clients.

405.2 OUTPUT LIMITING Options for determining output limiting levels include:

• Direct measurement of the real-ear saturation response (RESR) for each ear;

• Use of measured or age-appropriate and transducer-specific RECD values along with the calculated desired SPL values (see APPENDIX 8: RECD TABLES and HE 401.5 Criteria for Amplification - RECD)

• Frequency-specific loudness discomfort levels in each ear should be obtained on all children capable of providing reliable responses.

405.3 REAL EAR MEASURES Probe microphone measurements (actual Real Ear or simulated using RECD) should be used to take into account individual ear characteristics. However, Real Ear aided measures are not often possible on infants and young children due to movement. http://www.dslio.com

If real-ear measurements are not obtainable, age-appropriate and transducer-specific RECD values should be used. Use of age related RECD values provided by DSL™ v5.0 is required until such time as the software supports up to date RECD values. APPENDIX 8: RECD TABLES Until further evidence, RECD should be measured each time the earmold is changed. Prior to the direct evaluation of the hearing instrument on the child, the hearing instrument should be preset in a hearing instrument test box to the calculated desired targets. 405.4 CRITERIA FOR SUCCESSFUL TARGET MATCH Appropriately fitted hearing aids meet the following minimum requirements:

405.4.1 SPEECH-LEVEL INPUTS Test signal: Speech or speech-shaped, at 70dB SPL input level Tolerances: Targets should be achieved within ± 5 dB

Degree of Hearing Loss Target Bandwidth Mild to Moderately-Severe (65dB HL) Flat 500-4000 Hz Sloping* 500-3000 Hz


Severe to Profound (90dB HL) Flat 500-4000 Hz Sloping* 500-2000 Hz

Profound (>90dB HL) Flat 500-1500 Hz Sloping** 500-1500 Hz

*Sloping = >10dB/octave ** If the dynamic range is less than 10dB, fit-to-targets may not be reached.

405.4.2 Maximum-Level Inputs Test signal: MPO or 90 dB SPL pure-tone sweep Tolerances: Response should be less than 5 dB over the UCL

Degree of Hearing Loss Target Frequency

All degrees and slopes Any frequency

406 VERIFICATION OF AIDED AUDITORY FUNCTION

406.1 BACKGROUND The goal of amplification is to ensure the child’s own speech and that of others is audible, comfortable and clear. Verification is accomplished over time through use of aided performance, functional auditory skill assessment, input from the Early Interventionist, parental observations, etc. Performance measurements should be obtained in a binaural presentation mode unless the intent of the assessment is to document asymmetry in aided performance. Where little or no benefit is shown from consistent use of hearing instruments a referral should be made to other services as appropriate, in consultation with family and interventionists.

406.2 AIDED PERFORMANCE Although functional gain is not recommended for verification of hearing aid fitting as per ASHA 2000, it may be useful in gaining information about the child’s auditory development. Therefore, until contraindicated, behavioural audiological assessment, directly measuring the child’s aided and unaided performance, including aided sound field responses to speech (speech awareness, speech production) and frequency specific stimuli are required when the child is developmentally ready for these tasks.


406.3 FUNCTIONAL AUDITORY ASSESSMENT 406.3.1 BACKGROUND Functional auditory assessments typically take the form of self assessment or parent/caregiver or teacher questionnaires. They add an important element to the hearing aid validation and habilitation process in that they tell us not only about what a child hears but how they are using what is heard in everyday situations, and how their listening abilities are changing over time and across situations/environments. As a part of the initial fitting with amplification, and ensuing follow up, functional assessment tools are recommended as they can help to foster the family centredness of the process, and can help to encourage open communication throughout the adjustment period and beyond. They can help us, as clinicians, to be aware of what areas of difficulty a family may be encountering, and perhaps what, if any, changes need to be made to the initial fitting.

Functional assessment tools may also be used for:

• evaluating the effectiveness of amplification • documenting any parent or teacher concerns which may

also assist in “fine tuning” of the fitting • for comparing a change in amplification - for example,

when trying a different set of hearing aids • to help parents, caregivers and professionals better

understand the effects of the hearing loss on the child and later on, the benefits derived from the hearing aids

There is little empirical data in this area, however recognition of the importance of this aspect of validation is evident, with various groups advocating the use of functional assessment tools (Colorado guidelines, American Academy of Audiology etc.)

406.3.2 FUNCTIONAL ASSESSMENT TOOLS

The three assessment tools which have been selected for use within the BC Early Hearing Program are:

• ELF – Early Listening Function Discovery Tool for Parents and Caregivers of Infants and Toddlers

• PEACH – Parent Evaluation of Aural/Oral Performance of Children

• IT-MAIS – Infant Toddler Meaningful Integration Scale See Training and Resource Manual Section 7.3 and APPENDIX 7: FUNCTIONAL ASSESSMENT TOOLS for detailed information.

406.3.3 COMPLETION OF ASSESSMENT TOOL Functional auditory skill assessment information is obtained by the audiologist, early interventionist and family. At a minimum the functional assessment should be completed within 2 months of the initial fit in addition to a follow up done one-year post fit. Additional administration is at the discretion of the audiologist.


406.4 SPEECH, COMMUNICATION AND LANGUAGE Speech, communication and language skill assessment is obtained by the early interventionist working with the family. Further information is included in the Intervention document. 406.5 MINIMAL PROGRESS IN AUDITORY DEVELOPMENT Minimal progress in auditory development will be defined together with the BCEHP Intervention Group. Referral to the Cochlear Implant program is indicated if there is little or no benefit from consistent use of appropriately fitted hearing aids worn at least three to six months as shown through minimal progress in auditory development. APPENDIX 5: BC CHILDREN’S HOSPITAL COCHLEAR IMPLANT REFERRAL CRITERA


HE 500 FM 501 RECOMMENDATIONS REGARDING FM USE WITH INFANTS AND YOUNG CHILDREN

• Introduce as soon as family is comfortable with hearing instrument and child is wearing the hearing instruments consistently. The exception is, if FM is being used to manage feedback, introduce as indicated.

• The recommended microphone setting on the transmitter is “Directional” aka “Zoom” (Lewis and Eiten 2003 and Eiten 2006). (Note: There may be three settings available: “omnidirectional mic” aka “omni”, “directional mic” aka “zoom” and “super directional” aka “super zoom”. )

• The recommended receiver setting is to have both the hearing instrument microphone (aka environmental microphone) and the FM microphone active.

502 FM MATCHING PROTOCOL

502.1 GOAL The goal is to maintain approximately 10 dB difference between FM and HI (Hearing Instrument mic) signals when both are active simultaneously. That is, optimal intelligibility of speech via the FM signal while remaining connected to the immediate environment via the hearing instrument’s microphone.

502.2 ASSUMPTIONS • FM advantage should be measured with the Hearing instrument microphone

(aka environmental microphone) and the FM microphone active.

• An FM advantage of +10 dB is the best starting point (Lewis and Eiten, 2003)

• No clinical measurement systems are currently available to measure simultaneous inputs. Sequential measures (defined as “FM Offset” or FM transparency) is the method of choice for the BCEHP to estimate simultaneous performance when the HI and FM experience the same amount of compression (i.e., inputs are of the same magnitude) (Platz 2004). If we measure the hearing aid only and HI+FM output using the same level (65dBSPL) they will undergo the same amount of compression. We can compare these two measurements and see if they are transparent. If they are not transparent, we should adjust the FM gain setting to make them so. Once we know that they are transparent, we have to assume that when we have a high input to the FM, the FM advantage will be 5-10 dB (i.e. the amount of FM advantage that is programmed to the receiver). NB: A 5-10 dB FM advantage may be difficult to achieve when fitting a severe to profound hearing loss.


• The type of input stimuli used will affect the measurement. Input signals should be as speech-like as possible. (FM advantage that is measured using composite signals is lower than FM advantage measured for real speech.)

503 COCHLEAR IMPLANT AND BONE ANCHORED INSTRUMENTS FM is also recommended for use with cochlear implant and bone conduction devices where applicable.


HE 600 FOLLOW UP GUIDELINES: HEARING INSTRUMENTS AND FM 601 RATIONAL

It is important to develop an understanding of whether the amplification provided to the infant is appropriate and effective in the daily life of the infant and family. Depending on the outcome of the follow up process, adjustments may be required.

602 FOLLOW UP SCHEDULE

Follow up audiological appointments should be scheduled at least once during the adjustment trial period (within 60 days of initial fit) then at 2-3 month intervals for the first year of amplification, then every 4-6 months until age 3 1/2. This follow up schedule may vary from infant to infant depending on the status of diagnosis of the hearing loss, stability of the hearing loss, child and family adjustment factors, and other medical factors. Consider booking a ‘maintenance’ appointment with the Audiometric Technician prior to audiological review. The Audiometric Technician may need to take an earmold impression at this time so that the new mold will be ready in time for the appointment with the audiologist. This may save time in ensuring molds fit and the hearing instruments are working.

603 FOLLOW UP PROCEDURES

Follow up appointments include a combination of the following:

603.1 BEHAVIOURAL AUDIOMETRIC EVALUATION Aided and/or unaided at every appointment NOTE: Aided soundfield measures are not recommended for hearing aid verification; i.e., they are not a substitute for real-ear or simulated real-ear measures. However, aided and unaided thresholds provide important information. Unaided thresholds should be measured periodically to monitor any progression in hearing loss. Aided thresholds are used as a validation measure to confirm that the child is hearing with the hearing aids but do not replace the real ear verification measures (see 406.2).

603.2 ADJUSTMENT OF AMPLIFICATION SYSTEM As needed based on updated audiometric information and input from parent/caregivers and interventionists.

603.3 LISTENING CHECK AT EVERY APPOINTMENT

603.4 ELECTROACOUSTIC ANALYSIS Electroacoustic evaluation of both FM and hearing instrument at least annually and as needed based on listening check and family report.


603.5 EARMOLDS Check fit of earmold at every appointment.

603.6 PROBE MICROPHONE MEASUREMENTS Probe microphone measurements (real ear or RECD) must be measured where possible each time earmold is changed or at least every 6 months.

603.7.1 FUNCTIONAL ASSESSMENT MEASURES Requirement is to complete the questionnaire within the trial period and again at one year post hearing aid fitting. APPENDIX 7: FUNCTIONAL ASSESSMENT TOOLS


HE 700 COUNSELING The quality of parent/caregiver training and orientation has been found to have a direct effect on whether the hearing aids are functioning properly at any given time and whether they are being worn consistently. Once an appropriate hearing aid has been selected and an appropriate initial fitting achieved, the counseling and support provided to the families as they embark on the next phase is critical. Information counseling must be provided in a parent/family-centred manner with the family actively involved in the process. Families need to be able to inform professionals of what they want and need to know. As part of this process, goal setting appears to facilitate inclusion of the child, family and the clinician. At the beginning of each session, check in with the parents regarding their expectations and develop a plan for the session. Audiologists and technicians will provide information to parents/caregivers that are consistent with BCEHP protocols. The “ Clinician’s Hearing Instrument Orientation Checklist” APPENDIX 12: CLINICIAN’S HEARING INSTRUMENT AND FM ORIENTATION CHECKLIST may assist in this process. BCEHP Hearing Equipment Parent Brochure This brochure should be provided to parents by diagnostic centre audiologists at the time of referral for amplification. Confirm with parents that they have a copy, and provide a copy if parents do not have one. Answer any questions they may have. Multiple formats may be used including discussion, practical “hands on” training, written information and even videos. A few sessions may be necessary depending on the family’s and child’s abilities and needs.

Family Centred Care results in practices in which the pivotal role of the family is recognized and respected. Families are supported in their caregiving roles by building on their unique strengths as individuals and families. Opportunities are created for families to make informed choices for their children and more importantly, these choices are respected. Sheldon &Stepanek 1994
