newborn hearing screening protocol (cg570) protocols and guideline… ·...

Author: Jo Young, Ali McMaster Date: April 2018

Job Title: Team Lead, Local Manager Review Date: April 2020

Protocol Lead: Group Director Urgent Care Version: 2.0 ratified 6/4/18

Location: Policy hub/ Clinical/Maternity/ Postnatal/ CG570

This document is valid only on date last printed of 14

Newborn Hearing Screening Protocol (CG570)

Approval

Approval Group Job Title, Chair of Committee Date

Maternity & Children’s Services Clinical Governance Committee

Chair, Clinical Governance Committee

6th April 2018

Change History

Version Date Author, job title Reason

1.0 March 2016

Jo Young, Team Lead Trust requirement

2.0 March 2018

Ali McMasters, Newborn Hearing screening manager

Review due






Newborn Hearing Screening protocol (CG570) April 2018

Contents

1.0 Purpose .......................................................................................................... 3

2.0 Scope .................................................................................................................. 3

3.0 Process .............................................................................................................. 3

4.0 Roles and Responsibilities ............................................................................... 7

5.0 Consultation Undertaken PHE National newborn hearing programme ........ 8

6.0 Dissemination/Circulation/Archiving ............................................................... 8

7.0 Training .............................................................................................................. 8

8.0 Monitoring of Compliance ................................................................................ 8

9.0 Supporting Documentation and References ................................................. 10

9.1 NHSP Contacts ................................................................................................ 10

Appendix 1 - Well baby Protocol .......................................................................... 11

Appendix 2 - Newborn hearing screening NICU or NNU Protocol ..................... 12

Appendix 3 - Decline of screening- well baby ..................................................... 13

This document must be read in conjunction with:

Map of medicine www.hearing.screening.nhs.uk

Infection Prevention and Control Reporting and Responsibilities Policy (CG077)

Non Attendees at Antenatal Clinics / No Access Visits protocol (CG499)

http://www.hearing.screening.nhs.uk/







1.0 Purpose

This protocol will enable trained newborn hearing screeners to perform newborn hearing

screening in accordance with the National Newborn Hearing Screening Programme. It will

enable early identification of potential hearing loss in newborns to audiology for optimum

outcome. Early identification of hearing impairment gives children a better chance of

developing speech and language skills, and of making the most of social and emotional

interaction from an early age.

The protocol defines roles and responsibilities for The Hearing Screening Team, Neonatal

Unit Staff and Audiology.

2.0 Scope

The newborn hearing screening protocol covers screening for detecting hearing impairment

in newborn babies. The target condition for the screen is bilateral, permanent hearing

impairment (sensorineural or permanent conductive) averaging 40dB or more in the better

ear. The aim is to complete screen by 4 weeks of age.

3.0 Process

The eligible population is any baby born to mothers whom registered GP practice is the

agreed boundaries of responsibility of RBH. This will include babies we are responsible for

that have been born in other hospitals and in some instances, ‘shared’ babies on behalf of

other responsible sites.

A daily list will be produced from CMIS of all babies born in the preceding day within the

hospital and home when a birth notification is completed. The national S4H database for

newborn hearing screening is electronically notified of all birth with production of an NHS

number and a list will be produced daily for all outstanding eligible babies.

The newborn will either enter the hearing screening pathway as a well baby or babies

resident in the NNU for more than 48 hours. See appendix 1 and 2

Screening for both well babies and NNU babies will be performed by the Newborn Hearing

Screening Team.

The screeners will approach all parents of eligible newborns and offer screening, ensuring

the availability of the screening booklet ‘screening tests for you and your baby’ in an

appropriate language. Screening tests for you and your baby can be accessed in other

languages via https://www.gov.uk/government/publications/screening-tests-for-you-and-

your-baby-description-in-brief

Alternatively the screener will access an interpreter via prestige network 01635 246700.

The parents will have received the ‘screening tests for you and your baby’ booklet at the

https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief

https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief







beginning of pregnancy and also discussed screening at the 34-36 week antenatal

appointment with their community midwife. Consent will be verbally gained as is nationally

accepted.

The aim is to carry out the offer of screen and the screen prior to discharge from hospital at

the bedside. If it is not possible to perform or gain consent prior to discharge an

appointment will be offered. An out-patient appointment will also be offered to the following

groups:

Babies born at home

Babies born in another hospital (if not already screened) if we are the responsible

site

Babies we are sharing and screening (when we are not the responsible site)

Initial contact will be made by phone offering an appointment. If unable to contact by

phone the following letters will be sent dependant on the situation –

- NBHS - First appt letter

- NBHS – OAE2 appt in clinic letter

- NBHS - SCBU missed appt

3.1 Well Babies

Screeners will perform a hearing screen following the well baby pathway. The initial

screen is called AOAE (Automated Otoacoustic Emission). The result will be - Clear

response/No Clear response/Incomplete test.

The terms Clear response and No Clear response is in line with National Hearing

Screening Programme (NHSP) as these terms are more family friendly than

pass/fail.

Clear response (CR) - Screeners will document in the personal child health record

book PCHR ‘red book’ the hearing test outcomes

No Clear response (NCR) - On 1st screen. Screeners will organise to return to

screen a minimum of 5 hours later explaining the potential reasons for a NCR and

an opportunity for parents to ask any questions. Parents may choose not to stay in

hospital to have 2nd AOAE and the screeners will organise an appointment for the

parents to return to hearing screening clinics being run throughout the week.

No Clear response (NCR) on 2nd test. Screeners will refer parents back to the

patient information leaflet ‘Screening Tests for You and Your Baby’. The AABR test

will either be performed immediately (depending on availability of a machine,

availability of screeners or suitability for baby to have the test) or following







agreement with the parents, the screener will organise an appointment for the

parents to return to the next, most convenient hearing screening out-patient clinic.

If there is No Clear Response from the AABR- The screeners will provide parents

with National Screening Committee leaflet, ‘Your Baby’s Visit to the Audiology Clinic’

and be responsible for organising a referral to audiology. Parents should be seen

within 4 weeks for the appointment. Screeners will document in the personal child

health record (PCHR) book ‘red book’ the hearing test outcomes

Targeted Follow up – Some conditions may results in the baby developing a

hearing loss after the screen has been completed. These babies, despite having

CR/CR at screening, should be offered a targeted follow-up appointment with

audiology at 7-9 months of age. Conditions include:

Craniofacial anomalies e.g. cleft palate

A syndrome associated with hearing loss e.g. Downs Syndrome

Congenital infection:- Rubella, CMV or toxoplasmosis

NICU baby with bilateral NCR at AOAE and bilateral CR at AABR

Screening Contraindications – Two groups of babies will be referred directly to

Audiology for a full diagnostic assessment WITHOUT screening as follows:

Microtia/atresia in one or both ears

Confirmed or strongly suspected bacterial meningitis or meningococcal

septicaemia

The screeners will upload screening outcomes preferably between each screen but

at a minimum daily to S4H, the National Newborn Hearing Screening database.

At the end of each day the screeners are responsible for setting ‘outcomes’ of each

screened newborn on the national database (including any ‘incomplete’ screening

outcomes). This allows for recognition of outstanding hearing screens and failsafe’s

to be actioned to ensure no baby is missed the offer and acceptance or decline of

newborn hearing screen.

If parents decline hearing screening then they will be signposted to the PCHR for

checklists they can carry out to monitor their baby’s’ hearing. The screener will be

responsible for giving a decline letter to the parents and notifying their GP (in the

letter will be details of how the parents can contact the screening team if they

change their mind). The HV will be aware of parents declining Newborn Hearing

Screening as it will be documented in the PCHR (see Appendix 3).







The Local Manager for the Newborn Hearing Screening Team is responsible for

performing a weekly search on S4H to ensure all babies requiring referral to

Audiology (immediate and targeted) have an appointment.

Local infection policies will be followed

3.2 NICU Babies

In instances where the baby has been in NICU for a period of > 48 hours, screeners will perform a hearing screen following the NICU/SCBU baby pathway (see Appendix 2) once the baby is well enough and over 34 weeks gestation. Screening of NICU babies will only be carried out after the ‘NICU NHSP Risk Factor’ sheet has been completed by a Paediatrician.

3.3 Baby born out of area

The Screening local manager will be responsible for ensuring babies the RBH is

responsible for, but are born in other hospitals, have completed the screen (transfer

ins). Completed means result of CR/NCR with referral/Decline or NCR with decline

of referral. The local manager achieves this by using S4H to provide a list of babies

that require a Newborn Hearing Screen. The Local Manager will ensure that if the

baby was born in a hospital other than RBH that an ‘outcome’ has been set. If there

is no outcome set it will be the Local Managers responsibility to request that this

information is added by the screening site. Excellent pathways of communication will

be fostered between hospital sites to greater improve offer rates. The Local Manager

will also monitor share in and share out of newborns to ensure screen has been

completed or is offered.

3.4 Babies Moving in to the Area

The Hospital based screening programme is responsible for babies up to 12 weeks

of age. CHIS will provide a monthly list of all babies moving in to the cohort area. If

not already carried out elsewhere, the Local Manager will be responsible for

ensuring screening is offered. The case will be closed when appropriate

investigations have confirmed that screening has already taken place and no follow-

up is required by our site or the parents have been offered the screen with an

outcome or declined the screen.

3.5 Deceased Babies

CHIS are responsible for the timely notification, via email, to the newborn hearing team of any infant deaths in the area. The Local Manager is responsible for ensuring that these emails are checked daily and that S4H is updated accordingly and without delay.







3.6 DNA for Newborn Hearing Screening Appointments

The Newborn Hearing Screening Programme follows the Trusts’ DNA policy. The

following letters will be sent dependant on the stage of screening.

- Missed Appointment Letter

- Missed Appointment – Bilateral Letter

- Missed Appointment – Unilateral Letter

- Missed Appointment GP Letter

The Health Visitor will be made aware of this as incomplete form in PCHR record.

3.7 Equipment QA Checks

Newborn hearing screeners are responsible for personally completeing the required daily QA checks on all screening equipment that they use, as detailed in the NHSP Operational Guidance 5. Equipment, paragraph 7.1 Equipment Quality Assurance (QA) Checks. The results of these checks are entered into the appropriate log and if there are any concerns about the results not being as expected, the equipment must not be used and the matter must be referred to the LM.

3.8 Record Retention

Paper copies of patient ‘proformas’ will be retained in the NHSP Local Manager’s

Office for a period of 12 months, after which, they will be destroyed.

4.0 Roles and Responsibilities

The screening team is structured with a Team Leader who is strategic lead for the

local programme. They have clinical and professional responsibility for the overall

running of the programme.

The NHSP Local Manager (formally known as the Local Co-ordinator) is the

operational lead for the local NHS Newborn Hearing Screening Programme and is

responsible for the day to day management of all aspects of the programme and staff.

This includes ensuring protocols for the screening programme are adhered to and

dissemination of National Screening Programme updates in to clinical practice.

The NHSP Screener works as a member of a team participating in the hearing

screening of newborn babies, under the supervision of the NHSP Local Manager. The

NHSP screener role involves the gathering and accurate recording of clinical and test

data relevant to the screening process. The role also involves direct handling of

newborn babies and contact with parents.







5.0 Consultation Undertaken PHE National newborn hearing programme

RBH has undertaken the role of ensuring newborn hearing screens are performed to

the eligible population. Service specifications were agreed between Public Health

England and RBH. The service is to be provided as a hospital based service, with a

dedicated team of staff. Accommodation has been provided in the relevant settings to

enable good quality screening to take place. Stakeholders include NHS Public Health

England, Head of Midwifery, NHSP Screeners, GP’s, Neonatal Unit and Health

Visitors.

6.0 Dissemination/Circulation/Archiving

This protocol will be published on the Maternity Intranet site and will be available for

all Trust employees. In addition, service users and GPs can access the site via the

Intranet.

Staff involved in Newborn Hearing Screening will regularly be updated and

monitored in compliance with NHSP standards.

7.0 Training

All newborn hearing screeners must have undertaken and achieved Objective

Structured Clinical Examination (OSCE) qualification.

Training required to fulfil this protocol will be provided in accordance with the Trust’s

Training Needs Analysis. Management and monitoring of training will be in

accordance with the Trust’s Learning and Development Protocol. This information

can be accessed via the Learning and Development pages on the Trust intranet.

CPD will be undertaken and achieved by all newborn hearing screeners, in

accordance with the NHSP Operational Guidance 2. Training, paragraph 3

Established Screener.

8.0 Monitoring of Compliance

Set out how you will monitor compliance with the document. The table below should

be completed - only include what is feasible and what you will actually do – not what

you think should be done.







Aspect of compliance or effectiveness being monitored

Monitoring method

Individual or dept. responsible for the monitoring

Frequency of the monitoring activity

Group/committee which will receive the findings/ monitoring report

Committee/ individual responsible for ensuring that the actions are completed

Daily cohort S4H/CMIS LM daily NHSP/S4H LM/TL

Transfers in and Out

S4H LM daily

LM LM/TL

Discrepant Data Reports

S4H National Team/Local Manager

monthly LM LM/TL

Audiology Appointment Search

S4H LM Weekly LM LM/TL

Missing results search

S4H LM Weekly LM LM/TL

Yield Report National Team S4H

National Team/Local Manager

monthly LM LM/TL

Patient Survey Survey LM Weekly LM LM/TL

KPI’s S4H National Team/Local Manager

Quarterly NHS Public Health England, Trust Board and Head of Midwifery and LANNBSG

LM/TL and chair of the LANNBSG and Head of Midwifery

Individual screener report

National Team S4H

National Team/Local Manager

monthly LM LM/TL

Annual Report National Screening Committee

Local Manager

Yearly NHS Public Health England, Trust Board and Head of Midwifery LANNBSG and NSC

Head of midwifery

Parents receiving written and verbal information/ survey/LM/Yearly/Team lead

Offer of screen/KPI+S4H/LM/daily+quarterly/LM PHE+S4H/Team lead

Completion of screen/S4H/LM/Daily+monthly/LM PHE +S4H/Team lead

The Trust reserves the right to amend its monitoring requirements in order to meet the changing needs of the organisation. **Some tasks may be delegated by the LM to members of the newborn hearing screening team, if deemed appropriate **S4H is the current national database, however the previous national database, eSP is still in use for historical cases. It is expected that eSP will be decommissioned in early 2018.







9.0 Supporting Documentation and References

9.1 NHSP Contacts

Contact Number

Newborn Hearing Screening Office 0118 322 7556

Newborn Hearing Screening mobile 0774 818 1174

Newborn Hearing Screening email [email protected]

Jo Young Team Leader [email protected]

Audiology 0118 322 7238

Child Health Information Services 0207 004 1501

mailto:[email protected]







Appendix 1 - Well baby Protocol

https://www.gov.uk/government/publications/newborn-hearing-screening-care-pathways









Appendix 2 - Newborn hearing screening NICU or NNU Protocol










Appendix 3 Decline of screening- well baby

newborn hearing screening protocol (cg570) protocols and guideline… ·...

Documents