The Next Step in Paediatric Remote Cochlear Implant ...Symposium on Cochlear Implants in Children. July 11-13, 2019. Good morning everyone. I’d like to talk to you today about a
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The Next Step in Paediatric Remote Cochlear Implant Programming in Australia Paula Berkley (Clinical Audiologist) Kylie Chisholm, Rachelle Hassarati and Wai Kong Lai CI2019 Pediatrics, Treating the Whole Child: 16 th Symposium on Cochlear Implants in Children July 11-13, 2019
The Next Step in Paediatric Remote Cochlear Implant Programming in Australia
Paula Berkley (Clinical Audiologist)Kylie Chisholm, Rachelle Hassarati and Wai Kong Lai
CI2019 Pediatrics, Treating the Whole Child:16th Symposium on Cochlear Implants in ChildrenJuly 11-13, 2019
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Presentation Notes
Good morning everyone. I’d like to talk to you today about a new method of providing cochlear implant programming services that we’ve been trialling in the last 12 months at SCIC.
Disclosures
• Financial Relationships: employee of SCIC/RIDBC
• Non-financial Relationships: nil
SCIC Cochlear Implant Program – An RIDBC Service
We are the LARGESTnon-government
service provider in HEARING & VISION
in Australia
We support
8,000+ PEOPLE
across Australia
We have
470+STAFF
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SCIC supports over 8000 people across Australia. With close to 100 recipients living over 200 km from their nearest clinic. Telepractice ensures remote patients can continue to access CI programming and ongoing support no matter where they live in Australia. One such teleaudiology strategy is remote mapping using a tablet and wireless programming pod.
Longitudinal Use of Telepractice at SCIC
2002
Initial telepractice
2007
Teleschool
2010
CI mapping
2014
CI assessment & mapping
2018
Tablets device programming
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SCIC has utilised Telepractice to reach remote clients for the past 16 years. 2010 saw the introduction of our audiological services for CI recipients and we have been routinely providing CI pre and post operative services ever since. In 2017 we commenced development of an APP to provide a standardised speech perception evaluation in the clients’ own home. And most recently we’ve developed a ‘remote mapping wireless kit’ to use with our families who live remotely.
History of Programming Hardware (Cochlear Ltd)
Portable Programming System (PPS)
Wired Programming System
Wireless Programming System (WPP)
Clinical Programming System (CPS) [1]
[1]
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The hardware required to program Cochlear Ltd implants has vastly improved over the last 30 years. The Wireless Programming System allows for the clinician to perform the programming session without the need for a cable connection. A Bluetooth link between the wireless programming pod and the tablet allows the data transfer and enables the clinician to program the sound processor wirelessly. It is powered by connecting a rechargeable battery.
• Does wireless help ‘the whole child’?
• Age limits?
• Improve, maintain or degrade outcomes?
• Help or hindrance in service?
Objectives
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Our study aimed to investigate the impact of using wireless programming hardware with children and their families in remote mapping sessions. We wanted to evaluate the extent to which this technology could be accessed by our paediatric CI population and to evaluate the influence of the ‘freedom’ offered by wireless programming on the outcomes of a child’s mapping session. What are the challenges? What are the benefits? What are the limitations? Does wireless programming remote mapping help ‘the whole child’ and their family?
• Wireless pod + tablet computer + instructions couriered to family
• Tablet contains - Skype/Polycom, Teamviewer and Custom Sound/NFS loaded with client’s mapping file
• Kit returned to clinic, CDX uploaded to database, troubleshooting
The Wireless Programming Kit
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The Wireless Kit was compiled containing the tablet, programming pod and parent instructions. The tablet has dedicated software loaded purely for use in programming. The kit was couriered out to the family in the week prior to their session and then returned to the clinic soon after the session is completed. SCIC staff then uploaded the clients mapping file onto our database.
Basic Remote Mapping Components
Local SiteClient
ProgrammingHardware
Remote Site
Facilitator
Audiologist
Presenter
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The addition of the wireless pod, streamlines the components required at both sites. Previously the remote mapping components consisted of a laptop, additional monitor or tablet at the local site and a laptop, wired programming pod and monitor/tablet at the remote site. (CLICK) Where now, the setup consists of a tablet computer connected to the wireless pod with Skype or Polycom used for visual display and communication between audiologist & family.
• 7 Children with Cochlear Ltd CIs were programmed remotely
• Age range: 5-18 years
• Living at distances of up to 1881 km from their nearest centre
• Audiologist-controlled remote programming system
• Verification:
– Data logging record comparisons
– Ling 6 sound check
– Parent & Audiologist Questionnaires
Method
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A total of 7 children aged between 5-18 years, living at distances of up to 1881 km from their nearest centre, were programmed remotely by an audiologist. All families had previously been mapped remotely using wired programming setups. To monitor the quality of the sound processor fitting, data logging record comparisons, Ling 6 sound checks pre and post-mapping as well as parent and audiologist questionnaires were used.
LING 6 Sound Test
Results: Data Logging and Verification
AH M OR EE OO S SHDetection √ √ √ √ √ √ √
Imitation √ √ √ √ √ √ √
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Comparisons of data logging with wired and wireless programming systems revealed no significant difference in the measurement of thresholds or the outcomes of functional checks like the Ling 6 Sound Test.
• Questionnaires completed by the parent and audiologist
• 16 questions detailing their experience of the wireless vs wired pod
• Quotes from families:
“I would never want to go back to the wire. It is so much easier to use from a parent perspective and my son has the freedom to move if he gets up to move around.“
“It can be a pain to start working with - (my child) was bored waiting for all the computers to work in sync.”
“There needs to be an alternative power source when the battery runs out”
“Very interesting and fun session, way too easy for both of us.”
Results: Questionnaires
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Questionnaires comparing wired and wireless remote mapping were completed by the parent and audiologist immediately following each session. All families reported that they preferred the wireless pod and would happily use it again. Most of the feedback surrounded issues with internet connection, batteries and pairing issues. Some quotes from families were: “I would never want to go back to the wire. It is so much easier to use from a parent perspective and my son has the freedom to move if he gets up to move around.“ “It can be a pain to start working with – (my child) was bored waiting for all the computers to work in sync.” “There needs to be an alternative power source when the battery runs out” “Very interesting and fun session, way too easy for both of us.”
Challenges
– Battery life is limited
– Size/weight of PS + Battery + Wireless Pod
– No Kanso option
– Distance limit: 2.5m from pod to tablet
– Internet stability, connection and speed
– Parent needs to be tech savvy and willing to act as ‘distractor’
Results: Audiologist & Parent Feedback
Positives
– Accessible and time-efficient
– Natural interaction when wireless
– Less irritation if child is sensory-sensitive which leads to better focus and attention
– Convenience of ‘Remote Kit’ with parent instructions
Presenter
Presentation Notes
The questionnaires revealed some consistent positives and negatives for most of the families. The Positives were - having the child comfortable in their own home with the wireless kit allowing for more natural interaction with them and their child. It also allowed flexibility around where the child is positioned without cables limiting them. As there was less irritation from cables this often led to increased focus with less distraction, particularly for those children who were more sensory sensitive. This convenience and accessibility for both the family and the clinic was the most common feedback. A big plus for families was the convenience of the complete kit with all necessary resources for mapping being couriered to them prior to session. This also insured the software could be kept up to date and troubleshooting could be performed if needed. The negatives included the short battery life on the wireless pod, giving just 30-45 minutes of connection and often going flat without warning. The pod prefers to be paired to a dedicated tablet and not be used by multiple devices. There was no option to program Kansos wirelessly. The size and weight of the wireless pod + processor was difficult for some of the younger children or those with poor head control, with them needing to use a headband to keep it in place. The connection between pod and tablet would drop out if they are greater than 2.5m apart, creating delays in the session if the child was roaming too far. Internet stability is vital for these sessions to work smoothly – dropouts can disrupt the flow of the appointment and lead to the loss of concentration by the child. The parent is a more active participant in remote mapping than in-person mapping. The parent needs to be a multitasker - a troubleshooter, a distractor and a presenter of Ling sounds and loudness checks. They become the mapping assistant. Training and support for the parent by clinical staff is vital to a successful session.
Next Steps - Future Directions
Equipment Improvements i.e. Battery life
Improved Internet
Speeds and Stability
Access to Interpreters
Formal Speech
Perception Testing
Training Module for Families to
Assist
Funding Streams /
Reimbursement
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This study has highlighted areas needing further research and development – equipment improvements in battery life, the option of using disposable batteries with the wireless pod, improvements in internet speed & stability, the ongoing development of the speech perception App for use in remote sessions, development of a training module (including videos) for parents to assist in sessions and arranging access to interpreters. Lastly, the funding of teleaudiology is very limited in Australia. We would like to work strongly with government towards achieving recognition of this important service to enable reimbursement to occur and to be matched to in-person services.
Summary
• Telepractice plays an important role in today’s cochlear implant service delivery
• Wireless programming pods and tablets are a valuable next step
• research and development to build on potential
Presenter
Presentation Notes
Remote CI programming has worked reliably for a wide age range of clients including children. This greatly benefits clients and their families living in regional and remote areas of Australia, reducing the need to travel to clinical centres whilst still having access to expert clinical support. The use of a wireless programming pod and tablet is a valuable next step in improving this service and ensuring a family-centred approach. The future potential of wireless remote programming could be realised with further research and development by manufacturers, internet service providers and cochlear implant clinics to build on this potential and further benefit CI families. At SCIC we are looking forward to contributing to this in the future.
