National Center for Hearing

Assessment and Management

IMPLEMENTING

UNIVERSAL

NEWBORN

HEARING

SCREENING

PROGRAMS

IMPLEMENTING

UNIVERSAL

NEWBORN

HEARING

SCREENING

PROGRAMS

by Karl R. White, Ph.D

Utah State University

Antonia Brancia Maxon, Ph.D

University of Connecticut

 

Division of Services for Children

with Special Health Needs

MATERNAL AND CHILD HEALTH BUREAU
Implementing Universal Newborn Hearing Screening Programs i

CHECKLIST FOR IMPLEMENTING

UNIVERSAL NEWBORN HEARING SCREENING PROGRAMS

or over 50 years, there has been widespread acceptance of the need to identify hearing loss at an early age.

Until just recently, however, very few hospitals were operating universal newborn hearing screening

programs. Since 1993, hundreds of hospitals have implemented such programs. Based on the experiences

and using materials from many of these pioneering hospitals, this booklet is organized around a “checklist”

of 13 points that need to be addressed in implementing and operating a successful early identification of hearing loss

program for newborns. The booklet provides a brief explanation of each activity in the checklist. In addition, the Appendices referred to in the text are available from NCHAM’s World Wide Web site (www.usu.edu/~ncham) or in hard copy

from NCHAM, the Marion Downs National Center for Infant Hearing, or the National Maternal and Child Health

Clearinghouse.

POINT 1. ENLISTING SUPPORT FOR NEWBORN HEARING SCREENING .................................................................. 1

POINT 2. DETERMINING AN APPROPRIATE PROTOCOL FOR YOUR HOSPITAL .......................................................... 3

POINT 3. DEALING WITH PROCEDURAL ISSUES ............................................................................................... 5

POINT 4. COMMUNICATING WITH PARENTS, PHYSICIANS, AND HOSPITAL STAFF .................................................... 8

POINT 5. TRAINING NEWBORN HEARING SCREENERS ..................................................................................... 15

POINT 6. KEEPING REFER RATES LOW ....................................................................................................... 17

POINT 7. MANAGING DATA AND PATIENT INFORMATION ................................................................................... 20

POINT 8. FINANCING THE PROGRAM ............................................................................................................ 23

POINT 9. CARING FOR EQUIPMENT AND SUPPLIES ......................................................................................... 26

POINT 10. REPORTING ............................................................................................................................. 27

POINT 11. COMPLETING AUDIOLOGICAL DIAGNOSIS AND FOLLOW UP ................................................................ 29

POINT 12. COORDINATING WITH STATE SYSTEMS ......................................................................................... 33

POINT 13. CONSIDERING LEGISLATIVE MANDATES ......................................................................................... 35

A FINAL NOTE ........................................................................................................................................ 36

F
ii Implementing Universal Newborn Hearing Screening Programs

ACKNOWLEDGEMENTS

T he material in this booklet is based on the experience of staff at the

National Center for Hearing Assessment and Management

(NCHAM), who have directly or indirectly assisted with the

implementation and successful operation of hundreds of hospitalbased newborn hearing screening programs. Although NCHAM is responsible

for assembling this information, it would not have been possible without the

assistance of many different organizations and individuals who have graciously

allowed the use of materials or contributed ideas. Particularly extensive

contributions were made by staff at the Departments of Health in Texas,

Michigan, Hawaii, Colorado, Connecticut, Utah, New York, Iowa, and Oregon.

Coordinators of hospital-based newborn hearing screening programs in each of

these states, as well as programs in Florida, Missouri, Illinois, and Washington,

DC, and staff at the American Academy of Audiology, the American SpeechLanguage-Hearing Association, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the Health Resources and Services

Administration (HRSA), the Directors of Speech and Hearing Programs in

State Health and Welfare Agencies, and the Marion Downs National Center for

Infant Hearing, also provided valuable material and made many helpful

suggestions which substantially improved the final product.

Producing and distributing the booklet would not have been possible without

financial support from the Maternal and Child Health Bureau of the Health

Resources and Services Administration (HRSA/MCHB). The opinions

expressed and positions advocated, however, are those of the authors and

NCHAM and should not be interpreted as HRSA/MCHB policy. Readers

should also note that some states have laws or regulations which take precedence over the suggestions made here. Therefore, anyone interested in implementing a hospital-based newborn hearing screening program should become

informed about policies in their area and should coordinate their efforts with

the State Department of Health, other state agencies, and existing hospital

programs. Given the multifaceted needs of children with hearing loss, such

coordination is invaluable in the development of effective early hearing

detection and intervention programs.
Implementing Universal Newborn Hearing Screening Programs iii

PREFACE

I n 1988, when he was serving as Surgeon General of the United

States, Dr. C. Everett Koop set a goal that all children with significant

hearing loss would be identified before 12 months of age. At the

time, it seemed like an unrealistic goal, given that the Commission

on Education of the Deaf had just reported that the average age of identification

of hearing loss in the United States was 2-1/2 to 3 years of age, and there were

no proven methods for substantially improving the techniques then being used

for newborn hearing screening. A short time later, that goal was incorporated into

the Healthy People 2000 Report as a part of a national effort to improve the health

of the nation’s citizens by the Year 2000. At about that same time, the Maternal

and Child Health Bureau of the Health Resources and Services Administration

(HRSA/MCHB) convened an advisory group to recommend how HRSA/MCHB

should respond to the recently issued report of the Commission on Education

of the Deaf. Among other things, that advisory panel

suggested that HRSA/MCHB fund some research and

demonstration projects to improve the effectiveness of

hospital-based newborn hearing screening programs.

Shortly thereafter, HRSA/MCHB began a series of

initiatives, which has dramatically altered the way in

which infants and young children with congenital

hearing loss are identified and provided with early

intervention services. Starting with a large clinical trial of

universal newborn hearing screening conducted by Utah

State University in conjunction with Women and Infants

Hospital of Rhode Island (often referred to as the Rhode

Island Hearing Assessment Project, or RIHAP), continuing with the National Consortium for Universal Newborn

Hearing Screening, which operated from 1993-1996, and

funding from 1996-2000 for the Marion Downs National

Center for Infant Hearing, HRSA/MCHB has taken a

leadership role in significantly reducing the age at which

children with hearing loss are identified and ensuring that

they receive appropriate medical, audiological, and early

intervention services which are coordinated, familycentered, community-based, and comprehensive. During

this time, the techniques and procedures for newborn

hearing screening have continued to improve. In fact,

the goal of identifying all children with hearing loss by

12 months of age, which was considered unrealistic in

1988, has been continually revised downward. Recently,

the National Institutes of Health stated that children with

congenital hearing loss should be identified early enough

that intervention could start before 6 months of age.

As a result of various HRSA/MCHB efforts over the past 10 years, hundreds of

hospitals are now operating successful universal newborn hearing screening

programs, and at least six states are screening 90% or more of all births.

Color copies of the above poster (12" x 17") are available

from NCHAM for the cost of mailing.
iv Implementing Universal Newborn Hearing Screening Programs

However, there is still a lot of work to be done as evidenced by the fact that

more than 80% of all birthing hospitals are not yet doing universal newborn

hearing screening. To assist hospitals which have not yet started, HRSA/

MCHB is distributing this booklet about Implementing Universal Newborn

Hearing Screening Programs to all birthing and children’s hospitals in the

United States.

The appendices referred to in the booklet and additional information and

supporting materials for starting hospital-based newborn hearing screening

programs are available from the National Center for Hearing Assessment and

Management (NCHAM) at Utah State University, NCHAM’s World Wide Web

site (www.usu.edu/~ncham), the Marion Downs National Center for Infant

Hearing at the University of Colorado, or from the National Maternal and

Child Health Clearinghouse.

Preface

University of Colorado at Boulder

Campus Box 409

Boulder, CO 80309-0409

Phone 303.492.6283

FAX 303.492.3274

Utah State University

2880 Old Main Hill

Logan, UT 84322

Phone 435.797.3589

FAX 435.797.1448

NATIONAL MATERNAL AND CHILD

HEALTH CLEARINGHOUSE

2070 Chain Bridge Road, Suite 450

Vienna, VA 22182-2536

Phone 703.356.1964
Implementing Universal Newborn Hearing Screening Programs 1

POINT 1. ENLISTING SUPPORT

FOR NEWBORN HEARING SCREENING

A

STATES OPERATING SUCCESSFUL

UNIVERSAL NEWBORN HEARING

SCREENING PROGRAMS:

■ STATEWIDE NEWBORN HEARING

SCREENING PROGRAMS.

■ STATES SCREENING MORE THAN

HALF OF ALL BIRTHS, BUT NOT YET

STATEWIDE.

■ STATES SCREENING MORE THAN

20,000 BIRTHS EACH YEAR.

MS

LA

KY

IA

MI

NY

RI

NY

NJ

DE CO UT

AZ

WY

HI

NM

ID

CA

GA

IL

TX

TN

lthough hundreds of

hospitals have now

implemented universal

newborn hearing

screening programs, thousands

have yet to do so. The first step is

usually persuading the various

people associated with providing

health care to infants that such

programs are feasible, worthwhile,

and affordable. The following

information and strategies can be

used to help these people understand

the importance of newborn hearing

screening.

SUPPORT FROM AUTHORITATIVE

GROUPS

Government advisory panels,

commissions, and task forces have

been recommending for over 50

years that

children with

significant

hearing loss be

identified as

early as

possible.

However, in the

last decade, the

frequency and urgency

of such statements

have become much

more pronounced.

Some of the most

convincing statements come from

the National Institutes of Health

Consensus Development Panel,

the Joint Committee on Infant

Hearing, the American Academy

of Pediatrics, the American

Academy of Audiology, the

Commission on Education of the

Deaf, and the Healthy People 2000

report. (Complete references to

each of these statements and a

summary of the contents are

included in Appendix 1.)

MANY OTHER HOSPITALS ARE

DOING IT SUCCESSFULLY

By the beginning of 1999, more

than 550 hospitals in 46 different

states were operating successful

universal newborn hearing screening programs. Six states (Hawaii,

Mississippi, New Mexico, Rhode

Island, Utah, and Wyoming) have

statewide programs (i.e., screening

90% or more of all births); others

(e.g., Colorado, Delaware, Idaho,

Iowa, and Michigan) are screening

more than half of the births in their

state; and several others (e.g.,

Arizona, California, Georgia, Illinois,

Louisiana, New Jersey, New York,

Tennessee, and Texas) are screening

tens of thousands of babies each

year. Appendix 1 includes a listing

of names and addresses of coordinators for more than 100 different

universal newborn hearing

screening programs. Call some of

the people on this list and talk with

them about how they were able to

do it. Those hospitals are no better,

richer, or more dedicated than your

hospital. If they can do it, your

hospital can do it too.

HAS NEWBORN HEARING SCREENING

BECOME THE STANDARD OF CARE?

The fact that so many different

authoritative groups have recommended newborn hearing screening, coupled with the existence of

so many successful programs

scattered all across the country and

the ready availability of relatively

inexpensive equipment and

procedures, means that hospitals

are running a significant liability

risk if they do not do newborn

hearing screening. Although this

should not be the primary reason

for starting a program, it is

appropriate to make administrators
2 Implementing Universal Newborn Hearing Screening Programs

Point 1. Enlisting Support for Newborn Hearing Screening

aware of the liability risks and to

meet with your hospital’s risk

manager concerning these issues

(see references in Appendix 1).

PHYSICIAN SUPPORT IS ESSENTIAL

It is important to have the support

of two different groups of physicians. First, most hospitals have a

pediatric committee, a medical

policy committee, or other such

group that makes decisions about

what constitutes standard of care

in that hospital. Make sure that the

physicians in that group understand why newborn hearing

screening should be the standard

of care. Once they become

convinced about the practicability

and benefits of newborn hearing

screening, a giant leap has been

made toward it

becoming a

reality in your

hospital.

Second, physicians in the

community who

care for babies

need to understand why

newborn hearing

screening is

important and

how the process

is supposed to

work. Ideally, for

each baby born,

there should be a

physician who

knows that baby

and its circumstances and is

responsible for

ensuring that it

receives consistent and appropriate

health care. Often referred to as

the baby’s “medical home,” the

baby’s primary care physician is

the key to an effective early

hearing detection and intervention

program. Because the baby’s

primary care physician is responsible for the total health care of the

baby, he or she needs to be assured

that newborn hearing screening

will not interfere with or complicate other health care activities.

The physician at the baby’s

medical home is also extremely

important in encouraging parents

to keep appointments for followup screening and diagnostic

procedures when it is necessary.

You may need to use slightly

different strategies to enlist the

support of these two groups of

physicians, but spending the

necessary time in the beginning

will pay huge dividends in the

long run.

IT WON’T HAPPEN WITHOUT SUPPORT

FROM THE NURSING STAFF

Doctors may determine how

medicine will be practiced, but

babies live in the nursery while

they are in the hospital. If nurses

are not convinced that newborn

hearing screening should be

happening in your hospital, it will

be almost impossible to have a

successful program. If the nursing

staff want newborn hearing

screening, they can often convince

the doctors and administrators to

give it a try. In fact, some of the

earliest successful hospital-based

newborn hearing screening

programs were started and largely

operated by nursing staff.

Photo courtesy of Bio-logic Systems Corp
Implementing Universal Newborn Hearing Screening Programs 3

POINT 2. DETERMINING AN APPROPRIATE PROTOCOL

FOR YOUR HOSPITAL

O nce you decide to

implement a screening

program, one of the first

decisions you will have

to make is what equipment to use

and what type of basic screening

protocol to follow. The good news is

that you have a lot of options, and

almost all of those alternatives have

been successfully implemented at

one hospital or another. The bad

news is that there are so many

options, you might unnecessarily

delay the implementation of the

screening program to sort

through them all. Our advice is

to talk to some people who

have tried different options;

devote some brief, but intensive, study time to what type of

equipment and protocol you want

to use; and then make your choice

and move ahead.

WHICH EQUIPMENT IS BEST?

In the last 10 years, a variety of

different types of equipment

have been developed which can

be used successfully in universal

newborn hearing screening

programs. Transient evoked

otoacoustic emissions

(TEOAE), distortion product

otoacoustic emissions

(DPOAE), and automated

ABR (auditory brainstem

response) equipment have all

demonstrated their practicality and

effectiveness in hospital-based

newborn hearing screening

programs. Each type of equipment

has its proponents, and debates

about which technique is best are

sometimes quite energetic. It is

clear, however, that the type of

equipment you select is not the

most important issue in whether

the program will be successful.

Equipment continues to be

modified and improved, and it is

almost certain that better, faster,

and easier-to-use equipment will

become available on a regular

basis. That is no reason, however,

to delay implementing a program

at the current time. The equipment

currently available is more than

adequate for operating a successful

newborn hearing screening program.

A brief summary of the issues to be

considered in selecting equipment

is included in Appendix 2, as well

as a listing of names and addresses

of various manufacturers.

WOULDN’T IT BE BETTER TO

WAIT FOR THE NEXT GENERATION

OF SCREENING EQUIPMENT?

Absolutely not! Although it’s easy

to predict that newborn hearing

screening equipment will continue

to improve, there are two problems

with waiting. First, no one can

predict the timing of improvements.

The next dramatic step forward in

newborn hearing screening

equipment may occur in 2 months

or 5 years. Second, and most

importantly, every day you wait,

33 babies are born in this country

with sensorineural hearing loss.

You don’t want one of those to be

born at your hospital and be

undetected because you are waiting

for even better, cheaper, and faster

screening equipment than is now

available. The equipment now on

the market is effective, easy to use,

and relatively inexpensive. Therefore, the best approach is to move

ahead now with a newborn hearing

screening program and then make

your program even more efficient

by purchasing the new and

improved screening equipment

when it becomes available.

THE EQUIPMENT CURRENTLY AVAILABLE

IS MORE THAN ADEQUATE FOR

OPERATING A SUCCESSFUL NEWBORN

HEARING SCREENING PROGRAM.

Photo courtesy of Otodynamics Ltd

Photo courtesy of Natus Medical

Photo courtesy of Madsen Electronics

and University Hospital, Copenhagen

Photo courtesy of Starkey
4 Implementing Universal Newborn Hearing Screening Programs

Point 2. Determining an Appropriate Protocol for Your Hospital

a Based on universal newborn hearing screening programs that

were operational as of January 1, 1996. The second technique

listed for any protocol is only done if the infant does not pass the

first technique.

b Only those screening techniques used prior to referral for a

diagnostic evaluation are listed here.

HOW MANY TESTS SHOULD BE

INCLUDED IN THE SCREENING

PROTOCOL?

The purpose of any screening

program is to select a subgroup

from the general population which

is at higher risk

of having a

particular

condition so that

a more in-depth

diagnostic

assessment can

be done with

members of that

group. Therefore, it is

expected that

there will be

some false

positives (i.e.,

infants with

normal hearing

who do not pass

the screening

test) and

occasional false

negatives

(infants who pass the screening

test but do have a hearing impairment). For hospitals who use only

one screening test prior to the time

the baby is discharged from the

hospital, 2-10% of the infants will

not pass prior to discharge.

Therefore, many hospitals have

implemented a two-stage screening

process. Sometimes this is done

with the same type of equipment;

sometimes with different types of

equipment. Furthermore, some

hospitals do a two-stage screening

with different types of equipment

before the baby is discharged from

the hospital, while others do a

single stage before the baby is

discharged and then follow with an

outpatient screen several days

later. Table 1 shows the many

different kinds of protocols being

used by hospitals in 1996.

You must decide which type of

protocol is best for your situation

based on factors such as the

following:

• How long babies typically stay

in the hospital before discharge.

• How difficult it is in your area

to get parents to come back for

rescreens.

• The availability of different

types of equipment.

• Who is doing the screening.

• Personal preference.

The fact that successful programs

currently use such a variety of

protocols suggests that no one

protocol is really best for all

situations. Regardless of the

protocol you select, it is best to

have a written document to guide

the activities of all people associated with the program. Examples

of several such written protocols

are included in Appendix 2.

Photo courtesy of Natus Medical

Different Protocols Used in Universal

Newborn Hearing Screening Programsa

After Hospital

Dischargeb

Number of

Discharge Programs

Before Hospital

Screening Procedure

OAE OAE and ABR 44

OAE OAE 5

ABR ABR 24

ABR OAE 2

OAE and ABR 8

ABR 30

OAE 7

TABLE 1
Implementing Universal Newborn Hearing Screening Programs 5

POINT 3. DEALING

WITH PROCEDURAL ISSUES

R egardless of the technology selected or the

protocol used, decisions

have to be made about a

number of procedural issues that are

important for an efficient, successful

program. It is often useful, and in

fact, many hospitals require a written

summary describing how the program

typically addresses the following

issues (see Appendix 3 for examples).

WHO’S IN CHARGE?

If everyone is responsible for a

task, it often remains unfinished.

Hundreds of hospitals have now

demonstrated that newborn

hearing screening is relatively

straight-forward and can easily be

incorporated into the routine of a

hospital. Just like any other

procedure, however, it takes

attention to detail and someone

who is ultimately responsible to

make sure that all of the specifics

are done. The person responsible

for day-to-day operation of the

program needs to have good

connections with the nursery,

understand how screening happens, and most of all be committed

to the success of the program.

Instead of looking for reasons why

newborn hearing screening won’t

work, that person needs to be

committed to its success. Depending on how the program is

organized, most hospitals find this

person will require between 2 and

6 hours per week per thousand

births to coordinate and manage

the overall program.

WHO WILL DO THE SCREENING?

Reports from hundreds of operational programs provide clear

evidence that newborn hearing

screening can be done by a wide

variety of people, including

nurses, audiologists, technicians,

health care assistants, volunteers,

and students (see Table 2). Some

states have laws regarding who

can screen for hearing and how

they must be supervised; others do

not. Regardless of who does the

screening, make sure they are

properly trained and supervised

and keep data on how each

screener is doing. Such data will

enable you to give timely and

appropriate training and assistance

when it is needed.

WHEN SHOULD SCREENING BE DONE?

All other things being equal,

newborn hearing screening is

faster and easier if babies are quiet

and the environment is not too

chaotic. Because of this, most

screening is done in the early

morning or during the night when

there are fewer people wanting

access to the baby (e.g., doctors,

visiting relatives, nurses, parents,

etc.). Even so, depending on who

is screening, what other responsibilities they have, and how the

hospital’s nursery is organized,

you may decide to do screening at

TABLE 2

People Doing Screening

in 130 Newborn Hearing

Screening Programsa

Audiologists 34%

Technicians 27%

Nurses 60%

Volunteers 11%

a Percentages sum to more than 100%, because many sites have

different groups of people doing screening. Data taken from a

survey conducted in 1997 by the Marion Downs National Center

for Infant Hearing.
6 Implementing Universal Newborn Hearing Screening Programs

Point 3. Dealing With Procedural Issues

some other time or continually

throughout the day. Whatever

you decide, there are dozens

of other hospitals doing it

at approximately the

same time. The

conclusion? There

really is no wrong

time to do newborn

hearing screening.

MAKING SURE

EVERY BABY IS

SCREENED

If the hospital has

accepted newborn

hearing screening

as the standard of

care, there should

be procedures to

ensure that no

babies are missed.

Setting up a system to

log the birth of every

baby, making sure

screeners are available to

screen every baby prior to

discharge, and incorporating the

hearing screening into the discharge plan should all be considered. Because some hospitals

discharge babies after very short

stays, you will probably need 7-

day-a-week coverage and people

available to do screening whenever babies are likely to be

discharged. Many hospitals have

found that by incorporating

screening duties into the job

responsibilities of existing

personnel, they have an easier time

achieving 7-day-a-week coverage.

SCORING

Some types of equipment automatically produce pass/fail results, so no

scoring is necessary. Other equipment requires someone to make a

pass/fail decision based on established criteria. With such equipment, you have to decide who will

make those decisions and when they

will be made. In most cases, this

isn’t a big deal, since it requires just

a few seconds and many hospitals

have the screening technician

make the decision following

established guidelines. Some states

have laws or regulations governing

such decisions, however, so make

sure you are consistent with such

requirements if they exist.

Even in those cases where the

result is automatically produced,

you need to make sure the results

are written down or entered into a

database. This will enable you to

keep track of all of the results and

make sure that infants referred from

the screening program receive the

appropriate diagnostic and, as

necessary, intervention services.

SHOULD SCREENING BE DONE

WITH THE PARENTS PRESENT?

You must decide whether or not you

want to encourage parents to be

present during the screening. If the

parent is present for the screening,

they will have questions and want to

discuss the process. This is wonderful from an educational perspective,

but it requires more time and,

consequently, increases the cost of

the screening program. If you can

afford it and want to provide the

extra education, it’s a great thing

to do, but be mindful of the extra

time required. Even if you decide

not to actively encourage parents

to be present, if they ask to watch,

you should certainly accommodate

them. The important thing is to

make sure parents are involved

and supported at every opportunity.

Photo courtesy of SonaMed Corp
Implementing Universal Newborn Hearing Screening Programs 7

Point 3. Dealing With Procedural Issues

SHOULD PARENTS BE ASKED TO

SIGN A PERMISSION FORM?

There are really two different, but

related, questions here:

• First, should you have procedures to ensure that parents

have a reasonable understanding of what happens during

newborn hearing screening so

they can decide whether they

want their baby to be screened?

• Second, should parents be

required to sign a written

permission before their baby is

screened?

The answer to the first question is

definitely yes, while the answer to

the second is probably no. With

regard to the first question, every

effort should be made to educate

parents about newborn hearing

screening prior to when it happens

(what it is, why it is important,

how it is done, etc.). This can be

done with information in the

preadmission materials, prenatal

classes, media materials, or placed

in the baby’s crib. If, based on this

information,

parents do not

want to have

their baby

screened, they

have the right

to refuse (it is a

good idea to

require that

they give you a

written

documentation

of that refusal,

which is kept

on file).

With regard to

the second

question, it is

important to remember that newborn

hearing screening is not an experimental research procedure. If it

were, written parental permission

for every baby screened would be

required. However, most people

agree that if the medical procedures

committee at the hospital has

decided that newborn hearing

screening is a standard of care,

written parental permission is not

necessary. Although it requires extra

time (in some cases, more than the

total time required to do screening),

a few hospitals still obtain written

permission from parents before

screening the baby. As noted above,

this does provide an opportunity to

explain to parents exactly what the

screening is and why it is important.

It is also important to note that some

states have laws or regulations regarding such issues. For example, in

several states with legislative mandates for newborn hearing screening, parents may refuse screening

for religious reasons. Therefore, it

is important to know exactly what

the situation is in your state.

Photo courtesy of Intelligent Hearing Systems
8 Implementing Universal Newborn Hearing Screening Programs

POINT 4. COMMUNICATING WITH PARENTS, PHYSICIANS, AND HOSPITAL STAFF

Many people have a stake

in the results of a

newborn hearing

screening program.

Making sure these people receive

timely information is essential to the

program’s success. In many cases, it

is also important to document that

communication has occurred and to

have a system in place to quickly and

accurately retrieve information

which has been communicated.

COMMUNICATING WITH PARENTS

Parents are among the most

important stakeholders in the

results of a newborn hearing

screening program, since they are

the ones who have long-term

responsibility for ensuring that the

baby receives appropriate care.

They are also the ones who have

the strongest feelings (but usually

limited experience) about what it

means to have a child with a

hearing loss.

RESULTS OF THE

SCREENING TEST

For most parents,

communicating

the results of the

screening test is

more than just

saying that the

baby passed or

was referred.

Instead, parents

need to know

what the result

means and what

the next steps

should be. Even

when the baby

passes a screening test, this is a

great opportunity

to help parents

understand the importance of

monitoring language development

and of being aware of the indicators of recurrent conductive or

late-onset hearing loss.

Most successful newborn hearing

screening programs use a variety

of materials to educate, inform,

and follow up with parents. For

example, a 3-minute videotape

explaining how newborn hearing

screening is done, why it is

important, what the results mean,

and what should happen next is

available in both English and

Spanish from NCHAM. Such a

video can be used during birthing

classes so that mothers know what

to expect when the screening is

done. Other examples of parent

information which can be copied

or modified for use in your

program are included in Appendix

4a. These include information

pamphlets about the screening

program, parent education

materials, letters sent to parents

when their baby does not pass,

and cards used to make return

appointments for rescreens or

diagnostic evaluations. Use the

ideas from other programs and

then develop your own to meet

your unique circumstances. If

keeping costs as low as possible is

important, acceptable print

materials can be done with

almost any word processing

program. With a little extra

money, they can be done in color

with pictures and professional

layout. The important thing,

though, is to communicate the

correct information to parents at a

time when they can understand it

and when they are likely to benefit

Photo courtesy of Otodynamics Ltd from it.
Implementing Universal Newborn Hearing Screening Programs 9

Point 4. Communicating With Parents, Physicians, and Hospital Staff

WHEN TO COMMUNICATE THE RESULTS

If the logistics can be worked out,

there are some real advantages to

informing parents about the results

of the newborn hearing screening

test before the baby is discharged.

Then, if there is a need to continue

the screening procedure on an

outpatient basis, it can be scheduled before they leave the hospital,

and parents can have their questions answered and any misunderstandings clarified. For babies who

pass the screening, most hospitals

communicate results in writing

because of the time involved in

speaking individually with parents.

Some hospitals, however, view

this as an ideal educational

opportunity and believe that it is

worth the time it takes to spend a

few minutes with each parent. At

least for the babies who do not

pass the screening test prior to

discharge, it is highly desirable to

make sure there is an opportunity

for parents to have their questions

answered when they are informed

about the results of the

inpatient screen.

You should also consider the

opinions of the child’s medical

care provider. Some physicians

feel keenly about their

role in medical

management

and want to be

the first to

inform the

parents.

Therefore,

make sure you

have discussed

your procedures

for informing

parents with

representatives

from the medical community.

Whatever procedure and timing

you select to inform parents, make

sure that the health care team is

aware of what has happened.

Some screening programs are not

able to communicate results to

parents before the baby is discharged. This is not so unusual.

For example, most metabolic

screening programs inform parents

that if there is a problem, they will

be contacted later. In most states,

the parents of babies who pass the

metabolic screening test receive no

information at all. There’s nothing

wrong with operating the newborn

hearing screening program in the

same way, as long as it is clearly

communicated to

parents

that this

will be the

case.

Photo courtesy of Madsen Electronics and University Hospital, Copenhagen
10 Implementing Universal Newborn Hearing Screening Programs

Point 4. Communicating With Parents, Physicians, and Hospital Staff

BEING SENSITIVE TO PARENTS’ FEELINGS

Many people have worried about

creating unnecessary anxiety in

parents or disrupting family

functioning, because most babies

referred from an inpatient newborn

hearing screening test will have

normal hearing. There is no

evidence that this is a frequent

problem. The key to avoiding such

anxiety or disruption of family

functioning is to make sure parents

understand that the screening test

is not a diagnostic evaluation and

that a referral for further testing

does not mean that their infant has

a hearing loss. Using the materials

and activities described in the

previous section can help to do

this. Another simple, but effective,

tool is to make sure that everyone

associated with the screening

program is careful about how

information is communicated to

parents. For example, it is much

better to refer to babies who do not

pass the screening as being

referred for further evaluation,

instead of as having failed.

AWARENESS OF LANGUAGE

DEVELOPMENT MILESTONES

The activities associated with a

newborn hearing screening

program provide an ideal opportunity to help parents understand the

importance of language development. Just because a child has

passed a newborn hearing screening test doesn’t mean that there

will not be future problems with

hearing or language development.

Materials distributed in conjunction with the newborn

hearing screening (such

as those included in

Appendix 4a) can

help parents be more

aware of their child’s language

development and what they should

do if the child does not achieve

developmental milestones in a

timely manner. The newborn

hearing screening test provides

information about the status of the

infant’s hearing at that time.

However, common childhood

diseases can later cause fluctuating

or permanent hearing losses that

will interfere with language

development. As a part of the

newborn hearing screening

procedures, you should emphasize

the importance of parents requesting another hearing evaluation if

they have any concerns about their

child’s language development.

COMMUNICATING WITH PHYSICIANS

In recent years, there has been a

major effort among health care

professionals to make sure every

child has a medical home. In other

words, every child should have a

primary health care provider who

is aware of that child’s needs and

medical history so that the child

receives appropriate and timely

health care. Because of this emphasis, it is not surprising that one of

the biggest concerns physicians

have about newborn hearing

screening programs is that they

will not have sufficient input into

making decisions about a medical

issue for one of their patients. Such

concerns are legitimate, and the

program should be organized in

such a way so this is not a problem.

GENERAL AWARENESS OF THE

PROGRAM AND ITS IMPORTANCE

From the very beginning, physicians need to understand how

newborn hearing screening relates

Photo courtesy of Logan Regional Hospital, Logan, Utah to the care of their patients.
Implementing Universal Newborn Hearing Screening Programs 11

Point 4. Communicating With Parents, Physicians, and Hospital Staff

Presenting

information to

the hospital staff

about newborn

hearing screening

or presenting to

the pediatric

committee are

two effective

strategies. If this

is not possible

when the

program is being

implemented,

you should distribute appropriate

written materials to all pediatricians

and family practice physicians

who have babies at the hospital

(see examples in Appendix 4b).

As the program is starting, it may

be useful to do some screening of

babies at the times physicians

typically make their rounds. Be

sure you don’t interfere or take

their babies while they are trying

to examine them. Just being there

and doing your work, however,

will prompt a lot of questions and

understanding of what is involved

in newborn hearing screening. As

babies with hearing loss are

identified, be sure to communicate

the results to that baby’s physician.

Periodically, you should use letters,

reports to the hospital’s pediatric

committee, or a newsletter to

inform the hospital’s medical staff

about the success of the program.

Case histories and personal

experiences of families whose

babies have been helped by the

program are particularly useful.

WHAT WERE THE RESULTS FOR THEIR

PATIENTS?

Make sure you develop a mechanism to efficiently notify each of

the physicians who are responsible

for babies in your hospital about

the results for their patients.

Although this is particularly

important for babies who do not

pass the initial screen, it is best if

you can develop a system for

giving them information about all

of their patients. Some of the

newborn hearing screening data

management programs automatically print a monthly report which

provides a summary for each

physician of the results for all

babies for which he/she is responsible. In those cases where babies

do not pass the initial screen, it is

particularly important that the

primary care physician receive a

timely written report of this result

with a clear recommendation of

what should happen next.

ENSURE THAT PHYSICIANS UNDERSTAND

THE IMPORTANCE OF FOLLOW UP

Few things can undermine the

success of a newborn hearing

screening program as much as a

physician telling the parent during

a well-baby check that it is really

not that important to follow up

with the outpatient screen or

diagnostic evaluation procedures.

Some health care providers still

have the mistaken idea that they

can use some simple behavioral

techniques during the well-baby

check to determine whether the

infant has a hearing loss. Actually,

there is a wealth of well-documented information showing that

using behavioral evaluation as the

only way of assessing hearing loss

in 1 to 3-month-old infants is

extremely difficult, even for welltrained audiologists with a sound

booth and all of the latest equipment. The best approach for a

Photo courtesy of Grason-Stadler, Inc
12 Implementing Universal Newborn Hearing Screening Programs

Point 4. Communicating With Parents, Physicians, and Hospital Staff

physician is to encourage parents

to follow through with the

screening and appropriate diagnostic audiological procedures. In

addition, if parents have concerns,

they should be encouraged to see

an audiologist who has experience

in treating young babies.

MEDICAL MANAGEMENT ISSUES

When a baby is referred from a

screening program, medical

evaluation is an essential part of

the diagnostic process, and

newborn hearing screening

program staff must recognize and

communicate to physicians that

they are a critical part of that

multidisciplinary team. It is also

important that everyone involved

in the baby’s medical management

understand how unfortunate it is

when the diagnostic process drags

out over several months, instead of

being completed within a few

weeks. For babies without other

medical complications, there is no

reason why amplification cannot

be appropriately fitted and early

intervention begun within a few

months. For that to happen,

however, all members of the team

have to recognize the importance

of early diagnosis and intervention

and then work together to make it

happen as quickly as possible.

COMMUNICATING WITH THE

HOSPITAL

Hospital administrators, risk

managers, nursery supervisors, and

community education staff, among

others, also need to be kept

informed about the newborn

hearing screening program. If

various people in the hospital are

receiving the information they

need on a timely basis, the

continuation of the newborn

hearing screening program is

almost guaranteed, because the

benefits will be well documented,

and consequently, many different

groups can work to support and

improve the program.

RECORDING RESULTS IN THE CHILD’S

MEDICAL RECORD

It is important to make sure that

the results of the screening are a

part of the child’s permanent

medical record maintained by the

hospital. Many programs use a

stamp in the baby’s medical chart

which indicates the results of the

hearing screening. Some equipment

and data management programs

can print a label (showing name,

date, type of test, and result) with

sticky backing that can be affixed

to the infant’s medical chart.

DOCUMENTING THE SUCCESSES AND

DIFFICULTIES OF THE PROGRAM

Hospital administrators at various

levels want to know how the

program is doing. Having an

effective data management system

Photo courtesy of Grason-Stadler, Inc
Implementing Universal Newborn Hearing Screening Programs 13

Point 4. Communicating With Parents, Physicians, and Hospital Staff

in place that can quickly compile

information can be extremely

useful, such as:

• The percentage of babies

screened.

• The percentage of babies

passed at discharge.

• The percentage of invalid tests.

• The percentage of babies who

are referred from the initial

screening who eventually

receive diagnostic evaluations.

• The number of babies identified with sensorineural hearing

losses.

Often, administrators need such

information at a moment’s notice

for a particular time period you

weren’t expecting (e.g., last

month, or the first quarter of this

year, or year-to-date). If data is

being maintained by a computerbased data management system,

such requests are easy to meet. If

not, you should try to anticipate

the type and timing

of information

administrators will want so you can arrange

to produce the necessary reports.

REGULAR REPORTS TO HOSPITAL

ADMINISTRATORS

In addition to statistical summaries, you should make sure that

hospital administrators at various

levels are regularly informed about

the progress of the newborn

hearing screening program. You

don’t want to burden yourself with

creating reports which no one is

reading. Depending upon the

situation, however, you should

summarize at least annually the

successes of the program, the

challenges which still need to be

addressed, and the strategies for

resolving those challenges. It is

particularly important to highlight

the human side of any success

stories so administrators see that

people’s lives are better off as a

result of this program. (Appendix

4c contains examples of several

such reports.)

JUSTIFYING ONGOING PROGRAM

SUPPORT

The first thing most administrators

think of when faced with questions

about continuing a particular

program is whether the

revenues generated have

covered the costs. In this

context, it is important to

point out that many

newborn hearing

screening programs

are implemented

for just a few

dollars per baby of

“out-of-pocket

costs.” A simple, but

complete, cost analysis

of the program after the

first year, and then at

Photo courtesy of Woman’s Hospital, Baton Rouge, Louisiana
14 Implementing Universal Newborn Hearing Screening Programs

periodic intervals thereafter, can be

extremely important information

when it comes to decisions about

continuation. Also, it is important

to make sure that hospital administrators hear from people who are

seeing the long-term benefits of

newborn hearing screening

(parents, audiologists, state

department of health officials). For

example, a letter sent each year

from the state department of health

to hospitals where newborn

hearing screening programs are

functioning, which summarizes the

success in the state during the past

year and congratulates them on

their foresight and commitment to

making such a valuable service

available to children born at their

hospital, can have an extremely

positive impact.

Point 4. Communicating With Parents, Physicians, and Hospital Staff
Implementing Universal Newborn Hearing Screening Programs 15

POINT 5. TRAINING

NEWBORN HEARING SCREENERS

G iven enough time, you

could probably figure

out on your own

everything involved in

operating a successful universal

newborn hearing screening program.

However, it makes a lot more sense

to learn from the experiences of

others instead of using trial and error

as your primary method of deciding

how to operate a program efficiently.

INITIAL TRAINING

Screening babies for hearing loss

is like riding a bicycle—almost

anyone can do it, but it is easier to

learn how if you have some help in

the beginning. Regardless of which

screening equipment you decide to

use, screeners will become

proficient much faster if there is a

hands-on, competency-based

training session at the beginning.

The best people to provide such

training are those who are already

successfully participating in a

newborn hearing screening

program. Sales representatives can

show you how to operate their

equipment, but the best training is

usually delivered by people who

have experience operating a

newborn hearing screening program. Ideally, such training should

include ample time screening reallive babies in the same environment where the screening program

will be conducted. Once a person

acquires skill with the screening

equipment, just like riding a

bicycle, it is easily remembered.

DON’T TRAIN MORE PEOPLE

THAN NECESSARY

The number of screeners needed to

operate a universal newborn

hearing screening program

depends on the annual number of

births and how the program is

organized. Because babies are

often released just a few hours

after being born, you will probably

need 7-day-a-week coverage.

However, the total amount of

screening time is relatively small.

Studies conducted by NCHAM

suggest a range of 4 to 10 hours

per week of screener time per

thousand babies. Although you

need to be sure to have enough

people trained to achieve adequate

coverage, many hospitals make the

mistake of training too many

people (e.g., all of the nursing

staff). Not only does this require

extra time for training and supervision, but it often results in a less

efficient program because responsibility for screening babies is

diffused and the quality of

screening technique suffers.

REGULAR SUPERVISION

It is often said that practice makes

perfect. Actually, practice makes

permanent. Consequently, it is

important to provide timely

feedback to people who are just

learning to screen so you can

correct errors before they become

ingrained. Subsequently, there

should be regular supervision and

Photo courtesy of Logan Regional Hospital, Logan, Utah feedback regarding screening
16 Implementing Universal Newborn Hearing Screening Programs

Point 5. Training Newborn Hearing Screeners

performance. One-on-one observation and instruction are the most

effective and should be done

periodically. A written checklist

(see examples in Appendix 5) can

be very useful. In addition, a

regular report which shows the

performance of each screener with

regard to number of babies

screened, number of babies

passed, number of invalid tests,

number of screens completed per

hour of work, can be useful in

identifying screeners who are

having difficulty and need inservice instruction. Be careful to

organize such supervision in such

a way that screeners view it as a

help instead of a punishment.

RETRAINING TO ACCOMMODATE

STAFF TURNOVER

It is not unusual to experience a

fair amount of turnover among

those people responsible for

screening babies (e.g., nurses,

health care assistants, technicians,

clerical staff). Therefore, it is

important for you to plan from the

beginning how new people will be

trained and supervised. Once you

have an operational program in

place, this is usually accomplished

quite easily by existing personnel.

Many program coordinators

identify one of their most proficient screeners to be responsible

for training new people. In some

cases, state licensure laws or

regulations will impact on how

training must be done. Training is

best when it is competency-based

and requires trainees to actually

demonstrate their proficiency in

the same way as is required in the

screening program. It is usually

best to make the training intense

enough so the new trainees can

achieve and demonstrate proficiency within a few days and

then have an opportunity to

solidify the skills they have

learned over the next several

weeks.

Photo courtesy of Intelligent Hearing Systems
Implementing Universal Newborn Hearing Screening Programs 17

POINT 6. KEEPING

REFER RATES LOW

R egardless of the type of

technology or protocol

used, the goal of

newborn hearing

screening is to create the smallest

reasonable subset of the general

population which still contains all of

the infants with hearing loss. In other

words, without missing any babies, it is

generally best to minimize the number

of infants referred from the screening

process to a diagnostic evaluation (of

course, this goal must be balanced by

other factors, such as time and cost).

Some strategies to reduce referral

rates are applicable regardless of the

technology being used, and others

apply only to specific technologies.

SCHEDULE SCREENING WHEN

BABIES ARE IN THE BEST

BEHAVIORAL STATE

Even though it is

possible to screen

babies who are awake

and restless, screening happens much

more quickly and the

results are better if

the screening is

performed when the

baby is quiet (or

even asleep), happy,

well fed, and

comfortable. Therefore, if possible, you

should schedule the

majority of your

screening activities

when babies are

most likely to be in

this optimal state.

When and where

you do the screening

will depend on other

activities, routines,

and available space

at your hospital.

MAKE A SECOND EFFORT PRIOR TO

DISCHARGE TO SCREEN BABIES

WHO DO NOT PASS AT FIRST

Most programs do not consider the

initial screening to be complete

until the baby leaves the hospital.

Typically, the first attempt to

screen the baby is made shortly

after birth. It seems to work best to

not spend too much time with the

baby during this initial attempt. If

the baby passes (as the majority

will do), you are finished. If not,

wait several hours and try again.

Regardless of the equipment or

protocol being used, these second

efforts prior to discharge can

substantially reduce the number of

babies who need to come in for

outpatient screens or diagnostic

procedures. Instead of spending 30

minutes with the baby during an

initial attempt, it is much more

efficient to make a quick first

attempt, followed by a second or

even third attempt a few hours

later. In other words, repeated

short attempts are usually more

successful than a single prolonged

effort.

MINIMIZE NOISE AND CONFUSION

IN THE SCREENING AREA

None of the screening equipment

requires extraordinary measures to

make the screening area quiet.

Newborn hearing screening is

routinely being done in neonatal

intensive care units and crowded

and relatively noisy well-baby

nurseries. However, all other

things being equal, screening will

be faster and more effective if you

do what can sensibly be done to

minimize noise and confusion in

the screening area. In other words,

where possible, do most of your

Photo courtesy of Madsen Electronics and University Hospital, Copenhagen screening when doctors are not
18 Implementing Universal Newborn Hearing Screening Programs

Point 6. Keeping Refer Rates Low

making their rounds, do not screen

directly under a ventilator fan, and

find an area to screen which is not

adjacent to a bathroom where

running water creates unnecessary

noise. Where sensible and inexpensive modifications can be done

to reduce noise (e.g., carpeting on

the floor, curtains on windows, a

portable room divider which

provides some sound attenuation),

they are worth considering to

increase the efficiency of the

screening program. However, it is

certainly possible to operate a

screening program without any

such enhancements.

USE THE BEST PROTOCOL FOR

YOUR SITUATION

In an effort to keep refer rates as

low as possible, some hospitals

use both OAE and ABR technology prior to discharge. In situations where it is difficult to get

babies back for an outpatient

screen, such a protocol can save

time, money, and hassle for the

program and families. The

downside, of course, is the

additional cost of using two types

of equipment. Some manufacturers

offer both OAE and AABR on the

same unit at substantially less than

what it would cost to purchase

both pieces independently.

HAVE BACKUP EQUIPMENT AND

SUPPLIES READILY AVAILABLE

Because some babies are discharged after just a few hours in

the nursery, it is essential to make

sure your screening program has

arranged for backup equipment in

the event of a breakdown. Most

newborn hearing screening

equipment is extremely reliable.

However, if your equipment

unexpectedly stops operating and

it takes you 3 days to get a

replacement, you will probably

miss 10% or more of the babies

born at the hospital that month.

Although you can have such

babies come back for outpatient

screening, it is extra work for

everyone and unlikely to be

completely successful. Therefore,

you should make arrangements to

obtain replacement or loan

equipment within a very short time

from the salesperson, a neighboring hospital, university, audiologist, or school district. It is also

important to have sufficient

supplies or replacements for

consumable parts (e.g., probe tips,

electrodes, probes).

FOR OAE PROCEDURES, PROBE

FIT IS CRITICAL

If OAE technology is being used,

the single most important factor in

reducing refer rates is to make sure

screeners understand how to

achieve appropriate probe fit.

Although this is relatively easy to

learn, it may not be immediately

obvious to screeners and usually

has to be taught. A screening

Photo courtesy of Intelligent Hearing Systems program whose personnel have not
Implementing Universal Newborn Hearing Screening Programs 19

Point 6. Keeping Refer Rates Low

mastered the techniques of good

probe fit will generally have refer

rates at the time of hospital

discharge two to four times higher

than a program where screeners

have mastered probe-fitting

techniques.

FOR AABR PROCEDURES,

SCREEN WHEN MYOGENIC

ACTIVITY IS LOW

AABR screeners have artifact

rejection systems built in so data

are not included in the average

when myogenic activity is high.

Myogenic activity is caused by

muscle tension. If babies are tense,

wiggly, or restless, myogenic

activity will be higher, and it will

substantially increase the screening time. It may even result in

more babies who need to be

brought back for rescreening or

diagnostic procedures because a

pass could not be obtained. Thus,

it is best to do screening when

babies are relaxed, happy, well fed,

and, if possible, asleep.

Photo courtesy of Natus Medical
20 Implementing Universal Newborn Hearing Screening Programs

POINT 7. MANAGING DATA

AND PATIENT INFORMATION

T he goal of a universal

newborn hearing

screening program is to

identify babies with

hearing loss and enroll them in

appropriate intervention programs as

early as possible. This will require

coordination with the baby’s medical

home, one or more audiologists, and

various state and local agencies who

are responsible for providing services

to infants and young children with

hearing loss. The screening which

happens prior to hospital discharge is

only the first step. In fact, most

screening program managers report

that keeping track of what happens in

the screening program and managing

babies through the referral and

diagnostic process is the most

challenging part of an early hearing

identification program. Data and

patient information management

includes keeping track of which

babies have been screened, what

screening or diagnostic procedures

should happen next, and which babies

have missed appointments and need to

be located. It also involves generating

reports for program management,

accountability, and program continuation, and generating letters to parents

and physicians concerning the

outcome of various screening and

evaluation procedures.

Not only is such data and patient

information management complex,

but if it is not handled appropriately,

it can be much more time consuming

than the actual screening. The most

successful early identification

programs are those which have a

system in place to deal with all of

these issues when they start the

program. Data and patient information

management is the kind of task that

many people procrastinate (think of

how you keep track of all those

records, business expenses, and

donations needed for filing your

income taxes each year). With a

newborn hearing screening program,

the amount of information you need

to manage continues to multiply as

more and more babies are born. If

you don’t have a system in place to

efficiently manage the information

when you first start, you will soon find

that you are overwhelmed, and the

whole system begins to collapse in

piles of paper and yellow sticky notes.

COMPUTER-BASED DATA

MANAGEMENT

The information management

tasks associated with an early

detection of hearing loss program

are well-suited to computer-based

data management. Summarizing

data from individuals into understandable reports, generating

letters to parents and pediatricians

at different times based on the

most recent outcomes, and

reminding you of upcoming and

overdue screening and diagnostic

activities are all easily done with a

computer-based program. Information about several complete data

and patient information packages

which can be used by hospitals is

summarized in Appendix 7.

HI★TRACK PATIENT AND

INFORMATION MANAGEMENT MODULE

FROM NCHAM
Implementing Universal Newborn Hearing Screening Programs 21

Point 7. Managing Data and Patient Information

In some cases, the State Department of Health will have a data

and patient information management system in place, which can

be used by hospitals. In other

cases, hospital-based systems may

want to consider developing their

own program.

SHOULD YOU TRY TO DESIGN

YOUR OWN SYSTEM?

Small hospitals with only a few

births each month (less than 100

per year) may be able to keep track

of all of the necessary information

using a paper and pencil system.

However, even if it is possible to

do so, it often requires much more

time and will probably result in a

less efficient system than would be

the case with a computer-based

management system. Designing

your own computer-based software is also an option. However,

many hospitals who have tried to

design their own comprehensive

data management system have

found that it is a much more

difficult and time-consuming task

than they anticipated. Some

hospitals with newborn hearing

screening programs, after spending

several months and hundreds if not

thousands of dollars, have decided

that they ought to use one of the

programs referenced in Appendix 7.

CAN YOU MODIFY ONE OF THE

DATABASES YOUR HOSPITAL

ALREADY HAS?

Many hospitals already have a

number of computer-based data

management systems (for example, more and more hospitals

are converting to computerized

medical records and charting).

However, in most cases, the data

and reporting needs for a newborn

hearing screening program are too

idiosyncratic for these systems to

be of much use. For example, with

metabolic screening programs,

hospitals only need to provide a

blood specimen and very limited

demographic data for each child. If

the baby fails the test, the name is

given to the primary care physician, and the task is finished as far

as the hospital is concerned. With

most newborn hearing screening

programs, however, hospital staff

stay involved with outpatient

screening and perhaps even into

the diagnostic process. Therefore,

the most successful early identification of hearing loss programs are

using data management systems

that are specifically tailored to

their needs.

SAFEGUARDING YOUR DATA

The way in which computers store,

process, and recall information is

still somewhat of a mystery for

most people. Even though a

computer-based data management

system can save you enormous

amounts of time and result in a

much more efficient program, they

can also lose huge amounts of

information if you are not careful.

As with any computer-based

SCREENING AND INFORMATION

MANAGEMENT SOLUTION (SIMS)

FROM OZ SYSTEMS
22 Implementing Universal Newborn Hearing Screening Programs

system, the information in your

newborn hearing screening

database needs to be backed up on

a regular basis. The basic rule is

that you should always have two

copies of all important information. Computer viruses can also

destroy or scramble data, making

it unusable. Fortunately, most

hospitals have an information

management office who can

assist you in backing up your

data on a regular basis and

protecting against viruses. Often,

a phone call to the staff of that

office is all that is necessary to

get onto their schedule to ensure

that your data is safe and secure.

Point 7. Managing Data and Patient Information
Implementing Universal Newborn Hearing Screening Programs 23

POINT 8. FINANCING

THE PROGRAM

A s pressures to contain

rising health care costs

increase, anyone

interested in starting a

new program will have to be

concerned about costs. Even though

everyone recognizes that newborn

hearing screening is a wise investment, it is still necessary to find the

dollars necessary to make that

investment.

HOW MUCH DOES IT REALLY COST?

Depending on how your program

is organized, you can expect the

total costs of the program to be

between $8 and

$75 per baby.

This includes all

of the costs

associated with

personnel

(including fringe

benefits),

equipment and

supplies, and

hospital overhead. These

estimates are

based on cost

analyses conducted with

actual programs

and include all

of the costs for

activities related

to screening the babies prior to

hospital discharge, outpatient

screening, and tracking the

babies into the diagnostic

assessments. It does not include

the costs of diagnosis or early

intervention. (References on

which these estimates are based

are summarized briefly in

Appendix 8.)

WILL INSURANCE PAY FOR

NEWBORN HEARING SCREENING?

Some states have legislatively

mandated that all health insurers

must pay for newborn hearing

screening (e.g., Massachusetts,

Rhode Island, West Virginia). In

other states, however, it depends

on the insurer, and most programs

have been reasonably successful in

getting health insurers to pay. In

many cases, however, it hasn’t

been automatic, and someone has

had to spend a significant amount

of time educating insurance

company staff about the rationale

for and benefits associated with

newborn hearing screening.

Programs which have tracked

reimbursements have found that

by working with the various

insurance companies, they are able

to achieve very respectable

reimbursement rates.

IS NEWBORN HEARING

SCREENING COST BENEFICIAL?

There is fairly convincing data

from cross-sectioned, correlational, and retrospective studies

that children who are identified

early will do much better in

school and will generate many

times the cost of the newborn

hearing screening program in

educational savings (summaries of

such studies are included in

Appendix 8). However, it is

generally not very effective to try

to convince health insurance

companies that they will save

money in the long-term by paying

for newborn hearing screening. In

fact, by identifying children

earlier, it will probably cost the

health insurance company more,

Photo courtesy of Natus Medical
24 Implementing Universal Newborn Hearing Screening Programs

Point 8. Financing the Program

since there will be more and

earlier visits to the doctor, more

speech and language management,

and earlier use of hearing aids.

Nonetheless, many insurance

companies are willing to reimburse for newborn hearing

screening, because they recognize

it is good health care policy.

HOW DO I CONVINCE THE

INSURANCE COMPANIES TO PAY?

The best argument is that newborn

hearing screening is the right thing

to do and is a relatively

small cost when

compared to

other medical procedures. However, some insurance companies

do not like to pay for universal

screening procedures for low

incidence conditions. It may be

useful to point out to such companies that the alternative to universal newborn hearing screening is

to do conventional ABR on the

10% of the population that exhibits

high-risk indicators. Because that

subgroup of the population has a

condition which has long been

recognized by the medical

profession as being at higher risk

for hearing loss, almost all

insurance companies will pay for

conventional ABR for those

infants. Unfortunately, high riskbased hearing screening programs

miss at least half of the babies with

congenital hearing loss. Also,

because the new screening

technologies are so much more

efficient, universal screening is

actually less costly for the insurance

company than doing conventional

ABR on the high-risk population.

DOES MEDICAID PAY FOR

NEWBORN HEARING SCREENING?

Depending on where you live,

Medicaid has been either very

good or very bad about reimbursing

for newborn hearing screening. In

some cases, Medicaid has approved newborn hearing screening

as a part of the first well-baby

checkup in the EPSDT (Early and

Periodic Screening, Diagnosis, and

Treatment) program. Under

EPSDT guidelines, Medicaid is

then obligated to pay for the

screening procedure (see a copy of

the regulation from Utah in

Appendix 8). In other cases, the

Medicaid office ruled that newborn hearing screening would only

Photo courtesy of Otodynamics Ltd
Implementing Universal Newborn Hearing Screening Programs 25

be paid for if it occurred on an

outpatient basis, which effectively

eliminates Medicaid reimbursement for universal newborn

hearing screening. The best advice

about getting Medicaid to pay for

newborn hearing screening is to

find someone sympathetic to

children’s issues in the state

Medicaid office and work with

that person to find a way for

Medicaid to pay the costs. Again,

education and persistence are the

keys.

USING EXISTING STATE RESOURCES

Every state has existing programs

to provide some services to infants

and toddlers with special health

care needs. In addition to those

funded directly by the state, the

federal government requires states

to operate several programs which

can be used to make sure infants

referred from newborn hearing

screening programs receive timely

and appropriate diagnostic and

intervention services (e.g., IDEA—

Individuals With Disabilities

Education Act—or CHIP—Child

Health Insurance Program). Taking

advantage of these existing programs will substantially reduce your

costs and improve the quality of

services for participating families.

GRANTS, DONATIONS, AND

COMMUNITY SUPPORT

In the early 1990s, federal research

and demonstration grants were

used to support a number of

universal newborn hearing

screening programs. Such grants

are difficult to obtain now because

federal agencies are hesitant to

support the routine provision of

health care. Because the concept

of newborn hearing screening has

now been endorsed by so many

different federal agencies as being

the desired standard of care, it is

unlikely that you will find a

federal grant to provide support for

establishing a program. Private

foundations and service clubs are a

possibility, but will most likely

limit their donations to the costs

associated with establishing the

program and not to the ongoing

operation. Many hospitals have

been successful in getting service

clubs and auxiliary organizations,

such as Quota Club, Lions Club,

or Sertoma, to provide the money

necessary to buy newborn hearing

screening equipment for their

hospital. Suggestions about

foundations and other organizations who may be willing to fund

such activities are included in

Appendix 8.

Point 8. Financing the Program
26 Implementing Universal Newborn Hearing Screening Programs

Photo courtesy of Grason-Stadler, Inc

POINT 9. CARING FOR EQUIPMENT AND SUPPLIES

ll newborn hearing

screening equipment

uses a microprocessor,

computer chip, or

computer in some way. Such

equipment will last for many years if

proper attention is given to care and

maintenance. In most cases, using

common sense and taking advantage

of services already offered by hospital

support staff is all that is needed.

AN OUNCE OF PREVENTION IS

WORTH A POUND OF CURE

The best way to avoid breakdowns

in screening and computer

equipment is to take care of it.

Educate people so they don’t eat or

drink while using the equipment,

use a dust cover when

the equipment is not in

use, and get a surge

protector to ensure

consistent

supply of

electrical

power.

Although

most screening equipment is very

durable, it

shouldn’t be

handled roughly,

dropped, or exposed

to temperature

extremes. For

example, leaving the

screening unit in the

trunk of your car on

a freezing winter

night or in the front

A seat on a hot summer day could be

the end of it. Also, make sure that

people know that computer disks

need to be handled sensibly. Don’t

get them wet, fiddle with the

movable parts, or expose them to

extreme temperatures. With

common-sense care, screening

equipment will last for many

years.

DON’T ASSUME PEOPLE KNOW

HOW TO TAKE CARE OF COMPUTERS

Even though the guidelines for

taking care of computers are

common sense for most people, it

is amazing how often they are

violated. Many people have little

or no experience with computers.

Also, people are sometimes

careless and forgetful. Diplomatically posting “rules for computer

use” and making sure that everyone has been informed about those

rules is very important.

MOST HOSPITALS PROVIDE

COMPUTER SUPPORT—ASK FOR IT

Hospitals have been using computers to process and store important

information for many years. As a

result, almost every hospital has

someone responsible for information systems, data processing, or

computer support. Generally, this

person’s job is to make sure that

all of the computers and computerrelated equipment in the hospital

continue to function effectively

and is available at no additional

cost to your program. All you have

to do is ask for help.

Photo courtesy of Natus Medical

Photo courtesy of Otodynamics Ltd

Photo courtesy of Bio-logic Systems Corp
Implementing Universal Newborn Hearing Screening Programs 27

POINT 10.

REPORTING

Many different people

have an interest in the

outcomes of an early

identification of hearing

loss program. As with any worthwhile program, a universal newborn hearing screening program

will not manage itself. When you

first implement the program, you

need to decide who the most

important stakeholders are, what

information they need, and when

they need it.

GENERATING REGULAR REPORTS

FOR PROGRAM MANAGEMENT

AND IMPROVEMENT

The person in charge of the early

identification of hearing loss

program needs a continual flow of

information, including:

• The number of babies born at

the hospital.

• The percentage of babies

successfully screened.

• The percentage of babies

referred.

• The percentage of babies

rescreened and/or diagnosed.

• The number of babies identified with hearing loss.

• How well each of the screeners

is functioning.

Regular and timely summaries of

such information is critical if the

program is to be successful. At the

beginning of the program, you

should have a coordination

meeting monthly, if not more

often, to review such information.

This meeting should be attended

by the program coordinator, a

representative of the screening

staff, the nursery coordinator, an

audiologist who is involved with

the program, and a physician who

cares for newborns at that hospital.

The purpose of the meeting is to

review the functioning of the

program during the previous time

period to make sure that the goals

of the program are being accomplished, such as:

• Why were only 80% of the

babies screened last month?

• Are there any babies who have

been referred for diagnostic

evaluation who are still waiting

after several months?

• Are some screeners performing

significantly less well than

others?

Reviewing such information

regularly is the key to enhancing

program efficiency and success.

Results from a computer-based

data and patient information

management program will provide

all of the necessary data, but you

still need to convene the meeting,

take minutes, and follow up on

assignments.

DON’T EXPECT TO FIND A LOT OF

BABIES WITH HEARING LOSS

Over the long-term, an efficient

hearing identification program will

identify 3 to 4 infants per 1,000

with sensorineural hearing loss.

However, because hearing loss is a

low-incidence condition, it may

take 10,000 babies before you hit

that average (this is similar to

newborn screening programs for

metabolic disorders which have an

even lower incidence rate). In

other words, it is not unusual for a

hospital to screen 1,000 babies and

not find a single infant with a

sensorineural hearing loss. That

same hospital, however, may

find 5 or 6 infants in the next

1,000. Therefore, don’t be

discouraged if it takes a while to

identify your first baby with a

hearing loss.
28 Implementing Universal Newborn Hearing Screening Programs

Point 10. Reporting

MAKE PEOPLE AWARE OF YOUR

SUCCESSES

Having convinced people that a

newborn hearing identification

program is important, you need to

make sure they know about your

successes. Whenever you find a

baby with a hearing loss, make

sure that physicians and hospital

administrators are aware of your

success and understand how much

better off the baby is because of

having been identified early. Even

if your hospital administration

does not ask for regular statistical

reports, you should generate them

on at least a yearly basis and send

them to key administrators. You

should also consider involving

the local news media to report

about the successes of the

program.

ONE OF THESE INFANTS HAS

A HEARING LOSS.

Photo courtesy of Starkey

NEWBORN HEARING SCREENING

CAN HELP YOU DETERMINE WHICH ONE.
Implementing Universal Newborn Hearing Screening Programs 29

POINT 11. COMPLETING AUDIOLOGICAL

DIAGNOSIS AND FOLLOW UP

T he real goal of any

screening program is to

provide better health

care services to people

in need. Consequently, newborn

hearing screening is only the first

step. In many cases, developing an

efficient network of diagnosis and

intervention will require extensive

input from the state department of

health, the state Title V program,

and/or the state’s lead agency for

serving infants and young children

with disabilities. Even in cases where

the hospital staff only participates

indirectly in these efforts, you should

know what needs to be done and

how the system is supposed to

function so you can be supportive.

A GOOD SCREENING PROGRAM IS

NOT ENOUGH!

Successfully screening all of the

babies in your hospital is not very

useful unless those babies who do

not pass the screening complete a

diagnostic evaluation, and the ones

identified with hearing loss are

enrolled in appropriate early

intervention programs within a

few weeks. Unfortunately, some

“successful” newborn hearing

screening programs are not

effective in completing diagnostic

evaluations and enrolling children

in early intervention. Whether

your hospital is responsible for

doing diagnostic evaluations or

whether you refer children to

Photo courtesy of Mayo Clinic Scottsdale
30 Implementing Universal Newborn Hearing Screening Programs

Point 11. Completing Audiological Diagnosis and Follow Up

outside agencies or audiologists, it

is important to develop a systematic mechanism to make sure

children referred from the screening program receive a diagnostic

evaluation. Such a system should

produce periodic reports to tell you

how well the real goal of the

program is being accomplished.

INVOLVE EXPERIENCED

AUDIOLOGISTS

Whether the hospital has its own

audiologists or you refer to outside

audiologists, it is important to

have clearly established criteria to

make referrals for audiological

evaluation. Once a child is

referred, there should be a tracking

procedure to ensure that the

referral has been followed. In

addition, the audiologist to whom

the baby is referred should be

given as much information as

possible about the referral (e.g.,

type of screening and refer

criteria). Efficient newborn

hearing screening programs are

able to refer infants needing

audiological evaluations within the

first several weeks of life. Not all

audiologists, however, have the

appropriate experience and

equipment to conduct the types of

assessments that are needed to

diagnose and confirm the nature

and degree of hearing loss for

infants and young children. It is a

good idea to work with your state

department of health or other

licensing agency to identify those

audiologists in your community

who can and want to diagnose and

fit amplification for very young

infants so you can refer parents to

those audiologists.

USE APPROPRIATE DIAGNOSTIC

PROCEDURES FOR INFANTS AND

TODDLERS

It is essential that the audiologists

to whom babies are referred for

diagnostic evaluations have

experience using age-appropriate

diagnostic techniques for such

infants. Various organizations,

such as the American SpeechLanguage-Hearing Association,

have produced guidelines and

recommendations that can be very

helpful. (Examples of some of

these are given in Appendix 11.)

Typically, a combination of

otoacoustic emissions and auditory

brainstem response (ABR;

including frequency-specific tone

bursts, air conduction, and bone

conduction measures) are used to

diagnose hearing loss for children

younger than 4 months of age. For

such young children, behavioral

observations in the sound field are

Photo courtesy of Mayo Clinic Scottsdale typically used to support OAE and
Implementing Universal Newborn Hearing Screening Programs 31

Point 11. Completing Audiological Diagnosis and Follow Up

ABR results when amplification is

recommended. After four months

of age, ear-specific behavioral

measures using visual reinforcement audiometry (VRA) should be

considered. The diagnostic

evaluation should also include

middle ear measurements using

electroacoustic immittance

measurements. Tympanometry

should be used carefully for

infants who are younger than 4

months of age, because some

methods produce misleading

results for very young children. If

an infant has middle ear disease,

otological referral for evaluation

and management must take place.

MOVE AS QUICKLY AS POSSIBLE

It is critical that the diagnostic

process be completed as soon as

possible. For many infants and

toddlers, appropriate ear-specific,

frequency-specific air and bone

conduction ABR provides enough

information to determine the type

and degree of hearing loss.

Although some audiologists may

be reluctant to make decisions

about amplification without

behavioral results, use of

frequency-specific tone bursts in

ABR can ensure that amplification

gain is appropriate (i.e., there is

enough amplification, there is not

over amplification, the frequency

response characteristics are

adequate). Monitoring the infant’s

auditory responses (through homebased and clinical methods) is also

essential to continually refine the

fitting. It is important to note that

diagnostic techniques and equipment for infants continue to evolve

and improve. Therefore, people

responsible for ensuring timely

and appropriate diagnosis of

referred infants need to stay up-todate with this rapidly changing

area.

MONITORING OF AMPLIFICATION

Providing the first set of hearing

aids is not the end of the process.

Therefore, an audiologist with

pediatric experience and expertise

will fit the infant and then modify

the fitting as more information

(e.g., ear-specific behavioral and

additional real ear measurements) becomes

Photo courtesy of Mayo Clinic Scottsdale
32 Implementing Universal Newborn Hearing Screening Programs

available. Additionally, the infant’s

behavioral responses, such as

alerting to sound; responses to

speech; or negative responses,

such as flinching to moderately

loud sounds, should be used in

conjunction with clinical measures

to ensure that the amplification is

appropriate. The audiologist

should not postpone amplification

until a long-term amplification

recommendation can be made. The

goal should be to get the infant

using amplification within a few

weeks of the diagnosis (even after

accounting for the time necessary

to obtain

medical

clearance

for fitting

hearing

aids and

fabricate

earmolds).

Often,

loaner hearing aids are used as a

way of getting amplification to the

infant as soon as possible.

Photo courtesy of Childhood Hearing

Impairment Program (CHIP), University

of Connecticut

Point 11. Completing Audiological Diagnosis and Follow Up
Implementing Universal Newborn Hearing Screening Programs 33

POINT 12. COORDINATING

WITH STATE SYSTEMS

very state already has a

number of systems in

place to provide services

to children with disabilities and special health care needs. In

addition to being a potential source

of funding for infants and toddlers

with hearing loss, it is essential for

you to coordinate your efforts with

these programs to ensure that

services are delivered in a way which

is efficient, family-friendly, minimally disruptive, and culturally

appropriate. Because these systems

are funded by a variety of different

initiatives, each has its own rules,

eligibility requirements, and procedures. Therefore, families often need

help negotiating their way through

the system. Although few, if any, are

designed specifically for infants and

toddlers with hearing loss, many are

appropriate for such children.

Because they are sometimes labeled

differently in each state, it may take

some research to find them, but the

results can be well worth the effort.

TIMELY, APPROPRIATE, FAMILYCENTERED INTERVENTION IS THE

REAL GOAL

The infant

diagnosed with

hearing loss

within the first

few months of

life has much

greater potential

of acquiring

listening,

language, and

communicative

skills at a rate

that will prevent

the negative

effects of hearing

loss. Even with

amplification, the

infant (and the family) will need

help to learn to make use of

audition, stimulate communication, and develop language.

Additionally, families will need

information about the amplification and ways to optimize the

listening and communication

environment for the baby. Therefore, as soon as the hearing loss is

diagnosed, an immediate referral

to an early intervention program

should be made so that intervention can begin. It is important that

such referrals be coordinated with

the infant’s primary care physician

(i.e., his or her medical home) so

the total health care program can

be appropriately coordinated).

Several state agencies and other

groups have developed excellent

guides and booklets to assist

parents of infants and young

children identified with hearing

loss. (Annotated references to

several of these are available in

Appendix 12.)

COORDINATE WITH EARLY

INTERVENTION PROGRAMS

The whole purpose of doing a

universal newborn hearing

screening program is to help infants

with hearing loss get the assistance

they need to maximize their

development. Under federal law,

every state is required to provide

appropriate early intervention

services to infants and toddlers

with disabilities. Although every

state establishes its own eligibility

requirements, most, if not all,

children with congenital hearing

loss will qualify. (A list of contact

people in each state is included in

Appendix 12. You should coordinate with these people to make

sure infants and young children

E

Photo courtesy of Bio-logic Systems Corp
34 Implementing Universal Newborn Hearing Screening Programs

Point 12. Coordination With State Systems

identified in your program receive

the services they need.)

Although some hospitals are

structured in such a way that they

do not become involved in

diagnosis and intervention, you

should at least consider staying

involved with infants through the

entire process. Experience has

shown that infants born in hospitals that remain involved through

the entire process are much more

likely to receive the services they

need and to enjoy the benefits of

early identification and intervention.

DON’T WAIT TO START SCREENING

UNTIL THE DIAGNOSTIC AND

INTERVENTION SYSTEM IS PERFECTED

Some people have delayed the

implementation of a universal newborn hearing screening program because they felt there was not sufficient availability of high-quality diagnostic and early intervention services in their area. This is a mistake.

The best way to expand the availability and improve the quality of

diagnostic and early intervention

programs is to identify more and

more infants with hearing loss. As

in other areas of social and health

services, demand will drive supply.

Whether or not the children are identified, they still exist, and the best

way you can get needed services for

infants and toddlers is to make public officials aware of the existence

of positively diagnosed children. An

excellent strategy is to involve the

parents of those children previously

identified in efforts to expand and

improve the quality of early intervention programs.

COORDINATION WITH OTHER

PUBLIC HEALTH INFORMATION

DATABASES

Most state departments of health

already maintain a number of

electronic databases (e.g., Vital

Records, Immunizations, Metabolic Screening, Birth Defects,

Follow Up of High-Risk Births).

Developing a statewide electronic

Early Hearing Detection and

Intervention (EHDI) database and

linking it to one or more of these

existing databases has substantial

advantages. For example, the Vital

Records database could be

compared to the EHDI database to

make sure no newborns missed the

screening test. If your state uses an

Immunization database, when

children come in to their health

care provider for immunizations at

8 weeks of age, an electronic link

with the EHDI database would

show whether they needed a

follow up related to newborn

hearing screening. The potential

for such linkages is enormous, and

the technology is presently

available. Although only a few

states have started such linkages,

you should keep such possibilities

in mind as you design your EHDI

system.
Implementing Universal Newborn Hearing Screening Programs 35

POINT 13. CONSIDERING

LEGISLATIVE MANDATES

T wenty-one different

states have legislative

mandates related to early

identification of hearing

loss. Nine of those require universal

newborn hearing screening, while

the others are all targeted on highrisk groups. Unfortunately, some are

unfunded and have not resulted in

operational programs. However,

more and more states are considering

legislation which would mandate

universal newborn hearing screening.

In almost all cases where legislation

has been passed, hospital-based

people have been among the prime

movers in making it happen.

IS LEGISLATION A GOOD IDEA?

Although some states have had

many hospitals implement

newborn hearing screening

programs without legislation (e.g.,

Iowa, Michigan, New Mexico,

New York, Texas, Wyoming), most

states which are screening more

than 90% of the

babies have a

legislative

mandate (e.g.,

Hawaii, Mississippi, Rhode

Island, Utah). A

legislative

mandate also

ensures that

newborn hearing

screening

programs will not

be discontinued

as a result of key

people leaving

the hospital or

changes in

hospital ownerPhoto courtesy of Woman’s Hospital, Baton Rouge, Louisiana

ship. Furthermore, a legislative

mandate can be used to ensure that

an effective statewide data and

tracking system is created and that

hospitals will participate in such a

system.

DON’T WAIT TO START UNTIL YOU

HAVE A LEGISLATIVE MANDATE

Although it is often very helpful to

have a legislative mandate, you

shouldn’t wait to initiate universal

newborn hearing screening

programs until a mandate has been

passed. In fact, many legislators

want to see evidence in their own

state of some successful programs

before they will even consider

passing a legislative mandate.

Furthermore, since it often

requires 2 or 3 years to get a

mandate passed, many children

with hearing loss would not be

identified if you waited to get a

mandate before initiating programs. The best approach is to

work simultaneously on implementing programs and getting a

mandate in place.

WHAT LEGISLATIVE ACTIVITIES ARE

HAPPENING IN OTHER STATES?

In deciding what should be

contained in a legislative mandate

for your state, you should consult

laws which have been passed or

are being considered in other

states. The complete text of those

laws is available on NCHAM’s

Web site (www.usu.edu/~ncham/).

Of course, you will want to tailor

your legislation to the specific

circumstances in your state, but

the legislation from other states

can give you a good head start.
36 Implementing Universal Newborn Hearing Screening Programs

A FINAL NOTE

he 13 points included in this booklet’s checklist will help you

benefit from the experience of other hospitals as you design a

universal newborn hearing screening program for your hospital. In

completing the checklist, though, you should remember that each

hospital and situation is unique, and the timing or the specific way in which the

various activities are accomplished may have to be modified. Based on the

hundreds of hospitals that are now operating successful universal newborn

hearing screening programs, most, if not all, of the activities described in the

checklist will have to be addressed. Remember that successful newborn

hearing screening programs almost always involve a “team approach” with

many stakeholders (e.g., audiologists, physicians, nurses, parents, etc.) being

collaboratively involved.

Additional information about starting a universal newborn hearing screening

program is available by contacting:

T

University of Colorado at Boulder

Campus Box 409

Boulder, CO 80309-0409

Phone 303.492.6283

FAX 303.492.3274

Utah State University

2880 Old Main Hill

Logan, UT 84322

Phone 435.797.3589

FAX 435.797.1448

www.cdc.gov/nceh/programs/edhi

www.hrsa.dhhs.gov

www.colorado.edu/slhs/mdnc/

www.usu.edu/~ncham

A wealth of information can also be obtained from the following World Wide

Web sites:

The appendices referred to throughout this booklet can be obtained from

NCHAM, the Marion Downs National Center for Infant Hearing, the National

Maternal and Child Health Clearinghouse, or on the World Wide Web at

www.usu.edu/~ncham.