What happens when you refer a patient to Audiology?

‘To provide high quality services for people with hearing loss,tinnitus and balance disorder across the UK’Adult RehabPaediatricsRBFTAUDIOLOGYBalanceHearingTherapy

Why are pathways important?Almost a decade after NHSModernising Hearing Aid Services(MHAS), demand for digital hearingaids continues to rise

Appointment demand3000No. of Direct referrals250020001500100005-06 06-07 07-08 08-09 09-10

Why are pathways important?Almost a decade after NHS Modernising Hearing AidServices (MHAS), demand for digital hearing aidscontinues to riseMore tests

Pure toneaudiometryPlayaudiometryDistractiontestingSpeechAudiometryVideo-NystagmographyCaloricsPerformancetestingVisualreinforcementAudiometryTESTS NOWAVAILABLE!Auditory Steady-StateResponseTympanometryAcousticreflexesOtoacousticEmissionsCorticalauditoryevokedpotentialsVestibularEvokedMyogenicPotentialsCentralAuditoryProcessingDisorderAuditoryBrainstemResponse

Why are pathways important?Almost a decade after NHS ModernisingHearing Aid Services (MHAS), demand fordigital hearing aids continues to riseMore testsMore treatments

AssistiveListeningDevicesAdulthearingaidsNeonatalhearingaidsVestibularRehabilitationTREATMENTBPPVTinnitusCounsellingBoneanchoredhearing aidsCentralauditoryprocessingdisorder

Why are pathways important?Almost a decade after NHS ModernisingHearing Aid Services (MHAS), demand fordigital hearing aids continues to riseMore testsMore treatmentsWaiting times

Why are pathways important?Almost a decade after NHS ModernisingHearing Aid Services (MHAS), demand fordigital hearing aids continues to riseMore testsMoreWaiting timesCost

Make sure that every referral follows anagreed pathway which optimises both theiroutcome and the use of resourcesData from the Action On and Collaborativepilot sites suggest that some 10 - 40% ofnew referrals from GPs do not require asurgical opinion. The benefits of puttingthe patient on the right pathway from theoutset are considerable.

BPPV treatment –the long wayroundBPPV treatedGP refersre.‘dizziness’ElderlyCareENTAudiologyNeck physioVestibularrehabilitation36 weeks!Nationally, balance service audits show an averageof 4-5 specialists before patient receives a diagnosis

Improving pathways?BPPV treatedGP refersre.‘dizziness’ElderlyCareENTAudiologyNeck physioVestibularrehabilitation

Good practice guidelines

Process mapping –reduce number of stepsConsider telephoneand email referralsonly (use of template)Audiology (paediatric admin +clinical) Process MapReferrals received fromGP,hospital,SALT,SHA,CDT, Parent,HounslowBy letter, phonecall,template or sharedemailPost/emails triaged intoreferrals for 3yrsdate stamp appliedDatabase checkedfor previous referral.Database updated.If previously referred,put aside for adminperson to find notesReferrals reportedon demand +capacity formNew pts added toregistration folder.And entered ondatabaseCover sheetprinted, andattached withclinic sheet toreferralsCancellation messagescollected and added tocancellation slip andpassed to bookingspersonCancellation sheetpassed to personupdatingspreadsheetDetails ofcancellation addedto admin sheetCancellationsrebooked,electronic diaryadjustedClinic listscompiledInterpretersbooked by fax withcitas if requiredPt phoned tomake appt or sentletter with appt on.Appt added toexcel databaseLiaise withaudiologists to seewhen they are freefor clinicsDiary checked forclinic spacesDatabase updatedClinic sheetupdated withcancellations+electronic diaryPhone pts toremind re apptPt called toconfirmattendance byclinicianNotes collected forclinicClinic detailschecked ondatabase/electronic diaryTest undertakenReport written(paper) andreferral if neededNotes filedClinic outcomessheet completedDx patientsmoved ontoDxspreadsheetConsider txt msgreminders frombookings staffAdmin staff to doFile dischargedand DNA ptsCopy and postletters (inc anyDNA letters)Letterstyped andgiven toclinicians tosignOnward referralsplaced in trayComplete reportsin clinic ?Value steps that will benefit the patient are highlighted inpink.A ll other processes need to be reviewed and eliminatedwhere possible

PaediatricsSpeech andLanguageTherapyClinicalPsychologyNeurologyAUDIOLOGYENTRadiographyPhysiotherapyElderlyCare (Falls)

Community-based care

…and further afield

Provision of community-based care8070RBHCommunity60% activity5040302010005-06 06-07 07-08 08-09 09-10

Referral criteriaBritish Academy of Audiology Guidelines forReferral to Audiology of Adults with HearingDifficulty (2009) –based on Based on Guidelinesof the Liaison Group of Technicians, Therapistsand Scientists in Audiology (TTSA), 1989

Direct referral red flagsPersistent pain affecting either ear (defined as earache lasting more than 7 days inthe past 90 days before appointment);History of discharge other than wax from either ear within the last 90 daysSudden loss or sudden deterioration of hearing (sudden=within 1 week, in which casesend to A&E or Urgent Care ENT clinic)Rapid loss or rapid deterioration of hearing (rapid=90 days or less)Fluctuating hearing loss, other than associated with coldsUnilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5minutes at a timeTroublesome, tinnitus which may lead to sleep disturbance or be associated withsymptoms of anxiety or depressionAbnormal auditory perceptions (dysacuses)Vertigo (defined as hallucination of movement, but here includes dizziness, swayingor floating sensations (frequently associated with unsteadiness) that may indicateotological, neurological or medical conditions).Normal peripheral hearing but with abnormal difficulty hearing in noisy backgrounds;possibly having problems with sound localization, or difficulty following complexauditory directions.

Direct referral red flagsOn examination:Complete or partial obstruction of the external auditory canal preventingproper examination of the eardrum and/or proper taking of an auralimpression.Abnormal appearance of the outer ear and/or the eardrum (e.g.,inflammation of the external auditory canal, perforated eardrum activedischarge).Audiometry:Conductive hearing loss, defined as 25 dB or greater air-bone gap presentat two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.Unilateral or asymmetrical sensorineural hearing loss, defined as adifference between the left and right bone conduction thresholds of 20 dB orgreater at two or more of the following frequencies: 500, 1000, 2000 or 4000Hz.Evidence of deterioration of hearing by comparison with an audiogram takenin the last 24 months, defined as a deterioration of 15 dB or more in airconduction threshold readings at two or more of the following frequencies:500, 1000, 2000 or 4000 Hz.

Choose and BookOP Appt or Advice and Guidance Request + Priority selectionsSNOMED search – these are set by RBFTSpecialty and Clinic Type search – these areset by the Royal CollegesNamed Clinician search – these are set on PMS. Canonly be smartcard registered consultantsPatient’s postcode (this test patient is based at RBFT)Distance limit of search – will show services based ondistance from the entered postcodeIndicative wait time is approx. 3 rd next available appt onCaBAge and Gender Appropriate services – many services arespecific to either paeds or adult and this option ensuresonly appropriate services are returned. These are set byCaB Team with the departmentSearch Primary or Secondary care – all Audiology servicesare secondary.

Choose and Book –Adult hearingLocation Service name Specialty Clinic typeRBHRBFT - Adult Audiology Hearing AidAssessment & Rehabilitation - RoyalBerkshire Hospital – RHWDiagnosticPhysiologicalMeasurementAudiology - Hearing Aid Assess and FitAudiology - Hearing Aid ReviewAudiology - Hearing Assess / ReassessWBCHRBFT - Adult Audiology Hearing AidAssessment & Rehab - West BerkshireCommunity Hospital - RHWDiagnosticPhysiologicalMeasurementAudiology - Hearing Aid Assess and FitAudiology - Hearing Aid ReviewAudiology - Hearing Assess / ReassessWallingfordRBFT - Adult Audiology Hearing AidAssessment & Rehab - WallingfordCommunity Hospital - RHWDiagnosticPhysiologicalMeasurementAudiology - Hearing Aid Assess and FitAudiology - Hearing Aid ReviewAudiology - Hearing Assess / ReassessWokinghamRBFT - Adult Audiology Hearing AidAssessment & Rehabilitation -Wokingham Hospital - RHWDiagnosticPhysiologicalMeasurementAudiology - Hearing Aid Assess and FitAudiology - Hearing Aid ReviewAudiology - Hearing Assess / ReassessSkimped HillRBFT - Adult Audiology Hearing AidAssessment & Rehabilitation - SkimpedHill Surgery - RHWDiagnosticPhysiologicalMeasurementAudiology - Hearing Aid Assess and FitAudiology - Hearing Aid ReviewAudiology - Hearing Assess / ReassessTownlandsRBFT - Adult Audiology Hearing AidAssessment & Rehabilitation -Townlands Hospital - RHWDiagnosticPhysiologicalMeasurementAudiology - Hearing Aid Assess and FitAudiology - Hearing Aid ReviewAudiology - Hearing Assess / Reassess

Choose and Book –Tier 2 PreschoolAssessment Clinic (PSAC)Community clinics for children presenting WITHOUT clear riskfactorsParental and professional concerns with hearing30 minute appointmentsLocation Service name Specialty Clinic typeRBHRBFT - Audiology Pre-School Assessment forUnder 3s - Royal Berkshire Hospital - RHWDiagnostic PhysiologicalMeasurementAudiology - Hearing Assess /ReassessChildren's & AdolescentServicesAudiologyRBH RBFT - Audiology Pre-School Assessment (3-5yrs) - Royal Berkshire Hospital - RHWWBCH RBFT - Audiology Pre-School Assessment -West Berkshire Community Hospital - RHWDiagnostic PhysiologicalMeasurementChildren's & AdolescentServicesChildren's & AdolescentServicesAudiology - Hearing Assess /ReassessAudiologyAudiologyWokingham RBFT - Audiology Pre-School Assessment -Wokingham Hospital - RHWChildren's & AdolescentServicesAudiology

Choose and Book –Tier 3 Children’sHearing Assessment Clinic (CHAC)For children presenting with a risk factor e.g. family history,developmental delay, autismClinics held at RBH due to specialised test environment andsenior clinician supportRBH45 minute appointmentsLocation Service name Specialty Clinic typeRBFT - Paediatric Audiology HearingAssessment for Under 3s - RoyalBerkshire Hospital - RHWDiagnostic PhysiologicalMeasurementAudiology - HearingAssess / ReassessChildren's & AdolescentServicesAudiologyRBHRBFT - Paediatric Audiology HearingAssessment for Over 3s - RoyalBerkshire Hospital - RHWDiagnostic PhysiologicalMeasurementAudiology - HearingAssess / ReassessChildren's & AdolescentServicesAudiology

Choose and Book –Tinnitus andBalance ClinicsLocation Service name Specialty Clinic typeRBH RBFT - Audiology Balance Service with Audiologist -Royal Berkshire Hospital - RHWEar, Nose & ThroatEarBalance /DizzinessRBH RBFT - Audiology Tinnitus Clinics with Audiologist -Royal Berkshire Hospital - RHWEar, Nose & ThroatTinnitusWBCH RBFT - Audiology Tinnitus Clinics with Audiologist -West Berkshire Community Hospital - RHWSkimped Hill RBFT - Audiology Tinnitus Clinics with Audiologist -Skimped Hill Surgery - RHWEar, Nose & ThroatEar, Nose & ThroatTinnitusTinnitus

Further streamliningTriaging in surgeries allowing selection of eitherfast-track assess and fit or regular review via:Use of hearing screening devicesUse of more enhanced referral criteria re.dexterity, vision etc.Wax removal if requiredOr even:One-stop direct access Audiology and Balanceclinics in your surgery ?Pilot project

From: Provision of Adult Balance ServicesA Good Practice Guide

Helping you choose the right pathBetter informationabout which referralpathway is bestFacilitate directaccess to appropriatecare pathwayShare information andknowledge ofadvances inaudiological testingand treatments

“A A hearing loss is more obvious than ahearing aid.Smiling and nodding your head when youdon't understand what's being said, makesyour condition more apparent than thelargest hearing aid.”

Thank you!