Last Modified: 06/25/2015
IV. Live Evaluation Procedures
The following steps outline essential procedures to be followed during a tele-audiology (T-A) session. Many T-A procedures involve following standards for in-person evaluations:
Prepare the Patient Physical Environment and Infant State
As with any in-person audiolological service, the rooms at the patient site and specialist site for a T-A session should be setup in a welcoming and professional way.
- Ensure privacy in both the patient location and the specialist location. The American Telemedicine Association suggests “efforts should be made to ensure privacy so clinical discussion cannot be overheard by others outside of both the patient room and the [specialist] room where the service is provided. If other people are in either the patient or the professional’s room, both the professional and patient shall be made aware of the other person and agree to their presence” (ATA, Practice Guidelines) [PDF].
- “Both professional and patient should maximize clarity and visibility of the person at the other end of the video services. Cameras should be on a secure, stable platform to avoid wobbling and shaking during the videoconferencing session. To the extent possible, the patient camera should be placed so that the infant’s head will be clearly visible to the other person” (ATA, Practice Guidelines).
- Due to the necessity of the infant to be in a sleep state, the room at the patient end should be a comfortable temperature and with lighting that can be dimmed. A comfortable chair for the caregiver to hold and feed the infant to induce sleep is needed.
Prepare the Infant
Stated in the Ontario Infant Hearing Program Tele-audiology Manual [PDF], is the appointment will be “arranged around the infant’s sleep schedule so as to have the infant arrive at the [patient] site ready to sleep. [Caregivers] will have been advised that the infant should not sleep prior to, or on the way to testing. The infant may be irritable and may awaken during preparation for electrodes, so this should be done as soon as possible upon the infant’s arrival. Swaddling the infant at this time may be helpful for inducing sleep once the prep work is done”.
Confirm the Identities of all Present
The name and credentials of the diagnosing audiologist, the assistant at the patient site, and the name of the patient shall be verified at the start of the live session. This can be initiated by the assistant at the patient site or by the audiologist. In addition, ATA has provided the following rules to be followed (ATA, Practice Guidelines) [PDF]:
- All individuals present/entering each site must be introduced to the family/patient.
- All individuals entering the patient site should be introduced to the specialist.
- When an individual leaves either site this should be communicated to each site.
- Family must agree to all individuals entering either room. It is possible for caregivers not to be aware that someone has entered the room because they cannot see or hear that person, so it is the responsibility of the specialists to announce anyone else in the room at either site.
- All observers who are at the specialist site must be invited in the room after the patient/parent has given permission. They should not be in the room when the call is connected because this does not allow for permission.
Confirm Roles during the Diagnostic Process
The caregiver of the infant being assessed should receive clear information about the roles of the assistant and the diagnosing audiologist. This is important to ensure that the caregiver understands that the diagnosing audiologist is the provider who is providing the direct service and the provider with whom the caregiver is to direct communications regarding the procedures, results, and follow up.
Conduct a Modified Evaluation
Some accommodations are likely in conducting a full audiological assessment:
- Ambient noise levels are generally set with a threshold limit of 25 dB HL. One may consider visiting a potential site to ensure the noise level is low enough to perform the testing successfully.
- The audiologist will direct the audiology assistant to place probes in the infant’s ears as the test session progresses. This may include insert transducers for Auditory Brainstem Response (ABR), a probe for Otoacoustic Emissions (OAEs) or a probe for immittance measures.
- The audiologist directs the assistant to attach the electrodes to the infant. Recording electrodes are used for diagnostic ABR assessment. Electrode impedances (or contact to the skin) can have significant effects on successful testing and is an important task for the assistant. The audiologist will need to be sure that the appropriate impedance values are met.
- The assistant will need to be trained to determine which type and size of probe is most useful for an individual. Initially the audiologist will assist the assistant with the most appropriate probe size while in time the assistant may need less guidance in this area.
- Special attention may be necessary when training an assistant to place a probe for immmitance measures. Because a seal is necessary specific training will be necessary. It is useful to have immittance measures performed at the same time as the ABR and OAE evaluation, although an alternative is to conductive immittance measures during a follow up appointment with a provider in the infant’s community. This follow up will likely be necessary if automated tympanometry is not available.
- All audiologic testing that are performed in person can be performed remotely when PC based equipment is utilized.
- Otoscopy is an important aspect of the infant evaluation. Video otoscopy can be performed remotely. Special attention must be given to selecting desktop sharing software because not all software is compatible with video otoscope units. It is best to test this application prior to purchasing equipment. In addition detailed training will be necessary to teach the assistant how to perform video otoscopy with sufficient opportunity to practice on adult followed by pediatric subjects. An alternative is to utilize a previously trained professional, such as a nurse or nurses assistant, to perform otoscopy and report findings.
Images for the different pieces of audiological equipment can be found in section VI.
Learning community examples:
A description of diagnostic tele-audiology with infants is offered, along with general recommendations provided in Chapter 6 of Sound Foundations, 2010, eEHDI, Function and Challenges [PDF].