An Example of Interventional Audiology in an Inter-Professional Post-Trauma Clinic



Author: by Lori Zitelli, Au.D. and Catherine V. Palmer, Ph.D.

Introduction
Although often discussed separately, interventional audiology and inter-professional healthcare ideally go hand-in-hand. This article describes how we apply interventional audiology in an inter-professional setting affecting the care of trauma patients on the day of services and in the future to improve recovery and reduce future trauma. In addition, we provide data that illustrate that the inter-professional setting affects future practices of the professionals who become aware of the positive impact improved communication has on their patients. A review of the necessary components for successful inter-professional health care is provided, followed by a brief review of the data related to health care provider awareness of hearing loss and the potential effect of hearing loss on health outcomes. Also, an introduction to the concept of interventional audiology is provided. With this background in mind, we describe the audiologist’s role in the inter-professional UPMC (University of Pittsburgh Medical Center) Post-Trauma outpatient clinic that highlights interventional audiology on the day of service as well as coordinated care post-visit. Finally, we review data that illustrate the effect interventional audiology in an inter-professional setting has had on subsequent health care provider practice in the inpatient setting.
Inter-professional Healthcare
A team is considered to be interdisciplinary if it is comprised of providers from different disciplines who work toward a common goal by each contributing specific knowledge, skills, and abilities (Greiner & Knebel, 2003). Interdisciplinary healthcare in the United States of America emerged in the 1940s (primarily from efforts to treat soldiers efficiently during World War II) and has progressed through several phases, experiencing declines and growths in popularity over the years (Baldwin, 1996). As providers continue to focus on quality, satisfaction, and efficiency in healthcare, interdisciplinary care has become an important way of promoting collaboration among professions, streamlining patient care, reducing errors, and eliminating redundancies (Halm et al, 2003). Several factors have been identified as elements that are necessary for successful inter-professional teamwork. Figure 1 lists these factors along with a description of how the UPMC Post-Trauma Clinic meets these criteria.
Figure 1. Factors related to successful inter-professional teams.


Healthcare Provider Awareness of Hearing Loss and its Effect on Health Care Outcomes
Many healthcare providers are not aware of the extent to which hearing loss can negatively affect healthcare outcomes. When considering accessibility of healthcare providers for patients with hearing loss, many providers perceive accessibility to be a matter of physical access only (Sanchez, 2000). While it is important to meet physical accessibility guidelines, not every patient needs a ramp to access their providers. Every patient does require the ability to communicate with their providers.

Untreated hearing loss can (and does) negatively affect healthcare outcomes. Communication disabilities can lead to poor adherence to treatment recommendations and clinical outcomes that may include accidental injury or further medical difficulties (Lawthers et al, 2003). These barriers lead to difficulty obtaining a patient history, recognizing the appearance of a new health problem, and probing for adverse effects and often result in less than optimal outcomes. Bartlett et al (2008) reported that patients with communication problems are three times more likely to experience a preventable adverse event (e.g., readmission, hospital-incurred patient injury or infection, adverse drug reaction, inappropriate discharge) than patients without such communication problems. Also, older adults with a communication disability reported dissatisfaction with the overall quality, accessibility, and receipt of information related to their healthcare (Hoffman et al, 2005). Recently, Genther et al (2013) reported that patients over the age of 70 with hearing loss were more likely to be hospitalized (and tended to be hospitalized more often) than patients in that same age group with normal hearing.

Thirty-one percent of the patients seen in Post-Trauma Clinic are there because they experienced a fall. Lin & Ferrucci (2013) found that hearing loss is significantly associated with the odds of reported falls. Other research indicates that auditory cues influence postural sway (Kanegaonkar, Amin, & Clarke, 2012). Spatial hearing ability is helpful in maintaining postural control (Zhong & Yost, 2013). Lastly, women with hearing impairment were shown to have twice the age-adjusted risk for walking difficulties as those without hearing impairment (Viljanen et al, 2009).

Although there are many providers who do seem to perceive communicating difficulties when serving patients with hearing loss (e.g., increased time, effort, and frustration during these appointments), they report a lack of knowledge of alternate communication methods (Hemsley et al, 2001). Grabois, Nosek, & Rossi (1997) surveyed several primary care physicians regarding their provision of auxiliary aids or alternate means of communication for patients with hearing difficulties. A few did report that they provided notepads and pencils to facilitate written communication, sign language interpreters, or videotapes with captioning. Eleven percent of those surveyed reported that they did not use anything because it was either too much work, there was not enough demand, or it never occurred to them. For these providers, it was easier to refer patients with hearing loss to other providers because they were either unaware of their obligation to serve patients with disabilities or they did not want to invest the time and energy required to comply with Americans with Disabilities Act regulations.
Interventional Audiology
Interventional medicine has developed in recent years by emphasizing the treatment of chronic diseases and promoting a healthy lifestyle. As healthcare costs climb, we are seeing an urgency to prevent illnesses whenever possible. Interventional audiology is vital for patients with hearing loss because early identification and treatment result in higher quality of life. Our goal, then, should be to minimize the impairment caused by the hearing loss and maximize the patient’s function by helping to prevent and treat it (Taylor & Tysoe, 2013). In our clinic, we interpret interventional audiology as communication improvement that is facilitated through improved hearing when hearing loss was not the patient’s primary concern but has a high likelihood to affect outcomes related to the primary concern.

If we can focus on earlier treatments for the patient’s hearing loss, it will not interfere with their ability to be treated for other medical conditions. Also, hearing may accelerate some disabilities (e.g., cognitive dysfunction,), so earlier treatments can target this as well. Ultimately, prevention, early detection, and evidence-based treatment can result in improved quality of care, better patient compliance, improved outcomes, and reduced overall cost of care (Taylor & Tysoe, 2013).

There are many reasons why a patient may not report his hearing ability accurately. Patients have proven to be unreliable self-reporters of their own hearing abilities when using a written screening assessment (Boatman et al, 2007). Hetu et al (1990) reported that a group of noise-exposed workers with hearing loss experienced denial and minimized their hearing problems in an attempt to appear normal. Patients have reported that they do not want to wear hearing aids (despite having hearing loss) because they feel that they will be perceived by others as weak, feeble, disabled, old, or mentally impaired (Kochkin, 2007).

Because patients can be unreliable self-evaluators of their own hearing ability, it is imperative that healthcare providers are aware of the need to screen and correctly identify patients with hearing loss in their offices so that communication strategies can be implemented when needed. This may be easier said than done – many providers continue to rely on non-standard methods of evaluating hearing, such as the finger rub, whispered speech, watch tick, and tuning fork tests (Nuwer & Sigsbee, 1998), despite the evidence that these tests have poor sensitivity (Boatman et al, 2007). Mulrow & Lichtenstein (1991) outlined several reasons why hearing screenings should be implemented more consistently for elderly adults in primary care settings using a portable audiometer: the burden of hearing loss results in a significant handicap, a portable screening audiometer provides good sensitivity, most hearing loss is treatable (either medically or with amplification), and subsequently many older patients with hearing loss could be identified, referred for further evaluation, and treated.

Alternatively, audiologists may be part of inter-professional teams and provide these screenings in order to recommend strategies/technologies on the day of the visit and create a subsequent plan for hearing health care. This investment in time and resources potentially increases patient visits to the audiology clinic in the future. In the case of our involvement in the UPMC Post-Trauma Outpatient Clinic, our investment of time and resources has significantly increased consults to the audiology department on the inpatient side. Evaluations and provision of amplifiers are billed as part of our contract with the hospital. So although we are not billing for the hearing screenings, we have seen increased revenue through the follow-up care patients pursue in our outpatient clinics and through the increased orders in our inpatient settings for new patients.
UPMC Post-Trauma Clinic Goals & Data
The audiology goals that have been established for Post-Trauma Clinic extend beyond the day of the actual appointment (and, in some cases, hopefully impact other patients before the clinic visit occurs). These goals include: intervening on the day of clinic, referring for help after the day of clinic, helping future patients before the day of clinic, promoting awareness of our services, and preventing future trauma.
Intervening on the Day of Clinic
Firstly, our goal on the day of Post-Trauma Clinic is to evaluate the patient’s ability to effectively communicate with her providers and to provide any intervention necessary to facilitate this exchange of information. To date, 899 patients have been seen in clinic and we have provided communication interventions for 378.

Approximately 20% of Americans could not pass a 25 dB HL hearing screening in both ears (Lin et al, 2011). This percentage is much higher in an inpatient trauma population - 42% of the total number of patients seen in the Post-Trauma Clinic did not pass the screening and needed some sort of intervention (i.e., personal amplifier, hearing aids, or education for their providers about how to communicate with them) to converse with their providers (see Figure 2). This means that these patients spent days (sometimes weeks) in the hospital without being able to fully participate in their own care. For most of the patients who did not pass the hearing screening, intervention with a device was not needed. However, 2.5% (22 patients) required the use of hearing aids during their appointments (most were working appropriately, but 3 patients had hearing aids that required troubleshooting to function correctly) and 2% (18 patients) required a personal amplifier.

Figure 2. Hearing status across all post-trauma


When the patients were divided by age into groups (65 and older in one group, under 65 in the other), the differences were dramatic (Figures 3 and 4). Only 9% of the patients over the age of 65 were able to communicate without any intervention while nearly 70% of the patients under the age of 65 passed the hearing screening.

Figure 3. Hearing status for patients 65 years of age and older.


Figure 4. Hearing status for patients younger than 65 years of age.


The following description provides the protocol we use in the inter-professional post-trauma outpatient clinic. At UPMC (University of Pittsburgh Medical Center) patients who have been discharged from the inpatient trauma unit are seen for follow up two weeks post-discharge.

Figure 5. Inter-professional Clinic Flowsheet


Inpatients are assigned to the Trauma Service at UPMC Presbyterian Hospital when they are admitted as a result of an accident or trauma that requires immediate and often life-saving medical treatment. Although the majority of patients seen in Post-Trauma Clinic are recovering from falls and motor vehicle accidents, we also have seen patients recovering from assault, work injuries, and sports injuries. When the patient is stabilized and can be discharged from the hospital, they are given instructions to follow-up at the Post-Trauma Clinic (located adjacent to the hospital) within two weeks. It is acknowledged that these individuals are often released from the hospital prior to being able to completely manage their care and the purpose of this appointment is to ensure that patients are receiving appropriate follow-up care to promote appropriate recovery. At this outpatient appointment, the patient undergoes a number of evaluations and receives a coordinated treatment plan including home-care plans and/or referrals to conveniently located clinics. The overarching goal is for patients to return to their functional baseline, while they recover at home.

Currently, the Post-Trauma Clinic has team members from the following rehabilitation disciplines: audiology, speech-language pathology (SLP), physical therapy (PT), occupational therapy (OT), and nutrition. Rounding out the team are medical assistants (MAs), a nurse, and several advanced practice providers (APPs). The APPs are certified registered nurse practitioners (CRNPs) and physician assistants (PAs). When patients arrive for their appointment with the Post-Trauma Team, an MA takes their vitals and a brief history. In order for the APPs to integrate the various information and make appropriate referrals, the rehabilitation evaluations must occur first. Each rehabilitation professional will make recommendations on the Inter-professional Clinic Flowsheet (see Figure 5), which is completed and given to the APP managing the patientfs care so that all referrals can be coordinated.

The audiology evaluation occurs first in order to positively impact the patientfs care on the day of clinic and hopefully to impact their long term care in terms of solving communication problems caused by hearing loss. The audiologist has three goals in this clinic: 1) to facilitate effective communication between the patient and providers so that the patient can participate in his/her own care, 2) to provide a plan for pursuing a more long-term communication solution with referrals to providers near home, and 3) to impact future inpatient care by calling attention to the importance and effect of improved hearing during the provider-patient visit.

The audiologist does a brief assessment (relevant history, otoscopy, and pure tone hearing screening) to determine if the patient has adequate hearing for successful communication for the provider interactions on that day. If the assessment reveals a significant hearing loss, a simple personal headset amplifier is provided to ensure that any barriers to effective communication, caused by a lack of audibility, are addressed. If the individual has personal amplification, we ensure that it is functioning. Simple repairs can be done on site and reduce additional clinic visits that are a burden for these patients. We make recommendations for other providers regarding the most effective way to communicate with that patient by categorizing the patients into one of three categories using color-coded stickers that are applied to the Flowsheet. By employing these color-coded stickers,which use an intuitive stoplight color scheme, providers are able to glance at the Flowsheet and determine how to effectively communicate with each patient.

If a patient passes a 25 dB HL hearing screening at 1000, 2000, and 4000 Hz, he will receive a green sticker on the Flowsheet. The green sticker (Figure 6) indicates that the patient has normal hearing and the provider does not need to use any special strategies to communicate effectively.

Figure 6. Normal hearing indicator.


If a patient fails the hearing screening at any frequency, he will be assigned a yellow sticker (Figure 7) which indicates that he has a significant hearing loss. All providers will need to be aware that they can communicate effectively with this patient with the use of specific strategies. They do so by using clear speech, remaining face-to-face, ensuring good lighting in the room, and reducing all sources of background noise.
Figure 7. Communication strategies recommendation.


When a patient fails the hearing screening at all frequencies in both ears, reports a known significant hearing loss, or wears hearing aids, he will receive one of two red stickers on his Flowsheet. The first red sticker (Figure 8) indicates that the patient has a known hearing loss and is a current hearing aid user. If the patient reports that the hearing aids are not functioning, they will be visually inspected, cleaned, and troubleshot in the hopes of restoring function. The first red sticker lets providers know that the hearing aids are functioning and should be worn during their interactions in order for the patient to be able to communicate effectively. It also reminds them to use good communication strategies for these patients.
Figure 8. Recommendation to use personal hearing aids.


Lastly, patients who fail the hearing screening or have a known significant hearing loss who are not current hearing aid users (or do not have their hearing aids with them) will receive a headset amplifier device to use during their appointments in the Post-Trauma Clinic. This device has an adjustable volume control that the patient is taught how to operate. All providers are alerted that they need to speak into the microphone when communicating with this patient, as well as using the other communication strategies outlined on the sticker (Figure 9).
Figure 9. Non-custom amplifier provided.


On the day of clinic, the audiologist also makes recommendations based on the otoscopic exam, the results of the hearing screening, and the patient’s history. These recommendations are documented on the Flowsheet. Typically, these recommendations include: comprehensive audiograms, hearing aid or assistive device evaluations, medical follow-ups, hearing aid follow-ups, and hearing protection.

The nutritionists screen each patient for any potential dietary issues (weight loss or gain, nausea or vomiting, diarrhea or constipation, swallowing issues, non-healing wounds, etc) that they may be able to address. For these patients, issues often arise during their recovery period that can be treated with changes to their diet. The PT, OT, and SLP providers see patients independently but also work together to make referrals to each other based on their findings. The PT provider sees patients to identify mobility deficits and provide care or referrals to address these issues. The OT provider’s goal is to help the patient return to their baseline of function and independent living after experiencing trauma. These patients are always eager to get back to normal and OT is often essential in helping them to progress toward that goal. The SLP provider works to make sure that patients with concussions or head injuries resulting in cognitive issues receive appropriate and timely treatment. The SLP also screens for speech, language, voice, and swallowing issues that may be a result of trauma or that may have been exacerbated by trauma. Some of these issues may be difficult to identify and a delay in treatment can lead to less-than-optimal outcomes.

Once the patient has been evaluated by each of the rehabilitation disciplines, the APP will be alerted that the patient is ready to be seen. The APPs, who are often familiar with these patients due to their interactions during their inpatient stay, will review the Flowsheet and make the appropriate referrals and recommendations. Our APPs aim to ensure adequate follow-up after trauma to identify any lingering deficits that, left untreated, may lead to readmission or additional trauma.

Referring for Help After the Day of Clinic
Based on our evaluations on the day of Post-Trauma Clinic, recommendations are made for the patients who require follow-up care. To date, we have recommended a total of 359 comprehensive audiograms, 76 hearing aid evaluations, 116 cerumenectomies, and 92 medical follow-ups (regarding tinnitus, otalgia, abnormal otoscopy, etc). Many of the patients seen in clinic are traveling to Pittsburgh to be seen (sometimes from several hours away) and require information for clinics that are convenient for them, so it is impossible to know how many of the patients have followed-up. We can, however, track the number of patients who reported that a UPMC facility is convenient for their follow-up care. Out of a possible 231 patients to whom follow-up care was recommended (and who also reported that a UPMC clinic was in a location that was convenient for them), 35 (15%) followed the recommendations shortly after being seen. Given the degree of trauma some of these patients are managing, it would not be surprising if some will delay follow-up regarding hearing until other issues have resolved.

In the future, we are hoping to add a scheduling component to the clinic so that the patients can have all of their follow-up appointments scheduled for them on the day that the recommendations are made. The literature has indicated that patients who have their follow-up appointments scheduled for them by hospital staff before leaving are more likely to attend these appointments than patients who just receive recommendations (Kyriacou et al, 2005; Magnusson et al, 1993; Murray & LeBlanc, 1996; Richards et al, 2007).
Helping Future Patients Before the Day of Clinic
Our audiology clinic is located within a hospital, which makes our services very convenient for providers needing to order hearing evaluations, hearing aid services, and personal amplifiers for their hospital inpatients. However, many providers were not aware of the services we provide before Post-Trauma Clinic started. Since the trauma APPs began to realize how many patients in the 65+ age range have needed intervention to communicate, they have been ordering personal amplifiers regularly for this population. Please see Figure 10 for a graph of the number of amplifiers distributed to inpatients at UPMC’s Presbyterian and Montefiore hospitals over the past several years.
Figure 10. Amplifiers dispensed to hospital inpatients, per month.


To date, 18 patients in the Post-Trauma Clinic have needed an amplifier to communicate with their providers on the day of clinic. Only one of these patients had a provider who thought to order an amplifier for them during the course of their inpatient hospital stay. This is unfortunate because a simple consult to audiology could have easily and inexpensively helped the remainder of these patients to participate in their own care. Interestingly, the number of inpatient audiograms ordered by physicians in our hospitals has not increased significantly. We believe that this is because these providers are ordering amplifiers for the patients who clearly have hearing problems that are interfering with their ability to communicate effectively (or report a history of hearing loss) rather than ordering the audiogram to tell them something that is already evident. This practice is consistent with interventional audiology where the treatment is to improve communication and exact hearing levels are not relevant for the immediate solution to be put into place.

Interventional Audiology in the Inter-Professional Post-Trauma Outpatient clinic has been beneficial to the patients seen in this clinic and to new inpatients who have been admitted to our hospital. The overarching goal in health care is to have patients fully participate in decision making, and this cannot be accomplished without the ability to effectively communicate. Untreated hearing loss is a barrier to shared decision making. Audiologists can play a critical role in mitigating the effects of hearing loss if they are willing to leave the comfort of their clinics and think differently about the goal of improved hearing, no longer a means unto itself, but rather as a means to positively affect a more immediate health care concern for the patient.    
Lori Zitelli joined the staff of audiologists at the UPMC Eye & Ear Institute in 2012. She received her clinical doctorate and master’s degree in Audiology from the University of Pittsburgh. Her special interests include amplification, diagnostic testing, tinnitus treatment, intraoperative cochlear implant testing, and interventional audiology. She teaches the Clinical Procedures Lab for first year AuD students at the University of Pittsburgh. Dr. Zitelli can be contacted at zitellild@upmc.edu.

Dr. Palmer is an Associate Professor in the Department of Communication Science and Disorders at the University of Pittsburgh and serves as the Director of Audiology and Hearing Aids at the University of Pittsburgh Medical Center. Dr. Palmer conducts research in the areas of adult auditory learning post hearing aid fitting, the relationship between hearing and cognitive health, and matching technology to individual needs. She has published over 80 articles and book chapters in these topic areas as well as provided over 100 national and international presentations. Dr. Palmer teaches the graduate level amplification courses at the University of Pittsburgh and serves as Editor-in-Chief of Seminars in Hearing. Dr. Palmer opened the Musicians’ Hearing Center at the University of Pittsburgh Medical Center in 2003 and has focused a great deal of energy on community hearing health since that time. This work has included a partnership with the Pittsburgh Public Schools and the Pittsburgh Symphony that promotes hearing protection for young and professional musicians.


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