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       The Introduction of an Otoacoustic Emissions Hearing Screening
                       Tool into the Healthcare Setting

                             Brittany DeRuvo
                             Katherine Hage
                              Emily Murphy
                                Noel Robb

                The State University of New York at Buffalo
                                                                   Otoacoustic Emissions        2

        Every year, 12,000 babies are born with a hearing loss. According to the National

Institute of Health, this problem occurs in 2-3 of every 1,000 newborns in the United

States (Lacey 2005). Hearing loss is the most common birth defect and early

interventions before 6 months of age maintains language development (SonaMed, 2007).

It is, however, difficult to detect in babies as their language is unintelligible and not yet

developed. How can newborns be screened for hearing loss easily, accurately, fast, and

cost-efficiently? Newborn hearing screening is mandated in New York State, as it is with

more than 30 other states. The Joint Committee on Infant Hearing (JCIH) and the

American Academy of Pediatrics indicate that universal newborn hearing screening is

warranted based on many factors. These requirements include the benchmarks that

significant congenital hearing loss is common and can be detected by screening but not

by other means, early intervention is effective in improving outcome, the physiologic

screening methods are portable, accurate, and easy to us, and the cost for performing the

screening test is acceptable (Lemons, et al. 2002).

        The need for new, more efficient and easy to use screening equipment has been

brought to attention by most of the nursing staff on mother-baby units across the nation.

Audiologists are not necessary to perform/interpret the test since it is automated and

gives a “pass” or “fail” result, “pass” meaning that cochlear function in the infant is

normal, and “fail” indicating that the test is suggestive of a possible hearing loss and a

referral needs to be made so the child can be retested (Smith 2003). This means that the

nurses are taking on yet another responsibility in the nursery. Given that universal

newborn screening is essential, nurses would like for it not to be time consuming or add

to their work-related stress. Complaints regarding the current model, Natus ALGO2e,
                                                                 Otoacoustic Emissions       3

range from it taking up too much time to the machine not working correctly and failing

the left ear often for no reason. The testing takes anywhere from 10 minutes up to 2

hours and a second test is usually required because the first was either interrupted or

falsely failed. The test time needs to be minimized for the sake of the baby, the parents,

and the nurses. One nurse responded, “All the nurses have getting a new one at the top of

their list.” The current model by Natus uses ABR (auditory brainstem response) which

“measures neural synchrony of the auditory nerve through the auditory brainstem

structures but does not proved frequency-specific information about the auditory system”

(Dolphin, 2004).

       The proposed new model is a SonaMed Clairty Screener that screens both ABR

and OAE (otoacoustic emissions). “OAE testing assesses the function of outer hair-cells

in the inner ear and provides frequency-specific information regarding preneural cochlear

function” (Dolphin, 2004). In other words, the actual otoacoustic emissions are the

sounds that are produced by the ear and then measured by the machine, whereas the

auditory brainstem response transfer clicking sounds into the infant’s ear, which cause

brainwaves to be picked up by the equipment (Lacey 2005). The two tests assess

different aspects therefore, combined use provides a complete screen which especially

valuable in high-risk newborns. Both tests are reliable by themselves, however, the

increased amount of time it takes to screen an infant as well as the increased cost per

newborn using the auditory brainstem response alone require a change in protocol. This

machine is currently being used at other area hospitals and with no complaints. One

nurse manager claims, “It is very easy to use and most infants pass in 5 minutes.” The

most cost-effective and efficacious approach is the two-stage protocol (Dolphin, 2004).
                                                                Otoacoustic Emissions        4

Infants are initially screened using the faster, less expensive OAE test. Those that pass

are discharged and those that fail are screened with the ABR test. Infants passing the

second test are discharged with recommended follow-up and those that fail are referred

for a full diagnostic evaluation an out-patient hospital/clinic. This protocol minimizes

false positive and false negative results reducing the number of referrals. Referrals are

costly, time consuming and cause needless parental anxiety and concern. The sensitivity

of otoacoustic emissions equipment is said to be close to 100%, as only 1 in 16,000

newborns have a false negative hearing screen result (Smith 2003). The SonaMed Clarity

Screener provides a database to easily retrieve pertinent test information such as the

number of infants tested, passed, and/or referred, what test was performed, and raw data

on all infants tested (SonaMed, 2007). Additional advantages of the SonaMed include

ease of use and maintenance, avoidance of missed permanent hearing loss, assurance of

stimulus sound level regardless of a baby’s ear canal size, tester’s choice of OAE only for

well babies or combined OAE-ABR screening for NICU high-risk babies, lower refer

rates substantially, and the automated test frees the nurse’s hands to perform other tasks

while the test is being performed on the newborn (SonaMed, 2007). Finally, neither the

testing room nor the infant need be completely silent during the screen with equipment

using otoacoustic emission technology. This is a great advantage alone because hospital

nurseries, mother-baby units, and various other health care settings are constantly

bustling with activity. Thus, the nurse does not need to worry about the test being

disrupted by interruptions such as slamming doors, whimpering infants, ringing

telephones, or conversation.
                                                                  Otoacoustic Emissions       5

       Cost is a major matter to consider, yet it is also a key advantage of the otoacoustic

emissions. First, money is saved in the cost of the equipment. An OAE-like screener can

range from $3,000 to $5,000 based on the make and the amount of supplementary

equipment also purchased. Additional equipment includes ear probes, printing paper, a

cradle, and database software. The single ABR involves many more disposable costs, as

three adhesive pads and two adhesive earphones must be used with each screening

attempt. A new computer cord must be purchased every few years for the ABR as well.

The OAE only requires the use of two ear probes, one for each ear, which can cost as low

as fifteen cents a piece, and the total disposable costs per screening total to less than a

dollar per newborn (Smith 2003). When first beginning a brand new hearing screening

program, the costs must be well assessed and justifiable. A study conducted in 2002 by

the Journal of Perinatology assessed the total preliminary costs for a health care setting. It

was calculated that a new otoacoustic emissions program is estimated to cost $9,580,

while an auditory brainstem response system will cost almost double that amount at

$18,500 (Lemons, et al. 2002).

       Secondly, money is saved because insurance companies are spending less. Every

newborn in New York State is mandated to receive hearing screening in the hospital

before discharge. However, if the screening test is unable to be performed for any reason,

including lack of time or equipment difficulty or malfunction, the family is still billed for

the mandated hearing screen. These newborns that are unable to be screened must then go

to a primary care physician for an initial screen. As a result, these families and their

insurance companies are being charged by the hospital for tests that aren’t even taking

place. Even though OAE testing is reimbursable by insurance under a few different codes
                                                                Otoacoustic Emissions        6

to health care providers for services under hearing screening programs, money is still

being spent in areas where there is no need (EroScan 2002). Thus, the need for a hearing

screening tool that can complete the test completely in a short period of time is once

again established.

       Time is even a greater benefit of the OAE. The Auditory Brain Response system

takes longer to set up, because adhesive patches and earphones must be stuck to different

areas of the infant’s body. Even if administered correctly in the first place, the ABR can

take minutes and even as long as an hour to complete. The time spent performing

prolonged hearing screens could be used to complete other tasks needed on the unit. The

saving of a great deal of time may prevent other nurses from being called in to come to

work, which will save money from payroll. Overall, the permanent implementation of the

otoacoustic emissions test is a huge resource conserver.

       In order for the nurse manager to make an effective decision as whether to use the

otoacoustic emission equipment or not, she or he would need to be open to varying

opinions and able to analyze contradictory information. The nurse manager would need

to motivate the others to use the new equipment by showing the staff how to use it or

bring in the vendors to demonstrate to correct way to use it. After educating the staff on

how to use the new equipment, a plan should be made to begin using it shortly thereafter,

while the information is still fresh in everyone’s minds.

       While we may hypothesize that the otoacoustic emissions equipment is more

effective and efficient than the automated ABR, it is best to have the staff to compare

them both and provide feedback on both types. We feel that this may be accomplished

by having half of the staff use the new equipment and the other half use the former type.
                                                                  Otoacoustic Emissions        7

Naturally the new equipment would need to either be rented or leased first, before

making the final investment. A time frame would be implemented with a deadline for

decisions and feedback from both sides after two weeks of the trial period. A survey

would be taken and a meeting held, in order to communicate with each other and to gain

information from both sides of the study. During the meeting, everyone could present his

or her information and opinions, and provide feedback as to which method seemed to

work the best, with most ease and with the most accuracy. A confidential evaluation form

could also be handed out to each person who worked with the otoacoustic emissions so

that the managers can get a better idea of how well each individual staff member

preferred it to the audiometric brain response system.

       Of course, there are possible barriers to obtaining this new equipment. Barriers

such as funding, staff compliance, finding available time to implement and teach new

procedures. All of these can be justified and overcome. Managers of the hospital budget

may either not want to or be unable to find room in the budget for new hearing screening

equipment. However, the initial cost of the equipment will easily prove to be well worth

it by the quick financial return and increase in customer satisfaction, as fewer parents will

have to go to a primary physician because their child’s hearing was unable to be even

initially screened. Also, there will be an increase in nurse satisfaction, as this equipment

is relatively easy to use. This again brings up the issue of staff compliance. Those nurses

who have just gotten used to using the Auditory Brainstem Response will not likely be

looking forward to learning how to use a new machine, until motivating factors are

presented to them. The OAE will certainly save all staff members a great amount of time,

yet there may be an initial lack of time at first, as nurses will have to balance training
                                                                  Otoacoustic Emissions         8

sessions for how to operate the OAE and growing accustomed to applying it to the daily

clinical setting. This, however, can be accomplished in a very short period of time due to

the straightforwardness of the otoacoustic emissions.

       No one can put a price on one’s hearing. Although the prevalence of hearing loss

in newborns is low, it is still critical to screen every infant in order to make an early and

proper diagnosis. The otoacoustic emissions test is an optimal screening tool for several

reasons. Its simplicity and ease of use make it adaptable to any health care setting. It is

lower in cost initially, and will continue to save both time and money in the long run.

Though many adjustments will have to be made for any hospital or healthcare

organization that chooses to switch from any hearing screening program to another, it is

clear that the transfer to an otoacoustic emissions-like product such as the SonaMed is a

positive choice for both provider and patient.
                                                               Otoacoustic Emissions       9


Dolphin, W.F. (2004). Auditory neuropathy and configured hearing loss: the case for

       two-stage screening. Pediatric Audiology.

Etymotic Research (2002). Ero-Scan: OAE test systems. Retrieved April 9, 2007 from

Lacey, J. (2005). Your baby’s ears: hearing tests for newborns. Retrieved April 1, 2007


Lemons, J., Fanaroff, A., Stewart, E.J., et al. (2002). Newborn hearing screening: costs

       of establishing a program. Journal of Perinatology, 22(2), 120-124.

Smith, S.D. (2003). A guide to otoacoustic emissions for school nurses. Retrieved April

       9, 2007 from

SonaMed Corporation (2007). Retrieved April 6, 2007 from