QI project helped pediatric offices improve detection of hearing loss
Ted R. Abernathy, M.D., FAAP, is part of an office that loves the latest and greatest,
and the doctors pride themselves on giving patients complete care. So he was surprised
to discover an area where his Virginia practice had become complacent — identifying
infant hearing loss.
“It’s one of those things you don’t want to miss,” Dr. Abernathy said.
While newborn patients received a hospital hearing screen, the office didn’t have
a protocol to follow up on babies’ hearing. “The one question you would have thought
we’d be asking was, ‘Do you have any concerns about your child’s hearing?’” he said.
“Think about how you might feel if you missed something that could be easily corrected.
That’s what drives us.”
Dr. Abernathy’s practice joined the AAP Early Hearing Detection and Intervention Quality
Improvement (QI) Project to improve identification of infants with and at risk for
hearing loss and ensure they receive timely intervention. Six practices participated
in the first year and five in the second year of the project, which wrapped up this
Many newborns who fail the hospital screening or have hearing loss later aren’t being
diagnosed quickly. One study showed about 36% of infants who failed hospital tests
in 2012 did not receive a follow-up diagnostic exam or didn’t have documentation of
“That’s where kids were falling through the cracks,” said Robert C. Cicco, M.D., FAAP,
principal investigator of the project. “It’s hard to change the culture, to place
importance on something that is rare.”
Nearly all newborns receive hospital screens for hearing loss, and about 2% don’t
pass. Only nine children in the two-year project needed diagnostic testing.
Because early intervention is essential for speech and language development, infants
ideally would be screened at 1 month of age, diagnosed at 3 months and receive services
by 6 months, said Dr. Cicco, a neonatologist in Pennsylvania.
“Pediatricians are integral to this whole process of screening, diagnosis and treatment,”
System for tracking
Leslie Katz Lestz, M.D., FAAP, found her Texas practice was good at ensuring newborn
screening results were on file but didn’t have a central place for them in its electronic
record. The results weren’t trackable. After fixing that, she made sure to build hearing
into the record. Now, risk factors for hearing loss have to be reviewed with families.
Doctors also add a tracking code for those with or at risk for hearing loss.
Making the changes required some education for her peers. Because hearing loss is
rare, it’s not a focus of pediatric residency programs.
“I stress we have to continually monitor hearing. It doesn’t end with a newborn screen
and then begin again with a kindergarten screen,” said Dr. Lestz, who has a daughter
with hearing loss.
She has the same message for parents, telling them screenings only show results for
how their baby is doing at that moment. She encourages them to speak up if they feel
their child isn’t meeting milestones.
QI participants had great success improving medical records and protocols to track
infants. By the end of the project, all newborns had hearing screen results and almost
all had hearing loss risk factors documented in their charts by 6 weeks of age. Screening
results were shared with nearly every family by that time, and individualized care
plans were created for children with risk factors by the time they were 4 months old.
Doctors also got infants who failed the initial screen into an audiological evaluation
more quickly. Prior to the project, only about 25% went for the second test by 3 months
of age. Under the project, all had the evaluation by then, and results were in their
charts by the following month.
Participating doctors said the QI project involved a lot of work, including reviewing
charts, attending monthly webinars and collecting data. Dr. Lestz’s practice, for
example, reviewed about 40 charts a month. Ultimately, many said participation made
their practices stronger. They also received Maintenance of Certification credit and
can say they follow best practices.
“We all have opportunity and room for improvement,” Dr. Lestz said.
A Tennessee practice saw firsthand the value of timely tracking of children with risk
factors. A baby born before the project was underway had a sister with progressive
hearing loss. However, his chart wasn’t flagged for monitoring, and he wasn’t sent
for an audiology referral until he was 19 months old and had a speech delay. At 25
months, he was a candidate for cochlear implants.
Heeding parents’ concerns
Besides a family history of hearing loss, parental concern should be a red flag, Dr.
“The most important risk factor is when a parent comes in and says, ‘I’m nervous my
child can’t hear me.’ That should trigger an evaluation,” he said.
A parent partner experienced with hearing loss was added during the project’s second
phase. Practices found the parent was particularly helpful for families dealing with
hearing loss for the first time.
“We never thought to engage a parent who had been through a similar situation,” Dr.
Abernathy said. “I don’t know the emotions and fears parents face. I can’t give what
a parent who has a child with a hearing loss can give.”