ROUGH EDITED COPY

EHDI CONFERENCE

Newborn Hearing Screening in a "BabyFriendly" Environment

3:00 P.M. 3:30 P.M. (ET)

FEBRUARY 28, 2017

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CART CAPTIONING PROVIDED BY:

ALTERNATIVE COMMUNICATION SERVICES, INC.

P.O. BOX 278

LOMBARD, IL 60148

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This is being provided in a roughdraft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.

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>MS. WALKER: Good afternoon, everybody. How is the volume?

Volume good? Okay. Great.

My name is Kristin walker.

My name is Kristin Walker and am an administrator with newborn hearing screening programs with onsite neonatal and my colleague is Kathy Aveni, she's a research scientist with the New Jersey Department of Health, and Linda Biando is a public health consultant with the New Jersey Department of Health, and we're here to talk to you about the importance of newborn hearing screening in a baby friendly environment from the perspective of the hearing screeners, program coordinators and the parents.

So first let's talk about what baby friendly is. Hospitals with a "BabyFriendly" designation promote breast feeding and mother/infant bonding and the "BabyFriendly" initiative is global in scale. And it was started in 1991 by the World Health Association, and UNICEF, and it encourages and recommends hospitals that offer an optimal level of care for infant feeding and mother, baby bonding and for hospitals that abide by certain criteria, or what they call the ten steps to successful breastfeeding, and these includes among other things, helping moms to initiate breastfeeding in the first hour after birth, encouraging breastfeeding on demand, and practicing rooming in. So allowing mothers and infants to remain together, at least 23, if not 24 hours a day during their hospital stay.

As a result of that particular step, most examinations and procedures are done in the mother's room. And these steps are thought to crow feeding cues for new moms, promote longer feeds, and generally get the mother baby pairs off to a nice successful start with their breastfeeding.

The ten steps are endorsed by and promoted by most of the major maternal and childhood health authorities in the U.S. So organizations like the American Academy of Nurses, pediatricians, the American Colleges of Nurse Midwives and OB/Gyn's, WIC, the U.S. Surgeon General, and the CDC.

In 2007 about 3% of all U.S. births occurred in "BabyFriendly" designated facilities and the healthy people 2020 goal for "BabyFriendly" is about 8%. So if you weren't familiar with what "BabyFriendly" is, when you walk through the door I expect you're going to hear a lot more about it in the coming months and years.

As we began to see a shift toward hearing screening in the mother's room as a result of the baby friendly practices, we had a few questions. Since newborn hearing screening traditionally has been performed in a specialized area or in the nursery, how does baby friendly impact newborn hearing screening? And what do parents think about having the hearing screens in the rooms with them? And what are the newborn hearing screeners views and how are they adapting to this new change?

We also wanted feedback from program leaders, and we wanted to identify challenges and technical issues that can potentially occur and benefits associated with inroom hearing screening. And lastly we hope to understand some troubleshooting methods and helpful hints for screening in baby hospitals friendly hospitals.

So let's talk about who we are. We're all three based in New Jersey, and there's a little map there so you can get yourselves get your bearings geographically. In New Jersey there are a total of 49 hospitals with maternity services, and as of this spring of 2016, 11 of them had been designated as "BabyFriendly", and another 20 were in the process or on the path, as they say of working towards "BabyFriendly" designation.

It usually takes a couple of years to move through that path.

Now it's important to note that there's a spectrum of adherence to the rooming in feature of baby friendly, and on the one end of the spectrum there's no separation of the mother/if not pair at all. There's no nursery set up. There's no space for a nursery in some hospitals that have "BabyFriendly" and on the other end of the spectrum there's more flexibility for procedures and examinations to be done in the nursery or outside of the mother's room during that onehour out of the 24 when the pair can be separated as per "BabyFriendly" guidelines.

But it's safe to say that most of the time in "BabyFriendly" hospitals the hearing screen process is moved to the mother's room.

So to find out the answers to our questions, we questioned a newborn hearing screeners in the state of North Carolina by sending out a link to a brief five or tenminion line survey via Survey Monkey, and we did the same thing with the newborn hearing screening program cord natures at the hospitals providing maternity services, and then we provided a short paper questionnaire, a hard copy, five question survey to the parents of newborns at one particular hospital in New Jersey over the course of two weeks. We chose this hospital because they transition to "BabyFriendly" about six months prior to our survey start, and they had a clear delineation of their location of their screens before they went "BabyFriendly" and after.

They also have a good number of deliveries so we hoped that we could capture a good number of parents for the survey, and then they also have two dedicated hearing screeners that screen every single baby, and they're both very experienced and have been with the hospital for about eight years, so we were looking for consistency and less variability in terms of the screeners and their skills, and the definite demarcation of the screen location before and after.

And we didn't include any parents of babies that were in the NICU.

Just the well kids.

We also wanted to compare noise levels, and so we had one of the screeners measure the decibel level with a Smartphone application in both the mother's rooms when she was screening, and also in the former location where screens used to take place, which is in a room adjacent to the nursery. So in looking at who responded to the survey, the 33 hearing screeners who responded, and you'll see them on the right side of the screen were more likely to perform hearing screens in the mother's room more than 75% of the time, and that's that green bar.

However, of the 23 coordinators who responded only 40% led programs where the hearing screens primarily in the mom's rooms, and another half represented screens less than 50% in the room or never. And the remainder were somewhere in between 50 and 75% of the screens done in the rooms.

The coordinator responses roughly correspond to the number of hospitals in New Jersey that are either already "BabyFriendly" or on the path z in looking at who the responders were professionally. It was an even split between audiologist coordinators, nurses and physicians and those who fell into an other category. They were mostly administrative in administrative roles.

So on the left you see the breakdown for all New Jersey hospital coordinators and on the right you see the respondents. We had a relatively low response from the nurse and physician coordinators overall. Not 100% why, but we think it may have to do with the fact that they have multiple and varied tasks that they perform as part of their roles and they're just busy.

When we look at the benefits of screening in the mom's rooms, improved communication what parents was at the top of both the coordinators, and screeners list, and they were also likely to include parent benefits, and more time for education and the parents enjoying the process along with involving the parents with assisting the screen, and this makes sense, you know, as you know like the program coordinators they work directly with the parents every day, and they're really connected to their parent experience.

Interestingly 21% of the coordinators saw no benefits to screening at the bedside as compared to only 3% of the hearing screeners. Again, you know, probably due to the fact that they have direct knowledge and experience with the process.

When we looked at the perceived issues with screening at the bedside, at the top of the list were noise and various interruptions. For both the screeners and the coordinators, and there were a slew of people, as you can imagine who potentially entered the room during the hearing screen, so visitors, nurses, photographers, OB's, pediatricians, lactation consultants, the dietary team, and then sometimes the parents themselves created interruptions of the screens.

About half of the screeners and coordinators considered parent worries and anxiety about the hearing screen results to be an issue as well with inroom screening especially if the screen duration was lengthy. Only 3% of the screeners and 13% of the coordinators thought it was absolutely smooth sailing with no perceived issues. And, you know, clearly there's less control the in the hearing screening environment if they're done in the mom's room. You know, you never know what you're going to walk into and it takes a lot more effort to create an atmosphere conducive to hearing screen.

Kathy is our data guru, so I'm going to hand it over.

>MS. AVENI: As she said I'm the research scientist which means I'm the data geek for the EHDI program and my job in this was just to kind of throw together a few more numbers and graphs for you to look at.

And one of the things we realized as we looked at the results of the survey that we regretted is we asked about benefits of screening in the room, and problems with screening in the room. You just saw that. We didn't get a general measure of overall do you think it's a good idea or bad idea. So I tried to calculate that just based on of all the benefits we listed, you know, did you check off all of the boxes? And none of the problems or did you check off all of the benefits and problem of the benefits so there's an overall perception calculation that I'll get to that's really what percentage of the positive things did you check and which percentage of the negative things did you check, and I subtracted one from the other, so a value of zero would mean you're neutral and a positive value is you had more benefits checked off.

And we looked for the at the coordinator responses and, again, Kristin showed you the breakout of different provider types and what we did see is the audiologists were much more likely to check off the problems and overall have a more negative perception of screening in the room whereas, the nurse respondents and physician respondents more often had a positive response with the administrative folks somewhere in the middle.

And this was not surprising to us. We realize that audiologists are a little more used to being having their their patients that their screening in a very controlled environment, in a booth, and it can minimize those sounds and those noises so we thought it might be a little more anxiety producing for audiologists to think about having to be in an noisy room and uncontrolled environment, and that's pretty much what we saw.

We also looked at the screener responses, and we did not ask the screeners what their provider type was. We did ask them about how long they'd been screening, how long they'd been screening in the room. We thought those things might be relevant. The responses were really all over the place, so there really wasn't anything notable in those.

And we looked at the experience level. Hearing screeners, and we defined this as the number of years performing newborn hearing screens.

The more experienced screeners were more likely to do hearing screens in the mom's room. So on the left you have the less experienced screeners and on the right you have the more experienced screeners with three or four years of having done hearing screens.

And, you know, it makes sense, perhaps, as a hearing screeners became more comfortable with the equipment and troubleshooting equipment issues and dealing with a tiny fragile newborn in front of anxious, and vulnerable parents it gets easier the more times that you do that.

So we also asked the hearing screeners who worked in hospitals where the screens are done primarily in the rooms why they would why hearing screen might be done elsewhere. And parent unavailability to care for the infant because mom was in surgery or had other medical issues as well as parent request for both factors, batching of newborn care while in the nursery is another. Some hospitals maybe the most out of that one hour out of the 24 do as much infant care as possible so that might include the routine daily assessment, the circumcision, the heel stick metabolic screen and the hearing screen.

Screeners may also make the decision to take the baby elsewhere if there's just too much going on in the room. So, for example, one screener told me that after being in the room with a sibling of the newborn who was a toddlers roaming around after the toddlers yanked the cord out of the machine not once, but twice he made the decision to move back to the nursery and do the screen there.

Having said that I've also heard maternal child health administrators say that in that kind of a situation, it would be the family and/or visitors and/or other children who would need to relocate, not the baby. So there is a little bit of, you know, difference of opinion from one hospital to the next in terms of how of how to handle those situations.

Also, some screeners come in very early in the morning to do the hearing screens to avoid conflict with other providers who need to access the baby. The pediatricians and the lab personnel, for example. So in order not to wake the moms, they may do the hearing screens in the nursery. And then roommates. Many hospitals have private rooms now so that may be less of an issue, but when there are roommates, of course, you increase the potential for noises and visitors and other interruptions.