Guidelines for Hearing Screening in the School Setting

Referrals

Referral criteria in this manual may be used, but it is important to have a consensus of the medical and audiological professionals in the community, regarding what they consider the appropriate referral criteria. The medical professionals in your area providing further evaluation and assessment need to be aware of, and in agreement with, the district’s screening program, including the referral criteria. The nurse has the responsibility of follow-up of referred students. The nurse should notify the family of the results of the failed hearing screening and any other evaluations conducted, as well as, the need to obtain professional care. Ideally, a telephone call or personal visit to the parent should precede a written referral. This provides an opportunity to determine the parents’ understanding of the referral, to gather any pertinent information about prior history or outcome of previous referrals, and to determine whether the family has the information and resources to complete the referral.

The nurse or speech language pathologist should be prepared to explain the results of the screening and the importance of a thorough follow-up examination to the parent/guardian, or student, as appropriate. Parents should understand the extent of the examination needed, i.e., primary health care provider; ear, nose, and throat specialist; audiologist; or speech-language professional. The nurse should inform the parent that the screening was not conducted in a sound-treated environment and provide written information regarding the findings on any screening or evaluations done by school personnel. The referral form should communicate the findings of the screening, as well as any additional observations made in the school setting. The parent should expect that the health care provider might need to do an evaluation that is more comprehensive. The nurse should request a written report from the professional with the results of the examination and any recommendations for the school setting. Referrals should be on school district or school health services letterhead.

It is helpful to provide information about the appropriate services available in the area, the average cost of a visit, what to expect from the examination, etc. Families of students in managed health care programs may need to contact their health insurance plan for information on how to access the appropriate services, including treatment available to them.

Follow-Up

The nurse should develop a method of tracking the referrals made. It is not unreasonable to expect a response from the parent/guardian within a two-week period, demonstrating that the parent/guardian understands the referral and has made an appointment for the evaluation. The nurse should contact the parent/guardian periodically until he/she knows the disposition of the referral. Many times the parent/guardian is reluctant to say they cannot afford the cost of the evaluation. The nurse should be aware of community resources for those who need this financial assistance and offer this when indicated.

Tracking Referrals

Tracking logs should make note of the date of the referral, how and when the parent was contacted, the date of professional evaluation, and result of follow-up. This will allow for evaluation of the screening program for validity (identified children who have a hearing deficit), reliability (consistency of results of screening process), and yield (number of students identified with a problem). This would include inability to follow-up due to financial constraints (need to work on resources), parent inattention (need for more education about the screening program and the impact of hearing deficit on schoolwork), and lack of providers to complete the referral (need to develop assistance to get student to closest provider). It is important to identify the reasons for incomplete follow-up so the cause may be addressed.

Following an evaluation, the nurse has the responsibility to see that any recommendations made are implemented. Any child the nurse refers for a hearing evaluation needs to be put on a “watch list,” and monitored at least annually, to determine their status. Ideally, a repeat audiometric screening should be done two-to-four weeks after treatment. The nurse could perform this screening if the provider of the treatment does not.

Teacher Notification

The nurse should notify the child’s teacher(s) that the child has been referred for a possible hearing impairment. In addition to being alert to the possibility the child is having hearing difficulty, school personnel are often in a position to reinforce the need to follow through on the referral. It is important to monitor the child closely; documenting the nurse and teacher concerns for the effect the suspected hearing impairment is having on the child’s education. The school should communicate these concerns to the parent.

Watch List

School nurses should make note of students who would benefit from monitoring for hearing difficulty. Some of the reasons to include a student are:

• Family history of risk factors;
• History of frequent ear problems in infancy and preschool period;
• History of allergic responses affecting the ear, nose, and throat;
• History of academic failures, i.e., repeating grades;
• Enrolled in special education programs;
• Repeated concerns of teacher;
• Behavior that might be due to a transient problem with decreased hearing, i.e., allergies; and
• Students that consistently fail a frequency in the speech range but do not meet referral criteria.

The nurse would not necessarily generate a referral for evaluation, but could communicate the findings to parents and teachers, especially regarding any change in status.