Meanwhile, in Denmark, the audiologic community had been discussing the implementation of UNHS since the early 1990s – the obstacles have been many, and include the scarcity of funds, the absence of political backing and the shortage of qualified staff.
An ironic situation for a country, which has been a trailblazer in the fields of audiology, hearing aid technology and otology for more than half a century.
While less than satisfactory, at least the stalemate gave the hospitals and other stakeholders the op-portunity to plan thoroughly for implementation – and to learn from the mistakes made elsewhere.
The green light comes at last
Finally, in the last quarter of 2003, funds were allocated in the national budget for 2004 towards a two-year pilot screening project. By the Spring of 2004, the Ministry of Health and the Association of County Councils had reached agreement on who was to do what, and how the program was to be financed.
The National Board of Health (Sundhedsstyrelsen) then began work on how best to organize and implement the screening project. A working group under the Board of Health was appointed, which included heads of hospital audiology and pediatric departments as well as a senior midwife, planners and other technical experts. They were given the task of putting together comprehensive guidelines covering:
- screening protocols
- screening technology
- organization
- training
- information materials
- data processing
- evaluation
The Guidelines were published on August 12, 2004, and the green light was given for the long-awaited program to start on September 1 and to run until September 1, 2006, when the program is to be evaluated.
National Board of Health guidelines
The guidelines were introduced with the information that about 65,000 babies are born in Denmark p.a. Of these, about 100 or 1.5 per thousand have a bilateral hearing loss (defined as in excess of 30 dB HL). A further 150 babies have a unilateral hearing loss.
The guidelines recognized that, in the past, neither screening of high-risk babies nor the widespread use of the BOEL test have proved satisfactory. The importance of early identification and intervention was likewise acknowledged.
Another factor that is described is the recent development of “reliable, hand-held devices that can be used for screening large populations. These devices can be operated by personnel without special healthcare qualifications, just a short period of training.”
The choice of screening methods was limited to TEOAE (Transient Evoked Otoacoustic emissions) and AABR (Automated Auditory Brainstem Response).
Overall goals:
- to identify for early intervention babies with uni- or bilateral hearing impairment greater than 30 dB
- to ensure that the screening process is concluded no later than 30 days after birth (or 30 days after discharge from NICU)
- to screen a minimum of 80% of all newborns in the first year and 90% in the second year of the program
- to conclude diagnostics by 3 months of age and begin hearing aid fitting
In Denmark, all babies are screened for PKU (1) (phenylketonuria) between the 4th and 10th day after birth. This screening is routinely carried out by biomedical analysts (2), midwives, and in some few cases, by nurses – and involves collection of a blood sample by pricking the baby’s heel. It was decided that hearing screening was to be carried out at the same time – and by the same personnel. And that the personnel were to be thoroughly trained in all aspects of screening.
It was also determined that screening was to be performed in quiet premises adapted specifically for this purpose, and by a minimum of personnel to ensure high quality and a minimum of referrals. The local audiological department was to be responsible for:
- training and retraining of screening personnel
- supervision of personnel by means of regular meetings
- uniform information to parents
- quality assurance
- maintenance of equipment
- re-screening in case of referral
- diagnostic follow-up
Re-screening is to take place as quickly as possible, and within 2 weeks. Subsequent remedial intervention in case of identified hearing impairment is to be done by audiological departments with prior experience in treatment of infants.
The screening protocol can be summarized in the following diagram:
Organized under counties
From the beginning, it had been agreed that the program would be organized under the individual counties of Denmark. Consequently, while the work on establishing the guidelines was nationwide, planning for implementation was carried out at a more local level. Key decisions were made at the beginning of this process specifying the test methods to be used and defining the time and place of screening.
This case story focuses on the counties of Copenhagen and Frederiksborg, and the municipalities of Copenhagen and Frederiksberg (which both have the status of counties and their own hospital association, H:S).
Intensive preparation
During the summer of 2004, a very productive collaboration came into existence between key personnel at the hospitals of Hilleroed, Bispebjerg, Gentofte, Frederiksberg and Hvidovre.
This collaboration bore fruit especially with regard to development of a training program and information materials, choice of technology and data processing.
When financing came on-stream from September 1, plans were already in place for training personnel, purchasing equipment, hiring new personnel, and writing and printing information pamphlets for parents.
The first classes of screeners were trained over the winter and actual screening started in January and February, 2005.
Notes:
1) PKU is an inherited
disorder of body chemistry that, if untreated, causes mental retardation. Fortunately, through routine
newborn screening, almost all affected newborns are now diagnosed and treated early, allowing them to
grow up with normal intelligence.
2) Relatively new name for hospital laboratory technicians