With more than 6,000 births each year, Hvidovre Hospital is the primary location for baby screening in Copenhagen. It also has a sizeable staff of biomedical analysts and its consulting pediatrician, Dr. Klaus Boerch, has played a pivotal role in the startup phase of UNHS in Denmark.
To efficiently manage the hearing/PKU screening of an average of 32 babies per day, 10 biomedical analysts went on a 5-day training course and perform screening duty once a week, two at a time.
Kirsten Marie (KM), what’s your background, and how did you join the program here at Hvidovre?
KM ”I’m a biomedical analyst and work here in our out-patient department. And since hearing screening has been combined with blood testing and the PKU test, it’s a job for biomedical analysts. Consequently, it was decided that those volunteering would be trained to perform this function. And I did.”
More than 6000 births a year, that’s a lot of screenings to organize and track?
KM ”Yes, we plan for 32 screens a day at present. Each of our team of 10 screens one day a week on average because of Board of Health requirements for maintaining competence.”
That requires effective processing?
KM ”Yes, it has to run like clockwork. The babies are assigned times, they don’t just all come at 8 a.m., but have an appointment. Our schedule gives us time for lunch and breaks, with our last appointment at 2 p.m. So we’re cleared up and ready to leave by 3 p.m.
How do you feel about baby screening?
Is it fun or difficult? 
KM ”I consider this to be a really nice assignment! Of course, it’s very new for us – we’re not accustomed to giving parents results of a test, and it’s hard for us to tell parents that their baby needs further testing. You really have to think about how you’re going to explain to these possibly very nervous parents that we have to refer them to the Audiology department. But it is also very stimulating. I don’t think it’s difficult – it’s challenging.”
Challenging, but not difficult – and what about the parents?
KM ”There are many different types of parents. Some are well-prepared. They’ve thoroughly read through the material they were given during pregnancy and know how screening is done. Others have no idea what to expect, and have lots of questions. Some are nervous. So, from the minute they come in through the door, you have to assess them so that you can brief them appropriately.”
Are there any differences between mothers and fathers?
KM ”Well, remember that the baby is also having a blood test. Usually, the mother takes the baby into the room where they do that. On the other hand, it’s typically the father that takes the lead during the hearing screening – they’re interested in the technology. They’re also the ones who know what the baby’s ID number is.”
I’ve heard a story from another hospital where there was a father who wasn’t just content with an OAE, but also wanted an AABR – he’d obviously been reading up on the internet. Have you had any similar experiences?
KM ”Yes, we also get some who are very well-informed, and who ask lots of technical questions, some of which we can’t answer.”
Have you had to deal with any unexpected situations?
KM ”Yes, we’ve received some babies we shouldn’t have. For example, babies with handicaps, where we’ve had to explain to the parents that there’s been a mistake.”
If most of the babies you get are “well” babies, when do you test with AABR?
KM ”If the babies have spent more than 48 hours in the Neonatal ward and thus are “high-risk” babies, they are given both tests.”
M ”We also get the prematurely born infants.”
KM ”Yes, we perform AABR on them just before they are discharged.”
How easy or difficult is it to learn to use the AccuScreen?
KM ”I think it was very easy to learn, and easy to use. We attended a course where we were given thorough theoretical and practical training, including hands-on.”
How long a course was that?
KM ”It lasted five days. There was one whole day for practical training with the instrument. We also had some parents come in with newborn babies for us to practice on.”
M ”I was also on the course, but I don’t screen regularly. I also found AccuScreen very easy to learn to use. There are a few easy to navigate menus, and the language is easy to understand. The only negative thing is that the date is awkward to enter because it’s the other way round.” [yy/mm/dd whereas it’s dd/mm/yy in Denmark]]
What did your colleagues have to say about the training?
KM ”Well, in our profession we’re accustomed to using – and troubleshooting – complex equipment. So learning to use technology is part of our education, something we know we’re good at. Other kinds of personnel might have a different perspective. But then we’re also good at following instructions!
Is the manual good?
KM ”Yes. It’s 50-60 pages long, and we’ve chosen to install it on our PCs. I doubt it gets used much as most of us are experienced users. Which only goes to show how easy it is to use. Otherwise, we’d probably need to have it in hard copy. There’s nothing complicated about the device.”
I guess the AccuScreen is relatively simple technology compared with your other instrumentation?
M ”Yes. For us, the most difficult aspect of this assignment has been talking to the parents and informing them about the status of their baby’s hearing. It’s easy to give positive news, but there are always those we have to re-test or refer further up the system. In cases where we reckon the problem is some obstruction in the ear, we ask the parents to come back after a few days to repeat the test. If the parents seem very worried, we prefer to send them to Bispebjerg.”
[All babies to be re-screened are referred to the Audiological department at Bispebjerg Hospital]
KM ”As we have some fixed times at Bispebjerg, it’s often possible to send them straight away.”
Did you have any training in handling parents, psychology, etc., on your course?
KM ”Yes, we even had some role-playing. Including situations where the father is talking on his mobile and so on. It was a lot of fun, but sometimes things like that happen in real life. One becomes good at handling these situations, and helping parents how to deal with the screening.”
M ”It’s really a question of experience.”
Have you had any refers where the parents said that they didn’t want to be re-screened?
KM ”A few have not shown up for their appointments at Bispebjerg [for re-screening]. Some say that their baby hears OK, and they don’t need a hearing test. They just settle for the blood test. Fortunately, that’s only a handful.”
M ”I believe something like 93% accept the offer – and that’s a lot especially when you take into consideration that the target for the first year was 85%. So we’ve already reached the target for the second year.
You’ve both said that the user interface was easy. What about the actual screening?
M
”Well, if you’ve got a quiet baby, it’s quick and easy to perform OAE. AABR is a bit more sensitive.
Generally, it takes longer and it’s important that the baby is quiet throughout the procedure. One can
normally perform OAE even when the baby is a bit unsettled, but not with AABR, which is also sensitive
to electrical noise.
On occasion, we’ve had to switch off mobile phones and other electrical
devices.”
How long typically does an OAE measurement take?
KM ”From when the baby is ready for testing, it can take from 10 seconds to max. 5 minutes.”
And AABR?
KM ”If the baby is a little unsettled, it takes longer – maybe the parents have to go out so that the mother can feed the baby. The measurement itself usually takes about 30 seconds. Sometimes you don’t even get to look at the instrument before the result appears on the display.”
I guess you don’t have any problems keeping to 15 minutes per baby?
M ”Not on average. Otherwise, the whole day would slip. We’re almost always finished by the end of the working day. And we often get people coming without appointments whom we never turn away.”
KM ”But you can’t keep thinking about whether we’re behind schedule or not, because you’ll affect the parents. We project a very relaxed and settled environment, with a calm tempo. You can’t force the pace.”
M ”You see, the parents draw a number when they get here and then sit down and wait. No knocking on doors. It’s OK if they have to wait 10 minutes.”
How does the AccuScreen probe perform on a daily basis?
KM ”I can’t recall any problems with the probes. We conduct a probe test every morning, so the only thing we have to remember is to change the probe tip between each baby. The eartip itself is only used once.”
How about fitting the eartip into the baby’s ear?
KM ”That works very well. One quickly learns which size tip to use, even though one might need to use two different sizes on one baby’s ears. One soon gets to know all the variations in ear canal shape and size. At the beginning, it’s a case of learning by doing.”
M ”I haven’t come across any problems with it either.”
KM ”At the start, we were told we could expect that approximately 10% of screenings couldn’t be completed due to insufficient experience, i.e. until we had learned to use the equipment correctly. However, we soon found that the percentage of referrals was closer to 2-3%. We can conclude that the training was first-class, but we biomedical analysts have also been good at learning by doing. We have very few referrals, and many of them are genuine.”
You mentioned testing prematurely born infants. Isn’t it difficult to insert the probe into such a small ear canal?
KM ”No, only if there’s some kind of constriction – but I’ve never come across that.”
After screening more than 30 babies in one day, you must have a lot of data to process. How do you do that?
M ”At the end of the day, and according to the screening protocol, we transfer all test data to a database at Bispebjerg handled by Erik Kjaerboel. In addition, we have our own internal patient registration system in which we record the test result in each baby’s electronic journal. We use international codes for pass, refer or absent.”
How many AccuScreens do you have?
M ”Three. We use two at a time, with one as back-up. We use four rooms for testing and we swap them around regularly. We recharge batteries every day, and discharge them at the end of the day on Fridays.”
With less than 3% being referred to Bispebjerg, how is your relationship with them?
KM ”We have fixed times there so we can give parents an appointment on the spot. It’s nice for them to know that when they leave us. We write the baby’s ID number on a form, together with our observations about the screening, and we fax it to Bispebjerg so that they have all the details for their follow-up examination.”
Bispebjerg isn’t exactly busy, is it?
KM ”Bispebjerg does also have patients from other departments including Frederiksberg, and they have opened a new screening room especially for this program.”
Yes, I’ve seen it, it’s very attractive.
KM ”Yes, we’re green with envy!”
How would you assess the program now that it’s been running for 10 months?
M ”I think it’s gone well, and we’re all very satisfied with it.”
KM ”No doubt because it has gone very well!”
M ”Our expectations have been exceeded, especially when one is anticipating ”teething problems” as with anything new. I think that the success of the program can largely be explained by the fact that it is voluntary – the parents are coming of their own free will. And then the midwives, who have the first contact with the parents, have also been very positive.”
KM ”There’s still a lack of information in other languages for all those parents who don’t understand Danish sufficiently well, so we need some translations.”
In conclusion, do you have any data regarding how many babies have been screened here at Hvidovre so far – and how many have been referred?
M ”We have some old data from the screening seminar back in September: we had screened approximately 3,500 babies, or about half the total number of births we have a year. Of these, we had referred 53, equivalent to less than 2%.”
[According to Erik Kjaerboel’s status dated 20.09.05, the actual percentage of referrals is 1.5% out of a total of 4560 screened at both Frederiksberg and Hvidovre hospitals; three of which were found to have bilateral hearing loss and one with unilateral hearing loss.]
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