4 Number of Hospitals Doing Universal Newborn Hearing Screening Number of Programs
5 Status of Universal Newborn Hearing Screening 3Status of Universal Newborn Hearing Screeningin the United States.Percentage of BirthsScreened.90%+%%1 - 20%
6 Conventional ABR 2 Newborn Hearing Screening Prior to 1990 !Too expensive
7 Newborn Hearing Screening Prior to 1990 2Conventional ABR!Too expensive2High-Risk Indicators!50% of children with congenital hearing losses donot exhibit any high-risk indicators!Only about 1/2 of those who have a high-riskindicator make an appointment for further testingand only 1/2 of those are ever tested
8 How Many Hearing Impaired* Children were at High Risk as Infants? 49%Feinmesser et al. (1982)54%Pappas & Schaibly (1984)48%Elssmann et al. (1987)43%Watkin et al. (1991)50%Mauk et al. (1991)50100* Limited to children with permanent bilateral hearing loss>50 dB
9 Newborn Hearing Screening Prior to 1990 2Conventional ABR!Too expensive2High-Risk Indicators!50% of children with congenital hearing losses do not exhibit anyhigh-risk indicators!Only about 1/2 of those who have a high-risk indicator make anappointment for further testing and only 1/2 of those are ever tested2Home-Based Behavioral ScreeningPrograms!Requires very expensive infrastructure!Not as successful as widely believed
10 Percentage of Children with Permanent Hearing Loss Identified by the Infant Distraction TestPerformed at 8 Months of Age5040302010Severe/ProfoundMild/ModerateBilateralBilateralUnilateral(n = 39)(n = 72)(n = 60)Watkin, P. M., Baldwin, M., & Laoide, S. (1990). Parental suspicion and identification of hearing impairment.Archives of Disease in Childhood,65,
11 Newborn Hearing Screening 1990-1993 ,Healthy People 2000 Goals,Effectiveness of Automated ABR demonstrated,RIHAP and others demonstrate the effectiveness ofTEOAE-based universal newborn hearing screening,NIH Consensus Conference in March 1993
12 NIH Consensus Panel The consensus panel concluded that all Early Identification of Hearing Impairment in Infants and Young ChildrenMarch, 1993The consensus panel concluded that allinfants should be screened for hearingimpairment...this will be accomplished mostefficiently by screening prior to dischargefrom the well-baby nursery. Infants who fail... should have a comprehensive hearingevaluation no later than 6 months of age.
13 Comprehensive Hearing NIH Recommended Screening ProtocolOAE Screening PriorABRComprehensive HearingEvaluation Before 6Months of Ageto HospitalFailScreeningFailDischarge
14 Statements Endorsing Early Detection of Hearing Loss The Department of Education, in collaboration with the Department of Health andHuman Services, should issue federal guidelines to assist states in implementingimproved [hearing] screening procedures for each live birth.Commission on Education of the Deaf, 1988Reduce the average age at which children with significant hearing impairment areidentified to no more than 12 months.Healthy People 2000 Report, 1990All hearing impaired infants should be identified and treatment initiated by 6 months ofage. In order to achieve this ... the consensus panel recommends screening ofallnewborns ... for hearing impairment prior to hospital discharge.NIH Consensus Statement, 1993The 1994 [JCIH] Position Statement endorses the goal of universal detection of infantswith hearing loss ... [and] recommends the option of evaluating infants beforedischarge from the newborn nursery.Joint Committee on Infant Hearing, 1994Universal detection of infant hearing loss requires universal screening of all infants.American Academy of Pediatrics, 1998
15 Good work, but I think we might need just a little more Implementing Universal Newborn Hearing Screening ProgramsoutThen amiracleoccursStartGood work,but I think we mightneed just a little moredetail right here.
17 Issues to be Considered In Deciding Whether Universal Newborn Hearing Screening Should Be theMethod of Choice in Detecting Hearing Loss?I.Prevalence of Congenital Hearing LossII.Consequences of Neonatal Hearing LossIII.Effects of Earlier Versus Later Identification and InterventionIV.Accuracy of Newborn Hearing Screening MethodsV.Efficiency of Existing Early Detection ProgramsVI.Costs of Newborn Hearing ScreeningVII.Has Hospital-based Hearing Screening Become the Standard ofCare?
18 Reported Prevalence Rates of Bilateral Permanent Childhood Hearing Loss (PCHL) in Population-based Studies4.03.5123.02.58Prevalence per 1,0002.0931.54751.021110.51620253035404550556065dB Threshold Level (loss criterion)1. Barr (1980), n = 65,0007. Parving (1985), n = 82,2652. Downs (1978), n = 10,7268. Sehlin et al. (1990), n = 63,4633. Feinmesser et al. (1986), n = 62,0009. Sorri & Rantakallio (1985), n = 11,7804. Fitzland (1985), n = 30,89010. Davis & Wood (1992), n = 29,3175. Kankkunen (1982), n = 31,28011. Fortnum et al. (1996), n = 552,5586. Martin (1982), n = 4,126,26812. Watkin et al. (1990), n = 51,250
19 Percentage of Sensorineural Hearing Losses Which Are Unilateral # of Hearing ImpairedAuthor (year) Children in Sample % UnilateralKinney (1953)130748%Brookhauser, Worthington182937%& Kelly (1991)Watkin, Baldwin, & Laoide (1990)17135%
20 II. Consequences of Neonatal Hearing Loss 2Severe/Profound PCHL Losses2Mild Bilateral and Unilateral PCHL Losses2Fluctuating Conductive Loss
21 Reading Comprehension Scores of Hearing and Deaf Students 10.0'9.0,Deaf'8.0'Hearing'7.0'6.0'Grade Equivalents5.0'4.0'3.0',,,,,,,2.0,,,,1.089101112131415161718Age in YearsSchildroth, A.N., & Karchmer, M.A. (1986).Deaf children in America. San Diego: College Hill Press.
22 Effects of Unilateral Hearing Loss Normal HearingUnilateral Hearing LossKeller & Bundy (1980)Math(n = 26; age = 12 yrs)LanguagePeterson (1981)Math(n = 48; age = 7.5 yrs)LanguageBess & Thorpe (1984)Social(n = 50; age = 10 yrs)MathBlair, Peterson & Viehweg (1985)(n = 16; age = 7.5 yrs)LanguageMathCulbertson & Gilbert (1986)(n = 50; age = 10 yrs)LanguageSocialAverage Results0th10th20th30th40th50th60thMath = 30th percentilePercentile RankLanguage = 25th percentileSocial = 32nd percentile
23 Effects of Mild Fluctuating Conductive Hearing Loss Teele, et al., 1990)194 children followed prospectively from 0-7 years.)Days child had otitis media between 0-3 years assessed during normal visits to physician.)Data on intellectual ability, school achievement, and language competency individuallymeasured at 7 years by "blind" diagnosticians.)Results for children with less than 30 days OME were compared to children with more than130 days adjusted for confounding variables.Effect Size forOutcome Measure Less vs. More OMEWISC-R Full Scale.62Metropolitan Achievement TestMath.48Reading.37Goldman Fristoe Articulation.43Teele, D.W., Klein, J.O., Chase, C., Menyuk, P., Rosner, B.A., and the Greater Boston Otitis media Study Group (1990).Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years.The Journalof Infectious Diseases,162,
24 III. Effects of Earlier Versus Later Identification and Intervention 2Prospective randomized trials have not been done.2Most existing evidence is weakened by:)potential for selection bias.)lack of long-term follow-up to assess "wash-out" effect.)small sample sizes.)subjective assessments of outcomes.
25 Yoshinaga-Itano, et al., 19966Compared language abilities of hearing-impaired children identifiedbefore 6 months of age (n = 46) with similar children identified after 6months of age (n = 63).6All children had bilateral hearing loss ranging from mild to profound,and normally-hearing parents.6Language abilities measured by parent report using the MinnesotaChild Development Inventory (expressive and comprehension scales)and the MacArthur Communicative Developmental Inventories(vocabulary).6Cross-sectional assessment with children categorized in 4 differentage groups.Yoshinaga-Itano, C., Sedey, A., Apuzzo, M., Carey, A., Day, D., & Coulter, D. (July 1996).The effect of earlyidentification on the development of deaf and hard-of-hearing infants and toddlers. Paper presented at theJoint Committee on Infant Hearing Meeting, Austin, TX.
26 Expressive Language Scores for Hearing Impaired Children Identified Before and After 6 Months of Age353025Language Age in Months201510Identified BEFORE 6 Months5Identified AFTER 6 Months13-18 mos19-24 mos25-30 mos31-36 mos(n = 15/8)(n = 12/16)(n = 11/20)(n = 8/19)Chronological Age in Months
27 Vocabulary Size for Hearing Impaired Children Identified Before and After 6 Months of Age300250200Vocabulary Size150100Identified BEFORE 6 Months50Identified AFTER 6 Months13-18 mos19-24 mos25-30 mos31-36 mos(n = 15/8)(n = 12/16)(n = 11/20)(n = 8/19)Chronological Age in Months
28 Watkins, 19876Comparisons made among 3 groups of bilaterally hearing-impairedchildren (n = 23 in each group)Group #1:Received average of 9 months home interventionbefore30months age, followed by preschool intervention.Group #2:Attended preschool beginning at an average of 36 months.Group #3:Received no home intervention and no preschool intervention.6Children matched on hearing severity (PTA ~ 85 dBHL), presence ofother handicaps, and analysis of covariance used to adjust for age atpost test, age of mother, SES, and number of childhood middle earinfections.6Data collected by uninformed, trained examiners when children were 10years old.Watkins, S. (1987). Long term effects of home intervention with hearing-impaired children.American Annals of the Deaf,132,Watkins, S. (1983).Final Report: work scope of the Early Intervention Research Institute, Logan, Utah: Utah StateUniversity.
29 Effects of Earlier Intervention (Watkins, 1989)ReadMathVocabularyNo EI or PreschoolArticulationChildrens Developmental OutcomesPreschoolIs UnderstoodEI<9 mos +PreschoolUnderstandsSocialBehavior20406080100Percentile Scores
30 Boys Town National Research Hospital Study of Earlier vs. Later )129 deaf and hard-of-hearing children assessed 2x each year.)Assessments done by trained diagnostician as normal part of early intervention program.6Identified <6 mos (n = 25)5Identified >6 mos (n = 104)4Language Age (yrs)322.214.171.124.126.96.36.199.24.8Age (yrs)Moeller, M.P. (1997).Personal communication,
31 IV. Accuracy of Newborn Hearing Screening Methods ,How many children with hearing loss are identified?,How many children with hearing loss are missed?
32 Sensitivity of Various UNHS Techniques )Although various rates of sensitivity are reported, there areno studies of UNHS with sufficient sample sizes todefinitively establish sensitivity for any of the techniques.)Weakness with existing studies of "sensitivity"2Small sample sizes.2One screening technique compared to another screeningtechnique (e.g., OAE vs. ABR).2All screening passes are not followed.2Samples include only high-risk babies.
33 Accuracy of ABR for Newborn Hearing Screening Hyde, Riko, and Malizia (1990))713 at-risk infants screened with ABR prior to hospital discharge.)Children evaluated by "blind" examiners at mean of 3.9 years of age (range 3-8years).)Results based on 1367 ears with reliable ABR and pure tone thresholds.Hearing StatusHearing StatusImpairedNormalImpairedNormal4457Refer45125ReferABR Screen (40ABR ScreendBHL)(30 dBHL)112651197PassPassSensitivity = 98%Sensitivity = 100%Specificity = 96%Specificity = 91%Hyde, M.L., Riko, K., & Malizia, K. (1990). Audiometric accuracy of the click ABR in infants at risk for hearing loss.J Am Acad Audiol,1,
34 Accuracy of ABR for UNHS Saint Barnabus Medical Center, NJ)15,749 infants born from 1/1/93 to 12/31/95 screened with Nicolet CompassABR system without sedation.)Normal care nursery babies screened at 35 dB HL; NICU and High Riskscreened at 40 dB HL and 70 dB HL.)Screening done by audiologists, usually within 24 hours of birth.)Babies with a High Risk Indicator who passed initial screen werere-evaluated at 6 months.# and %# and %PCHL # andBirthsScreenedReferredPrevalence16,22915.74948552(97%)(3.1%)3.3/1000Barsky-Firkser, L., & Sun, S. (1997). Universal newborn hearing screenings: A three year experience.Pediatrics,99(6), 1-5.
35 What Percentage of Hearing Impaired Children were High Risk as Infants?49%Feinmesser et al. (1982)54%Pappas & Schaibly (1984)48%Elssmann et al. (1987)43%Watkin et al. (1991)50%Mauk et al. (1991)50%Mehl & Thomson (1998)0%50%100%
36 Accuracy of High Risk Based UNHS Programs Mahoney and Eichwald (1987)2Program operational from2JCIH indicators incorporated into legally required birth certificate.2Computerized mailing and follow-up, and free diagnostic assessments at regionaloffices and/or mobile van.2Program now discontinued because:)parents only made appointments for about 1/2 the children who had a riskindicator.)only about 1/2 of the children with an appointment showed up.)of difficulty obtaining accurate information from hospitals for some riskindicators.Mahoney, T.M., & Eichwald, J.G. (1987). The ups and "downs" of high-risk hearing screening: The Utah statewide program.Seminars in Hearing,8(2),
37 Results of Birth Certificate Based High Risk Registry to Identify Hearing Loss in Utah ( )Births, 283,298Live Births with HighRisk Indicators24,082 (8.5%)Parent ResponseNo Response12,699 (52.7%)11,383 (47.3%)Appointments forNo ConcernDiagnostic Evaluation5,254 (41.4%)7,445 (58.6%)Diagnostic EvaluationBrokenCompletedAppointments5,644 (75.8%)1,801 (24.2%)Summary:23.4% of live births with high-risk indicators completed a diagnostic evaluation;.36 SNHL per 1000 identified.Mahoney, T.M., & Eichwald, J.G. (1987). The ups and "downs" of high-risk hearing screening: The Utah statewideprogram.Seminars in Hearing,8(2),
38 Accuracy of Home-Based Behavioral Screening Watkin, Baldwin and Laoide, 1990*)Retrospective analysis of 171 hearing impaired children to determine howthey were identified.)Hearing loss first noticed by:Home visitor or Other than ParentSchool Screening Parent (e.g., teacher, doctor, etc.)Severe/profound181011Bilateral (n = 39)(46%)(26%)(28%)Mild/Moderate51147Bilateral (n = 72)(71%)(19%)(10%)Unilateral34188(57%)(30%)(13%)*Parental suspicion and identification of hearing impairment.Archives of Disease in Childhood,65,
39 Percentage of Hearing Impaired Children in Watkin, et al. (1990) Identified by Home Screening at 7-9 Monthsof Age5040302010Severe/ProfoundMild/ModerateBilateralBilateralUnilateral(n = 39)(n = 72)(n = 60)
40 Newborn Hearing Screening Accuracy of OAE-BasedNewborn Hearing ScreeningPlinkert et al. (1990)Sample:95 ears of high-risk infantsComparison:TEOAE vs. ABR (>30 mean age = 9 weeks)Results:TEOAE compared to ABR: sensitivity = 90%;specificity = 91%Plinkert, P.K., Sesterhenn, G., Arold, R., & Zenner, H.P. (1990). Evaluation of otoacoustic emissions in high-risk infants byusing an easy and rapid objective auditory screening method.European Archives of Otorhinolaryngology,247,
41 Kennedy et al. (1991) Sample: 370 infants (223 NICU, 61 normal nursery with riskfactors, and 86 normal lnursery with no risk factorsComparison:TEOAE, ABR (>35 dB), and Automated ABR (>35 dB)all at 1 month vs. behaviorally confirmed hearingloss, mean age = 8 monthsResults:TEOAE identified same 3 infants with sensorineuralhearing loss as ABR and automated ABRKennedy, C.R., Kimm, L., Dees, D.C., Evans, P.I.P., Hunter, M., Lenton, S., & Thornton, R.D. (1991). Otoacoustic emissionsand auditory brainstem responses in the newborn.Archives of Disease in Childhood,66,
42 Rhode Island Hearing Assessment Project (RIHAP) 1850 infants (normal and special care) screened prior to hospital discharge with TEOAE and ABR)Referrals for either TEOAE or ABR were rescreened at 3-6 weeks and referred for diagnosis asnecessaryFail TEOAEFail ABRNICUHigh-RiskFailed test, Present in NICU, Risk Factor PresentPassed Test, Not in NICU, Risk Factors AbsentWhite, K.R., & Behrens, T.R. (Editors) (1993). The Rhode island Hearing Assessment Project: Implicationsfor universal newborn hearing screening.Seminars in Hearing,14(1).
43 11 79 1643 Accuracy of TEOAE 2-Stage Screen* RIHAP Screen Sensorineural LossHearing StatusImpairedNormal1179ReferRIHAPScreen1643Pass"Sensitivity" = 100%"Specificity" = 95%*Note: Analysis is based on heads. Infants initially screened but lost to follow-upor rescreen because of parent refusal, lost contact, or repeated brokenappointments (> 3) are not included.White, K.R., Vohr, B.R., Maxon, A.B., Behrens, T.R., McPherson, M.G., & Mauk, G.W. (1994). Screening allnewborns for hearing loss using transient evoked otoacoustic emissions.International Journal of PediatricOtorhinolaryngology,29,
45 Accuracy of Automated ABR (continued)Von Wedel, Schauseil-Zipf andHermann et al. (1995)Doring (1988) (100 ears)(304 ears)Conventional ABRConventional ABRReferPassReferPass84426ReferReferALGO IALGO I286256PassPassSensitivity = 80%Sensitivity = 98%Specificity = 96%Specificity = 100%
46 Accuracy of Automated ABR Summary of 4 Studies (1187 ears)Conventional ABRReferPass10138ReferALGO I21046PassSensitivity = 96%Specificity = 98%Herrmann, B.S., Thornton, A.R., & Joseph, J.M. (1995). Automated infant hearing screening using the ABR: Developmentand validation.American Journal of Audiology,4(2), 6-14.
47 NIH Study: Identification of Neonatal Hearing Impairment Multi-Center Study Based at University of Washington2Null Hypothesis: ABR, TEOAE, and DPOAE are equally effective for newborn hearingscreening.27178 infants (4510 NICU and 2668 normal nursery) screened prior to discharge withABR, TEOAE, and DPOAE in random order.2Screening results will be compared with ear specific VRA at 8-12 months.*2Other issues investigated:!Influence of co-existing medical factors on characteristics of OAE and ABR.!Optimum stimulus and recording parameters for OAE.!Time and cost-efficiency of ABR and OAE.!Influence of external and middle ear status, test environment, and testercharacteristics.Data collection completed October, 1997; data expected to be reported April 1998.
48 V. Efficiency of Existing UNHS Programs 2Coverage and Referral Rates2Effects on Parents2Follow-up
49 Births Per Year, Percent of Babies Screened, and Reported Referral Rates of Universal NewbornHearing Screening ProgramsPercent BabiesReported Pass# ofAverage BirthsScreened BeforeRate atHospitalsPer yearDischargeDischargeaOAE-Based Programs64214094.991.6%b56134896.296.0%ABR-Based Programs120176795.593.7%All Programsa55 of 64 OAE-based programs were TEOAE, 9 were DPOAEb54 of 56 ABR-based programs were automated ABRWhite, K.R., Mauk, G.W., Culpepper, N. B., & Weirather, Y. (1997). Newborn hearing screening in the United States:Is it becoming the standard of care? In L. Spivak (Ed.),Neonatal hearing screening. Thieme: New York.
50 Possible Adverse Effects for Parents of Various Hearing Screening Results)False-Positive2Adversely affect parent-child bonding (e.g., rejection or over-protection).2Anger, resentment, or confusion when child is confirmed normal.2Lingering concerns about whether child's hearing is normal.)False Negative2Inappropriate confidence that child hears normally, thus delayingidentification.)True Positive2Emotional stress during time of emerging parent-child relationship.2Incomplete or inaccurate information may be used to make futurereproductive decisions.Adapted from Clayton, E.W. (1992). Screening and treatment of newborns.Houston Law Review,29(1),
51 Parents’ Perceptions of Screening Questionnaires administered by nurses to 169 babies born between 6/1/94 and 7/15/94.Question% Answering YesIf you were in a hospital where you had to give your98%permission to have your baby's hearing screened,would you give it?If this screening were conducted for a fee of71%approximately $30, would you be willing to pay it?Do you believe that any anxiety caused by your baby88%not passing the hearing screening would beoutweighed by the benefits of early detection if ahearing loss was found to be present?Barringer, D.G., & Mauk, G.W. (1997). Survey of parents' perceptions regarding hospital-based newborn hearingscreening.Audiology Today,9(1),
52 Parents' Views About Newborn Hearing Screening Watkin, Beckman, and Baldwin, 19952208 parents of children with sensorineural hearing loss (average age ofchild = 12.3 years) answered written questionnaires.2None of the children participated in a newborn hearing screening program.)58% wished their child had been identified earlier.)Only those whose children's impairments were mild or whowere confirmed in the first 18 months of life were satisfied withthe age of confirmation.)89% preferred having a newborn hearing screening programinstead of what they had.Watkin, P.M., Beckman, A., & Baldwin, M. (1995). The views of parents of hearing impaired children on the need forneonatal hearing screening.British Journal of Audiology,29,
53 Hearing Loss Identified Parent's ReactionConstructiveGriefActionDenialDepressionAcknowledgmentAngerGuiltParentalAdjustmentParentalExpectationDisability ModelCultural Modelof Learningof LearningLanguage & Communication
54 "...the 'harm-benefit ratio' of not implementing a universal newborn hearing screening program isbetter documented than thealleged dangers of implementingsuch a program."White & Maxon, 1995, p. 208
55 VI. Cost Efficiency of Newborn Hearing Screening ,What does early detection and interventioncost?,Is protocol A morecost-effectivethan protocol B?,Is early hearing detection and interventioncost-beneficial?
56 Actual Costs of Operating a Universal Newborn Hearing Screening ProgramCostPersonnel$ 60,654Screening Technicians (avg. 103 hrs./week)Clerical (avg. 60 hrs./week)Audiologist (avg. 18 hrs./week)Coordinator (avg. 20 hrs./weekFringe Benefits(28% of Salaries)16,983Supplies, Telephone, Postage12,006Equipment5,575Hospital Overhead(24% of Salaries)14,557TOTAL COSTS$110,775Cost Per Infant Screened = $110, ,253 = $26.05:Maxon, A. B., White, K. R., Behrens, T. R., & Vohr, B. R. (1995) Referral rates and cost efficiency in a universal newbornhearing screening program using transient evoked otoacoustic emissions (TEOAE).Journal of the American Academyof Audiology,6,
57 CDC Cost Study (1997)2Multi-center pilot UNHS cost study using 6 hospitals (oneeach in CO, GA, LA, TN, UT, and VA).2Cost estimates based on self-report questionnaires with sitevisits to 4 of 6 sites.2Standardized estimates used for equipment and overheadcosts.Grosse, S. (September, 1997).The costs and benefits of universal newborn hearing screening. Paper presented to the JointCommittee on Infant Hearing, Alexandria, VA.
58 Results of CDC Cost Study 3 Hospitals3 HospitalsCost categoryusing TEOAEusing AABRStaff time$13.04$10.73Equipment0.912.63Supplies0.519.33Overhead3.493.34Total Cost$17.96$26.03(Range)($15-$22)($22-$30)Initial refer rate8%2%Screening minutes per child31.442.9Audiologist minutes per child17.05.4
59 Prevalence of Various "Screenable" Diseases Among Newborns 43.53Incidence of Disease2.521.510.5PermanentHearing LossPKUHypothyroidismSickle Cell3.0/1000.10/1000.25/1000.20/1000Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewidesystem of services for infants and toddlers with hearing disabilities.Seminars in Hearing, 14(1),
60 Cost of Identifying Infants with Various Diseases Using Current Screening Protocols in Rhode Island$50,000$40,000Cost Per Infant Identified (1990 Dollars)$30,000$20,000$10,000$0PermanentHearing LossPKUHypothyroidismSickle Cell($8,683)($40,960)($40,960)($40,960)Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewidesystem of services for infants and toddlers with hearing disabilities.Seminars in Hearing, 14(1),
61 Cost of Educating Children with Hearing Loss in Various Settings $40,000$35,000$30,000Annual Cost$25,000$20,000$15,000$10,000$5,000$0Regular ClassesSelf-Contained ClassesResidential Programs($3,383)($9,689)($35,780)Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon, P.R., Sia, C.C.J., & Blackwell, P.M. (1993). Implementing a statewidesystem of services for infants and toddlers with hearing disabilities.Seminars in Hearing, 14(1),
62 VII. Establishing a Standard of Care ,Expectations for a reasonable practitioner undersimilar circumstances,Guidelines and standards,Availability of technology
63 A physician ... impliedly represents that he possesses ... that reasonable degree of learning andskill ... ordinarily possessed by physicians in hislocality.... [It is the physician's] duty to usereasonable care and diligence in the exercise of hisskill and learning ... [he must] keep abreast of thetimes ... departure from approved methods andgeneral use, if it injures the patient, will render himliable.Pike v. Honsinger, 1898
64 Guidelines and Standards ,Healthy People 2000,NIH Consensus Conference,Joint Committee on Infant Hearing,Joint Commission on Accreditation of HealthOrganizations
65 STANDARD OF CARE ... when does a guideline become a standard? The answer is when an inexpensive and reliable devicecomes onto the market, the technology and conceptof which have already been adopted by a groupwho specialize in the concept ... A guidelinebecomes a standard of care when the device behindthe guideline is available and readily usable as apractical matter by members of other medicalspecialities who have cause and reason to considerits use.Wm H. Ginsburg, Jr.,Annals of EmergencyMedicine, 1993,22,
66 What are the Objections to Hospital-based Universal Newborn Hearing Screening?,It's too hard to do it in the newborn nursery.,It's too expensive / Insurance won't pay for it.,Pediatricians can do it easier as a part of well-babycare.,There's no evidence that earlier is better.,It's not mandated.