Audiometric test referrals

Referral of some people to a specialist, or more likely in the first instance to a GP, will always be part of audiometry done in a workplace audiometric test screening programme.

Referrals generally come up in Category 3 and Category 4 cases. For me, how these are dealt with is a very important and useful tool for distinguishing between the good service providers who clearly have a bit of knowledge and are looking at each result individually, and those who are simply pressing a 'go' button, then saying little more than 'computer says fail, referral' if a Category 3 or Category 4 result comes up.

Unnecessary referral is not only a sign of shabby service and a screening technician who is frankly doing little more than a trained monkey could do, but it also causes the employer needlessly increased costs and the attendee pointless worry and wasted time.

Examples of cases where automatic referral is not required

  1. If someone has a medical history of known hearing loss. 
    Put so bluntly, it sounds like I am being deliberately obtuse here but I have come across companies who have a policy of always referring Category 3 cases whatever the presented history. If there is a known medical issue with the employee's hearing which the employee reports during the pre-testing questionnaire, and the result is consistent with what the employee would expect, then a referral is pointless and a waste of time.

    I have heard arguments saying you should still refer as you don't know what the previous diagnosis was and only have the employee's word on it. A screening technician is allowed to trust what an attendee reports so if they give a history of some losses or problems and the audiometry result is consistent with that, then you are allowed to take their word that this is normal for them.
     
  2. Marginal Category 3 or 4 with some blockage.
    Take a case of someone who has just tipped into a 'fail' by one or two results only, has wax in their ears and says they have no issues they are aware of (pain, etc.). This is an example of why the otoscopic visual check of the ears is so important as a build-up of wax can have enough of an impact on hearing to cause a Category 3 or 4. This does not mean the wax is so bad they have to go and get it syringed - it is perfectly normal for it to come and go. If the Category 3 or 4 is so marginal that one or two results would tip it back into a normal result, then hearing often changes by this much naturally every day so coupled with the wax a referral is over-kill. My advice in this situation, put them down for a re-test at some point and then see how it is going from there.  
     
  3. Marginal Category 4, a cold and no reported problems.
    I've seen plenty of cases in the past where a technician referred someone for a marginal Category 4 but where the attendee had a streaming cold at the time. Not all colds impact hearing so it's worth doing a test even if someone does have a cold, but if they do come in as a marginal Category 4 then a formal referral is overkill at this stage. Just schedule them for a repeat whenever the screening provider is next on-site and take it from there.
     
  4. Category 3 and a complex medical history.
    Ears are sensitive little beasties and can react badly to a wide range of drugs and treatments for other illnesses or medical conditions. If someone is taking drugs for another condition then the screening technician should be checking to see if these are potentially ototoxic (damaging to hearing) before making any referral decision. As an example, I came across one health screening company who had referred a lady for Category 3 hearing even though she was on a complex regime of treatments for advancing Multiple Sclerosis, where several of the drugs were ototoxic. She had been quite upset at the implied idea of losing her hearing as well as the MS, but follow ups with her GP had proved fine and the loss was down to the impact of the medication. A more appropriate response here would have been to recommend that when she was next with her GP for a review of her issues that a quick check of her hearing be asked for then. Informal, no drama and no panicking an already ill employee needlessly.
     
  5. Comparison to earlier audiograms is OK, just not the most recent one.
    Deep breath here as this one really annoys me as it is purely indicative of a lazy technician working for a lazy company doing a frankly crap job... In audiometry for workplace health screening, there is a time limit of how old an audiogram can be used for when doing the comparison calculations, which means if the audiogram is more than three years old it cannot be used for Category 4 calculation. Over the years I have seen cases where a person is tested and their result compared to the one three years ago and it is found to be lower, triggering a Category 4. BUT, if you look at audiograms going even further back, the new result is completely consistent with those, which means the result from three years ago is the odd result, not the new one. Yes, the older ones cannot be used for a calculation, but you can clearly see the current result is absolutely consistent with those. This is completely indicative of a testing technician not using their brain and being too lazy to look back beyond the most recent results.
     
  6. Not listening to what the attendee says.
    Another issue I have seen several times over the years is where an attendee comes in and says 'my left ear is good, but my right has no hearing at all due to an accident/illness/whatever'. The health screening technician puts the headphones on them and presses 'go' for a standard test, and lo and behold, their left ear comes out as a good Category 1, while their right ear records either nothing or a mirror image of the left, just at much lower volumes. (The latter is 'cross hearing' where the tone was played so loudly in the right ear that they heard it in their left and pressed the button). The audiometry technician, probably bored stiff and not looking at what's in front of them, just says the right ear is bad so refers for further examination. In this case not only have they ignored the reported medical history, but they've also done the test incorrectly as well. 
 This is a real-world example of this. In this instance, the right ear nerve was completely severed (car accident) meaning no hearing at all in the right ear. The technician was told this in the pre-test review but then did the test as normal, getting a mirror image in the right of the left ear, just at much lower volumes, then the attendee was referred for poor hearing in the right ear when i reality they had no hearing at all, and had been like that for many years.

This is a real-world example of this. In this instance, the right ear nerve was completely severed (car accident) meaning no hearing at all in the right ear. The technician was told this in the pre-test review but then did the test as normal, getting a mirror image in the right of the left ear, just at much lower volumes, then the attendee was referred for poor hearing in the right ear when i reality they had no hearing at all, and had been like that for many years.

Advice on referrals and a health screening provider

If you are buying-in audiometry from a specialist health screening company, ask them how they handle Category 3 and 4 cases.

If they say they always refer all Category 3 and Category 4 people, go elsewhere as they are simply following a path devoid of any thought and analysis. You could buy an audiometer and do that yourself, save yourself a lot of money and have the same quality of result.

If they say they refer all Cat 3 and Cat 4 people and will also offer you the option of referral to an in-house specialist which they can helpfully provide, DEFINITELY go elsewhere. That's just a way to make you spend more money with them, money which you don't need to spend!

Both of these, in my humble opinion, are very shabby ways to provide audiometry screening.