Managing referrals in audiometric tests

Audiometry referrals generally come up in Category 3 and Category 4 cases, or possibly in Cat 1 and 2 unilateral results. How these are dealt with is a very important and is 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 employee pointless worry and wasted time.

Impact of category of result

Standard category 1 are ‘everything is fine’’ so the default is no referral.

Standard category 2 is ‘a pass but getting low’, so the default is in-line with the HSE’s guidelines and no referral, but a warning given to the employee that their hearing is not as good as it should be and to protect it when around high noise.

Category 1 or 2 unilateral results may or may not be referred depending on the nature of the loss and the individual’s history, dealt with in more detail as below.

Category 3 and 4 - these are ‘fails’ and dealt with as below.

How we manage ‘fails’ and referrals

The goal in our screening is tow-fold. Firstly to confirm that the noise safety programme in the workplace is working sufficiently well, and secondly to identify the case where the employee has a potential issue and flag that up so the employer knows what is needed from them and they can focus on them and not worry about the rest of the bulk of the people. There is an important point to remember here:

Workplace audiometry is done as a safety-measure to guard against hearing loss potentially caused by noise at work. It is NOT to diagnose every health issue an individual may have with their hearing and the employer should not be getting involved in that.

This is so important we wrote it in bold text which makes it very important indeed.

To help with this and to make sure the employer only gets involved in cases where there is a possible noise link, or more likely simply where noise cannot be ruled out as a contributory cause, we introduced our own system of ‘informal' and ‘formal’ referrals. We did this so we could filter attendees into three groups for the employer rather than just referring big numbers of people which the employer then has to manage despite many not being work related at all, and to highlight the small number of people the employer would benefit from spending time on.

To this end, we have three groups of audiometric test results:

  1. Those with no problems.

  2. Those with a problem but chances are it is not noise related so the employer need not get involved in any subsequent action. We call this an Informal Referral.

  3. Those with a problem which has the potential to have an impact at work and which the employer should follow up on. We call this a Formal Referral.

Referral documentation for the individual

For all referrals, we will have given the employee a copy of their audiogram and explained exactly why we want them to go and make an appointment with their G.P..

This is a verbal conversation rather than a templated letter as templated letters are rubbish as no letter ever exactly fits the reason a person is being referred. Our way requires the Technician to give the employee specific advice about their specific result and their specific health history rather than just churning out ‘Cat 3 fail here is a letter’. If the referral was classed as Formal then the employer’s report will give more detail on that (see below).

Informal audiometry referral

We would recommend an individual seeks further attention where their result is poor and for their own health some follow-up examination would be beneficial, but it is unlikely to be related to noise at work. So as some examples:

  • where there is sign of infection in the ear when we have a look with the otoscope

  • where they report pain or ear-ache

  • where there is a lot of wax and the fail is marginal

  • where the loss is in one ear only unless their work is one of the rare jobs which generates more noise in one ear

  • where the loss is at frequencies which are unlikely to be involved in noise exposures

  • unilateral persistent intrusive tinnitus

In cases like these we will recommend the individual seeks further examination for their own health benefit, but in the report will tell the employer this has been done for the individual’s own health and the employer need not get involved in any follow-up. This way the individual attendees do get wider health issues looked at where it would benefit them, but the employer doesn’t have to get involved in cases which are not work related.

As a back-up, we always tell the individual to go back to their employer if the follow-up examination identifies anything which may impact on their hearing.

Formal audiometry referral

This is used where the attendee ‘fails’ the test, where there is no supporting history for the loss, where there is a chance it could be noise-related or it could impact on their safety at work. In cases such as these we will include some information on the referral in the report and say that the employer should follow up on it. This way, the employer knows exactly what action is needed of them.

What the employer should do with formal referrals

  1. Our report will state why they were referred and what the employer should do next.

  2. We would recommend the employer should have a on-to-one meeting with anyone who was given a formal referral, reiterating that it was made to determine if there are possible treatments for them and also if, following further examinations, there is anything the employer should or could do to assist the employee.

  3. We would recommend that to encourage the employee to follow the referral through, the employer makes it clear at this meeting that they are happy for it to take place in work time.

  4. Schedule a follow-up in around a month to six week’s time, (this can be dependent on how fast the employee’s G.P. can see them).

  5. Remember, it doesn’t matter in the slightest if it takes a little longer for them to get their appointment. If they are wearing suitable hearing protection at work and use is monitored and enforced, you are NOT going to make them deafer in the intervening time.

  6. When they have followed through with the referral, have a meeting with them again to discuss it. Make clear at this point that if the referral highlighted anything personal which is not work-related then you don’t need to know the detail of it, just whether their G.P. or other specialist has made any specific recommendations which you should act on or highlighted any issues which you as the employer should know about for the employee’s own safety.

  7. As a back-up, when the next batch of screening tests comes due, if the employee was referred we will also then speak to them about it. If they haven’t followed-up on the referral and their hearing has remained stable, chances are we will not refer again as although their hearing is weak, it isn’t deteriorating. If it has suffered further reductions however we would refer again and depending on the speed of the deterioration, may recommend they are removed from the noise risk in the meantime.

Who an employee should be referred to

Referral of some people to a specialist, or more likely in the first instance to a G.P., will always be part of audiometric testing done in a workplace screening programme. There are two routes for this:

  • Referral to a specialist Occupational Health G.P.

  • Referral to the employee’s own G.P.

To be perfectly clear, both are perfectly fine.

For very large companies they may have an Occupational Health G.P. on call, but for the vast majority of workplace screening referrals, the first referral is to the employee’s own G.P. Even where there is an on-site Occ Health Nurse, in most companies that Nurse also then refers to the employee’s own G.P..

There is a side benefit here which is not inconsiderable - as the individual employee is seeing their own G.P. and is the one giving them the audiometric test result, the employer is not involved in any transfer of medical data. When the employer then speaks to the employee following any follow-up examinations, again, as it is coming via the employee the issue of transfer of medical data is again avoided. In these GDPR days that is most definitely a good thing.