Signs of poor workplace audiometric testing

Hearing testing at work is important as it is the fall-back which ensures people are being kept safe and not harmed by noise risks. Poor hearing has such a terrible impact on every element of a sufferer's life that the effects cannot be understated, but all too often I've seen audiometry done so woefully done the provider should be thoroughly ashamed of it, and this applies equally to the big boys as well as the small ones. Some of the worst testing I've ever come across has been provided by a huge insurance company selling health screening services to its clients, although this was followed as a close second by a sole-trader occupational health nurse contracting out their screening services to several large clients.

Some of the things I have seen in workplace audiometry which scream out that the service is not good, and that a client should not wary of are: 

1. Lack of assigning date of birth

If no date of birth is assigned to the test then the appropriate category of result cannot be calculated, meaning the audiometric test is incomplete. This is absolutely fundamental to a screening test and if a service provider is generating tests with no result because of this I humbly suggest that they should be thrown out and any money paid to them for the testing reclaimed.

2. Lack of assigning gender

This is the same as date of birth as no gender means no result can be calculated. It is a basic and fundamental part of any audiometric screening programme that it cannot be omitted.

3. Skipping the otoscopic examination

It is far from uncommon for technicians providing screening to try and race through as many people as possible, and to do that they sometimes skip the visual otoscopic inspection of the ear. This is a basic part of the test as you need to look down the ears to see what state they are in as this can have a big impact on the results - infections, blockages, etc.

It is simple: No otoscopic examination = rubbish non-compliant test and a waste of money. Avoid.

4. Missing key audiometry frequencies

An audiometric screening test must include the 1, 2, 3, 4 and 6 kHz frequencies as these are needed to calculate the category of result and are the frequencies specified in L108 (Appendix 5, Table 13).

Most audiometric tests also include the 0.5 and 8kHz frequencies as this wider range can be helpful in identifying trends in the hearing, although these are not mandatory.

If any screening test doesn't include any of the five mandatory frequencies then it is incomplete and has not been done properly, and ideally it should include all seven to give the technician a better picture of what is gong on. Doing the minimum five is just the provider doing the least they can to complete the hearing tests, whereas the slightly wider band of seven gives a richer picture of the person's hearing ability.

5. Flat audiometric test results lines

Anything medical with a flat line is usually bad and means you are dead. Flat lines in an audiogram (the graphical result of a hearing test) are possible, but are very very uncommon. If you see one in hundreds of tests it is unusual, if you see several in a single batch of results a technician has created then it is suspicious. The most common cause of this is that the screening technician has put the headphones on the attendee, pressed 'go' and then is either working on something else or playing on their phone, but either way they are not watching the test. There are a few ways an attendee can end up with a flat line, but if the Audiometry Technician has not picked up on it, and there are few in a batch of tests, then it’s almost certain there is a problem with the Technician.

6. Suspiciously high audiometry results

This one is related to the flat lines above and is often indicative of an attendee guessing rather then responding when they can hear properly. Most of the time guesses are not registered as the attendee needs to be consistent in the level they guess at, but every so often one of them gets it right. If you get a 50 year old chap with the hearing of a 20 year old woman, then that's great for him. He is unusual and could probably navigate by sonar. If you get a few 50 year old chaps with the hearing of 20 year old women then that is getting suspicious and is worth asking the technician what they did to verify the results to ensure that this pattern is indeed correct, including checking their equipment to make sure it is reading correctly. My guess is that they didn't verify at all, or even think about it.

7. Not measuring the noise in the audiometric testing environment

This is especially critical for a mobile visiting service - you MUST know what the noise level is in the hearing testing environment to have any future reliance on the audiometry test results as being valid. I raise this from my own experience where:

  1. Mobile units can be instructed to park anywhere on the site and there is often noise from vehicles, air handling units, etc. The scope of this has to be known to be sure that the tests are valid.

  1. When the employer's insurer is defending a claim for hearing loss they may rely on the audiometry undertaken as part of the noise risk management programme. I have been asked in the past by insurers how I can prove the test results were valid, which when you can respond with a copy of that day's calibration check and a measurement of the noise levels in the testing environment means the results can and will be used by the insurer in defending the claim.

If you are using a visiting service with mobile screening units, unless they measure the noise in the testing environment and include that in the report, my advice is do not use them as a key element of any future reliance on those tests is now missing.

8. Not doing the daily audiometer calibration check

The British Standard for Pure Tone Audiometry requires a daily calibration check to ensure that all parts of the equipment are functioning as they should be. This is used to prove the hearing tests done on that day were valid. 

This is not the same as the annual calibration check of the audiometer which is done by a specialist technician, the daily check is a test against a known standard (such as the technician's own hearing) to confirm there is no undue variance. From experience, all bits of the equipment fail at some point and if you don't do this check in the morning, not only is the testing not compliant with the required standards but all tests done that day are questionable and should really be binned and repeated. 

Like the otoscope, this is simple - if the verification check was not done by the technician, in-situ, on the day of the tests, then tests are non-compliant with the British Standard for pure tone audiometry, and the provider or system should not be used. 

9. Referring every Category 3, 4 or unilateral case

This is a practice which I have come across quite a lot over the years and is one which is a red flag to me. For example, two historical cases were: 

  • Someone referred who was a Category 3 (poor hearing), despite knowing about the losses in their hearing for years. 

  • Someone who on a Year 2 hearing test was identified as having good hearing but was also Category 4 (rapid loss) compared to the test from the previous year, but the test from the previous year was clearly rubbish and incorrect however they were still referred. 

In both those cases, the service provider's policy was to refer all Category 3 and 4 cases which is a complete waste of everyone's time and is very indicative of audiometry technicians with only the barest level of knowledge or experience.

In addition, if that is all they expect of their audiometry technicians then chances are the technicians will not be engaged on the job, will just be going through the motions and will be almost guaranteed to not notice poor results or developing equipment faults which are rendering all that session's tests as useless. This final part applies to in-house testing as well where I have come across this 'refer everyone' policy just as often. 

If the screening company cannot select and train their technicians to such a level that they can make some basic judgement calls on when referrals are needed and when existing circumstances dictate they are not, I would recommend you look elsewhere.

10. In-house audiometry referrals

While not technically poor on its own, personally I would advise any company considering having hearing tests done at work to be very careful of any occupational health screening company offering to manage referrals in-house for you. It seems like a handy thing on the surface but it means the screening provider has a vested interest in generating the maximum number of referrals as they then get paid again for managing those. For any operator with a more flexible approach to scruples, that's potentially a nice extra money earner.

Back in the mists of time when I also did fire risk assessments, too many fire risk assessment companies would highlight an issue in a report and immediately followed with 'and we can provide this for you'.  The same principle applies to audiometry - a provider offering to do the in-house referrals for you sounds good on the surface but it's far too open to potential abuse for my liking and I would advise any company to avoid that.

11. Screening companies sitting on the audiometry results data

This is a little more controversial, but to me the audiometric testing data obtained is your data and does not belong to the screening company. Occupational health screening companies who only give the client anonymous reports or sometimes just the category of result, are to be avoided in my opinion. This is often dressed up as 'medical confidentiality' but is in reality just a clumsy way to try and tie the client into the screening provider and force you to go with them rather than choosing to use them again. 

GDPR also plays a part in this, but means now it is even more important that you, the client, receive all the data rather than it being held by the screening provider. Indeed there is a good argument that the client should hold the data and the screening company hold nothing at all under the new GDPR regime. One thing GDPR absolutely does not to is make the case stronger for screening companies to retain the data. 

12. Speed of audiometric testing - testing too fast

The speed at which people are being tested on a given day by a technician is a good indicator of whether they are doing the job properly or not.

If a single technician is testing anything more than one person at once, walk away. I have come across a provider with a mobile unit which has two audiometry booths in it and the technician sitting in the middle, running two tests at once. Not only will the technician never give their full attention to the attendee, it is also terrible for medical confidentiality.

If they are testing one attendee at once, as they should be, how many are they doing per hour? 

An ideal is four per hour, five is just about OK.

Why is testing too fast a sign of poor audiometry? The easiest thing to do is add up how long various parts of it take to do properly: 

  • The review of the pre-test questionnaire will take at least a couple of minutes to do properly, more with someone who has a history of issues.

  • The otoscopic examination another 30 seconds

  • Another 30 seconds to sit them down and get the headphones on and get the technician sat down again and ready to go

  • Then the actual audiometric test, the 'hear noise press button' bit. This should be composed of five key frequencies in each ear, plus another verification check, so 11 individual frequencies to test. Each frequency has at least four to five one second beeps the attendee can hear, with a one a half second gap between the beeps, then a beep they can't hear, then another they can, then another they can't and then a final one they can. If they respond accurately and with certainty then that's nine to ten beeps at three seconds a time so 30 seconds per frequency. Multiplied by eleven frequencies gives at six minutes at best for just the button-pressing, longer if the attendee is at all unsure or hesitant, as most are. Add another minute if they are doing the seven frequencies per ear rather than just the basic five.

  • Get them out again and sit them down, clean the headphones, another 30 seconds. 

Already you are on around 10 minutes. Another minute or two to explain the result to them and you are looking at around 12 minutes from start to finish, absolutely flat out, with an attendee who is nice and certain and completes the test as fast as possible. You then need another two minutes to update the records and prepare for the next person.

From experience it is possible to increase this to five tests an hour but at this rate the screening technician is really motoring and some of the admin side of it really backs up and has to wait. When I did testing at five an hour I had to adjust my routine to a series of five ten minute appointments starting at ten past the hour but then a gap on the hour itself as you need some catch-up time for the admin and records update to avoid the schedule running late.

I have even come across one major service provider doing tens of thousands of hearing tests every year who has technicians completing the hear-noise-press-button part of a hearing test in three minutes or less! To be totally unambiguous, that is simply not possible to do while doing it right! (I know what they do, they start with a quiet tone and get louder until the person presses the button, then take that as a result and move on to the next frequency, and if they have a previous result they just follow that. That is totally wrong, going to give rubbish results - and it does - and completely non-compliant with any standards governing workplace audiometry. But they are cheap.).

Four an hour is good, five an hour is OK, but if they are doing more than this then they may be cheap but I would almost guarantee that the testing is flawed.

13. Reusing single-use speculae

Ask what they do with the speculae - these are the plastic cone bits which go into the ear when having a look down them with the otoscope. They are single-use unless they are metal and autoclaved between examinations and no external provider ever uses these metal ones.

Wiping them down with an alcoholic wipe or something similar and then reusing them is frankly manky and cheap. If a company is skanky enough to be doing this, for speculae which cost a few pence each then you really don't want them doing your testing. It's actually rather disgusting that some will reuse single-use speculae with a simple wipe between people.

14. Testing people while wearing hearing aids

As utterly ridiculous as it sounds, I have come across companies where the technician doing the hearing tests happily puts the headphones on over the hearing aids for people wearing the smaller in-ear style of hearing aid. This is absolutely nuts and a huge sign that the technician hasn't got a clue what they are doing, or doesn't care, or both. If they test with the hearing aid in place, all they are testing is the effectiveness of the hearing aid and not the person's unaided hearing.

15. Contracts for workplace audiometric testing services

OK, I know I'm stretching it here as it's more to do with the arrangements for provision of the audiometry service than the actual testing itself, but do not tie yourself into a contract for provision of audiometric testing services! No, just no.

There are many providers out there who will do the hearing tests without a contract and will do everything a contracted provider will do - you want notification of who is coming due? No problem, us and others will do that. You want us to schedule your tests for you and take on the management of the sessions for you? No problem, us and others will do that and don't charge for it - it's all part of the normal service and no special contract is needed. You want a good price for it? No problem, us and others will often beat the prices of contracted services. Contracts do very little for the client and you can get all the same services without the contract, but they do offer benefit to the supplier by tying you in to them meaning if they turn out to be a bit crap then it's hard to go elsewhere.

16. Results saying 'Incomplete'

In 20 odd years of doing hearing tests at work I've never had a a single result finish as 'incomplete' - there is always a way to get the best result you can. 'Incomplete' says to me the technician wasn't really on the ball with the hearing test, was just going through the motions and didn't bother to make sure the test was finished properly.

17. Charging for a 'fit for work' note following the audiometry

A hot new entry on the list comes from a client whose previous provider was paid for doing the hearing tests, but then charged them again for each 'fit for work' letter issued for anyone who was assessed to have some form of hearing problem! That's what you are paying for in the first place and should be in the report by default, not something you should have to pay again a second time to receive. No, no and thrice no!

And a bonus extra - self-testing audiometry systems

These are systems where the client is sent a self-testing kit with employees then testing themselves with it. The short version is 'nope, not compliant', while the long version is ‘no otoscope, no verification check, no known noise levels, no individual review of the health history, no no no and no again’. I wish they were good, it would be great to just post a system to a client but they are a really really bad idea.