Signs of poor audiometry or poor service
Audiometric testing in heath screening 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 audiometric testing 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 audiometric screening which scream out that the service is not good, and 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. That applies no matter how sensitive the situation - see the transgender section for more advice on this.
3. Skipping the otoscopic examination
It is far from uncommon for technicians providing audiometric 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. This should be done and noted on the results.
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.
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 an audiometric test) are possible, but very very uncommon. If you see one in thousands of tests it is unusual, if you see several in a 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. If the attendee just keeps pressing the button repeatedly, chances are they will end up with a flat line at whatever the best sound level measured by the equipment is, usually -10 or -20dB depending on the audiometer. If the technician then compounds this by not identifying it at the end of the test as a potential problem then you should be very wary of their competence and wary of their results.
I've also seen this result because the attendee could see the reflection of a little red light on the audiometer which came on every time a tone was presented, so the attendee pressed the button when that lit up rather than when they could hear something.
6. Suspiciously high audiometric test 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.
I raise this one again from experience where in the past I was involved in an audiometric testing job with a large company with several thousand employees. They did their Year 1 screening in-house as people started their employment, using a sole-trader occupational health nurse contracted to them, and the company I worked for then did all the large-scale batch-testing for all subsequent tests. I saw crazily high audiometry results there time after time, to the point that in future screening tests we had a standing procedure to pretty much ignore their in-house results as they were just too unreliable. It doesn't matter if their suspicious screening results from their contracted nurse were a result of the equipment playing up or the nurse getting it wrong, either way the nurse doing the audiometric testing should have noticed the problem in the results, stopped testing and work out what was going on.
As another example, I once came across a case where Year 2 audiometry was done on a batch of employees and it gave a huge percentage of Category 4 results indicating rapid loss of hearing. The problem was that the current year's audiometric tests were spot-on correct, it was the previous year's results which were rubbish - a mix of high flat lines and just crazily good results, too many crazily good results to be real. The client then became aware the first year's money was completely wasted as those tests were useless, and the employees were needlessly worried by being identified as having rapid hearing loss when they were perfectly fine.
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 testing environment to have any future reliance on the audiometry test results as being valid. I raise this from my own experience where:
- 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.
- 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.
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 audiometric 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. In the latter of those the service provider also does the referrals to another part of their own company so they got to charge the client again for the referral, which is just fundamentally immoral. That meant they had charged the client for the initial crap test, the second good test, and now a third time for the referral, and all for someone with perfectly good hearing!
If a screening company has the policy of referring all Category 3, 4 or unilateral cases then they are treating their technicians as mindless morons who are there to just gather data, and as a result of which the data is often wrong, the employee given stress and worry where it is not needed, and the client often ends up paying out more than they should be. 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 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 so for any operator with a more flexible approach to scruples, that's potentially a nice money earner. If screening companies have policies of always referring Category 3 and 4 cases, along with all unilateral hearing loss cases (as above), which is simply poor practice to begin with, but then they manage the referrals in-house as well, they get to charge the client again for the referral when in many cases the follow up is not needed in the first place.
Any screening provider can provide advice on how the client can manage referrals and what the client should be doing, but that is a standard part of the audiometry screening report and is not something you should pay extra for.
Back in the mists of time when I also did fire risk assessments, I worked in a company which did not do fire alarms, extinguishers, lights, etc. meaning we could do a fire risk assessment which was demonstrably free of any further sales influence, an important point where a lot of it is not black and white and is more of a judgement call. 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 audiometric test data
This is a little more controversial, but to me the 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 hearing testing
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 is composed of seven frequencies in each ear, plus another verification check, so 15 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 fifteen frequencies gives at least seven minutes at best, longer if the attendee is at all unsure or hesitant.
- Get them out again and sit them down, clean the headphones, another 30 seconds.
Already you are on around 10-11 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. 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 pressed the button, then take that as a result and move on to the next frequency. 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 cheap enough to be doing this, for speculae which cost about 7p 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 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 audiometric testing services
OK, I know I'm stretching it here as it's more to do with the arrangements for provision of the 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 it 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.
I could use contracts - it's easy to do and costs nothing to implement but I would far rather companies came to us and came back to us because they like what we do and feel they get good service, rather than because a contract says they have to.
And a bonus extra - self-testing audiometry systems
These are systems such as WorkScreen 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 long answer is here.