PhiliPPine Journal of otolaryngology-head and neck Surgery 2120 PhiliPPine Journal of otolaryngology-head and neck Surgery

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 33 no. 1 January– June 2018

PhiliPPine Journal of otolaryngology-head and neck Surgery 2120 PhiliPPine Journal of otolaryngology-head and neck Surgery

ORIGINAL ARTICLES

Philipp J Otolaryngol Head Neck Surg 2018; 33 (1): 21-24 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.

Evaluation of the Newborn Hearing Screening
Program in The Medical City Based on

Joint Commission on Infant Hearing (JCIH) 2007
Position Statement Quality Indicators

Mary Harmony B. Que, MD, MBA1

Maria Rina T. Reyes-Quintos, MD, PhD1,2,3,4

1Department of Otolaryngology
Head and Neck Surgery
The Medical City

2Hearing and Dizziness Center
The Medical City

3Department of Otorhinolaryngology
College of Medicine - Philippine General Hospital
University of the Philippines Manila

4Philippine National Ear Institute
National Institutes of Health
University of the Philippines Manila

Correspondence: Dr. Maria Rina T. Reyes-Quintos
Department of Otorhinolaryngology
Ward 10, Philippine General Hospital
Taft Ave., Ermita, Manila 1000
Philippines
Phone: (632) 526-4360
Fax: (632) 525-5444
Email: rinatrq@yahoo.com

The authors declared that this represents original material that
is not being considered for publication or has not yet been
published or accepted for publication elsewhere, in full or in
part, in print or electronic media; that the manuscript has been
read and approved by all the authors, that the requirements
for authorship have been met by each author, and that each
author believes that the manuscript represents honest work.

The authors signed disclosures that there are no financial or
other (including personal) relationships, intellectual passion,
political or religious beliefs, and institutional affiliations that
might lead to conflict of interest.

Presented at the Philippine Society of Otolaryngology – Head
and Neck Surgery Descriptive Research Contest (1st place).
August 10, 2017. Natrapharm, The Patriot Bldg., Parañaque
City.

ABSTRACT
Objective: The objective of this study is to evaluate the newborn hearing screening program in
The Medical City based on the Joint Committee on Infant Hearing (JCIH) 2007 Position Statement
Quality Indicators.

Methods:
Design: Cross - Sectional Survey
Setting: Tertiary Private Hospital
Participants: All newborns who underwent newborn hearing screening in The

Medical City for the year 2015.

Results: Of 2,010 patients delivered in the hospital in year 2015, 1,986 (98.8%) were screened.
Among the 59 babies with initial “refer” results, 15 (25.42%) “referred” a second time while 24
(40.68%) “passed” the rescreening. Twenty (33.89%) did not undergo rescreening (10 were
classified as dropouts while another 10 did not undergo rescreening for various reasons. Of those
who “referred” during rescreening, only 9 (60%) had further evaluation done with ABR/ASSR.
Among these, 4 (26.66%) had hearing loss and proceeded with the appropriate monitoring and
management while 5 (33.33%) had normal hearing.

Conclusion: The current newborn hearing screening program in the Medical City was able to
reach JCIH 2007 quality indicators for screening but not for confirmation of hearing loss. All
patients with hearing loss were managed with early rehabilitation.

Keywords: Newborn hearing screening, otoacoustic emission test, auditory brainstem response test,
auditory steady state response test

Along with other countries around the globe, the Philippines has established newborn hearing
screening programs to detect hearing loss in children at a very young age. Screening is only the
beginning of the audiological testing battery which often involves rescreening and additional
audiological tests to confirm or repudiate the initial findings before diagnosis and rehabilitation.1
The Joint Committee on Infant Hearing (JCIH) is an association made up of members who are

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ORIGINAL ARTICLES

experts in their fields of audiology, otolaryngology, pediatrics and
nursing. They are responsible for making recommendations concerning
the early identification of children with or at risk for hearing loss. In
2007, they published the JCIH 2007 Position Statement which includes
the benchmarks and quality indicators as a guide and goal for hospitals
with hearing screening programs.2

The Medical City is a tertiary private hospital with a newborn
hearing screening program. The Medical City is also a Joint Commission
International (JCI) accredited institution. This means that it is committed
to quality improvement and dedicated to providing the best possible
care for their patients. Thus, the impetus for this study - which is to
improve the newborn hearing screening program of the hospital. A study
in the United States of America from year 2005-2011 showed a rescreen
follow up rate of 65% in 2011,3 similar to findings in an unpublished
Medical City study of 66.8% in 2009.4 According to JCIH, the quality
indicators for screening include a screening rate of > 95%, and a “refer”
rate of ≤ 4%.2 For the quality indicators for confirmation of hearing loss,
90% must complete a comprehensive audiological evaluation.2 To the
best of our knowledge, there has also been no published data about JCI
and JCIH nor JCI and newborn hearing screening programs.

It is important to know how The Medical City newborn hearing
screening program compares with the JCIH Quality Indicators for
Screening and Confirmation of Hearing Loss. This information can tell
us if the program is reaching the goals set by the quality indicators, and
if not, the possible reasons and solutions. The objective of this study is
to evaluate the newborn hearing screening program in The Medical City
based on the Joint Committee on Infant Hearing (JCIH) 2007 Position
Statement Quality Indicators.

METHODS
With Institutional Review Board approval, this cross - sectional

study retrieved the records of all newborns delivered in 2015 in Medical
City, a tertiary private hospital in the Philippines. The total number of
babies who underwent newborn hearing screening and the number
of babies who obtained “pass” and “refer” results using an Otoport Lite
TEOAE Model (Otodynamics Ltd., UK) were gathered and recorded from
the logbooks accomplished by the nurses after testing. As a routine
hospital practice before discharge, babies with persistent “refer” results
on hearing screening are automatically scheduled for rescreening at
the Hearing and Dizziness Center of The Medical City after 1 month.
They are given reminders of their rescreening schedule by the Hearing
and Dizziness Center (HDC) staff and the pediatric resident rotator via
phone calls. The HDC staff routinely inquire about the reasons why
the mother (or caregiver) refused or cancelled their appointment. The
parents answers are recorded in logbooks. These were the logbooks

searched by the investigators.
The investigators searched for the rescreening records of those

who had “refer” results and these were also collated. The parents of the
babies with “refer” results had all been advised to undergo rescreening
at the Hearing and Dizziness Center as well as diagnostic testing using
ABR and ASSR if the result was still a “refer.” The MADSEN AccuScreen®
two-step (OAE/ABR) hand-held screening system (GN Otometrics,
A/S, Denmark) had been used for rescreening, and the Navigator Pro
Multiple Auditory Steady-State Evoked Response System II (Bio-logic®
MASTER® II) (Natus, CA, USA) for additional diagnostic testing.

Parents or caregivers of all babies who deviated from the protocol
anywhere in the course of the program were identified. Those who
failed to follow-up for rescreening were contacted by non-recorded
phone calls and asked through open-ended questions why they did
not undergo the recommended tests. Parents or caregivers of babies
who were identified to have hearing loss based on diagnostic testing
were questioned if they had already proceeded with rehabilitation and,
if applicable, why not. The number of attempts to contact respondents
was also recorded. Those who could not be contacted by the Hearing
and Dizziness staff after 3 attempts, and for whom no evidence of a
repeat test in the Medical City could be found, were classified as
dropouts.

Based on the responses, factors such as ‘lack of education /
knowledge about the need for a repeat test,’ ‘lack of time,’ ‘unavailable
testing center (scheduling/ machine problems),’ ‘financial constraints,’
‘poor customer service,’ ‘advise not to proceed with retesting,’ ‘opted to
transfer to another hospital or testing center,’ ‘have forgotten or do not
care for a repeat test,’ ‘changed doctors,’ were identified and recorded.

Percentages were used to determine the fraction of newborn
babies screened, the fraction of babies who had a “pass” or a “refer
result,” fraction of babies returning for rescreening and those who did
not, fraction of babies who had a “pass” or a “refer” result after the repeat
screen, fraction of babies who underwent confirmatory tests and those
who did not. The software used was Microsoft Excel for Windows Version
16.0.6769.2017 (Microsoft Corp., Redmond, WA, USA).

RESULTS
Out of 2,010 babies delivered in our hospital for 2015, 1,986 (98.8%)

were screened. The remaining 21 patients (1%) were either discharged
against medical advice, transferred or expired before the hearing tests
could be done while 3 (0.1%) refused testing.

Of the 1,986 babies screened, 1,927 (97.02%) had initial screening
test results of “pass” and 59 (2.97%) had initial screening test results of
“refer.” This is seen in the first column in Figure 1.

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Among the 59 babies with initial “refer” results, 15 (25.42%) “referred” a
second time while 24 (40.68%) “passed” the rescreening. (Figure 1) Twenty
(33.89%) did not undergo rescreening, 10 of these were classified as
dropouts while another 10 did not undergo rescreening for other
reasons seen in Table 1 below.

Table 1. Reasons why parents did not bring their child for rescreening

Reason for not having a repeat hearing screening Number of
Patients

Parent has no time to bring patient for repeat OAE

Patient had other more pressing medical problems

Parent advised by pediatrician to observe patient

Parent advised to have repeat hearing test but has not yet
been able to do so

OAE machine was broken and parent couldn’t schedule a
repeat OAE

Parent clinically assessed patient to have no problems in
hearing hence did not schedule a repeat OAE

Total

Among those with hearing loss, 2 (50%) had unilateral mild hearing
loss for which they were advised close monitoring, 1 (25%) had bilateral
hearing loss (right moderate hearing loss and left moderate to severe
hearing loss) for which hearing aids were prescribed, while 1 (25%)
had bilateral profound hearing loss for which preparation for cochlear
implantation is being started. Hence, only 0.2% of 1,986 patients
screened had hearing loss and all have proceeded with the appropriate
management.

Our results show that The Medical City was able to reach the JCIH
2007 quality indicators for screening but not the quality indicators for
confirmation of hearing loss. (Table 2)

DISCUSSION
The Medical City was able to reach the JCIH 2007 quality indicators

for screening but not for confirmation of hearing loss.
This problem has also been seen in other places besides the

Philippines and successful interventions have been done for better
compliance with the many diagnostic audiological procedures needed
prior to starting rehabilitation. A University of Illinois study showed
that they were able to decrease loss to follow-up and documentation
rate from 71.36% to 46.36%.5 Their strategy involved educating the
primary health care providers and parents and preparing English and
Spanish materials about the importance of the program. Program
implementors also met regularly to monitor their progress.5 Two studies
in Massachusetts showed a loss to follow-up rate of 25% and 50.9%
respectively.6,7 These losses to follow-up were attributed to several
factors such as being non-white, receiving public insurance and a
mother who smoked during pregnancy. Those who had unilateral and
mild to moderate hearing loss were also more likely to be lost to follow-
up. 6,7 A possible solution to this problem was proposed by Hunter in
2016.8 Her research showed that collaborating with the Women, Infants,
and Children program in Ohio (wherein staff members would contact
family members to remind them of their pending schedules based on

Figure 1. Number of patients with a “pass” or “refer” and number of drop outs on 1st and 2nd OAE and
number of patients with normal or abnormal results after ABR/ASSR tests.

Of the 15 babies with rescreening results of “refer,” 9 (60%) had
further evaluation with ABR/ASSR. Of these, 4 (26.66%) were diagnosed
to have hearing loss and 5 (33.33%) had normal hearing. Five other
babies (33.33%) were considered dropouts, and 1 (6.66%) had not
undergone ABR/ASSR because the mother had no time to bring the
infant for the test. (Figure 1)

Table 2. JCIH Quality Indicators for Screening and Confirmation of Hearing Loss compared with
The Medical City results

JCIH 2007 Quality
Indicators

The Medical
City

Quality Indicators for screening

% Babies Screened

% Babies who “refer”

Quality Indicators for Confirmation of
Hearing Loss

% Diagnostic testing completed

≥ 95 %

< 4 %

≥ 90 %

98.8 %

0.75 %

60 %

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ORIGINAL ARTICLES

their newborn hearing screening protocol), as well as counselling and
educating them, had a strong impact on decreasing the loss to follow up
rate from 33% to 9.6%.8 These same strategies may also be applied in
our setting: making sure that stakeholders are regularly reminded and
updated about the existence and importance of the newborn hearing
screening program, hiring dedicated staff responsible for advising the
parents after screening (who should also be monitored so that they
impart the proper information in the proper manner), and writing
easy to understand brochures in the vernacular, may be instrumental
in educating reminding and encouraging the parents to continue with
the newborn hearing screening program and that it is worthwhile to
do so.

One of the limitations of this study is the study population; only
patients who were born in The Medical City on the year 2015 were

included in this study and these may not represent the larger population
of Filipino children with hearing loss since majority of the mothers who
give birth in the said institution are among the higher classes who
have better access to proper healthcare. The methodology can also
be improved to include a uniform script of questioning with a set of
choices for the parents to select as reasons why they did not come back
for further testing. Future studies can take these into consideration.

This study showed that The Medical City has attained the JCIH
benchmarks for screening but still needs to improve with regards to
follow up for confirmation of hearing loss which was 60% compared
to a minimum of 90% benchmark from JCIH. Steps should be taken to
address this low follow up for confirmation of hearing loss so that the
hearing screening program in The Medical City will fulfill its goal of early
screening and intervention for children with hearing loss.

REFERENCES
1. Universal Newborn Hearing Screening and Intervention Act of 2009. Republic Act No. 9709.

Republic of the Philippines. (Aug 12 2009).
2. Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for

early hearing detection and intervention programs. Pediatrics. 2007 Oct; 120(4): 898-921. DOI:
10.1542/peds.2007-2333; PubMed PMID: 17908777.

3. Alam S, Gaffney M, Eichwald J. Improved Newborn Hearing Screening Follow-up Results in
More Infants Identified. J Public Health Manag Pract. 2014 Mar; 20(2): 220-223. DOI: 10.1097/
PHH.0b013e31829d7b57. PubMed PMID: 23803975 PubMed Central PMCID: PMC4470168.

4. Abratique RJ, Batayola MC, Reyes-Quintos MRT. Current state of the universal new born hearing
screening program at the Medical City. Unpublished 2009: 1-17.

5. Reducing Loss to Follow-up after Failure to Pass Newborn Hearing Screening. Illinois Program
Narrative. Chicago: The University of Illinois. 2010-2011. 1-18. [cited 2017 June 12] Available
from:https://www.infanthearing.org/stategrants/grants_supplemental_2009/4-IL%20
Supplemental%202010-2011.pdf.

6. Liu CL, Farrell J, MacNeil JR, Stone S, Barfield W. Evaluating loss to follow-up in newborn hearing
screening in Massachusetts. Pediatrics. 2008 Feb; 121(2) e335-43, doi:10.1542/peds.2006-3540.
Epub 2008 Jan 10. PubMed PMID:18187812.

7. Crouch E, Probst J, Bennett K and Carroll T. Evaluating loss to follow-up in newborn hearing
screening in a southern state. JEHDI. 2017; 2(1):40-47. [cited 2017 June 12] Retrieved from
http://digitalcommons.usu.edu/cgi/viewcontent.cgi?article=10438&content=jehdi.

8. Hunter LL, Meinzen-Deir, Wiley S, et al. Influence of the WIC program on loss to follow- up for
newborn hearing screening. Pediatrics. 2016 Jul; 138(1) e20154301. PubMed PMID: 27307144
PubMed Central PMCID: PMC4925076.