Remote hearing screenings via telehealth in a rural elementary school

PURPOSE: Telehealth (telepractice) is the provision of health care services using telecommunications. Telehealth technology typically has been employed to increase the level of health care access for consumers living in rural communities. In this way, audiologists can use telehealth to provide services in the rural school systems. This is important because school hearing screening programs are the foundation of educational audiology programs. Therefore, the goal of this study was to determine the feasibility of providing hearing screening services by telehealth technology to school-age children. METHOD: Hearing screening services-including otoscopy, pure-tone, and immittance audiometry-were conducted on 32 children in 3rd grade attending an elementary school in rural Utah. Each child received 1 screening on-site and another through telehealth procedures. RESULTS: Immittance and otoscopy results were identical for on-site and telehealth screening protocols. Five children responded differently to pure-tone stimuli presented by the telehealth protocol than by the on-site protocol. However, no statistically significant difference was found for pure-tone screening results obtained by telehealth or on-site screening procedures (binomial test, p = .37). Likewise, overall screening results obtained by traditional and telehealth procedures were not statistically significant (binomial test, p = .37). CONCLUSION: The results of this study suggest that school hearing screenings may be provided using telehealth technology. This study did find that 5 students performed differently to pure-tone screenings administered by the telehealth protocol in contrast to on-site hearing screening services. Further research is necessary to identify factors leading to false responses to pure-tone hearing screening when telehealth technology is used. In addition, telehealth hearing screening protocols should be conducted with participants of different age groups and experiencing a wide range of hearing loss to further clarify the value of telehealth technology.     

Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer

OBJECTIVE: To assess the efficacy and associated complications of a leech therapy protocol used for patients with a head and neck free tissue transfer in whom flap viability is threatened because of surgically unsalvageable venous obstruction. DESIGN: Medical record review of a prospective protocol. SETTING: Tertiary care academic medical center. PATIENTS: Of the 450 free tissue transfers to the head and neck region performed by our microvascular program from January 1, 1995, to October 31, 2000, 8 patients (1.8%) developed venous obstruction not considered salvageable by conventional surgical or thrombolytic therapy. INTERVENTIONS: All 8 patients were placed on a protocol using leeches (Hirudo medicinalis), intensive care unit monitoring, antithrombotic pharmacotherapy, frequent hematologic evaluation, blood transfusions as needed, and antibiotic prophylaxis for Aeromonas hydrophila. MAIN OUTCOME MEASURES: Flap salvage rate, number of leeches used per patient, time needed for inosculation, duration of intensive care unit admission, transfusion requirement per patient, and complications during leech therapy. RESULTS: All 8 flaps survived with the application of this protocol. An average of 215 leeches were used per patient, and the average time needed for inosculation was 6.6 days. The average duration in the intensive care unit was 9.6 days. The morbidity of our protocol was substantial, with intensive care unit psychosis, prerenal azotemia, and large transfusion requirements being the most frequent complications. An average of 13 U of packed red blood cells per patient was necessary. CONCLUSIONS: Aggressive application of the presented leech therapy protocol can salvage free tissue transfers with venous obstruction that are otherwise unsalvageable. The associated morbidity can be marked. Thus, judicious application of this protocol for flap preservation is essential.     

Using otoacoustic emissions to screen for hearing loss in early childhood care settings

OBJECTIVE: Until recently, no objective tool has been available to help health and early childhood education providers screen young children for hearing loss. The aim of this study was to screen underserved children 相似文献   

Postoperative parathyroid hormone level as a predictor of post-thyroidectomy hypocalcemia

OBJECTIVES: To evaluate levels of parathyroid hormone following total thyroidectomy in order to ascertain its ability to predict postoperative hypocalcemia. To establish standardized criteria permitting the safe discharge of total thyroidectomy patients within 13 hours of surgery. METHODS: This is a prospective study in which parathyroid hormone levels were tested in 54 consecutive patients who underwent total thyroidectomy. Levels were measured postoperatively at 6, 12, and 20 hours. Corrected calcium levels were also measured at 6, 12, and 20 hours in accordance with the preexisting protocol. RESULTS: Statistical analysis demonstrates that patients with corrected calcium levels greater than or equal to 2.14 mmol/L and parathyroid hormone levels greater than or equal to 28 ng/L at 12 hours post-thyroidectomy can be discharged without further need for calcium monitoring. The analysis also demonstrates that patients with 12-hour parathyroid hormone levels less than or equal to 20 ng/L are at significant risk of developing hypocalcemia. CONCLUSION: Parathyroid hormone levels in conjunction with corrected calcium values are accurate predictors of the calcium trends of post-thyroidectomy patients. Implementation of this protocol can result in shorter hospital stays for the majority of post-thyroidectomy patients, which can translate into substantial cost savings for the health care system.     

Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices

Enhanced recovery after surgery (ERAS) protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery, functional outcomes, cost savings, and resource utilization. Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care, helping to reduce inpatient length of hospital stay, complications, and the overall resource and financial burden of surgical care. Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols, as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery, including breathing, eating, nutrition, pain, speech, swallowing, and communication. Implementing ERAS protocols for head and neck cancer patients may present unique challenges, and require significant interdisciplinary coordination and collaboration. We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients. Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff, medical specialists, and associated health professionals; designing interventions based on systematically evaluated, high‐quality literature; and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention. Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol, as well as resource limitations in a given health system.     

Emergent airway management in the labor and delivery suite

IntroductionCongenital airway obstruction is of varied etiology and uncommonly encountered. Prenatal care and imaging have enhanced detection of these abnormalities and allow for multi-disciplinary care planning for airway management at delivery. Despite the availability and advances in prenatal imaging, unanticipated airway obstruction may not be identified until the time of delivery.MethodsCase series.ResultsFour airway emergencies were encountered in the labor and delivery suite over an eight-month period. Clinical history is correlated with autopsy findings. Congenital upper airway and laryngotracheal anomalies are reviewed. Recommendations to improve timely and efficient airway management in the labor and delivery suite are discussed and a protocol for a multi-disciplinary neonatal emergency airway response team is offered for consideration.ConclusionsThe development and implementation of a multi-disciplinary emergency newborn airway protocol is both realistic and feasible. While it did not improve survivability in our small group, it did reduce response time. It, or a protocol like it, is recommended for institutions caring for high-risk pregnancies and with Neonatal Intensive Care Units with high acuity patients.     

Bilateral sequential adult cochlear implantation: Who should receive priority in the context of a constrained health care system?

Resource allocation decisions have become increasingly necessary as the cost of health care habitually increases. Bilateral (second side) adult cochlear implantation (CI) is an example of a novel technology with accruing evidence of benefit, yet expense has limited universal employ. Currently at our centers, bilateral implantation is only provided under research protocol. In this article, we discuss the need for a principled approach concerning the distribution of a second device, both during this period of investigation and if ultimately an insured service. Allocation strategies, while extensively addressed in some arenas, have yet to be developed for second‐side sequential adult CI. We advocate that physicians must assume an explicit role when both caring for individual patients as well as administering health care programs. We review social justice theories that inform resource allocation macrodecisions, and include a defence of age‐based considerations. Our approach to patient selection for adult second‐side CI sequentially considers clinical criteria (directly addressed in the article), a willingness to participate in rigorous research, and a 65 year cut‐off. Ultimately, we employ random blinded selection for allocating bilateral CI among the remaining similarly situated individuals. This approach functions impartially and in a manner that is transparent for both patient and physician. Laryngoscope, 123:3137–3140, 2013     

Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care.

BACKGROUND: The current health care climate demands the provision of quality patient care in a cost-effective manner. Clinical pathways define the essential components of care that are provided to patients with a specific diagnosis to achieve a desired outcome within a predetermined period. Development and implementation of clinical pathways streamline the provision of quality care in the most cost-effective manner. OBJECTIVES: To develop a clinical pathway for patients undergoing total laryngectomy and to evaluate its impact on the cost and quality of care provided to these patients. SETTING: A tertiary care academic medical center. PATIENTS AND METHODS: A total of 45 patients were included in the study. The clinical pathway was implemented for 15 patients, while the other 30 patients were treated without the implementation of the pathway guidelines. MAIN OUTCOME MEASURES: Length of hospital stay, readmission rate, and hospital variable costs. RESULTS: The clinical pathway affected all cost outcome measures. Length of stay decreased by 2.4 days (29%; P=.001), and the average hospital variable cost decreased from $3992 to $3419 per case. This represents a 14.4% reduction in cost associated with pathway implementation (P=.02). The standardization of care eliminated unnecessary variation and repetition in resource usage, resulting in overall cost reduction. Pathway implementation resulted in a lower readmission rate (7% [1/15]) than that of patients treated prior to protocol implementation (23% [7/30]). CONCLUSION: Implementing a carefully developed clinical pathway may reduce cost without compromising the quality of care for patients undergoing total laryngectomy.     

Cell phones in telehealth and otolaryngology

The worldwide prevalence of mobile phones makes them a powerful platform for providing individualized health care delivered at the patient's convenience. They have the potential to extend the health care interaction from a brief office visit to a continuous monitoring via body sensors of either a specific healthcare parameter or with multiple sensors in wireless body area networks. Remote data collection by way of mobile phones in underserved areas allows for better management of public health and provides the opportunity for timely intervention. Published data showing benefits specific to otolaryngology are primarily in remote consultation, body sensors specific to balance, and appointment compliance.     

小儿人工耳蜗植入术前准备与围手术期护理流程

目的讨论小儿人工耳蜗植入术前准备与围手术期护理的效果,为达到提高手术质量、手术效率和手术安全性提供临床经验,为制定小儿人工耳蜗植入围手术期护理标准提供参考。方法2007年4月-2008年10月,我院共接受台湾捐赠项目的人工耳蜗植入患儿106例,术前制定了围手术期的流程,包括患者与家长的心理准备、临床中的术前检查、术前准备、手术流程、麻醉方法、术后并发症的防范及注意事项各项流程,按流程进行澳大利亚Cochlear CA型号人工耳蜗植入手术。结果106例人工耳蜗植入手术全部一次成功,手术当日起使用头孢类抗生素2周,术后6天拆除包扎出院,未见围手术期并发症。结论术前认真严格制定围手术期流程,为规范人工耳蜗植入手术围手术期护理提供了科学的方法,提高了护理质量和水平。     

A test protocol for assessing the hearing status of students with special needs

Objectives

Individuals with disabilities are often reported to have a high prevalence of undetected hearing disorders/loss, but there is no standardized hearing test protocol for this population. The purposes of this study were (1) to examine the hearing status of students with special needs in Taiwan, and (2) to investigate the use of an on-site hearing test protocol that would adequately detect hearing problems in this population and reduce unnecessary referrals for off-site follow-up services.

Methods

A total of 238 students enrolled in two schools for special education and one habilitation center participated in the study. Most students had intellectual disabilities and some also had additional syndromes or disorders. A hearing screening protocol including otoscopy, tympanometry, and distortion product otoacoustic emissions was administered to examine students’ outer, middle, and inner ear functions, respectively. Pure tone tests were then administered as an on-site follow-up for those who failed or could not be tested using the screening protocol.

Results

Only 32.4% of students passed. When administered alone, the referral rate of otoscopy, tympanometry, and otoacoustic emissions were 38.7%, 46.0%, and 48.5%, respectively. The integration of these subtests revealed 52.1% of students needed follow-up services, 11.8% could not be tested, 2.5% had documented hearing loss, and 1.3% needed to be monitored because of negative middle ear pressure. The inclusion of pure tone audiometry increased the passing rate by 9.9% and provided information on hearing sensitivity for an additional 8.6% of students.

Conclusion

Hearing assessments and regular hearing screening should be provided as an integral part of health care services for individuals with special needs because of high occurrences of excessive cerumen, middle ear dysfunction, and sensorineural hearing loss. The training of care-givers and teachers of students with special needs is encouraged so that they can help identify hearing problems and reduce the negative impact of hearing disorders and hearing loss. The screening protocol needs to include subtests that examine the status of different parts of their auditory system. The addition of pure tone audiometry as an on-site follow-up tool reduced the rate of off-site referrals and provided more information on hearing sensitivity.     

A principal calling: professionalism and health care services

As heath care professionals, our "product" is clinical service. We demonstrate professionalism by attitudes, knowledge, and behaviors that reflect a multi-faceted approach to the standards, regulations, and principles underlying successful clinical practices. The issues facing practitioners who work in health care environments are complex, forming an infrastructure for conducting clinical and business operations. Issues discussed include: clinical quality and outcomes management; patient safety and medical errors; accreditation and compliance. A thorough knowledge of these topics forms the context within which we integrate our services with the larger health care community. In this age of accountability, inquiry, introspection and integrity are the keys to professionalism. LEARNING OUTCOMES: As a result of this activity, the reader will be able to: (1) discuss basic points related to the complex requirements and issues facing clinical practitioners today; (2) understand the components of "professional" practice within the health care community; (3) integrate quality management, regulatory compliance, and accreditation standards into every clinical practice. Profession: A calling requiring specialized knowledge and often long and intensive academic preparation; a principal calling, vocation, or employment. Professionalism: The conduct, aims, or qualities that characterize or mark a profession or professional person. -Webster's New Collegiate Dictionary.     

Effectiveness of a postoperative disposition protocol for sleep apnea surgery

Purpose

1) Evaluate the effectiveness of a postoperative disposition protocol for upper airway surgery in patients with sleep apnea. 2) Compare the cost-effectiveness of outpatient and overnight observational sleep apnea surgery versus surgical intensive care admission determined by preoperative screening criteria.

Materials and methods

A new preoperative protocol for sleep apnea surgery was instituted at the Durham Veterans Affairs Medical Center in 2008 to triage patients undergoing sleep apnea surgery to one of three postoperative dispositions: intensive care, routine ward bed, or discharge home. An Institutional Review Board approved retrospective chart review of patients undergoing sleep apnea surgery between May 2008 and January 2012 was performed. Postoperative complications and cost comparisons were assessed between each of the three postoperative disposition groups.

Results

115 patients underwent sleep apnea surgery between July 2008 and January 2012. 11 patients were excluded leaving 104 patients in the final analysis. Median follow-up was 1.25 months. Overall complication rate was 12.5%. Eight complications occurred in the group triaged to intensive care, and 5 occurred in those triaged to lesser levels of postoperative care. All serious complications occurred during the immediate postoperative period. Based on only room charges, $125,275 was saved over the 3.6 years of this study.

Conclusion

A post operative disposition protocol can be effectively used to triage patients to less than intensive postoperative care. In institutions like the Durham VA, where sleep apnea patients were routinely triaged to intensive care, postoperative resources will be more efficiently utilized.     

Parental awareness of hearing impairment in their school-going children and healthcare seeking behaviour in Kisumu district, Kenya

BACKGROUND: Hearing-impaired children who are identified early and appropriately managed have improved outcomes in speech, language, cognitive and social development. Enhanced parental awareness of their child's hearing disability, behavioral, developmental and psychosocial limitations is essential to sustaining timely detection and appropriate intervention. Additionally, availability of services for diagnosis, treatment and habilitation would improve the demand for pedaudiological care in this community. OBJECTIVE: To describe level of parental awareness of childhood HI and the pattern of access to and utilization of ambulatory care services. SUBJECTS: Thirty-three parents of lower primary school-going children who failed audiometric screening from sampled schools in Kisumu district, western Kenya. MAIN OUTCOME MEASURES: First person to detect HI, age of child at first suspicion of HI, source of ambulatory health care and use of the health care facilities. RESULTS: The prevalence of HI was 2.48%. Most parents/guardians (69.7%) were aware of their child's hearing impairment. Of these, 63.6% were first to detect HI in the pupils, while 30.3% were detected by screen. Most children (57.2%) were first recognized with (HI) after age 2 years. The mean age at identification was 5.5 years. The median travel distance to the preferred health care facility was 2 km (IQR 1-2.5). Parents seldom sought or lacked help for their hearing-impaired children. Of 27.3% who asked for hearing assessment, 9.1% received some counsel on HI and 12.1% received medication, one (3%) was referred for audiological assessment and none used a hearing aid. Use of health facilities for maternal care was (65.7%) and immunization (62.9%). CONCLUSIONS: Despite adequate parental awareness of chronic childhood disability, health facilities were underutilized. This indicates the need to further stimulate and maintain a desirable level of uptake of services for diagnosis, treatment and habilitation of childhood HI, while sustaining delivery of effective and acceptable high quality paediatric care.     

Dr. Miller Goes to Washington: You Should,Too

Otolaryngologists, like most physicians, tend to avoid local, state, and national politics for a variety of reasons. Although physicians and their patients are frequently affected by policies made in these political arenas, physicians tend to avoid active participation because of inexperience, lack of time, lack of knowledge about ways to influence policy development, and a general distaste for the political process. Otolaryngologists need to participate in the process to ensure that their particular perspectives and concerns are heard. However, otolaryngologists also need to look beyond their personal or specialty interests to influence the broader health care debate. Before we are specialists, we are first physicians who have a fiduciary responsibility to mankind (our patients) to improve the health care system for all Americans. We have a moral and ethical obligation to address, influence, and support health care beyond the specialty level. Health policy developed in an absence of physician input is missing the insight of expertise and experience.     

Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change

ObjectiveTo analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications.Study designRetrospective case series.SubjectsPediatric patients undergoing tracheotomy from February 2010–February 2014.MethodsIn 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed.ResultsThirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p = 0.0048; Bjork flap: p = 0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases.ConclusionA standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.     

Quality and safety in a complex world: why systems science matters to otolaryngologists

Almost all modern medical care is delivered in the setting of many overlapping systems. Each system may consist of multiple providers and in most cases electronic and mechanical components. Even "simple" outpatient care is delivered by teams of providers, administrators, and devices. Critically ill inpatients are cared for in extraordinarily complex systems with hundreds of human and non-human elements. The science of complex systems has exploded in recent decades, and there is a large body of knowledge about how such systems function effectively or ineffectively. Many principles of systems science are simple to understand and apply, but few Otolaryngologists are well educated about them. A basic knowledge of systems science will greatly improve the Otolaryngologist's ability to function in complex health care systems and to provide the best care for his or her patients.     

Outcomes analysis for hearing conservation programs

In health care, an increasing interest in accountability for outcomes, proof of quality care, and cost effectiveness is forcing many practitioners, including audiologists, in the direction of using outcomes analysis to provide proof of performance in their practices. Critical to the conduct of outcomes analysis are the selection of valid outcomes metrics and application of appropriate statistical processes. Modeling of clinical protocols is a useful exercise for developing outcomes data and data management standards. The authors describe the implications for wider use of outcomes modeling once the Health Insurance Portability and Accountability Act (HIPAA) administrative simplification law is implemented. This legislation will set up a wholly new administrative data set that has strong potential to provide outcomes metrics to a variety of Audiology practices. The modeling exercise described here was originally intended to derive assessment outcomes for evaluating hearing conservation program effectiveness in military populations from an administrative database implemented within the Military Health System starting in 1997. The outcomes modelers, however, soon realized the broader applicability of modeling techniques for other special populations and Audiology practices, particularly with the oncoming startup of HIPAA legislative mandates. The modeling exercise demonstrates a process of structuring standard health-care codes to produce outcomes data for epidemiologic and cost analyses, thereby providing better information to guide health-care practices toward improving quality and cost effectiveness. This information in time series should also provide a record of continuous quality improvement. The authors present a general hearing surveillance protocol for evaluating occupational hearing loss. The protocol is used as a specific instance to demonstrate the shaping of an outcomes metrics model. This same process can be applied more generally when used to model outcomes data from other audiology practices. Implementation of the administrative data model described here began at more than 400 Department of Defense (DOD) medical treatment facilities worldwide as of October 1, 1999. The exercise of developing similar outcomes metrics for newborn hearing screening programs, school hearing conservation programs, and other clinical and rehabilitative audiology practices in the civilian sector remains to be done.     

Tracheostomy in the intensive care unit: Guidelines during COVID-19 worldwide pandemic

PurposeCOVID-19 has become a pandemic with significant consequences worldwide. About 3.2% of patients with COVID-19 will require intubation and invasive ventilation. Moreover, there will be an increase in the number of critically ill patients, hospitalized and intubated due to unrelated acute pathology, who will present underlying asymptomatic or mild forms of COVID-19. Tracheostomy is one of the procedures associated with an increased production of aerosols and higher risk of transmission of the virus to the health personnel. The aim of this paper is to describe indications and recommended technique of tracheostomy in COVID-19 patients, emphasizing the safety of the patient but also the medical team involved.Materials and methodsA multidisciplinary group made up of surgeons with privileges to perform tracheostomies, intensive care physicians, infectious diseases specialists and intensive pulmonologists was created to update previous knowledge on performing a tracheostomy in critically ill adult patients (>18 years) amidst the SARS-CoV-2 pandemic in a high-volume referral center. Published evidence was collected using a systematic search and review of published studies.ResultsA guideline comprising indications, surgical technique, ventilator settings, personal protective equipment and timing of tracheostomy in COVID-19 patients was developed.ConclusionsA safe approach to performing percutaneous dilational bedside tracheostomy with bronchoscopic guidance is feasible in COVID-19 patients of appropriate security measures are taken and a strict protocol is followed. Instruction of all the health care personnel involves is key to ensure their safety and the patient's favorable recovery.