«National Vision and Hearing Screening Protocols Revised 2014 Citation: Ministry of Health. 2014. National Vision and Hearing Screening Protocols: ...»
Tympanometry is not required for children with grommets Children with patent grommets are likely to have an abnormal tympanogram. Before the tympanometry screen, parents should be asked as part of the consent process whether the child has grommets. If the child has grommets, no further action is required. If the VHT is unsure whether grommets are in place they should undertake tympanometry. The result is likely to show a flat (type B) tympanogram with a high middle ear volume (above 1.5 ml).
Preparing the child for tympanometry Follow these steps to prepare the child for the tympanometry screen.
1. Ask the child to stand in front of you, and explain that you will be using your ‘special camera’ to take a measurement/picture of their ears.
2. Show the child the tympanometer screen to reassure them; liken it to a small TV.
3. Tell the child they will need to stand still for just a minute while you take the picture.
4. When you feel the child understands and is ready, begin the procedure.
Procedure for tympanometry Change to a clean, unused rubber tip between each child screened.
Follow these steps to undertake the tympanometry screen.
1. Turn the child so that their right ear is facing you.
2. Place the tympanometer probe at the opening of the child’s ear canal and run a screen.
If the screen result is pass, record the result. Go to step 4.
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4. Turn the child so their left ear is facing you.
5. Place the tympanometer probe at the opening of the child’s ear canal and run a screen.
If the screen result is a pass, record the result. This is the end of the procedure.
If the result is abnormal, record the result, including the physical volume measure.
• Rescreen in three months’ time or refer using the appropriate pathway.
The results and outcomes (ie, pass, rescreen or refer) for tympanometry screening must be recorded in the B4 School Check database and Enrol database.
After the screening Notification to parents Parents will be notified of results following a screening test.
Pass and refer brochures for use with all four- and five-year-olds screened are available online (www.health.govt.nz).
Preschool and school recording systems The results and outcomes (ie, pass, rescreen or refer) for B4 School Check audiometry must be recorded in the B4 School Check database and/or ENROL database.
There are two national databases for recording hearing results:
Ministry of Education’s ENROL database • Ministry of Health’s B4 School Check Information System.
• Hearing screening results must be entered to meet the national reporting requirements for hearing screening. The default system for entering the hearing screening results is the B4 School Check database. Results will be transferred centrally to the ENROL system.
Follow-up Ear nurses, GPs, and audiologists are asked to inform the referrer of their findings and proposed treatments. This information is recorded for future reference.
If no feedback information has been received from the referral, a follow-up letter or phone call to the family should be made to see if any action has been taken. If there is no response to this contact, then the case should be referred to the Public Health Nurse Services or Community Health Team. The information provided must be recorded for future reference.
Where a child has already been assessed and determined as needing hearing aids or another assistive device (ie, cochlear implants, FM systems) but is not wearing them, or where a child failed to attend a hospital audiology clinic appointment, the school’s nurse or public health nurse should be informed. No further screening is warranted.
National Vision and Hearing Screening Protocols Cleaning equipment back at base Check audiometer headphones regularly. If cleaning is required, carefully remove rubber cushions from headphones and wipe with warm soapy water. Ensure cushions are totally dry before placing them back in the headphones.
Note: If headphone cushions become cracked or porous, they must be replaced to maintain hygiene.
Ensure all used tympanometer tips are wiped clean of any debris (eg, ear wax), then place in the dish of Milton solution. Milton solution tablets (or similar antiseptic solution) are acceptable for cleaning tympanometer tips. The tips should be totally submerged in the solution so that all surfaces are covered. The solution must be mixed according to the manufacturer’s recommendations and must be changed daily.
After soaking for the required period (manufacturer’s recommendation), leave the tips to drain onto clean absorbent tissue. When dry, store them in their covered containers.
Referral pathways for tympanometry Tympanogram is normal If audiometry screening test is abnormal and the tympanogram is normal, the child may have a sensorineural hearing loss. In this situation, refer the child to audiology for further assessment.
Tympanogram result cannot be obtained
If you are unable to gain a seal (ie, there is an air leak) when trying to run a tympanogram, then:
record ‘no seal’ on the child’s notes • refer the child to a GP or ear nurse for further assessment (note as a refer).
• Tympanogram is abnormal If the tympanogram shows no peak and the physical volume measure is under 0.3 ml or over •
1.5 ml, refer the child immediately to a GP/ear nurse.
If the tympanometry result shows no peak (ie, it is a flat graph), and the physical volume • measure is 0.3–1.5 ml, rescreen the child in three months’ time.
If a rescreen tympanometry result shows no peak, refer the child to a GP/ear nurse.
• Children with the conditions listed in Table 1 above are at high risk for developmental and • learning difficulties, which otitis media with effusion is likely to exacerbate. If they fail their hearing test and have an abnormal tympanogram in either ear or both ears, refer them straight away.
Note: The child’s hearing must be screened again to rule out an underlying sensorineural loss. This is the responsibility of the GP or ear nurse to arrange this test with an audiologist.
References ASHA. 1997. Guidelines for Audiologic Screening [Guidelines]. URL: www.asha.org/policy/GL1997htm (accessed 10 June 2013).
18 National Vision and Hearing Screening Protocols Vision screening Overview of vision screening Purpose
The purpose of this screening test is twofold:
Identify children who may have amblyopia (lazy eye) at an age when it may still be treatable.
• Measure visual acuity and refer children who are unable to complete this screen for further • assessment.
Key messages The prevalence of visual deficits in the preschool population is estimated to be 10–15 percent.
Treatment for amblyopia, the primary focus of preschool vision screening, is most beneficial if started before the child starts school. Around 1–3 percent of preschool children have amblyopia which can lead to permanent vision loss in one eye if not treated early.
If the child is currently under the care of an ophthalmic/optometric practitioner, a screening test is unnecessary, whether the child wears glasses or not.
B4 School Check and Year 7 vision screening is part of the National Vision and Hearing Screening Programme. Best practice requirements for vision and hearing technicians are described in the National Vision and Hearing Screening Protocols.
If a child has missed the vision and hearing component of the B4 School Check before starting school, then they will be screened at school (following consent process). The screening will also capture those who need a follow-up test as a result of earlier screening.
Personnel This screening is normally carried out by a VHT, but sometimes by other competent health practitioners.
Protocol Frequency of visits Venues should be visited regularly to ensure rescreens can be achieved. It is acknowledged that several visits may not always be possible in very small, remote rural areas. In these cases, rescreening could be carried out in a scheduled clinic setting.
Before visiting an early childhood centre or school, you should:
notify the venue of your intended visit and ask that quiet activities be planned for when vision • screening is being carried out obtain the list of children requiring screening (eg, ENROL, preschool attendance lists) •
ensure the informed consent of parents has been completed.•
National Vision and Hearing Screening Protocols Consent Although VHTs are still covered by Section 125 of the Health Act 1956, all DHBs should now have implemented a consent process to encourage parents to make informed choices about their child’s health. In addition, the recording of results in the national B4 School Check database requires the informed consent of parents. Therefore, all services delivering vision and hearing screening should implement an opt-off consent process. Section 125 should only be used in exceptional circumstances where the school, early childhood centre or health services have concerns for a child’s welfare.
The consent process should include information for parents about what their child is being screened for and asking about whether the child is already under the care of a vision specialist and/or has glasses.
Setting for vision screening Preschool vision screening is generally carried out in early childhood education centres or clinic settings. Screening of school age children is generally carried out in schools.
Vision screening requires a room that is free of distractions and more than 4 m long. The room should be uniformly and brightly illuminated. It should have a light level of at least 300 lux in the room with about 500 lux to illuminate the test chart. If you are unsure whether the lighting is sufficient, carry out a formal light meter test.
Equipment needed for vision screening
To conduct a vision screening, you will need:
4 m Parr letter-matching vision book with and without confusion bars with key card (or • equivalent Sheridan Gardner charts) Rigid plastic eye patch • Snellen eye chart • Hand-held eye occluder (Denver model or similar) • retractable 5 m tape measure • masking tape • light meter.
• Hygiene protocols for vision screening Screening involves the placement of a rigid plastic eye patch over the child’s eye.
Note: Vision screening is not performed on children with inflamed eyes, a stye, or where the surrounding skin is broken or inflamed. These children should be referred for treatment (with parental consent) and booked for a rescreen at a later date.
20 National Vision and Hearing Screening Protocols Procedures During screening – wipe rigid eye patch with alcohol swab after each screen. Allow to dry completely before using on a child.
Back at base – wipe eye patch thoroughly wiped with alcohol swab and store it in a clean container.
Note: Where VHTs have cuts or abrasions of the skin that may be susceptible to infection (ie, to the hands), it is advisable to wear disposable plastic gloves. Regular hand washing during screening is recommended. Where there is no access to a hand-basin, a topical antibacterial solution handrub or similar is suitable.
Suggested cleaning products
Suggested cleaning products are:
alcohol swabs: two ply – medium grade (saturated with 70% isopropyl alcohol) in sterile • individual packages.
handrub: Microshield Handrub (containing chlorhexidine gluconate 0.5% w/v in 70% v/v • ethanol) or similar.
National Vision and Hearing Screening Protocols Screening technique: Parr letter-matching vision charts or Sheridan Gardner charts The screening is conducted exactly 4 m from the child and at the same level as the child’s eyes.
Measure 4 m from the child with the tape measure, and mark the floor at both ends with a piece of masking tape.
Ensure that the chart (book) and the key card:
match (ie, both have confusion bars) • have a matte finish so that the child cannot see reflections • do not have marks such as fingerprints or pen ink.
• Also make sure the child is not facing a window or other bright light source that could make the chart difficult for them to see.
Remember that although the screen is done at 4 m, the results (eg, 6/6 or 6/12) are written as though the test was undertaken at 6 m. (Do not record the results as 4/4 etc.) Preparing the child for Parr letter-matching or Sheridan Gardner charts
1. Ask the child to sit so that the masking tape on the mat/floor and their eyes are level (approximately 60 cm distance).
2. Explain to the child that you will be playing a simple game.
3. Show the child a large letter (shape) from your book and point to the letter that is the same on their card.
4. Show the child another large letter and explain that they have to find the same shape.
Assist the child if needed.
5. Change the letter and ask the child to find the same shape.
6. When you feel the child understands the task, show the child the eye patch and suggest they need to be a ‘pirate’ to play the game.
Procedure for Parr letter-matching or Sheridan Gardner charts
1. Place the eye patch over the child’s left eye.
2. Move to the 4 m point. Ensure no other children are sitting between you and the child being screened.
3. Beginning with the largest letter, show the child progressively smaller letters from each level. Encourage the child as much as possible. Continue until the child has difficulty identifying the letters.
4. Record the smallest letter size at which the child correctly matches two out of three letter shapes at any level. Use the conversion table on the back cover of the book (ie, 6/30, 6/18, 6/12, 6/9, 6/6).
5. Place the eye patch over the child’s right eye.
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6. Move to the 4 m point.