Now hear this: upgrading residents' hearing amplification.

Introduction

According to the National Institute on Aging, one-third of Americans between the ages of 65 and 74 have a hearing loss that impacts the quality of their everyday life. The incidence increases to 50% of those individuals 85 and older. Other sources state that people over age 50 are likely to lose some hearing each year. Twenty-seven million Americans over 65 have significant hearing impairments.

Skilled nursing facilities are apt to encounter individuals with hearing impairments in greater proportions than the general public. This has several important implications: Hearing loss is reported to be a contributory factor to withdrawal and social isolation. Considering the financial and psychological trauma associated with leaving home and family to enter a nursing facility in concert with numerous physical maladies, reduced hearing acuity only serves to "put salt on an open wound."

It is the responsibility of skilled nursing facilities to prevent or slow residents' decline and to maximize their optimum function and well-being. This should not be limited to addressing gross or fine motor skills, such as ambulation and activities of daily living. Clinical observations at our facility revealed an unusually low percentage of residents using hearing aids, and even those tending to use them on only a very intermittent basis. We concluded that an innovative interdisciplinary approach was needed to promote residents' well-being and optimum function in terms of their residual hearing. We needed a comprehensive program to systematically analyze the situation: a CQI process combined with staff and family education and development.

The result: the Hearing Aid Recovery Program (HARP) program, initiated in March 1995 and finalized last November. We have continued to make modifications and adjustments as the needs of the residents dictate and our experience enlightens us. What follows is a description of the HARP program's inception and implementation along the outlines of the Optima Award submission process.

Problem

HARP was initiated due to the frequency of misplaced hearing aids and delays in identifying owners of found hearing aids. Identification was based on cursory visual inspection of the device and relied heavily on the CNA's familiarity with it. Often enough, though, residents misplaced their hearing aids before staff had had an opportunity to become familiar with them. Sometimes families would simply fail to mention or bring in the hearing aids at time of admission, either because they didn't want to burden. staff with the added task of caring for the hearing aid or a general fear that the aid would become lost. There was also an overall assumption that losing hearing with age was a given and that hearing aids did little to counteract this normal aging process. Benefits of amplification were underestimated, and the impact of its absence on residents' behavior was overlooked.

Developing a multifaceted approach to this problem meant that issues such as identifying residents in need of amplification, the appropriate devices (behind the ear [BTE] or in the ear [ITE], unilateral or bilateral), recommended volume controls/levels, and other steps needed to maximize residual hearing needed to be addressed.

Our observations revealed that residents in need of amplification were typically agitated, often expressing themselves in excessively loud voices that in turn provoked other residents. We knew that loss of hearing results in social isolation, depression and misunderstandings. This not only negatively influenced quality of life, but could also lead to misdiagnosis and unnecessary and costly treatment. When all of this is compounded by dementia, neurological deficits, etc., the results can be debilitating. Subsequently, individuals' participation in the healing process tends to decrease and the cost and intensity of medical treatment increase accordingly.

Throughout the program development process our Speech and Language Pathology (SLP) Department consulted with a number of practicing/licensed audiologists, universities and the American Speech Hearing and Language Association for input. Furthermore, SLP also contacted several skilled nursing facilities for brainstorming and information sharing. Interestingly enough, no other facility contacted could offer any additional insight or innovative approaches.

Objectives

Because our major objective was to enhance the quality of our residents' life by assuring presence of prescribed amplification, systems were implemented to achieve the following specific goals:

* Reduce hearing aid loss by at least 75%

* Report misplaced hearing aids within the relevant shift

* Reduce the turnaround time between reported loss and return to residents

* Provide residents in need of amplification with a loaner hearing aid until more permanent arrangements were made

* Increase the mean life of hearing aid batteries from the unacceptable base rate of 24 hours

* Conduct a massive in-house chart review, including review of case histories, to identify all residents in need of amplification

* Conduct a massive house search/master list of hearing aid users, including ear(s) used and the corresponding serial number of the device(s)

* Develop a system to match found aids with owners

* Investigate alternatives for amplification for residents refusing hearing aids

* Provide aural rehabilitation for residents, families and staff

* Establish inservice training for staff for hearing maintenance

* Develop a hearing aid check protocol to assure maximum usage

* Assure daily and maximum use of hearing aids

* Monitor AM as well as PM hearing aid management involving all three nursing shifts

* Develop a system flow chart for more immediate recovery of lost aids

* Create a hearing aid battery replacement program

* Develop an identification program for hearing aids that is initiated upon admission

* Organize a system for notifying and updating nursing staff as to who is aided

Implementation

In defining the problem, we wanted to identify how, when and why hearing aids were not being used. Once that was accomplished, we set out to develop and implement a plan of care and correction (i.e., alternatives/solutions), and then monitor for impact, success and efficacy.

A massive chart review was conducted to identify all residents with hearing aids. When this was in question, families were consulted to verify presence and / or availability of hearing aids for their loved ones. Hearing screens were conducted on all residents. When indicated, audiological evaluations and hearing aid evaluations were also performed. Every resident was checked for use/type/serial number of hearing aids in their possession, and manufacturers were identified. The consuiting audiologist contacted manufacturers and obtained the registered owner of the unclaimed hearing aids in our possession.

Based on all this, the facility compiled a computer-generated list of residents with hearing aids, including the devices' types, manufacturers and serial numbers - the "Heating Aid Identification List." This list is updated weekly by Rehabilitation Services and the SLP Department, and distributed to the nurses' stations, the Activities Department and Social Services. If a hearing aid is found, any nursing staff can now quickly refer to this posting and identify the resident-owner without significant delay.

The facility arranged with local universities to have graduate students provide yearly heating screens for all residents free of charge to the facility. As a routine screening procedure, all new admissions are checked for hearing aids and their names are added to the Hearing Aid Identification List by SLP department staff.

An innovative Hearing Aid Loaner Program was instituted. The facility encouraged donations of heating aids, which were then reconditioned and made available to other residents on a temporary basis. An individual ear mold, costing approximately $40, was created, pending physician's order and audiologist recommendations. In cases where the resident or family declined a hearing aid, a device called a Pocket Talker was used on a trial basis. Although this is not considered the ideal solution, in many cases it became the most viable option for some residents. Pocket Talkers were also made available to other departments for use with residents. Additionally, the SLP Department organized an elective battery replacement program to assure readiness and ample supply of common hearing aid batteries.

Inservice training was provided to families and staff on the benefits and maintenance of hearing aids. Staff and families were taught basic maintenance techniques and systematic problem-solving strategies. This process is now part of our routine Orientation Training Program for all new hires, as well as part of our facility's yearly inservices. A video training film was developed for ongoing inservice training.

Residents who may have previously been resistant to wearing their hearing aids were referred to SLP for desensitization training and aural rehabilitation, if appropriate, to maximize their residual hearing. When appropriate, audiological consults were obtained to assure amplification was sufficient for the resident's hearing loss. The ear mold was also evaluated for appropriate fit and comfort.

A system for quick recovery of lost hearing aids was clearly needed. In some cases, days went by before staff was alerted to the situation. In networking with other skilled nursing facilities, we found that it was not uncommon for a period of two to four weeks to pass before a lost hearing aid was discovered. Hearing aids, when found, were frequently in damaged or unusable condition. As with other skilled nursing facilities, we had many reports of hearing aids going through the washing and drying cycles, found wrapped in napkins on meal trays or soaking in denture cleanser, etc., all of which can render the aid useless. If not covered by the resident's hearing aid insurance replacement policy, (which also limits the number, as well as length of time, for replacements), replacement becomes the facility's liability.

Now, armed with the necessary information [TABULAR DATA FOR FIGURE 1 OMITTED] (the newly developed Hearing Aid Identification List), each nursing shift is responsible for monitoring the whereabouts of all hearing aids.

After a few attempts and with input from CNAs and RNs, a sign-in sheet or system for each shift was developed (see figure 1, "Nursing Hearing Aid Status Log"). Furthermore, all hearing aids are removed at night and housed in a specially designed container at each nursing station. The whereabouts of the hearing aids are checked on every shift by the CNA and documented on the Nursing Hearing Aid Status Log, which is then signed by the RN as a monitoring event. If the hearing aid cannot be located, the CNA reports this to the nursing supervisor, who alerts staff through the 24-hour report and initiates the Hearing Aid Retrieval process, as illustrated by the flow chart [ILLUSTRATION FOR FIGURE 2 OMITTED].

A Rehabilitation Aide is responsible for checking each hearing aid every morning to make sure it is in operating condition (i.e., battery is checked and replaced if necessary, ear wax removed, etc.). To accomplish this the Rehabilitation Aide uses a portable Hearing Aid Maintenance Kit, which includes otoscope, disposable oto-tips, alcohol preps, hearing stethoscope, flashlight, three sizes of hearing aid batteries, button cell battery tester, heating aid cleaning tool and brush, tweezers, magnifying glass, disinfectant wipes, BTE oto-clip, ear-mold air blower and a red marking pencil. The Rehabilitation Aide inserts the repaired hearing aid and adjusts the volume control according to specifications.

Another strategy adopted by our facility was the use of oto-clips, which helps to prevent loss of behind-the-ear (BTE) or in-the-ear (ITE) aids by attaching them to residents' clothing. The clips are also color-coded for right or left.

Evaluation/Assessment

We have been tremendously successful across all parameters of the program.

The staff and families are educated on the routine basic maintenance of hearing aids, thus maximizing the life of the hearing aid batteries. As a direct result of inservice training and aural rehabilitation, batteries which were replaced on a daily basis are now lasting three weeks, versus the previous baseline of 24 hours.

The chart (figure 3) illustrates the overall success of our program. In general, the frequency of lost hearing aids has been reduced from four per week to only one in six months. Turnaround time has decreased from weeks to hours. Misplaced hearing aids are now identified as missing and returned within the same shift. We have not had any hearing aids permanently lost or replaced in the past six months.

Because of our interdepartmental cooperation, the facility now goes into an "alert mode" when a hearing aid is misplaced. This serves to recover aids sooner and before significant damage has been incurred. Nursing staff is recognizing the impact of hearing aids on interpersonal communication and psycho-social behavior and, as a result, is utilizing Rehabilitation Services more appropriately (e.g., nursing no longer relies on skilled services to replace batteries, and will consult SLP to screen for candidacy for audiological evaluation, amplification and/or aural rehabilitation). Residents who become resistant to wearing aids are examined for possible excessive wax blocking amplification or improper fit of the ear mold resulting in annoying feedback and/or [TABULAR DATA FOR FIGURE 3 OMITTED] skin irritation. Hearing aids are now functioning at maximal levels. As the result of our team effort and the program described, all residents with hearing losses are now functioning at their maximum potential relative to their hearing capabilities.

Our approach was recently recognized by a faculty member of a local research university as being the most unique, progressive and aggressive hearing program in a geriatric setting. We have been encouraged to, and have agreed to, submit the program for possible publication in a clinical journal and present the program at a national conference.

As the ultimate testimonial, our service providers have revealed that, with this increased attention toward consistent amplification, residents are becoming more active participants in recreational activities, counseling sessions and small group interaction, and are generally more involved and independent. Clinical observations reveal families to be pleasantly surprised by their loved one's new acceptance of amplification devices and are typically reinforcing their use of hearing aids.

Deborah A. Kania is Director of Rehabilitation at Mt. Lebanon Manor, a 121-bed subacute/long-term care facility based in Pittsburgh, PA and equipped to provide a variety of physical and occupational therapy, respiratory care and speech & language pathology services. For further information, [phone], fax [phone].