The cochlear implant champion scheme was launched by Martin O’Driscoll from BCIG and Ann-Marie Dickinson from BAA Service Quality Committee at the BAA conference 2019. The aim of the scheme is to ensure all eligible adults and children, and their families, are well-informed about cochlear implants and are offered a timely referral.

ROLE OF THE CHAMPION:

To train, support and empower staff in your team to counsel patients/clients and their families about cochlear implants (CIs).

To ensure all eligible patients/clients and their families are offered informed-choice and shared-decision making when considering a CI referral.

To audit, the quality and quantity, of CI referral counselling taking place in your service, and monitor referrals.

TRAINING:

The first CI Champions training workshop took place on the 11th March 2020 at the BCIG conference in Nottingham, with online training and support offered pre- and post-workshop.  The champion role is important for audiologists working in a paediatric and adult setting, in the NHS and independent sector. All presentations from this day are in the members’ area here.

PERSONAL QUALITIES:

You should be motivated and committed to the scheme. You should have good communication skills and be prepared to share information and guide/inform discussions about implants within your team.

RESPONSIBILITIES OF THE CHAMPION:

  • Dedicate at least 1 hour per week to this scheme.
  • Monitor implant referrals in your service.
  • Audit the quantity and quality of implant counselling in your service.
  • Share audit results with your team at regular intervals.
  • Build a relationship with your local implant service.
  • Offer training and support to everyone your department.
  • Attend the annual CI Champion training day and engage with online training.

Your line manager must agree to support you in this role.  Please register your interest by sending your name and name of your department/service to admin@baaudiology.org

Articles, research, policy guidance, videos, websites and presentations

Optimally Aided

Cochlear implants should always be considered as a priority for adults with severe-to-profound deafness; however, it is important to ensure adults are optimally aided so they can get the best possible outcomes with their hearing aids.

The optimally added definition exists to support clinicians when making a decision about how to set hearing aids for adults who have severe to profound loss, and when to refer for a cochlear implant. Download the document here: Optimally Aided

Referral and Candidacy Research

Allen, S. Jones, L., Gregory, M.  (2018) Addressing the low uptake of cochlear implants amongst adults. The Ear Foundation.

Bierbaum, M, McMahon, C, Hughes, S, Boisvert, I, Lau, A, Braithwaite, J & Rapport, F 2019, Barriers and facilitators to cochlear implant uptake in Australia and the United Kingdom. Ear and Hearing.

Chundu, S., Buhagiar, R. (2013) Audiologists’ knowledge of cochlear implants and their related referrals to the cochlear implant centre: Pilot study findings from UK, Cochlear Implants International, 14:4, 213-224, DOI: 10.1179/1754762812Y.0000000025.

Dillon, B., Pryce, H. (2019): What makes someone choose cochlear implantation? An exploration of factors that inform patient decision making, International Journal of Audiology, DOI: 10.1080/14992027.2019.1660917.

Fitzpatrick, Elizabeth M.; Ham, Julia; Whittingham, JoAnne. Pediatric Cochlear Implantation, Ear and Hearing: November/December 2015 – Volume 36 – Issue 6 – p 688-694 doi: 10.1097/AUD.0000000000000184

Gaylor, J., Raman, G., Chung, M., Lee, G., Rao, M., Lau, J., Poe, D. (2013) Cochlear Implantation in Adults A Systematic Review and Meta-analysis. JAMA. Otolaryngol Head Neck Surg. 2013;139(3):265-272.doi:10.1001/jamaoto.2013.1744

Ng, Y., Lamb, B., Harrigan, S., Archbold, S., Athalye, A.,  Allen, S. (2016) Perspectives of adults with cochlear implants on current CI services and daily life, Cochlear Implants International, 17:sup1, 89-93, DOI: 10.1080/14670100.2016.1157314.

Mr Raghunandhan Sampath Kumar, Ms Deborah Mawman, Mr Divyan Sankaran, Mrs Christine Melling, Dr Martin O’Driscoll, Mr Simon M. Freeman & Professor Simon K. W. Lloyd (2016) Cochlear implantation in early deafened, late implanted adults: Do they benefit?, Cochlear Implants International, 17:sup1, 22-25, DOI: 10.1080/14670100.2016.1161142

Sandeep G. Mistry, Simon Carr, Jane Martin, David R. Strachan, Christopher H. Raine & Georgios Fyrmpas (2017) Cochlear implantation under local anaesthesia – Our experience and a validated patient satisfaction questionnaire, Cochlear Implants International, 18:3, 180-185, DOI: 10.1080/14670100.2017.1296986

Raine, C. (2013) Cochlear implants in the United Kingdom: Awareness and utilization, Cochlear Implants International, 14:sup1, S32-S37, DOI: 10.1179/1467010013Z.00000000077.

Raine, C., Atkinson, H., Strachan, D., Martin, J. (2016) Access to cochlear implants: Time to reflect, Cochlear Implants International, 17:sup1, 42-46, DOI: 10.1080/14670100.2016.1155808.

M. K. Shrivastava, S. T. Eitutis, J. W. Lee, P. R. Axon, N. P. Donnelly, J. R. Tysome & M. L. Bance (2020) Hearing outcomes of cochlear implant recipients with pre-operatively identified cochlear dead regions, Cochlear Implants International, 21:3, 160-166, DOI: 10.1080/14670100.2019.1707362

CI Audit Toolkit

Develop an audit schedule

Baseline audit:

• How is our service performing against the gold standard?
• Useful period to audit: March 2019-2020 (after NICE change, pre-champions, pre-covid)

Ongoing audit:

• Weekly/monthly audit/re-audit: How does our service currently perform against the gold standard?
• Is the training/support changing practice? What else needs to be done?
• Who are we missing?
• Which staff need more support?
• What needs to change/be developed?

Adaptions to this schedule

• Baseline does not need to be an entire 12 months.
• Ongoing does not need to audit every day/week/month.
• Develop a schedule to suit your time and resources available; anything better than nothing!

How to use the audit results:

  • Discuss audit results with team and consider why patients are not-offered. Is clear, consistent clinical decision making taking place in your service
  • Discuss case histories and PTA: age, health, shape of loss, and BC can cause confusion over candidacy
  • Offer training & support: ask staff what they need
  • Focus training on specific misconceptions.
  • Arrange extra training to staff that most need support.

What could your training look like?

  • Invite service users to tell their story
  • Tutorials, shadowing, observations, peer-review, jnl clubs (presentations unlikely to change practice)….
  • Focus on the principles of rehab: informed choice and shared decision making.
  • Support newly/less-qualified staff to understand candidacy and develop their referral counselling skills. Mentoring.
  • Manage expectations around HA technology (for patients and staff!)

A team approach

  • Support each other: experienced staff support new/less qualified staff.Adopt a ‘no blame’ culture.
  • Get all staff on-board: patients need a consistent message
  • Use posters and leaflets to empower patients to ask about implants. Patients are part of your team
  • Mentor from your local CI service is part of your team.

Thank you to the following people for contributing to the Audit Toolkit:

Lisa Kennedy and Anirvan Banerjee, North East Regional Cochlear Implant Programme; Joseph Blackaby, Southend University Hospital NHS Foundation Trust; Katie McNeill, North Devon Healthcare Trust; Lousie Fletcher, Walsall Healthcare NHS Trust; Rashmi Singh, Cochlear and Tom Lyon, Royal Free London NHS Foundation Trust

STEP 1: The gold standard

Adults:

NICE 2018 ‘After the audiological assessment, discuss with the person, referral for implantable devices such as cochlear implants, bone-anchored hearing aids, middle-ear implants or auditory brain stem implants, if these might be suitable’ NICE, 2018, pg. 20, https://www.nice.org.uk/guidance/ng98

Paediatrics:

Babies and children 0-5:

NDCS (2016) ‘Deaf babies and children who meet the criteria to be candidates to receive a cochlear implant or other implant are referred to an auditory implant service at an early stage for assessment, following discussion with the family’. Page 7. https://www.ndcs.org.uk/documents-and-resources/quality-standards-early-years-support-for-children-with-a-hearing-loss-0-to-5-england/.

Unclear for children over 5. If you want to help determine this gold standard, please email ann-marie.dickinson@manchester.ac.uk

STEP 2: Finding the patients

Search for all those eligible according to PTA as determined by NICE, 2019 https://www.nice.org.uk/guidance/TA566

Auditbase: Crystal report, can be developed in-house (based on audiogram) or contact Cochlear to use their report.

Cochlear has developed the Cochlear CI Referral Report, a standardised reporting tool, in collaboration with Auditdata and input from a number of pilot Audiology departments.

The Cochlear CI Referral Report allows Audiology departments to identify and analyse patients who fall within CI audiometric candidacy guidelines in a time-efficient way. Audiologists can monitor what happens to the referral status of their patients over time and identify initiatives to help improve their referral practice. Cochlear’s Engagement Team will be able to provide one-to-one support in using the report, analysing the results, and setting action plans.

Please contact Cochlear: UKLearnNow@cochlear.com if you wish to learn more.

Practice Navigator: A report,  shared by Champion Louise Fletcher from Walsall, can be used to extract ALL audiograms measured in a certain time frame e.g. 1 week, 1 month, 1 year. Download instructions.

We are unable to load the ‘audiogram analysis‘ file on this website, for a copy of the report please email: admin@baaudiology.org

A list of patients and their audiograms can then be saved into excel and manipulated to find the patients that meet the NICE criteria.

Search by clinics: e.g. look through your S&P/complex clinics to find those that meet the criteria according to PTA – see talk from BAA 2019 and BCIG 2020 by Ann-Marie (both available on this webpage)

STEP 3: Categorising the patients: 

Allocate each patient to a category…suggested categories are: 

a) Referred for a CI assessment.

b) Not referred: pt declined a CI assessment

c) Not referred: further assessment needed in audiology

d) Not referred: unsuitable at current time

e) No action taken – these patients fail to meet the gold standard 

Categories a-d meet the audit gold standard. Category e fails to meet the gold standard

STEP 4: How to manage the patients that have been missed i.e. those in the category of 'no action taken'.

Suggested options are shown below – decide what best meets your patient’s needs depending on urgency, your service set-up, risks of covid etc.

a) Offer a face to face review (with AB word test if possible).
b) Group information sessions
c) Send out information on CIs – Considering a referral for a cochlear implant-leaflet
d) Add notes to prompt staff at their next visit
e) Discuss with your mentor at CI centre -they might be able to help.

North Devon audit process and outcomes

The Audit Process

  • Patients were identified based on the audiogram and who have been seen in the past 12 months.
  • Removed patients who were outside criteria for BC but within audiometry criteria for AC because they are BAHA candidates rather than CI, and any deceased patient.
  • Identified whether these patients had been offered, accepted or declined a CI.
  • Identified if they were unsuitable and why they were unsuitable within criteria.
  • Looked at the reasons on the journal for why they had declined if available. Or if there was a reason for no discussion occurring.
  • These results were then fed back to Ann Marie for the larger scale audit and to the departmental team to inform them of the results and to consider ways to improve CI referrals.
  • What is stopping the conversation?

 

North Devon referral rates March 2019-March 2020

Of 108 patients:

  • There was no discussion with 51%
  • 19% declined a CI
  • 17% were unsuitable
  • 13% were referred for a CI

 

 

 

Southend audit process and results

The Audit Process

  • Run Cochlear CI Referral Report and output data to Excel.
  • Cross check each identified patient to confirm they are in criteria and assign an outcome status.
  • Output data and look for patterns in journal entries e.g. Did patients not referred have similar hearing losses?
  • Write report and make recommendations.

 

Southend referral rates

  • 5% of eligible patients were referred on
  • 52% had documented reasons for no referral
  • 43% had no action recorded

 

Download full report for Southend: CI 2020