Hello, everyone, and thank you for joining me for a presentation about recent updates to audiometric evaluation procedures. We hope to provide some clarity and give you the tools to implement the changes with your trainees. A little bit about me. My name is Rebecca Kraus. I have been a hearing instrument specialist for almost 10 years now. I have a bachelor's degree in educational technology and a master's degree in education with an emphasis in online teaching and learning. For much of my career, I was the director of an associate's degree program for hearing instrument science in Springfield, Missouri. I now co-own Rope Up, an online hearing instrument specialist training company, and work in a clinic full-time helping patients hear better. I am an active member of both the International Hearing Society and Missouri Hearing Society and volunteer my time to help support those organizations when I am able, which brings me here today. So thank you to IHS for hearing member feedback and making this presentation possible. So a little bit of housekeeping. I don't have any handouts for viewers for this presentation, but you can find more information about CE credit for this presentation by visiting ihsinfo.org. And during this presentation, we will identify updates to best practices, discuss strategies for implementation during the training process, and identify sources for future updates. So let's start by taking a look at some recent updates to best practices. These are the few of the topics that we're going to talk about today and some of the things that have been updated in our best practices document and in the 2022 edition of the distance learning course. So the first update we want to talk about is the recommendation to test bone conduction in the inner octaves. So many trainers feel that testing bone conduction at all frequencies between 250 hertz and 4,000 hertz is excessive. However, many textbook authors within our field recommend testing bone conduction at every frequency that air conduction was tested. And right now, IHS is also recommending that octaves and inner octaves be tested for air conduction. So best practice really is that between 250 and 4,000 hertz, we're testing all of those frequencies for bone conduction. And without knowing where the bone conduction thresholds are, we don't know if there are air bone gaps. Additionally, some fitting algorithms use bone conduction thresholds to calculate the patient's prescription. This is especially important in cases of patients who have mixed or conductive hearing losses. Giving the fitting software more information leads to more accurate hearing aid fittings. And in truth, it doesn't add that much time to our testing process. The next item is pure tone loudness discomfort levels. So many people have been testing UCL using cold running speech. And looking at research and patient outcomes, IHS has come to the conclusion that using pure tone LDLs are more impactful and beneficial to the patient's fitting. And thus, they recommend LDLs over speech UCLs. So LDLs should be completed between 500 hertz and 4,000 hertz. And this information goes into the fitting software and further personalizes the fitting, much like bone conduction. And the measurements are especially important for patients with recruitment. Estimated MPO may be too loud for those patients. So here, you can see an example of the LDL procedure from the IHS Distance Learning Course textbook. Their procedure recommends testing each frequency twice and averaging them. If the first two measurements are 10 dB or more apart, the recommendation is to take a third measurement and average all three. So there are the instructions there. And they use LDL and UCL, the terminology, interchangeably. So sometimes you'll see LDL. Sometimes you'll see UCL for pure tones or discrete UCLs. All the same thing. One of the textbooks I frequently refer to uses a slightly different procedure for measuring LDLs. They recommend testing at least two frequencies, usually 500 hertz and 2,000 or 3,000 hertz, or testing whichever frequencies have a hearing loss where amplification will be applied. So for many patients with high-frequency losses, you would choose at least two frequencies in the high-frequency range where they have a hearing loss. And it would be the same where you're taking two measurements and averaging those two or taking a third measurement if the two initial measurements are 10 dB or more different from each other. And I'd say here, use what makes sense to you, what makes sense to your trainee, and what makes sense for your clinic and your patients. If it's something that's eating up a lot of time, maybe doing just those frequencies where the patient has a hearing loss and amplification is going to be applied would be good enough. Or maybe having some standardization and just measuring all of those frequencies is going to work better. That's something that you'll have to work out, you know, talk to your supervisor, talk to your trainee, and you can, you know, kind of decide what to do there. So probably the biggest thing we've heard, I've heard it a lot from people I get a lot of questions from previous students, previous trainees I've worked with, from colleagues. And I know IHS got a lot of questions when this 2022 edition of the distance learning book came out. But there's been a change to the recommendation for word recognition presentation levels. And so many people have asked why the change? Well, the change was made because research has shown that commonly used presentation levels many times fall short of reaching a level that's loud enough to maximize audibility. So when people, when you use, you know, SRT plus 30 or 40, when we're testing word recognition at MCL, or even MCL plus five or 10, those levels are all very inconsistent. Sometimes they hit the mark and they're loud enough. Other times they're way below what they should be for maximum audibility for our patients. So the new recommendation is looking at the patient's pure tone threshold for air conduction at 2000 Hertz and adding a level, we'll go through a chart next that will show those different levels. And I've included a QR code here that links to an audiology online presentation or article by Gus Mueller on this specific topic. And I recommend it to people all the time. Anytime I get this question, it's an excellent article and really kind of breaks down all of these components to this topic. So here's a screen capture from the IHS distance learning textbook outlining this 2000 Hertz plus sensation level rule. So using this new procedure for figuring the presentation level, you would look at the threshold for each ear and then add the specified amount according to this breakdown. You could print this out, have this next to the computer, especially when you're working with a trainee so that it's close by, it's easy to access, and it's there until you have that memorized and kind of just have it all in the back of your head. And another thing that I've had a lot of questions about, I think that IHS has had some questions as well, is about the critical differences chart and the sprint chart used in the 2022 edition of the distance learning course. And the sprint chart and the critical differences chart that are referenced were created using the NU6 lists. So NU6 are what is recommended, be used by providers and clinics. And if you need help locating a sprint chart, feel free to send me an email or reach out to IHS. I'll have our contact information at the end of this presentation. And the sprint chart is a tool for verifying if the obtained word recognition score correlates with the PTA. Interpreting the sprint chart will be covered in our next presentation in this series. So we'll do more, take a closer look at that. And if, you know, you need to be doing a full 50 words with your NU6 W22 lists, that is, there's been plenty of research on the poor outcomes when we use 25 word lists, which it's not even 25 word lists, it's a half list. So all of the research and studies have been done on the 50 word list as a full 50 word list. And if doing a full 50 words is, you know, you feel that it takes too long or that it's can be fatiguing for a patient, then I would highly recommend ordering an NU6 ordered by difficulty list. It's research based. It starts with 10 words. And if the patient gets all 10 words correct, then you mark their score and move on to your next test. If they miss, you know, a certain number within the 10, then you go to 25. If they miss a certain number within the 25 words, then you go to the full 50. So for those cases where you have patients with really good word recognition scores, a ordered by difficulty list is going to make that test shorter, save time, and, you know, maybe cause less fatigue for the patient. I've got some QR codes there with places to purchase the ordered by difficulty list. And I would recommend reaching out to your equipment provider, whoever services your audiometer, all of your equipment in your office, and talk with them about getting those lists installed so that you can use them with your equipment. And now let's take a look at speech and noise tests. So speech and noise tests have been around for some time. And the most popular list speech and noise test is the quick speech and noise test. A lot of manufacturers offer the option to purchase a license when you purchase new equipment or to add on to current equipment. You can also buy the test through Oak Tree or Edemonic directly, and it'll come either as a download or a CD, and you can load it into your software. And performing some type of speech and noise test is a best practice recommendation. There are many options. There's the hint hearing and noise test. There's the win words and noise. And most recently released is the ACT, audible contrast threshold test. And I've linked an article there if you are interested and want to learn more about it. But it's not actually a speech and noise test because it doesn't use speech. It uses a siren and then some background noise to measure the patient's ability to differentiate the siren signal from the noise. And so that makes it a great option for patients who don't speak English or English is not their first language. And I haven't personally run the test, but from articles that I've read and a couple of videos that I've seen, it looks like it could be a quick and effective test to see, you know, what features would be best recommended for that patient. And the results are very similar to the QuickSend, and they have a chart that tells you what the results mean and maybe what some features in the hearing aid programming software might be good to help that patient. And just a quick update on tympanometry. Some of you might have noticed that normative values have changed in the newest edition of the distance learning course. I'd encourage trainers who have been doing tympanometry to keep a quick reference guide available while adjusting to these changes and besides that nothing else has changed about how to perform tympanometry. But it's just some good information to know something to be aware of especially if you're working with the trainee and maybe they're quoting some different values than you and so just something to keep in mind and to maybe keep close by your tympanometer. So those were all the topics that have been coming up related to you know audiometric evaluations. So let's look at some strategies for implementing these changes with trainees. First and foremost, I'd say that if there was anything I previously mentioned that what you're not familiar with take time to practice so you get comfortable with the changes and can answer trainee questions as they arise. When implementing these changes into your daily practice be honest and open with your trainees. Let them know you're learning something new. Things change and this allows you to explain to them that as research emerges sometimes we have to change the way we perform tests or we have to add tests to our standard procedures. Allow them to see your learning process and take it as an opportunity to learn something together. That really helps build the bond between the trainer and the trainee and it makes you seem more like a human being. You're a person, you know, you have to learn things too and maybe things aren't always easy to learn at first. So just just be honest and you know, take that time to to learn new things and be patient with yourself and you know, not everyone knows everything and we shouldn't put that expectation on ourselves as trainers. So looking at ways to implement these changes with your trainees when you're used to training one way and doing things in clinic with patients one way is to one practice on your own implement these strategies in your own practice and then when you're working with trainees use the tools that IHS has built already for you in the trainer manual in the distance learning course workbook. Those two work together seamlessly and were built as complement. So everything in the workbook ties into the trainer manual and the trainer manual has answer keys, has prompts, has suggestions on activities to do, on things that you can do to demonstrate skills and it has checkoffs so you can make sure that that trainee is mastering these concepts. So I've included a couple of screen captures here and anytime a trainee is learning a new procedure or concept it helps tremendously to link the new information back to previous topics that they've already mastered. So at this point in their training, they should have had some kind of look at pathologies and anatomy and physiology. So in the case of bone conduction relating bone conduction scores to various pathologies is a good way to build connections, critical thinking skills and to drive home the importance of performing bone conduction accurately. And some ways you can support the learner and help build those skills so that it becomes just muscle memory that they're going through these steps is to use virtual audiometers. There's a few available. The images that I have here are of Theta. There's also Counselor, Otis, and I believe a few others. And using these tools will help them improve their accuracy and speed. So this is something they can do at home or in the office just at a different computer. That way they're not taking up, you know, time at the audiometer or ending up in appointments that are running way over and put the whole day late. So yeah, since they have their virtual, they have access to them so they can work on this anytime. Once the trainee starts practicing, you can have them prove their competence by by providing you with screen captures or printing out reports or by spending some time demonstrating their abilities in clinic just at a computer where you can observe what they're doing. In some of these softwares, trainers can set goals for trainees and you know, goals can be set outside of the software as well. So you could, you know, set a goal for the trainee to complete testing in a specific amount of time or challenge them to be their personal best with, you know, this number or fewer of errors. I'm most familiar with Theta and they have excellent resources for trainers and provide wonderful user support. They're very responsive and really want to help elevate the field and help people learn how to perform these audiometric tests properly and efficiently so that it's, you know, not taking so much time in clinic. The images that I'm showing here, little screen captures, are showing where Theta has an audiogram of the day feature and this is free to anyone. So you don't have to have an account. You don't have to log in. There's no charge. You can go to their website and have your trainee every day go through the audiogram of the day and each day it provides a new scenario and shows how the user compares to other users who have completed the audiogram for that day and each day there's a new audiogram. So you could have friendly competition between you know multiple trainees between the trainer and the trainee. There's a lot of ways to make this you know more fun and engaging for trainees who might feel like, you know, it's a little monotonous having to go through this many tests over and over and over again, but like I said in the first presentation, perfect practice makes perfect. So they have to be doing things accurately many many times to ensure that they're going to be consistently doing that further down the road. So thinking about ways of supporting learners when they're learning how to perform pure tone loudness discomfort levels. It's an easy test to add into the audiometric evaluation process. There's no like extra tracks. You're using pure tones. They're already comfortable with that. And I would recommend integrating it right after air conduction or after air and bone or you know, maybe once you've done SRT going back whatever works. It doesn't really matter what order you do the tests in as long as you're getting them done. But I'd say letting the trainee build their confidence with pure tone threshold testing, air conduction, bone conduction, is going to be good before moving on to loudness discomfort levels. And one way to build critical thinking skills and develop a deep level of understanding is to have trainees look at how LDL scores or a lack of LDL scores impacts MPO settings in the software. So this could be accomplished by having the trainee create two practice patient profiles in NOAA or whatever patient management software you use and have them both have the same air and bone conduction thresholds but have one with LDLs and one without LDLs and then have them look at the differences between the two fittings. Is MPO different? Are sudden noise settings different? You know, what features are different because of this information added or lacking? Then have, you know, set time apart to have a discussion. To talk about the importance of performing LDLs with each patient. And again here, I've got a little screen capture of the trainer manual and it has some prompts there for discussing loudness discomfort levels with trainees. And some tools to help support trainees learning how to perform loudness discomfort levels or even speech UCL measurements for the first time. Using one of those virtual audiometers can help build muscle memory so they can complete the measurements efficiently and it can also help with their patient instructions. Having a trainee give their patient instructions to you or record themselves and send it to you or record themselves and they listen to it is a great way to help them figure out where their instructions might be confusing or maybe they're going on too much and explaining too many things. It usually just takes a couple times of listening to themselves that they start to really hone in on where they're doing well and what things they need to change or maybe just get rid of. And I recommend to trainees all the time to use the categories of loudness discomfort levels the categories of loudness chart. It's shown here on this slide. It includes excellent LDL UCL patient instructions. There's a whole packet and it sets the trainee up to obtain accurate levels. And if you've you know spent time working with trainees doing uncomfortable level testing many trainees are afraid of hurting the patient by presenting loud sounds. You know you get up 80, 90, 100, 110 and they're really stressed about it and this anxiety of not wanting to hurt the patient not wanting to damage their ears can lead to giving poor instructions, the patient being confused about what the test is really looking for what they're supposed to be doing and it can even cause the patient anxiety because they don't want their ears to hurt either. And all of that translates into unreliable results like LDLs being too low. So giving them lots of practice in a virtual audiometer or having them practice in clinic giving instructions and then giving them feedback on what parts of the instruction, you know sound good and clear what parts they might need to work on a little bit more. And then using that categories of loudness chart and instructions is a really really good way to get them started on the right foot. That QR code will take you to that categories of loudness chart and the instructions. So looking at word recognition levels or presentation levels some strategies for implementation really the best way to you know get into the habit of using these new recommended presentation levels is to have a cheat sheet that you're using and have it at the audiometer. That way it's right in front of them, it's right in front of you and you're being prompted by seeing it all the time. I usually have students and trainees complete pure tone testing and get comfortable with SRT before we work in word recognition testing. Whatever you know process works for you and your clinic and your trainee is just fine. There are some prompts in the trainer module and assignments in the trainee workbook around word recognition, how to get them familiar with the process, having them observe is a great way to for them to learn good instructions for the patient. So ways to support ways to support learning and build skills regarding word recognition presentation levels include using those virtual audiometers. Theta has word lists and speech testing built into the software. Other virtual audiometers may have this ability giving them access to this type of software allows them to practice in you know when they're not sitting in front of a patient with such high stakes. So as with bone conduction and LDLs, the trainee can provide the trainer with reports, screen captures, et cetera, to demonstrate that they are becoming proficient. And trainers can review the results for accuracy and provide feedback so the trainee can correct any problems before they start working with patients. And you can also make trainee observation time more interactive by asking trainees to calculate presentation levels, forward recognition for the professional that they're observing. So while the trainer's doing testing, the trainee can be watching for results and calculating PTA, calculating presentation levels, starting levels, writing down when to mask, et cetera. It can be a really good time for them to build those critical thinking skills without having to be doing that and learning the equipment and working with the patient all at the same time. So kind of adding those little bits in throughout the training process builds the skills without having it all in one overwhelming situation. So in my first presentation for this trainer webinar series, I talked about the concept of perfect practice makes perfect. And we mentioned this a few slides ago, too. This is one of those situations where the trainer has a responsibility to demonstrate best practice and demonstrate perfect practice. And it isn't enough to tell the trainee that they have to present 50 words. And then as the trainer, you go and present your 25 words or however many words you're shortening the list by. Trainees need to see that what they're learning is applicable in the workplace. And this is especially applicable for Gen X and millennials. Many learners in these generations are only motivated to learn new things when they know they're going to be applying that knowledge to their job or to a hobby somewhere. They don't necessarily just like to learn things to learn them. And they definitely don't want to spend time learning something that is not applicable. So this is definitely a scenario where a trainer has to set the example if they want the trainee to do the right thing when they're practicing on their own. If the schedule in the office is really packed and time is a concern, again, consider purchasing the order by difficulty list and follow the instructions for those lists. Cutting corners with word recognition lists results in scores that are just not valid. And again, go back a few slides and check out the article that I referenced earlier by Gus Mueller on Audiology Online if you'd like to learn more about the research and kind of the why on this topic. So even in the trainer manual, IHS is referencing using the ranked by difficulty or ordered by difficulty word lists and talking with the trainee about the benefits and advantages of using this list versus a full 50. So speech and noise tests, we talked about there being many different options for speech and noise tests. It really depends on what's available in your clinic, what you were taught, a variety of things. And there's a lot of different options for speech and noise tests. And it's good to set goals for these additional tests. So we know, according to best practice, you should be doing some type of speech and noise test with every patient. But some of this is slow to work its way into daily practice for the majority of providers. So as your trainee is learning, so you have pure tone, air conduction, bone conduction, then you add LDLs, you add SRT, you add word recognition, you add speech and noise testing, and just kind of build on their testing procedures. The trainer manual and trainee workbook have speech and noise activities. I don't know of any virtual audiometer that has speech and noise tests integrated yet. So that'll be something that trainees will have to practice at the audiometer in the office. But luckily, most speech tests don't take a long time to perform. And it's good to set time apart to discuss the results with the trainee and how QIXIN or WIN, HINT, whatever speech and noise test you're using, how the results from those tests inform the recommendation for hearing aid technology, adjusting software features, et cetera. And also relating speech and noise results to any validation questionnaires or complaints the patient made during intake about struggling with speech in noisy environments. So do the patient's complaints correlate with the results of the speech and noise test? It's a good way to say, OK, we heard that you were saying you struggle when you go to dinner with your family. After we ran this test, we can see that you do have a moderate speech to noise ratio loss. So that makes sense. Our results are showing that you do have some difficulty with those situations. It's just a good point of discussion with the trainee. And just like when you're learning with the word recognition, the new presentation levels, if speech and noise tests are not something that you've usually done, but you're going to start working them in, keep a scoring guide and instructions near your audiometer for quick reference. You can always tell the patient, I've got to figure some numbers, give me a minute, something like that. And they understand. Patients don't know what they don't know, what is going into the test. So if it takes a couple minutes to figure out what buttons to click and what level to set it at, that's OK. So again, use the trainer manual if that's something that you have access to or something that you're interested in. I would highly, highly recommend it. It gives you all of these activities so that you don't have to spend the time to come up with them. So here, there's a trainer task to help you have a discussion with your trainee about what speech and noise test you use and why you use it. And then you're demonstrating the test for the trainee. And then in the trainee's workbook, they have an assignment to, in their own words, explain the benefits of completing speech and noise testing. And this is something that you can have them work on and then have them pull up and review with them. And then in the trainer work, in the trainer manual, there are competencies. So you have items where you're discussing these things with the trainee, or you're observing them complete tasks, and you're marking them as far as their proficiency level. So there's one there in the middle, relates the rationale for speech and noise testing to recommending technology and providing counseling. So again, we're building on the skills and pulling in those critical thinking aspects and relating these tests to other aspects of the patient's hearing health care journey. So how do we keep up with these changes when they arise? Sometimes it's so busy day to day, and you get into the group, and then all of a sudden you hear, oh, that's not the right way to do that. Or maybe your trainee pulls up a book and says, well, why are we doing it this way instead of this way? It's important to keep up to date with changes to best practice. And especially for trainers who have trainees off and on, the gaps in time between having a trainee can mean that there are multiple changes. That's not to say that best practice recommendations are changed frequently. Updates are made when there's new research or an industry standard has changed. So it's important to have sources that you're tied into, that you're checking into for future updates. So here are some ways that you can stay in the know with future changes and emerging research. Updates to content and additional resources are added to the online trainer toolbox, included with the trainer manual as they arise. So if there are new resources, if there's a correction to something, if the best practices change, IHS uploads all of that into the trainer toolbox so that you have access to the most up-to-date information. But you can also follow social media pages, bookmark the IHS best practice guidelines, and keep up with your hearing health care journals. You can even subscribe to various journals and get email updates with articles under whatever category you mark as being interested in. There are a lot of ways to stay up-to-date, attending conferences, many, many, many ways. But here are just a few that are easy, you can do from home, and are kind of already built into some of the things that you're doing anyway. And if you ever hear about a change that you're not sure about, you can always reach out to IHS for clarification. Their email address will be included in the last slide of this presentation. So originally, our idea for this presentation is what to do when you don't know what to do. And really, when the new edition of the distance learning book came out, I had a lot of questions from trainers and supervisors about, well, I don't know how to do this. And how am I supposed to show someone how to do something? Or maybe they were giving some pushback on, well, that's not the way I was taught. There's nothing wrong with the way that I'm doing it now. And my challenge to trainers is to embrace change and work on developing a mindset of lifelong learning. As new research emerges, as technology changes, and we learn new ways to provide the best care possible for our patients, there will be moments when what you're used to doing has changed. And when you develop a positive mindset toward change, it instills those values in your trainees and the people you're mentoring, truly everyone around you. And it can be hard. But as I said earlier, if you're learning something at the same time a trainee is, be honest. Take it as a moment to bond and to show that things change, and you have to learn new things, no matter how long you've been in the profession. It's also important to share your process for staying up to date. It's important that trainees learn how to research information on their own. This prepares them for their licensing exams, which is important, and ultimately, to be an effective professional. If they observe you doing something, they will be able to learn from you. If they observe you demonstrating a commitment to learning beyond just the licensing process, they'll be more likely to adopt those habits long term. So, you know, be honest, be open with your trainee. No one knows everything, and that expectation is just not realistic. So, be kind to yourself as you're learning new things. And again, if you have questions, you're not sure, maybe you heard something from a colleague or read something online, IHS is always happy to help provide additional information and resources and point you in the right direction for, you know, clarifying or maybe learning something new. So, if you have any questions about some of the things we covered in this presentation, feel free to send me an email or email professionaldevelopment at IHSinfo.org, and we'll be happy to answer your questions, provide you with additional information, help in whatever way we can. And then again, there's my email address and my LinkedIn page. I'd be happy to connect with you. And for more information on obtaining CE credit for this webinar, visit IHSinfo.org. Thank you.

audiometric evaluation procedures

bone conduction testing

pure tone loudness discomfort levels

word recognition presentation levels

speech and noise tests

tympanometry

training process

lifelong learning

professional development