The primary objective of local, state, and federal response to COVID-19 is to minimize mortality and mitigate explosive demand for acute health-care services related to COVID-19 complications, especially those that require care in intensive care units.
Governmental responses have varied from statewide stay-at-home orders to more incremental approaches targeting restrictions in specific industries and locations. Certainly, many of these restrictions are warranted and necessary to achieve the desired public health outcomes.
Even so, these decisions are not without associated short- and long-term costs. Those with the authority to institute restrictions—mayors, governors, and the President—have had to make hard choices and balance many competing demands. Thus far, much of the public discourse about these costs has focused on economic tradeoffs—stock market plunges, the record number of job losses, and the associated increase in applications for unemployment. But there are other costs, not yet fully apparent, for which the public health community should prepare.
Here we describe the implications of the COVID-19 response on children who were born during the time when in-person health-care services were limited, focusing specifically on newborn hearing screening (NBHS) and follow-up services for infants identified with potential hearing loss.
We argue that non-essential service determinations related to NBHS and follow-up, and their associated care disruptions, will negatively impact children with hearing loss and their families.
Further, we make recommendations for improvements and more systematic approaches to determining essential services should our country face another pandemic or a second wave this fall.
We use the response in Kentucky as an example since we reside here, and since Kentucky has been highlighted as a state with a successful response leading to fewer COVID-19 deaths (Courtemanche et al, 2020; Karimi et al, 2020).
We by no means intend to minimize the success of Kentucky’s response; rather, we seek to describe some unintended consequences of it that may be experienced by other pediatric audiologists across the country.
NBHS and Follow-Up Guidelines
NBHS is mandated in most states, and over 95 percent of infants are screened for hearing loss shortly after birth, most often in the hospital.
Critical to any successful public health screening program is the ability to provide timely follow-up, diagnostic, and intervention-related services for infants that fail the screening.
For state Early Hearing Detection and Intervention (EHDI) programs, “1-3-6” guidelines (National Center for Hearing Assessment and Management, 2020) are followed to ensure infants complete their NBHS by 1 month of age; any hearing loss is identified by 3 months of age; and early intervention is initiated by 6 months of age.
Ongoing monitoring of hearing is indicated for any infant that has risk factors for late onset or progressive hearing loss. Diagnostic testing is provided by licensed pediatric audiologists, who often practice in the outpatient setting. Besides their pediatrician, an audiologist is likely one of the first providers a family sees after their child fails their NBHS and is discharged from the hospital.
Determination of Essential vs. Non-Essential Services
On March 23, Kentucky Governor Andy Beshear issued KY Executive Order No. 2020-215 (State of Kentucky, 2020) restricting any “non-urgent” in-person health-care services.
The order offered guidelines for what is considered emergent (life-altering if care is not provided within 24 hours), urgent (life-altering if care is not provided within 24 hours to 30 days), and non-urgent, but these decisions were ultimately made at the individual organizational level.
In the case of pediatric audiology services, interpretations of this and similar orders have varied widely across the country. Some facilities, primarily hospitals, determined that pediatric audiology was an urgent service. Others determined these services were not urgent, or that only services that could be delivered curbside or through telehealth could continue.
These variations in interpretation within a state or across states have the potential to lead to care disruptions, particularly when telehealth is not an acceptable alternative, and ultimately to disparities in care or outcomes. For example, confirmatory diagnosis of hearing loss relies on the use of auditory brainstem response testing, which currently cannot be administered remotely.
Further, when hearing loss is identified, families are provided a host of options for interventions. Ninety percent of children with hearing loss are born to parents with normal hearing. Many, but not all, families choose to fit hearing aids for their child.
Hearing aids and the initiation of early intervention before 6 months of age has been shown to significantly improve early language development, and for many children their language skills are on par with typically hearing peers by kindergarten.
Others may pursue exclusive or complementary American Sign Language as a mode of communication and, in these cases, early diagnosis and support in language access is important so the parents can serve as language models for their children and so they can connect with the Deaf community.
Children whose hearing loss is identified later, or who do not receive timely intervention, take longer to reach speech and/or language milestones and are likely to experience academic delays as well.
During the initial stages of COVID-19 in Kentucky, all Early Hearing Detection and Intervention (EHDI)-related services including NBHS, diagnostic testing for infants that failed the NBHS, timely fitting of hearing aids, and professional and peer support in the family’s chosen mode of communication were negatively impacted due to various restrictions on face-to-face services.
For example, some hospitals did not provide NBHS to babies whose mothers were positive for COVID-19, and outpatient facilities providing the diagnostic testing were closed. The short- and long-term implications of these disruptions are yet unknown.
Compounding the confusion around how to comply with restrictions was the lack of formal guidance or consistent recommendations from professional stakeholder organizations, which could have played a large and important role in informing a unified response among this provider community. For example:
- The American Academy of Audiology issued the following statement regarding adult and pediatric audiology services:
- “Acknowledging that the majority of what we [audiologists] do is not life-sustaining (the definition of essential in the current crisis) does not diminish the significance of our work or imply that we should not be active in supporting our patients at this time. What we do is absolutely essential—communicating and successfully navigating space during a crisis is essential.
- Our challenge is to determine how best to do this essential work at a distance. This challenge necessitates innovation and use of available technology to support our patients’ communication and balance needs at a distance. Our patients need us to be our most innovative selves and share solutions amongst our colleagues. Rising to the challenge of innovation is not easy, yet, it is just as essential as our services.” (See Editor's Note below.)
- The American Speech-Language-Hearing Association suggested that audiologists follow recommendations from the CDC as well as state and local authorities, but did not offer specific guidance as to whether audiology services are essential, stating instead that a decision regarding essential/non-essential “is determined by their employer, city, or state.”
- The American Academy of Otolaryngology, in an article recently published online, has stated “care for patients who are Deaf and hard of hearing should be considered time-sensitive and essential during the pandemic”, and made specific mention of services provided in EHDI programs.
- The American Academy of Pediatrics issued guidance stating that adherence to EHDI best practices is recommended during the pandemic, in accordance with state-issued guidelines or orders.
Current Impact of COVID-19 on NBHS and Follow-Up Care
States are now starting to open up, restrictions are being lifted, and some health-care providers are back in their office providing in-person care.
For the states and the EHDI programs they manage, tracking infants whose NBHS and follow-up were delayed or not completed due to COVID-19 will present new challenges. Loss to follow-up rates are an important metric for state EHDI programs, and these rates are likely to increase during the COVID-19 period and in any future wave that disrupts direct service delivery.
Infants who failed the NBHS during the period covered by restrictions, and who require diagnostic testing, will need to receive highest priority for face-to-face services as soon as these services are permitted by individual states and can safely resume. For pediatric audiology practices that are scheduling these and other referrals, wait times will increase despite the importance of timely testing.
To alleviate increasing wait times, states should consider the following:
- Review their state EHDI guidelines for follow-up after NBHS to determine if babies can be further triaged to increase efficiency of follow-up. For example, in Kentucky, the EHDI Advisory Board implemented guidance on March 30, 2020, that infants who failed the NBHS in one ear and did not have any risk factors for hearing loss could receive a screening in an outpatient audiology clinic, provided they were seeing patients.
In Kentucky, rescreens are generally performed in the outpatient hospital setting. This decision sought to reduce the backlog of infants in the system, since a screening takes significantly less time than a diagnostic hearing evaluation and infants who fail a screening or rescreening will have priority and more timely access to a diagnostic evaluation.
- Assess provider readiness for delivering services via telehealth, particularly in specialties where urgent care is not feasible using telemedicine. Diagnostic testing, as well as arranging for a hearing aid fitting and early intervention services in a system that has been forced to function at significantly less than capacity due to social distancing requirements will increase time to intervention, and potentially affect speech and/or language outcomes for that child.
Telehealth platforms can address some, but not all, of these needs. For example, First Steps, Kentucky’s early intervention system, has long had a stance that telehealth services would not be reimbursed.
An emergency regulation implemented by Governor Beshear on 3/20/2020 allowed early intervention services to be rendered via telehealth for the duration of the pandemic, but the rollout and implementation has been problematic at best; and telehealth may not be permitted in the future.
Pediatric audiologists, and other providers serving children with hearing loss, cannot be expected to resolve this alone and at the expense of their patient outcomes.
As we begin to think about a second wave of COVID-19, or even plan for another pandemic, we need to ask what should be done differently, and how can we be better prepared next time?
We suggest the following considerations:
- Instead of a blanket classification of an entire profession’s services as essential or non-essential, consider development of a rubric to evaluate each individual service type. The literature supports that pediatric hearing loss is a neurologic emergency, and this should be a strong consideration. Using the language in Governor Beshear’s order referenced earlier as a rubric, all EHDI services would fall within the “urgent” category, which means that life-altering consequences could occur if services are not provided within 30 days.
- Stakeholder organizations in EHDI, or in any healthcare service, need to present a unified and consistent message to providers about which services should be considered urgent versus non-urgent. In the case of audiology services and COVID-19, the lack of consistent messaging among professional organizations, coupled with some states’ guidance that individual providers needed to decide for themselves if a service is urgent or non-urgent, increased the difficulty of organizations’ responses.
- Reimbursement of telehealth services for audiologists and other professionals serving children with hearing loss and their families must be put into state and federal regulations outside of current emergency orders related to COVID-19, in order to promote the use of remote support to reduce face-to-face contact when appropriate for the service being rendered.
- Newborn hearing screening and follow-up diagnostic testing are currently not widely available or feasible in a telehealth model. Infrastructure for these services needs to be standardized and expanded to assist in future situations where in-person services are not feasible. This may also help with loss to follow-up, since families would be able to access these services in a rural community or even in their own home.
So the answer is yes, we believe newborn hearing screening and follow-up services are essential and urgent during a pandemic. Despite inconsistent guidance early in this pandemic, we also believe the professional organizations would agree. We cannot yet measure the true impact of these recent EHDI screening and follow-up service disruptions. Even so, their potential negative effects on children’s communication, language, and learning outcomes should elicit a strong response from the audiology, public health, and otolaryngology communities so this does not happen again this fall or ever in the future.
Editor's Note: The Academy did provide additional guidance specific to infant and pediatric care, recognizing that institutions would need to make their own decisions about care during the pandemic. The Academy promoted to members a webinar offered by the Children’s Hospital of Pennsylvania (CHOP) and Academy and pediatric audiologists in the Academy. Many of the resources and tools from this live event are still available to Academy members on the Audiology Community (Pediatric Speciality Group).