Information for Referrers

Stakeholder / GP Training & Education

The service is already fully operational and integrated into the local health and social care community – voluntary sector, primary care, secondary care and tertiary services.

The service provides education and training such as supporting GP courses and courses for other hospital staff (medical, nursing, administration etc). We also provide training directly to the volunteers for Action on Hearing Loss and the Hearing and Sight Centre.

We provide training to all medical students as part of ENT rotation, so that all graduates from the Peninsula College of Medicine and Dentistry (PCMD) have a basic knowledge of audiometry and communication methods needed for the deaf and hard of hearing.  We also provide Special Study Unit for medical school – two week placements for advanced teaching.

Clinical Pathway Group

The Head of Audiology sits within the local Clinical Pathway Group, and works actively with commissioners, local GP representatives and ear, nose and throat (ENT) specialists to ensure that commissioned pathways are current and cost-effective. This group also enable feedback and changes to guidance to be fed to GPs in the area both by direct communication via Sentinel and through the Map of Medicine.

Any Qualified Provider Referral/Exclusions Criteria

For routine patients on the Any Qualified Provider (AQP) pathway, we will accept referrals that meet the criteria specified in the service specification as follows:

  • Patient is aged 55 or above
  • Patient has not had a previous hearing aid
  • Patient’s ears are clear of wax
  • Both ear drums are seen and healthy looking
  • Hearing loss is equal in both ears
  • No tinnitus or balance problems
  • No sudden deafness
  • No conductive element.

The exclusion criteria for this service is specified below:

Contra-indications which should not be referred into or treated by the Direct Access Adult Hearing Service (AQP):

History:

  • Under 55 years of age
  • Persistent pain affecting either ear (defined as earache lasting more than 7 days in the past 90 days before appointment)
  • History of discharge other than wax from either ear within the last 90 days
  • Sudden loss or sudden deterioration of hearing (sudden=within 1 week, in which case send to Accident and Emergency or Urgent Care ENT clinic)
  • Rapid loss or rapid deterioration of hearing (rapid=90 days or less)
  • Fluctuating hearing loss, other than associated with colds
  • Unilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5 minutes at a time
  • Troublesome, tinnitus which may lead to sleep disturbance or be associated with symptoms of anxiety or depression
  • Abnormal auditory perceptions (dysacuses)
  • Vertigo (Vertigo is classically described hallucination of movement, but here includes dizziness, swaying or floating sensations that may indicate otological, neurological or medical conditions)

Normal peripheral hearing but with abnormal difficulty hearing in noisy backgrounds; possibly having problems with sound localization, or difficulty following complex auditory directions. Ear examination:

  • Complete or partial obstruction of the external auditory canal preventing proper examination of the eardrum and/or proper taking of an aural impression.
  • Abnormal appearance of the outer ear and/or the eardrum (e.g., inflammation of the external auditory canal, perforated eardrum, active discharge).

Audiometry:

  • Conductive hearing loss, defined as 25 decibel (dB) or greater air-bone gap present at two or more of the following frequencies: 500, 1000, 2000 or 4000 hertz (Hz).
  • Unilateral or asymmetrical sensorineural hearing loss, defined as a difference between the left and right bone conduction thresholds of 20 dB or greater at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.
  • Evidence of deterioration of hearing by comparison with an audiogram taken in the last 24 months, defined as a deterioration of 15 dB or more in air conduction threshold readings at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.

Because of our highly qualified staff team, we are able to see most cases which are audiologically complex via direct referral. This is via our complex case pathway.

The only exclusions from this are listed below:

  • Unilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5 minutes at a time
  • Troublesome, tinnitus which may lead to sleep disturbance or be associated with symptoms of anxiety or depression
  • Vertigo (Vertigo is classically described hallucination of movement, but here includes dizziness, swaying or floating sensations that may indicate otological, neurological or medical conditions).
  • History of discharge other than wax from either ear within the last 90 days
  • Sudden loss or sudden deterioration of hearing (sudden=within 1 week, in which case send to Emergency Department or Urgent Care ENT clinic)
  • Rapid loss or rapid deterioration of hearing (rapid=90 days or less)
  • Fluctuating hearing loss, other than associated with colds

Where it is clear from the referral that the patient does not meet the AQP criteria, we will appoint the individual into our complex cases assessment service. This change will be coded onto the hospital system on the same day to facilitate the financial management. Due to the highly qualified staff we employ, this change rarely requires a physical change of appointment time or location, as our staff are able to see routine and complex cases. The GP will be informed in writing of the pathway the patient is on following the assessment.

If the referral meets one of these exclusion criteria, it will be rejected via the Choose and Book system with the reason noted, recommending an ENT referral. Again for information, we are currently working with the local clinical pathway group to enable the following criterion to also be accepted in our audiology complex pathway:

Troublesome, tinnitus which may lead to sleep disturbance or be associated with symptoms of anxiety or depression.

At assessment, if it becomes apparent that a patient seen under the AQP pathway meets one of the exclusion criteria, they will immediately be moved onto the complex case pathway. This seamless transition will enable management to continue with no loss of time or additional journeys for the individual patient, maintaining a patient-centred focus. This change will be coded onto the hospital system to facilitate the financial management. The GP will be informed in writing of the pathway the patient is on following the assessment.

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