management of these patient; aka Aural Rehabilitation.

If you get someone at birth, rather than rehabilitation, you use habilitation since there was nothing to rehabilitate.

Aural Rehab: LACE (Listening and Communication Enhancement)

Degraded speech

Aural Rehab: LACE (Listening and Communication Enhancement)

Cognitive skills

Aural Rehab: LACE(Listening and Communication Enhancement)

Communication strategies 

THE AMERICANS WITH DISABILITIES ACT (ADA) OF 1990

This law applies to all ages.  It provides comprehensive civil rights protection and prohibits discrimination to individuals with disabilities in the areas of

Title 1  employment,

Title II  public services (state and local government services including education)

Title III public accommodations

Title IV telecommunications

Title V  miscellaneous 

INDIVIDUALS WITH DISABILITIES EDUCATION ACT (5-21  - IDEA PL 94-132)

IDEA 

Part B (3 – 21 years)

Ensures early services for the children 3 – 21 years and address identification, evaluation, and rehabilitation of hearing loss.  Utilized the IFSP or individualized family service plan.

Part C (birth – 3 years)

Ensures services birth through 3 and may provide the hearing aids for the child if no other insurance coverage.  Also works with parents.

SECTION 504 OF THE REHABILITATION ACT OF 1973

This section applies to all students who do not quality for services under IDEA.  If a child with hearing loss does not meet the eligibility requirements for special education services under IDEA, provision of adaptations to or modification of regular education services to support the student’s academic performance under this section can be explored.

Some methods are:

a.    Auditory-Verbal approach (uses only audition and amplification)

b.    Aural/Oral Method (auditory and speech reading; child’s output is oral

communicate by sign and finger spelling

          Some methods are:

a.    ASL – American Sign Language – different grammar than oral English.  Communicates concepts rather than individual words, uses facial and body movement and is processed spatially

b.    Cued Speech – enhances those speech sounds that are difficult to differentiate

c.    Finger Spelling – this preserves rules of grammar and syntax

d.    Manually Coded English (MCE) – Signs correspond to English words and syntax is the same, includes Seeing Essential English and Signing Exact English)

Children spend their entire day in a regular class except for times to received support services related to their disability.  They are entitled to the “least restrictive environment”, however, this is not the right choice for all children.

children are in a class for the hearing impaired and attend a regular school equipped for this class.

Educational terms to be familiar with

IEP:  individualized education plan

IFSP: individualized family service plan – educate parent to make the decision

IDEA:  Individuals with Disabilities Education Act

Section 504 – Part of ADA and applies to those who do have an IEP

Part C – for those found to be significantly hearing impaired under 3

Part B – for those over 3

Ø   devices that look like hearing aids and emit a noise to cover over their tinnitus

Ø   similar to tinnitus maskers but more broad-band noise and go to mixing point where they hear both, their own sound and the noise

Ø   This mixes using noise generators and directive counseling and may take up to 18 months to give full relief

Ø   a new device from Australia using music with underlying noise & takes about 6 months for treatment

Ø   A homeopathic device with different sound cards including environmental sounds for sleep/relaxation and a card with sounds for tinnitus; often helpful during the evening for those suffering from tinnitus or to help get to sleep.

Ø   a handheld device which emits an ultra high frequency sound for one minute to temporarily inhibit tinnitus

Ø   This is a hearing aid which permits a concomitant noise.  As of the writing of these notes, two manufacturers had devices for amplification and tinnitus and two other manufacturers are about to get into it.

  customized audio device to be used daily using customized acoustic enrichment sounds.  As with all other devices, the objective is to beat the link between the tinnitus  and sympathetic nervous system so the user’s consciousness and attention is not to the perception of their tinnitus.

This device looks like an iPod as does the Neuromonics and uses “S” tones, their proprietary sound along with options for narrow band noise and broad band noise as a noise therapy

Pathogenic versus opportunistic:

1. we usually think about pathogenic, HIV, Hepatitis B.  They are inherently pathogenic organisms that make humans sick when they come in contact.  The other part of infection control deals with opportunistic organisms.  That is, those organisms that are supposed to be there, they live with us, they live on us, and they could make us sick by their absence.  These opportunistic organisms are capable of causing disease if we give them the opportunity and generally we give them the opportunity by some deficiency in our immune system.  Audiologists usually deal with people at 2 opposite ends of the age continuum:

1. We deal with young children with underdeveloped immune systems

2. We deal with older adults whose immune system begins to wear out as they continue to age.

Mode of Transmission (Vehicle):

a. contact

How germs are spread from one person to another.  There are 4 common modes of transmission.

a. Contact: the most prevalent form of transmission of germs.    

There are 3 types:

i.      Direct:  spread of germs between people by touch.  May occur from handshakes to pulling the ear back.

ii. Indirect: germs are spread via inanimate objects or surface, i.e. countertops, armchairs, etc.

iii. Droplet: occurs as we talk, cough, sneeze, etc.  Droplets of moisture are sent from our respiratory system into the air and the droplets of moisture contain little microorganisms that live in our bodies and our head is usually close to the patient and you may exchange respiratory droplets with those patients.

Mode of Transmission (Vehicle): 

b. vehicle 

2. Vehicle: this may be from food, water, blood, or other body substances.  Pathogenic and opportunistic organisms may be transferred through blood but ear drainage (mucous) and cerumen can be potentially infectious bodily substances.  The dangerous thing about cerumen is that because of its color and viscosity and the overall nature of that substance, it is difficult to ascertain whether or not that particular substance is contaminated.

Mode of Transmission (Vehicle):

c. Airborne 

3. Airborne: This is the sum total of all the things we put into the air.  The respiratory droplets, the heating and cooling system, walking on carpet, all join together.  Remember, what goes up into the air eventually settles down on surfaces and objects.  So we need to regularly clean surfaces, whether or not they need it.

Mode of Transmission (Vehicle): 

d. Vectorborne 

4. Vectorborne:  Not very pertinent to this discussion but this is where organisms are spread from one person to another via a vector.  A vector is an insect or small animal (e.g. lyme disease and ticks, malaria and mosquitoes).

This is how organisms enter the body.  The most common routes are the normal body openings, eyes, ears, nose, and mouth.  They are normal body openings.  But the ears are connected via the Eustachian tubes to the rest of the respiratory tract, the possibility for an organism to come from outside the body, find its way into the middle ear through the Eustachian tubes and into the respiratory tract is a very real possibility.  This is possible with small, microscopic teas and fissures on the TM that you cannot even see.  You can create a body opening through nicking, cutting, or scratching the patient through cerumen management or impression taking.  So you can crate a route or pathway allowing the organisms in to cause infection.

The basic premise of an infection control program is to:

Reduce the number of pathogens in the environment to a level where the normal resistance mechanism of the body may take over and prevent infection.

Based on this premise, the definition for an infection control program is:

An organized effort to manage one’s environment in order to minimize exposure to pathogenic microbes that can make you or your patients sick.

Specific Health Concerns:

1. HIV, HBV, CMV

a.    HIV – difficult to contract

b.    Hepatitis B:  Transferred by blood to blood contact through saliva and the human bite.  It is scary because many with this problem never show symptoms and so it doesn’t show up on a history form

c.     CMV:  there is concern with this due to the fact it generally leads to central nervous defects.  The most common is hearing loss in unborn children.  We get exposed when we see these children.  The most dire consequences occur during pregnancy.

Specific Health Concerns: 

2. TB, Flu, colds

a.    TB:  WHO thought this would be gone by Y2K and it isn’t.  It is now at epidemic proportions around the world.

b.    Flu:  an airborne disease that is transmitted via respiratory particles.  For many we see, this can be life-threatening so it behooves us to look into flu shots.

c.     Colds:  you can reduce this by simple things like washing your hands.

Specific Health Concerns: 

3. Fungal/Bacterial Transmission

This is probably the least severe but most common form of infectious situation.  You can transmit this through the handling of hearing aids and earmolds.  As the ear is the “greenhouse of the body”, it is the perfect place for growing organisms.  They are usually kept in check by our immune system.  But as you change the PH of the ear canal, it becomes vulnerable and the organism prolific.  They can spread and cause otitis externa.  The organisms can colonize on the hearing aid and earmold and then when you handle it, you can transmit them as well.   So disinfect hearing aids and earmolds carefully before handling them.  Always wash hands before and after patient contact and handling of hearing aids.

This is a 2-step process.  You must first:

a.    clean to remove the gross contamination and then

b.    disinfect to kill germs.

Areas to be disinfected are:

1.    Counter tops, chair arm rests in all rooms, all tables, etc.

2.    The lab area after working on devices.

3.    The reception counter in the morning, at noon, and at closing.

SURFACE DISINFECTION: 

Cleaning Products 

Note that some products that both clean & disinfect.  You should:

1.    Choose a hospital-grade, EPA registered, disinfectant/cleaner. 

2.    Spray or wipe the surface with the disinfectant/cleaner.  Wipe away all gross contamination with a paper tower or coarse brush if needed.

3.    Spray or wipe the surface again and leave it wet to the time as specified on the label.  It is during this dwell time that germs are killed.

4.    When there are multiple items, they can be disinfected in the ultrasonic machine.

IMMERSION DISINFECTION

An ultrasonic cleaning machine can be utilized to clean and disinfect noncritical objects and instruments.  The items to be disinfected in this manner include specula, probe tips and earmolds that appear free of blood, mucous, or significant cerumen.  They will remain in the disinfectant bath as long as directed on the label.  Remember to clean before disinfecting.  

Infection Process:

1. Virulence

1. This relates to how quickly our body can identify the organism, create the troops to kill the organism, and get rid of it.  That virulence is also related to how quickly that organism can reproduce in us.  If we don’t identify it quickly and it reproduces very quickly, then it can make us sick quickly and it is a virile organism.

Infection Process: 

 2. Titer (number)

2. This is the number of organisms you’ve been in contact with.  The titer being the overall number  you are spreading from 1 person to another and is directly related to
1. when was the last time you cleaned your hands
2. when was the last time you disinfected the specula
3. when was the last time you cleaned the hearing aid

All of these will have a dramatic impact on the titer or the number of germs that are available for infection.

Infection Process:          

3. Resistance of the Host

3. Resistance of the Host: An intact immune system is very good at fending off organisms but our immune systems aren’t always intact.  As we age, the immune system goes down and when we are very young, it is underdeveloped.  Then there are various states of health based on how you take care of yourself.

Basic Tenets of Infection Control

1. Environmental 

• Clean: you remove the gross contamination from an object or surface. You may or may not be killing germs. You do this to everything. Remove the gross, visible contamination.
• Disinfect:  You kill a specific number of germs.  The number killed is related to the level of disinfectant you are using (household or hospital).  EPA is the regulatory body that oversees the marketing and distribution of disinfectants.  Data must be submitted to the EPA of germs and amounts needed to kill germs.  The disinfectants are graded from household to hospital grade disinfectants.  Hospital disinfectants kill more germs in less time.  Use a minimum of a hospital grade disinfectant.  You can soak things in an ultrasonic machine, use wipes to clean and disinfect, or use brushes to clean and disinfect with spray, wipes, or soaking.
• Sterilize:  You kill 100% of the germs 100% of the time.  You not only kill the vegetative form of the germ (form capable of reproducing) but also the spore form of the germ.  When organisms are challenged, you throw chemical on them, you put heat on them, and they have the ability to revert to a spore form and this is more resistant than the vegetative form.  However, that organism is constantly trying to get back to the vegetative form of life.  So when you remove the challenge, it reverts to the vegetative from where it can reproduce.  Sterilize means killing all of them, including spores, 100% of them 100% ofthe time.  You sterilize everything contaminated with bodily substances or any object capable of breaking the skin.

i. autoclave: this is the preferred method of sterilization, it is heat or pressure.  This is not a good one for us.

ii. chemclave: a large chamber that is capable of handling things vulnerable to being melted because it uses a   chemical bath and a gas to kill the organisms.  They are expensive to acquire and maintain and thus impractical for us.

iii. gluteraldehyde: this is cold sterilization.  It is a sterilant in the 2% concentration or greater but not ideal.  It is toxic and carcinogenic.  Now you may use SPOROX as an alternative.

Basic Tenets of Infection Control 

2. Human 

2 . Human

A. Hands:  The single most important thing you can do to control the spread of infection and disease in  

your practice is to WASH OUR HANDS and do it before and after every patient.  You can used soap an water or “No-Rinse”.   If you use soap, use liquid soap as soap bars attract germs and if creamier, it will moisturize.  The germ-killing action is the rubbing.

B. Gloves: this is an important of any setting and you will want these in a number of instances.  If you cannot use latex or are allergic, use vinyl.

C. Eyes, Mouth, Nose:  these are common routes for pathways into the body so be careful.  Don’t eat where there is patient contact and wash your hands first.  Don’t touch contact lenses.  Cover your nose and mouth when you sneeze and cough.

D. Medical history: do this from an infection control standpoint. Write not only what they are being treated for but what  meds they are taking and look them up.