A: Regardless of the type of technology or protocol used, the goal of newborn hearing screening is to create the smallest reasonable subset of the general population which still contains all of the infants with hearing loss. In other words, without missing any babies, it is generally best to minimize the number of infants referred from the screening process to a diagnostic evaluation (of course, this goal must be balanced by other factors, such as time and cost). Some strategies to reduce referral rates are applicable regardless of the technology being used, and others apply only to specific technologies:

• Schedule Screening When Babies Are In The Best Behavioral State
  

  Even though it is possible to screen babies who are awake and restless, screening happens much more quickly and the results are better if the screening is performed when the baby is quiet (or even asleep), happy, well fed, and comfortable. Therefore, if possible, you should schedule the majority of your screening activities when babies are most likely to be in this optimal state. When and where you do the screening will depend on other activities, routines, and available space at your hospital.

• Make A Second Effort Prior To Discharge To Screen Babies Who Did Not Pass At First
  

  Most programs do not consider the initial screening to be complete until the baby leaves the hospital. Typically, the first attempt to screen the baby is made shortly after birth. It seems to work best to not spend too much time with the baby during this initial attempt. If the baby passes (as the majority will do), you are finished. If not, wait several hours and try again. Regardless of the equipment or protocol being used, these second efforts prior to discharge can substantially reduce the number of babies who need to come in for outpatient screens or diagnostic procedures. Instead of spending 30 minutes with the baby during an initial attempt, it is much more efficient to make a quick first attempt, followed by a second or even third attempt a few hours later. In other words, repeated short attempts are usually more successful than a single prolonged effort.

• Minimize Noise and Confusion In The Screening Area
  

  None of the screening equipment requires extraordinary measures to make the screening area quiet. Newborn hearing screening is routinely being done in neonatal intensive care units and crowded and relatively noisy well-baby nurseries. However, all other things being equal, screening will be faster and more effective if you do what can sensibly be done to minimize noise and confusion in the screening area. In other words, where possible, do most of your screening when doctors are not making their rounds, do not screen directly under a ventilator fan, and find an area to screen which is not adjacent to a bathroom where running water creates unnecessary noise. Where sensible and inexpensive modifications can be done to reduce noise (e.g., carpeting on the floor, curtains on windows, a portable room divider which provides some sound attenuation), they are worth considering to increase the efficiency of the screening program. However, it is certainly possible to operate a screening program without any such enhancements.

• Use The Best Protocol For Your Situation
  

  In an effort to keep refer rates as low as possible, some hospitals use both OAE and ABR technology prior to discharge. In situations where it is difficult to get babies back for an outpatient screen, such a protocol can save time, money, and hassle for the program and families. The downside, of course, is the additional cost of using two types of equipment. Some manufacturers offer both OAE and AABR on the same unit at substantially less than what it would cost to purchase both pieces independently.

• Have Backup Equipment And Supplies Readily Available
  

  Because some babies are discharged after just a few hours in the nursery, it is essential to make sure your screening program has arranged for backup equipment in the event of a breakdown. Most newborn hearing screening equipment is extremely reliable. However, if your equipment unexpectedly stops operating and it takes you 3 days to get a replacement, you will probably miss 10% or more of the babies born at the hospital that month. Although you can have such babies come back for outpatient screening, it is extra work for everyone and unlikely to be completely successful. Therefore, you should make arrangements to obtain replacement or loan equipment within a very short time from the salesperson, a neighboring hospital, university, audiologist, or school district. It is also important to have sufficient supplies or replacements for consumable parts (e.g., probe tips, electrodes, probes).

• For OAE Procedures, Probe Fit Is Critical
  

  If OAE technology is being used, the single most important factor in reducing refer rates is to make sure screeners understand how to achieve appropriate probe fit. Although this is relatively easy to learn, it may not be immediately obvious to screeners and usually has to be taught. A screening program whose personnel have not mastered the techniques of good probe fit will generally have refer rates at the time of hospital discharge two to four times higher than a program where screeners have mastered probe-fitting techniques.

• For AABR Procedures, Screen When Myogenic Activity Is Low
  

  AABR screeners have artifact rejection systems built in so data are not included in the average when myogenic activity is high. Myogenic activity is caused by muscle tension. If babies are tense, wiggly, or restless, myogenic activity will be higher, and it will substantially increase the screening time. It may even result in more babies who need to be brought back for rescreening or diagnostic procedures because a pass could not be obtained. Thus, it is best to do screening when babies are relaxed, happy, well fed, and, if possible, asleep.