Prior to 2016 there was only one school nurse in Co Wexford and many schools were screened by generalist public health nurses (PHNs) until that time. Following national review recommendations, changes in school screening personnel were made in Co Wexford. A second school nurse was appointed (of four recommended) and all school screening was then performed solely by school nurses. 

We used this opportunity to examine the benefits of employing specialist trained staff by researching referral rates from both hearing and vision screening. It was also possible to examine separately the impact of changes in the school hearing screening protocol, recommended by a national audiology review and introduced at that time. More details on screening methodology are available on request from the authors. 

This research was a randomised cross- sectional anonymised audit analysis of Co Wexford child health records (CHRs), designed and implemented jointly by the audiologist Theresa Pitt-Byrne¹ and the local school (public health) nurses² who worked together on the manual record audit; this was supported by the director of public health nursing.³ The hearing and vision screenings and subsequent referrals to audiology and ophthalmology of almost 900 school children were analysed, as well as the children’s preschool developmental referrals. Our objectives were:

• To analyse the impact of staffing changes (PHNs versus school nurses), and 2016 protocol changes,⁴ on school hearing screening outcomes especially and to review trends over time in outcomes 
• To summarise referral percentages for all preschool children to various allied health and medical specialists, relative to hearing status. 

We audited cohorts born between 2004 and 2012. The age of initial school hearing screening fell from a mean of 6.4 years to 5.3 years for those cohorts. Age differences between school vision and hearing screening in earlier cohorts existed because screening was often done in classes a year apart. Since 2016, specialist school nurses conduct all screening in junior infants.⁴

Overall findings/referral rates

• School hearing screening (SHS) referral and repeat pass rates fell significantly to below 2%, when school nurses took over all the screening. However, protocol changes did not significantly affect referral rates
• School vision screen (SVS) referrals remained around 10% throughout, reflecting a consistent policy/methodology in ophthalmology training over many years
• Co Wexford referral rates compared well to European SHS/SVS data; SHS rates were much lower than in recent UK studies.⁵

Recommendation one: Employ more specialist school nurses, with wider scope for educational roles. Retain SHS otoscopy to assess repeats/referrals. SHS had low impact on audiology services, so such well-screened, high-yield referrals should get waiting list priority, for both audiology and ENT since most had conductive hearing loss. Preschool audiology referrals easily outnumbered SHS referrals (51 compared to 12 from SHS).  No ‘new’ permanent hearing loss was identified at SHS during this audit.

Recommendation two: High priority for well screened SHS referrals to audiology. Caution is warranted on late-onset or progressive loss detection, due to low incidence of permanent hearing loss at under 0.2%.

Universal newborn hearing screen (UNHS) referral rates of 2% to audiology were costlier than SHS referrals. Documenting UNHS on all child health records in a standardised way better supports information access for HSE preschool service referrals. Experienced school nurses  could provide ‘special needs school services’ to children with mild to moderate learning disability, if an audit of current services shows gaps in such screening. Automatic data transfer (as in UNHS) could easily centralise SHS/SVS audit data.

It was notable that the children referred to specialist preschool services, particularly speech and language therapy candidates with simple developmental speech and language delays, did not have significantly higher rates of referral from SHS, hence the need for hearing testing when young children have already had UNHS must be questioned. Parental opinion and close family history remain strong indicators, rather than automatic referrals from allied health specialists.

Recommendation three: Ensure UNHS results are documented on child health records so that community preschool services can access them through the PHN, perhaps helping to avoid unnecessary preschool referrals. School screening by school nurses is cost-effective for audiology services compared to other referral sources. The research identifies various benefits of specialist school nurses.

Findings from this research were presented as a poster at an Allied Health Professionals Conference in November 2018 and this poster won an award at the Institute of Community Health Nursing annual conference in May 2019.

References

1. Pitt-Byrne T. School Entry Screening referral trends and cohort comparison with preschool specialist referrals. Int J Audiol 2018; 57(7):510-518 
2. Roche P, RGN, RM , Dip PHN, School PHN  and Walsh C, RGN, RM , Dip PHN, School PHN. Public Health Nursing
3. Finn Gilbride M. Director of public health nursing, Wexford Community Care
4. School Hearing Screening 2016 changes derive from a National Audiology Review (http://www.hse.ie/Eng/Services/Publications/corporate/AudiologyReview.pdf.
5. Fortnum H et al. A programme of studies including assessment of diagnostic accuracy of school hearing screening tests and a cost-effectiveness model of school entry hearing screening programmes. Health Technol Assess 20, 36 (2016) http://www.journalslibrary.nihr.ac.uk/hta/volume-20/issue-36#abstract