Clinical audiologists are often confronted with industrial employee referrals due to shifts in hearing identified by a company's audiometric monitoring program. It has been my experience that many clinical audiologists are not familiar with the needs of industry relative to their Hearing Conservation Program or what is expected by the U.S. Occupational Safety and Health Administration (OSHA) concerning the Work-Injury Log 300.
Audiologists often do not report their findings in a manner that is helpful to the referring company for OSHA compliance, but rather treat the referral the same as a Workers' Compensation assessment, which is not correct. Clinical conclusions often do not provide justification for cause of loss or shift in hearing, other than threshold pattern, degree of loss, and/or length of employment. I find that many audiologists do not want to make a determination on cause of loss because they feel this is beyond their scope of practice.
It is the intent of this article to review best practices in the gathering of pertinent information, assessment, and basic report writing relative to the needs of industry and OSHA. I will focus on the company and OSHA, not Workers' Compensation, since their needs are very different. OSHA compliance is intended to be a Loss Prevention Program whereas Workers' Compensation is litigation for compensation toward rehabilitation-nothing to do with prevention. (See sidebar for a brief explanation of the recently "revised" OSHA Standard Threshold Shift [STS] calculation criteria.)
First, it can be assumed that if an employee is referred to you by a company, the company is getting audiometric monitoring from either their own in-house Council for Accreditation in Occupational Hearing Conservation (CAOHC)-trained technician and/or an outside audiometric provider. The fact that a company referred their employee to you also indicates the likelihood that an audiologist was involved, directly or indirectly, in data review and the referral recommendation process. In addition, because the company is paying you for your assessment, it is an indication of their concern for their employees as well as the need for better documentation on the shift in hearing. Thus, it is the audiologist's responsibility to give the company the assessment and reporting necessary to meet their needs.
What OSHA Wants
- OSHA is only concerned with "shifts in hearing," not baselines, when it comes to reporting work injury.
- For any employee showing an STS, the company must record the shift as a work injury on the OSHA Log 300. It should be noted that any company not reporting a work injury can be charged with a felony. So OSHA and the company take this very seriously.
- OSHA also assumes that every STS is related to work noise. It is up to the company to show that it is not. However, OSHA states that even if only part of the STS may be work-related, it must still be recorded on the Log 300.
- Also, if an STS is persistent or if there has been no verification or re-testing, then the shift must still be recorded.
What a Company Wants
Companies want to avoid recording "non-work noise" hearing loss on the Log 300. They know that an increase in recordable injuries will increase their insurance premiums and can also spark an OSHA inspection. Therefore, they do not want to assume an STS as work-related, unless in fact, it is.
A company can make the decision not to record only if an employee works in noise below the OSHA Action Level of 85 dBA over an 8-hour Time Weighted Average (TWA) or there is documentation from a physician or audiologist indicating the shift to be non-work noise-related or the retest shows threshold improvement below the STS criteria. Thus, the primary reason a company refers an STS employee to an audiologist is to determine that the STS is "other than work-noise related."
If the STS is work noise-related, however, the company allows employees to have one-on-one counseling with an audiologist and review of their use of hearing protection. Documenting the visit and counseling also helps show a company is not negligent in their efforts to help protect their employees in cases of litigation, workers compensation, or OSHA compliance.
The Company-Audiologist Relationship
To establish rapport, the audiologist should become acquainted with the referring company, its noise levels, hearing protection program, audiometric monitoring program, and audiometric referral process. If possible, taking a tour of the plant and sitting down with the nurse or human resources to review the company's program will also enhance the relationship and will most likely improve your professional performance in meeting the needs of the company.
The company also pays directly (no third party) for the assessment in order to receive the report, control the referral process, and ensure that all their needs are met.
What the Audiologist Should Request
- When an appointment is made, it should be standard procedure to request the following prior to the appointment:
- reason for the employee referral
- noise levels for all jobs since hiring; they may not have much but you should get whatever they do have.
- all past audiometric tests. If possible, you may want to know if there were any "revised" baselines due to prior shifts. If the data have been reviewed using software, most software has reports showing Original and Revised Baselines.
What About Audiology Assessment and Medical Referral?
- The company is only looking to rule out work noise-related hearing loss. Therefore, testing beyond the basic battery is almost always not necessary.
- Identification of pathology or need to refer further is usually an indication of "non-work noise-related" hearing loss, which ends the company's financial responsibility and also completes their OSHA STS question.
The exception for additional referral can be wax impaction if the audiologist feels that cerumen may be a factor with the STS. According to OSHA, companies are obligated to pay for wax removal if the cause of the wax impaction was a result of wearing earplugs. Of course, this is a Catch-22 but there is no alternative for the company but to pay for wax removal. The company usually prefers this be performed by the audiologist, or the employee is referred back to the company to schedule wax removal with their local industrial clinic or plant physician.
If additional referral beyond wax impaction is recommended, the employee should be counseled and the report goes back to the company. The company will encourage employees to make an appointment under their own health plan and a copy of your report will be available for the referral.
If an employee, regardless of reason, is a hearing aid candidate, the employee should be counseled accordingly, but this too is not the responsibility of the company. If a hearing loss is determined to be work noise-related, rehabilitation is not a function of OSHA or Log 300 requirements. The company assumes responsibility through their Workers' Compensation insurance if and when a claim is made by the employee. It should be noted that some states automatically require a claim be made when an injury is recorded on the Log 300.
Hearing aid counseling can be a sensitive issue with a company and construed as a conflict of interest with the original intent of the referral. The audiologist must tread this ground carefully.
Can an Audiologist Determine Etiology of a Noise-Induced Hearing Loss?
- Old School-No
- New School-Yes
- ASHA Technical Report 2004-9(9): "Determine or assist in determining through evaluation or referral, work-relatedness of hearing loss for the purposes of otologic and/or audiologic referral and recording on the OSHA Log 300."
- OSHA 1910.95(G)(7)(III): "The audiologist, otolaryngologist, or physician shall review problem audiograms and shall determine whether there is need for further evaluation…."
Audiologists are the best professionals for determining whether the STS should or should not be recorded on the OSHA Log 300. Although some audiologists feel this is beyond their scope of practice, determining cause of loss for recording on the Log 300 is within the guidelines set by OSHA and ASHA as referenced above. At a minimum, audiologists should be able to at least rule out work noise as a cause of loss if substantiated by history and assessment. If an audiologist is not willing to make the determination then the audiologist should not take referrals concerning OSHA and STS.
The most common mistake made by most professionals is assuming cause of loss to be work-noise related based upon their job description or length of employment. Pre-conceived etiology ensures work-relatedness.
Work noise should be the "last" thing considered in your assessment. Personally, I make every attempt to find noise or other factors that may have affected hearing and only begin to look at work noise after I have completed my audiologic investigation of data and other non-work-related information.
In history taking, for example, we sometimes overlook important details such as issues regarding recreational shooting: Have you ever hunted or done recreational shooting? If yes, when was the last time, how often do you go, what about target shooting, how many rounds, do you currently wear hearing protection (although never when hunting), when did you start wearing hearing protection, what type of weapons, and so on. Do you ever light firecrackers? If yes, when was the last time? Most employees regard the impulse noise issues as trivial and seldom done, but as we know, the results can be very detrimental.
If there is a short length of current employment, what about prior employments? Military or reserves? Second jobs? Carpentry or other noisy hobbies? Auto or motorcycle racing? Never hesitate to ask about anything: My best story was an employee claiming workers' comp for hearing loss along with every other employee in that company (they were closing the plant). He was missing a forearm and when asked what happened, he said he lost it priming a cannon with his Civil War Reenactment Club. Need I say more?
When looking at threshold patterns, I seriously question unilateral high-frequency loss, flat threshold patterns, or severe to profound losses as work noise-related, especially when looking at the history of audiometric data, aging, noise-level exposures, noise characteristics, use of hearing protection, job description, and length of employment.
Even if I am unsure about the etiology, if the pattern is inappropriate based upon the work information provided, I make a "in my professional opinion" comment that the shift is "other than" work noise-related because…and attempt to explain my logic. The key is that you justify why you came to your conclusion-whether it be right or wrong, it is your best professional guess.
It has been my personal experience in almost all cases that physicians agree with my conclusions, mostly because I have detailed my justifications beyond what they may have considered and put the audiology into perspective that makes sense. Factually, in most cases, there are no concrete findings about whether the case is or is not work noise-related, so you have to give it your best "justified" guess.
Your Key Words
Include the terms "Original Baseline" and/or "Revised Baseline." Refer to the "dates" and the "ear in question" when referring to baselines and the current test.
- Use phrases like "pre-existing to employment," "in my professional opinion," "other than work noise-related," or "work noise-related."
- Do not use "noise-induced hearing loss (NIHL)." Better to be specific with terms like "shooting noise," "prior employment work noise," "recreational noise," "military noise," and so on. It is important not to group all noises into a single terminology of NIHL.
- Even if you cannot break out work noise from shooting noise, it is better to report, "The shift in hearing appears to be a combination of shooting and work noise exposures." Although this is still Log 300 recordable, it is also documentation that may help defend a company in litigation or workers' compensation in the future.
- Do not report percentages of hearing loss since OSHA STS and Log 300 are not concerned with degree of loss, only shifts in hearing. If audiologists determine percentage of hearing loss, the company can be confused by its meaning. It is important to know that OSHA and Workers' Compensation take different paths and in most cases the company STS referral is only on the OSHA path.
- Log 300 phrase examples: "Based upon the information provided and test results, the STS appears to be at least in part due to work noise exposures and therefore should be recorded on the OSHA Log 300," or "Based upon the information provided and test results, it is my professional opinion that the STS in the right ear is due to recreational shooting and is not representative of his type of work noise exposures. Therefore, this STS does not need to be recorded on the OSHA Log 300."
- Consistency is also a key to good reporting. Develop a report template for your industrial referrals that includes a detailed history, use of your key words, analysis, and comments relative to the needs of the company and purpose of the referral. Typing your report is always better than scribbling it on an audiogram form. The cost of a good report can always be added to your cost of services.
In summary, meet the needs of the referring company. Know that their primary purpose is to rule out STS and recording on the Log 300. Ensure that the company provides all past audiometric data and history information regarding noise levels and their policy on hearing conservation. Never assume any loss or shift in hearing to be work-related until all information is analyzed. As an audiologist, you are very capable of determining whether a loss or shift in hearing is OSHA-recordable. Make conclusions based upon the test results and the information collected and give it your best, justified, professional guess. Use key words in your reports that satisfy the needs of the company in helping them comply with OSHA criteria. Standardize your reporting to make it easier for the company and yourself.