Practice Resources

This broad guidance addresses pandemic driven changes to procedures for audiometric evaluations.  In this pandemic period the questions to be answered by clinic managers are:  When can evaluations be safely deferred?  When must testing be performed?  What procedural changes are needed for the safety of patients and clinic personnel?  The answers will require each occupational medicine provider to weigh the risks and benefits to staff and patients/clients.  

Considerations for the Professional Supervisor¹ include:

• Staff medical history including COVID-19 and exposure risk factors
• Clinic facilities and equipment
• Potential for waiting room exposures of occupational clients given proximity to general medical treatment areas
• Availability of appropriate personal protective equipment (PPE)
• Availability and speed of real-time RT-PCR SARS-CoV-2² testing 
• Local community, region, and state rate of COVID-19 cases³ and the effective reproduction number⁴

Both ACOEM and the Council for Accreditation in Occupational Hearing Conservation (CAOHC)⁵ issued statements recommending deferral of routine audiometric surveillance examinations where possible during the COVID-19 pandemic.  ACOEM has specifically requested that allowances be made for employers in enforcement of hearing conservation standards under OSHA, MSHA, and the FRA.⁶  However, we recognize that it may neither be possible ,nor desirable to defer audiometric testing to meet occupational hearing conservation standards, assessment of occupational hearing loss, or qualification of individuals with safety sensitive positions to meet occupational hearing standards.  

Clinics continuing to perform audiometric evaluations during the pandemic should implement appropriate engineering controls, administrative controls, and PPE to protect patients and staff.

Engineering controls:

General clinic/building ventilation systems should be adjusted based on COVID-19 building operations guidance from the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE)⁷ and the Centers for Disease Control and Prevention.⁸  HEPA filtration of return air from patient care and waiting areas is also recommended.  Ultraviolet Germicidal Irradiation  (UVGI) may also be considered.  In mobile testing facilities,the technician should thoroughly ventilate the facility by opening doors and vents between patients, when possible.

Consider use of headset covers, individual disposable transducer covers, and/or disposable bouffant caps to minimize patient contamination of the headset.  For otoscopy, use of disposable specula only is preferred.  For multi-place booths, when it is not possible to separate patients, or test them singly, install barriers between testing stations which are smooth, impermeable, durable and easily cleanable.  Acrylic or plexi-glass are examples of suitable materials.

Administrative controls:

Implement a pre-visit COVID-19-specific health screening questionnaire addressing COVID-19 symptoms,⁹ and history of recent illness, travel, and close contact to ill persons.

Display signage outside the clinic requesting patients/workers to refrain from entering the clinic and to call the clinic receptionist if they are experiencing any COVID-19-like symptoms or had symptoms within the last ten days, had close contact with a person with probable or confirmed COVID-19, or have been told to self-isolate or quarantine by a medical or public health professional.

Consider conducting the health screening questionnaire on the day of the appointment at the time of patient registration.  Further, examine the patient’s body temperature and general vital signs.  The professional supervisor¹⁰ should determine if the patient/worker should undergo the audiometric evaluation based on responses to the health screening questionnaire and the outcome from the objective vital sign assessment.  If the professional supervisor determines that the audiometric examination cannot be completed, the reason for the cancelled examination should be documented in the patient’s record, the audiometric examination should be rescheduled if possible, and the patient should be referred to their usual primary care provider for appropriate medical care.

At the present time, pre-examination testing for SARS-CoV-2 is unlikely to be available.  However, implementation should be considered if a rapid, inexpensive, and high-performance test becomes available, and if the prevalence of COVID-19 is high in the community.

Institute engineering controls, require six-feet of separation between patients or stagger patients in audio booths designed to accommodate multiple persons.

Clean and disinfect¹¹ audiometric booth(s) and related equipment (e.g., headset, pushbutton, chair) in accordance with equipment manufacturers’ recommendations, before and after use by each patient or group of patients.  Follow recommended contact times for all disinfection agents.  Audiometric equipment and booths should be permitted to dry thoroughly between patients.  Clean and disinfect frequently touched surfaces and objects such as tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets and sinks, and touch screens.

Establish separate waiting areas in facilities where patients are evaluated for primary/urgent/emergent care and occupational healthcare.  Separation can be accomplished physically, or temporally by staggered scheduling.

Patients should be asked to touch as few surfaces as possible in the testing  area, whether at a fixed clinic or in a mobile van.  

Scheduling must be adjusted to allow for additional time required for new processes.

Personal Protective Equipment

Where possible, clinic staff should use N95 filtering facepiece respirators (FFR).  If N95 FFRs are unavailable, consider the use of surgical procedure masks instead.  Visitors to the clinic should come with cloth face coverings.  Provide surgical masks if patients do not bring their own cloth face coverings 

Clinic personnel should wear disposable exam gloves while interacting directly with patients/workers.

Donning and doffing the audiometry headset should be performed by a clinic staff member, wearing disposable gloves.