Hello, and thanks for joining. Today we're going to be reviewing the Hearing Conservation Program. So hopefully all of you in attendance either support a hearing conservation program or looking to support a program. My name is Michelle Dahme-Smith, I'm Dr. Smith, I've been a nurse practitioner for a very long time, I would say since 97, and I've been in the occupational health space for the past 23 years. So I welcome you today and I hope you find this program to be of value to you. I would like to let you know I have no conflict of interest as I present this topic. So here are some of the objectives that we're going to review today and hopefully when you leave at the end that you'll find that you have met all of these objectives and a better understanding of how to support a hearing conservation program. Some of the objectives that we're going to do today, we're going to understand the purpose of the hearing conservation program, we're going to identify what noise exposure hazards are, we're going to review the employer responsibilities, we're going to discuss considerations for audiometric testing, STS, when do we refer, how do we refer, we're going to explore options for audiometric testing. So that's always a question of what's the best way to do it, and it depends on what programs that you are supporting. We're going to discuss and make sure that you understand how to determine if an STS is recordable versus non-recordable and what your role is in that determination. And lastly, we're going to discuss a little bit about OSHA state and employer considerations when we're talking about age correction in determining STS. So the first thing we need to do is define what noise is. And making sure you understand, which I'm sure you all do, but it's just a review, that noise is a vibration or unwanted sounds that can fluctuate in the air that may affect the human body. The vibrations that are detected by the human ear are classified as sound. So in that sound, employees have exposure to both the noise and the vibration that can harm the employees if they're exposed for long periods of time. So when we consider noise as a hazard, I want you to recognize as the provider of how it can be hazardous. It can be hazardous depending on how loud the sound is, how long does the exposure to that sound last, and how often the exposure is repeated. So it's not as simple as, okay, they're in a noisy environment. They need to be in the program. So there are several components that determines if a noise is considered hazardous. So before we go into understanding more of the program, I'm going to talk a little bit about the why. You know, many times it depends on where you're working. We have these hearing conservation programs, and we have people just churning in, and we're doing audiometric testing, and it's really important to understand the why behind the work that we do. So we are, as clinicians, we're trying to prevent several side effects, if you will, or several issues that can result from overexposure to noise that's not simply hearing loss. Some of the hearing loss can be permanent, it can be irreversible. So surely that's an important reason why we are running these programs. Surgery nor hearing aids can correct the loss. Hearing aids may be able to provide a different refraction of the noise, but would not result in full correction. So it is important that we prevent that. Even short-term hearing loss can cause uncomfortable tinnitus. So this is someone who may have, you know, a sudden burst of noise, and that tinnitus or that stuffy feeling in the ear can be uncomfortable to the employee. So we want to prevent that. Excessive noise can also cause stress and physiological and psychological stress. So think of someone who can be overstimulated by too much noise or too much exposure to outside stimulation. So it's important that we protect our employees from this. It also increases the risk of workplace accidents and injuries. So think of someone who's a crane operator that needs to have a hearing protection. They want to be able to hear if someone's saying, hey, watch out, right? So it can put someone at risk if they have hearing loss. It may limit someone's ability to hear high-pitched sounds. So that's common. Once someone starts to have hearing loss, they can't hear high-pitched sounds such as the phone ringing or the doorbell. Another concern is, again, difficulty hearing warning signals, sirens, because think of those sirens or high-pitched sounds like even a police car. They may not be able to hear that. Or difficulty understanding speech and overall communication. So we all know as we get older, we start to lose parts of our hearing. But if we're starting that process earlier because of exposure, that certainly is a problem. So this slide reiterates a little bit of what I just discussed in regards to considerations in regards to noise exposure, such as, like I said, the hearing loss and the tinnitus. But a few other things occur. So someone who has overexposure to noise may have to speak louder. And with that, they can develop vocal cord nodules from that need to speak at a higher tone. It also can affect workplace performance if there is hearing loss. We talked about the fight-or-flight effect a little bit in that employees need to be able to detect if they are in a place that they may be at risk because they need to be able to hear the noise. Or it can cause them stress because they're getting too much of it. Now when you are providing prevention, when you're preventing overexposure to noise, there are some things that you need to consider that hearing loss can mask. And we're going to talk about that just a little bit later more in depth. But hearing loss is not always a result of noise. It could be a result of something else. And if you're monitoring, the programs help to determine if someone's loss over time is maybe a result of the workplace, but it may be a result of something else. And examples are, I have a few examples here. Acoustic neuroma, for example. They can have an acoustic neuroma that's being missed as overexposure. Sociococcus is also a risk. And also exposure to occupational agents such as metals, lead, toluene, carbon disulfide. Those are examples of heavy metals that having overexposure to these heavy metals can result in hearing loss, but not recognizing that the hearing loss is not from the noise, but from a heavy metal. So it's a consideration when these people are in a program that you're considering of what other causes for the loss may be. Now our conservation programs are, as you're hearing me repeat, is to prevent noise-induced occupational hearing loss. And how do we do that? Is that we monitor the noise exposure. If it's at above 85 decibels, average over 8 hours of work, or otherwise an 8-hour time-weighted average. So that is when you have an employee with that level of exposure of the 85 decibels, that is when they should be over the 8 hours. That is when they should be in the hearing conservation program. There are some places that you should have an industrial hygienist, you should have someone in safety who is able to determine the amount of decibels, and they should have a way of monitoring that over time so they can make sure that the right people are in the program. Usually that's not within our jurisdiction as clinicians, but here's the problem. If they don't do that and they say, you know what, it's just easier to test everybody and we'll test everybody every year despite their exposure to noise, despite that 85 decibels. If they fall below that, they don't need to be in it because there could be other reasons for the loss that the employer is going to wind up buying if they develop loss and they're in the program, whether or not they're exposed to that 85, if they're under, they can wind up buying this STS that's not theirs. So if an employer asks, like, is it a big deal, like what's the big deal of just putting everybody in? I don't have time to test, you know, because an employee may or may not work in that area. It is worth finding out because then they'll wind up getting unnecessary OSHA recordables for STS that really isn't theirs. So that's a part of the why U.S. clinicians should know and should be a partner with your EHS or your industrial hygienist in determining who should be in the program. The program goes by the OSHA standards, standard 29 CFR 1910.95. So these standards help us with deciding who should be in the program and how the program should be run. Looking at this slide, it gives you that clarification from a visual standpoint of what is the permissible exposure to loud noise without adequate hearing protection. Once you are at the level of exposures of these decibels, and you can see to the left is a level of exposure to noise, and you'll see to the right the length of time that they should have hearing protection and for what period of time. So you know, for example, I already mentioned at 85 decibels, if their time weighted average is eight hours, then they should be in a hearing conservation program, and that's the allowable noise exposure for that time limit. You'll notice as the decibels increase in terms of exposure, the length of time decreases. So we as clinicians, we make sure that employees are wearing their protection and they're wearing the correct protection. So all protection are not made equally. So this is where you work with your EH&S to determine, and you may have different names for your safety, but you want to make sure that they're wearing the right muffs or plugs and that it provides them the protection within this exposure level. So the role of the employer. There are times that the employer may have a conversation with you as providers trying to determine where they start and where you start within that conservation program. So certainly you can work as partners, and you are partners in the program, but according to OSHA, there are responsibilities that are of the employer, and I think as clinicians it's important to know what they are and that the onus is on us to provide the service and to make determinations and work as partners, but recognizing that the employer has their responsibility as well. The responsibility includes they have to measure the noise levels. So they need to determine what that noise level is because then they need to enroll employees in that program. So it shouldn't be employees complaining to OSHA that it's too loud, they're not wearing a device. There should be a proactive way of knowing what the level of exposure is and what areas in which employees are exposed. Next, they should provide free annual hearing exams. They do not pay for their hearing test. They should be provided hearing protection in that the employer's responsibility is to provide the training. Now there will be some clients that say these employees are in the program, they assign this protection, and I need you to provide the training. So you as the clinician, if the determination and the decision is for you to provide the training, you certainly can do that. Your safety team may work with you on some form of protocol and checklist to prove that the training has occurred, but their responsibility is to make sure that the training is in place and that they have a process in place. And lastly, they have to conduct evaluations of the adequacy of the hearing protectors in use, which means that they determine the level, but then they need to make sure that they're using the right protection for the right level of exposure. So that's not something that we do, but if we're training employees on how to use their devices, we need to make sure that they know which device that they're using to muffle the noise. So goals are essentially prevent the loss, preserve and protect whatever remaining hearing that an employee has. They may come in with a low baseline, but we need to protect them where they are. And another goal is to equip them workers with the knowledge and hearing protection devices necessary to safeguard them. So audiometric testing. We all know and we all have been doing audiometric testing. If you're here with me today, I'm sure you've started and hopefully run a solid program. And as we get a deeper dive, we're going to talk about ways that we can run these solid programs and what, you know, after we just kind of go over some of these basics. So the audiometric tests, it's not invasive. It's measured in Hertz. So the results comes out at Hertz. It's performed by a professional or trained technician. I think the next slide or so tells who can do the testing, because I think at some locations that becomes a question of I have an MA, I have a physician assistant, I have a physical therapist, I have an EMT at this site, who can perform the test? So we're going to talk about that more in depth, because I think that comes up pretty often in determining who can run the test. Every person who is in the hearing conservation program who is exposed to noise, once there's a determination that there's an exposure to noise, they must have a baseline test. And that baseline test has to be done within six months of that eight-hour time-weighted exposure greater than or equal to 85 decibels. The exception is within one year if you're using a mobile test van for audiograms. So if you're running a program and you're doing pre-employment exams, it will be wise for you to find out if the person having the job description and within that description determining if that person is going to be exposed. Is that going to be a part of their job? Because ideally, you want to do it at the time of hire, and you don't want to risk it not being done within that six months, because that can create an issue in and of itself. That is the OSHA protocol. Our recommendation is that it's done within the six months of their exposure so that everyone has a baseline. And I'm going to talk to you about the different devices and making sure whatever you do, that there's a baseline in there, because that can completely affect the overall result and wind up, again, resulting in STS shifts that you may wind up buying, resulting in recordables unnecessarily. Most programs will leave the onus on to us as to how we want to maintain that compliance. So that is where, you know, an example is you can do it every year of their birth. You know, their birth month. So every January, if your birthday's in January, or you might want to consider doing it the month of their hire. I think the easiest is the birth month. So you should have a program that helps you with maintaining your compliance so they don't get missed. Repeat monitoring occurs when occupational exposure changes occur to increase that noise exposure. So basically, if someone has an excessive exposure to noise, you're not going to wait at the time of the annual testing. You repeat the exam to see if there has been any damage as a result of the unexpected noise. So who can administer a hearing test? This is always a question that I get. I have all different types of providers that are in the office, and can they do the testing? So the testing can be done by a licensed or certified audiologist, certainly by a physician, by any provider who is CAOC certified Occupational Hearing Conservationist. So in essence, if you have a physical therapist, a athletic trainer, a medical assistant, these are licensed providers who can be sent for training to CAOC. Your nurses, they can get the CAOC training, become a certified Occupational Hearing Conservationist. Doesn't mean that they're going to make determinations as an audiologist, but they can perform the test. A technician who has demonstrated competency in administering audiometric testing, and who is responsible to an audiologist, otolaryngologist, or a physician. So meaning that if your athletic trainer at your site, as an example, athletic trainer or RN, as long as they report up to a physician and they have that partnership, they can support the program and do the testing. So CAOC certification is not mandatory if you are of certain license. So an RN, or NP, or PA, or MD. But being CAOC certified does provide proof that a technician has met a high standard of training, that they've taken and they've passed a national standard exam leading to that certification, and it determines competency in administering the test. So that is an important piece to add, because let's say someone says that an employee is convinced that they had an STS, and the person who did the test didn't know what they were doing, and they don't agree with it. They think this is work related, and they were told it's not work related. It will behoove you to have your provider trained and to prove that they are certified to do the testing. Because if they're not, then that can become an issue. If an employee wants to argue that the test wasn't done right, they didn't know how to do it. Now, if you have someone who's hired, so you just hired a nurse, for example, and she didn't have time to do CAOC training. So I think that happens to all of us. You can't get CAOC training for two months. The provider still can provide the test. But I get that question a lot. Can they still do the testing? Yes, they can do the testing, but it's wise to get them not just trained on the device and trained on that quick training that says, hey, if SCS over 10, let me know. It should be more in depth. So I do highly recommend, and this is not a plug for CAOC. It's just getting that certification just is the best practice in supporting and hearing conservation program. Now, there used to be a time we only had access to a booth. The big monster booths that we would have in our clinics. And once you put them there, they usually stay there forever because they're so big. So we're going to talk about the advantages and disadvantages of using a booth versus a booth-less system. So the advantages of using a booth. So that's the big, huge, I don't know how many thousand pounds it is, but it's pretty big, and it's pretty heavy, and it's hard to get into a space. Now, the advantage of using a booth is that it's the process we use for decades, and it works. It's reliable. It's reproducible. It's quiet. It's tried and true. That you place a person into a booth, it's quiet enough. It can keep out the background exposure. So that's a big advantage because it's worked, and that's why. The disadvantage is the cost. It's much more expensive to get a booth versus a non-booth-less system. You need the space to house it. So you may not have an office big enough to put that booth, or you may be doing multiple testing. And that will take forever to kind of crank in one person at a time to that booth. So that one person at a time makes it a disadvantage. But again, it works. It's a great way to do your hearing test. Now, the booth-less system. So there are several companies out there that use this wireless headset system. So it's where they give you a tablet, and I've seen them in different ways. They give you a tablet, and you put earmuffs on, and they can do the test. You hand it to them, and they can actually, they hear the noise in their earmuffs, and they can press the button. Instead of clicking like when you're in the booth, they press a button. The advantage is that it's compact. They're usually some form of headset and just a device and not a big booth that is gonna cost you thousands and thousands of dollars to purchase and to bring into the workplace. Much more cost-effective. And you can actually test multiple people at a time. So that becomes very handy depending on where you are, which programs that you're supporting, that doing one at a time would take forever. So that may be a reason why you want to look at the booth-less system. Now, here's a disadvantage that is a real disadvantage. The couple that I'll share that I've actually noticed as well. The room needs to be quiet to do the test. The maximum background noise is 40 decibels per OSHA standard. So, you think of the different places that you're doing hearing tests, and it may be very loud. Maybe a construction site. I mean, it could be anything. Machines are in, we all can think of different ways and reasons that you just can't get the room to be at 40 decibels. So that is a challenge. You may need to soundproof a room. That's going to be a cost in and of itself. You want to consider, can you get your room quiet enough to be able to do the test? So that's one real problem. The second real problem is internet connectivity. So, in order for the device to work, it has to have access to the internet. You'd have to have access to the internet. So that can be challenging in some remote locations. So you want to consider, certainly, is it the right place, time? What time is it going to take to do it? And you may be the one that's helping the, either you're, if you're at a brick and mortar site, depends on where you're providing this program, of which one would be helpful. So, this one I think takes a really good thought, because usually whatever you decide is what you keep. And due to cost, you want to really just think about which would work best for you and the program. So, when you're performing the test, you want to get a complete, a hearing questionnaire. If you're not doing a questionnaire, you're not doing your program right. You should have a Otologic questionnaire that the employee completes before starting the testing. They should have no workplace exposure 14 hours before the baseline, or making sure they're wearing hearing protection during this time. Usually we just make sure they have no noise exposure for 14 hours. So, that way the numbers aren't skewed. The second thing is to do an otoscopic exam. Notice if there is any excessive cerumen, if there's any trauma, have they had a perforated drum? This can be embarrassing to you where you send someone to an audiologist and they're like, yeah, they can't hear because they have impacted cerumen, but you never checked. That should be a part of your program. I can't stress that enough because some shifts are as a result of the clinician simply not looking in the ear. Your audiogram, you should do daily functional calibrations before you test, but the device should have annual acoustic and exhaustive calibration done by a third party vendor. If you don't do this, this is where an employee can say that I did have a shift, their devices are not calibrated, it's not up to date, their numbers are wrong. Certainly daily calibrations in the office and sending your device out for a third party evaluation is important. Review the results and determine the follow-up. So, we're going to talk about what that's going to look like shortly. And you want to document, consider your documenting and your record keeping. So, if you're going to support a new hearing conservation program, where are you putting the results? Where are you putting the results and understanding how long you need to have the results? So, the duration of employment, you need to keep the results during their employment and at least two years after all normal. So, all results are normal, two years is your timeframe. However, if there is a confirmed occupational hearing loss that now becomes work-related, now is recordable, you have to maintain those records for 30 years, just like you would a work injury, a recordable work injury. When you review your audiograms, they should include the employee's name, their job classification, date, the examiner's name, the date of the last acoustic or exhaustive calibration. So, if you have an electronic medical record, that should be a part of your electronic medical record, a place where you can update that that has occurred. That's the easiest way where you can have a log book to make sure that you're maintaining that information. The baseline in the system for comparison. Mistakes that I see that's made is that you get a new device and you don't put in the baseline, you just start doing a whole bunch of tests and the computer has no way of determining. So, most computer systems, not all, some will make the first test the baseline if you don't put it in. If you don't manually or some way determine that the first result is the baseline, the first test is gonna be the baseline. We have some programs that it won't compare accurately because you haven't indicated which is the baseline. So, it's really important to know the device that you're using and knowing how that's put into the system. You must be able to have measurements of background sound pressure levels in the audiometric test room. So, remember I said how the booth will get you down to 40, but if you're doing the boothless system that you have to make sure that you have the adequate room level noise. An employee's most recent noise exposure measurement, you need to determine when's the last time they had exposure to noise. So, if it's a normal test, you just review the test result with them, you counsel them, make sure they're wearing their hearing protection, you advise them that you'll see them in one year and you file it. So, easy breezy. If you detect that there's a standard threshold shift in either ear, that is when there is an average shift in either ear of greater than or equal to 10 decibels at 2,000, 3,000 and 4,000 Hertz. That change could be in either ear, it doesn't have to be both ears. It can be one ear that they have that change. At the time that you do the test, you need to verbally let the employee know that there's a concern and you need to provide counseling of, are you wearing your hearing protection? How often are you wearing it? So, that's just for starters. What you'll do is, you need to be able to discuss with them about the what's next. You let them know that it doesn't mean because they had that STS of greater than 10, it doesn't necessarily mean that they have hearing loss, so they need to wait. We're not making a decision, a determination today, we're going to be doing a repeat. You must give them a written notification that there was an STS. So, according to OSHA, the formal notification must be given in 21 days. I say, why wait? If you notice that there has been a change, the letter comes out, you should have a letter that comes out of your system, your EMR system, your audiometric system, that says that an STS has been detected and that you need to return for testing. So, have them sign it, the date that the test is done, do not wait 21 days. If you're ever audited, they're going to want to see the signed letter. So, make sure you file that letter once they've been notified. Now, the requirement is that the follow-up audiogram has to be done within 30 days of that detected STS. So, before they leave, when they have that test and it's determined there's an STS, have them sign the form before they leave. And then before they leave, schedule the repeat test. And it must be done within 30 days. My recommendation is to, like, why wait? Why wait for 30 days? You can have them come 10, 14 days, and say, hey, look, I'll see you back. It doesn't matter, really, as long as they come to you at a time that they have had that 14 hours of no noise. I say schedule it no more than two weeks out because if they miss it because of vacation, they were sick, they had COVID, any reason, their car broke down, that they still can come back before the 30 days is out. The 30 days is out, they didn't come back, you bought a recordable. Regardless of the reason that they didn't come back. So, you may need to partner with the site that you're, or the employer, or whoever you're contracted with to let them know if someone doesn't return because if they don't return, you may need them to assist you with getting them back so you don't buy an unnecessary recordable. So, your retest. So, like I said, if it's normal, review, counsel, file, and you go on about the business. If there's an STS shift, give the employee that notification letter. The next thing you should be doing when they return to repeat that test is an extended questionnaire. I don't see this done consistently. This is to get more information about the employee, about noise, other excess noise, other medical concerns, looking at their job description. You should be starting to investigate and working as a partner in the investigation. If your place of work only does the hearing test, has them come back, and within that 30 days does the second hearing test, and only says, okay, it's, yep, they have hearing loss, it's work-related, that's not enough. And that's not really a solid way of running a program. You wanna be a part of the investigation. You wanna determine what's their exposure. And in that extended questionnaire, it'll make sure that they have exposure that greater than 85 decibels of exposure over that eight-hour time waited period. You wanna make sure that they wear hearing protection, that they don't do anything else that could cause them risk of having hearing loss that has nothing to do with work. You have to know when to refer. So you should be referring to your medical director or your audiologist to determine if it's work-related. And you should be giving them that information. You should be giving them the extended questionnaire, the job description, what noise exposure they were exposed to, what device that they're wearing. And if you're not doing that and you're just signing everything off as a STS OSHA recordable, then you're not supporting the program in the most effective way. You're creating, again, a necessary record. If the STS is in the left ear, you're gonna reset the baseline in that left ear, not both ears, okay? So make sure that you're considering, and remembering to adjust the baseline. Before I forget, only a physician, and maybe on another slide, only a physician or audiologist can determine if an STS is OSHA recordable. A nurse practitioner or a physician assistant cannot do that, it has to be a physician. All right, so finding a good audiologist, you want a good partner in your program, and not just someone that you're sending results to. So you wanna make sure they understand the OSHA standards, they understand the components of your hearing conservation program, your role as the clinician, and they have professional ethics. And what that means is that you know that they're not just signing off on everyone and saying, yes, yes, yes, all STS, all recordable, all work-related. They have no reason that they would just accept them all, because they like all the patients that come through, so they just say, oh, let's just make it work-related. That they're ethical in their decision-making as to whether or not it's work-related. So work-related versus not. Again, only a medical director or audiologist can determine if it's work-related, and PAs, PAs, and RNs, et cetera, may not determine recordability. So I know at some places they don't realize it, and I've heard people signing them, I'm like, ah, this is one of those things that hasn't been changed. If it's work-related, it must be placed on the OSHA log. It is considered then a OSHA recordable, so you've been hearing me say that. If it's work-related, the employee needs to be notified and counseled and advised on wearing the hearing protection, and make sure that you revise the baseline on that respective ear in the audiogram, because if you don't do that, it'll always come up as a new shift. So make sure you revise the baseline. Now, if it's not work-related, you still let them know that it's not, but you also need to revise the baseline on that respective ear as well, even if it's non-work-related. So just make sure you do that, still making that adjustment. And substitute the annual audiogram for the original baseline for future comparisons, because you want to basically make sure that you made the adjustment. So going forward, the system doesn't keep telling you that there's a standard threshold shift, because we already got it. We know, and it's been determined. Determination of an STS, so some considerations. So many programs that support hearing conservation do adjust for age. So they, and it's fine. The system, the computer system that you're using makes the natural adjustment. But just know that that is not an OSHA requirement. According to the OSHA standard, it's not a requirement to adjust for age. So there are some states, such as Oregon, for example, that does not adjust for age when it comes to the hearing conservation program. There are some employers who don't want you to adjust for the hearing conservation program. So that's a consideration when you're determining if there's an STS. So you as the clinician, the physician or the NP, you should be aware of that. If there's another consideration that I've mentioned, did you complete an extended questionnaire? Is the employee exposed to noise? Don't assume, because they may have been just placed in the program, but they're not even exposed to noise. They may have another reason why they have noise exposure. And then lastly, did you check the ears? This has happened and I've seen it one too many times and it's not good. You know, it's not good when you send someone to an audiologist and they come back to you and say, of course they can't hear. Did you ever check their ear to see that there's impacted cerumen? So to age correct or not? That is the question. So OSHA guideline, like I said, age correction is optional. So the age correction for the OSHA correction table is based on very old data and it had small sample size and it goes up to the upper limit of 60. So I'm guessing over time we'll see more studies and maybe OSHA will adjust the age corrected tables because some studies are showing that hearing loss has lessened over the years, but there's no updated data for age correction in terms of if there should be any change in the regulation, but this is what we have. So I'm gonna just kind of review a case sample of how age correction can make a difference. So let's say you have a 20 year old male who has right ear baseline thresholds at age 20 that are 10, 15 and 15 decibel hearing levels at two, three and 4,000 Hertz respectively. So he comes in, this is his baseline, looking good, all good. So his baseline is essentially 13.3 decibels looking at those three levels of hearing, three Hertz. But at age 40, his right ear is now 25 decibels. So this looks like if you do a threshold, you do the average, you'll see that the threshold shift is 11.7 decibels, which would be considered an STS and this is without age correction, no age correction. He has an STS of 11.7, all things being equal. We looked at his exposure limits. We looked at him wearing his ear hearing protection and determined like this is an STS. However, if the employer chooses to use an age correction, it would show expected values of four decibels at age 20. So that's where the age correction would be four decibels at age 20, but at by age 40, it's at 10 decibels. So basically there's a age related shift of six decibels. So looking at, you're minusing his average by six when you compare 20 years old to 40 years old. So the age related shift of six decibels will be subtracted by the threshold of 11.7. And without age correction, he will be 11.7, but as a result of subtracting that six, he has the age corrected shift of 5.7. So now this does not constitute a standard threshold shift. So it's important to know if the employer wants you to correct for age. And again, there are some states in Oregon as an example of a state that doesn't correct for age. So ultra recordability of STS has been since the year 2003. Employers are required to record work-related hearing adjustments for hearing loss caused by age. They can seek advice from a physician or a licensed hair care professional to determine if the loss is work-related and perform additional tests to verify the persistence of the hearing loss. So it is important, as I said, that you have a program in place if there is indeed an overexposure to noise of that 85 decibels. So your role as the occupational health clinician is to educate. When I say educate, you're educating the employer. If you notice a deficit, if you notice that they, and this has happened where you may be in an area where you notice that there's a lot of exposure, but they're not wearing protection, you as a clinician, that's your role to also have those discussions and say, they either need to be in the program or discussing your role in supporting the program and any trainings that they may want you to partner with. You also, your role is to monitor, to do the testing, to know how you're maintaining the compliance trait. There are some places at your work where you do nothing but compliance. You're just doing the testing as they're requesting it, as it's coming in. And there's some places that'll say, look, I want you to do the whole thing. I want you to remind people that they need tests. I want you to remind them if they haven't followed up. So you need to know what your partnership is to determine that role that you play in the monitoring. And overall being proactive, don't forget that you are a patient advocate and you want to do what's right by the patient, by the employee, and you want to do what's right by the employer to make sure that you're running a rock solid hearing conservation program. All right, I'm going to kind of review a couple of cases because when you're supporting a program, sometimes it becomes like you're so used to doing it. It's like, okay, let's just put you in the booth, do the test, get the results, send them on their way. But they're not all created equal. And it's not always cut and dry as to what is going on with the patient. So if you have a 39 year old factory worker who you detect that there's an STS shift in the right ear, he works 12 hours per day for the past 18 years. He's in the hearing conservation program and he tests yearly. The question is what are some reasons that it may not be work related? So this is someone regardless that has an STS shift and it looks like he's been doing his thing, right? And he's been coming to you every year to do your testing, but you're now noting the shift. Some of the reasons may be he works at a shooting range and he's had sudden exposure to noise. So when you start to get to know these employees, you get to know what their side hobbies are or their jobs. And you may be that partner that works with the employer and says, you know, I do have a concern that this may not be work related and this is why I work at a shooting range. Another reason is he doesn't wear his hearing protection properly, so inconsistently. So you need to know if he's wearing it and that may be a cause of him having the STS. Another consideration, and I've seen this happen of recent, is that someone that you're testing is in the program. Everybody's in the program. This is why you don't wanna put just everyone in a program who you are not sure has an exposure to that 85 decibels because what happens is he suddenly develops a shift. It's because he works at the shooting range. But when you look at and complete the hearing questionnaire and get more information from the employer, he's only exposed to 80 decibels. So this has nothing to do with work. So it's not a work related exposure because all the employees at the workplace is in the program. And this is a reason that in any medical surveillance program, you shouldn't just throw everybody in it because whatever sticks, they wind up buying something that's not theirs and has nothing to do with work because they're not exposed. But no one took the time to determine who should really be in the program. So there's one example. The second case is a 52 year old engineer. This person has right here STS of 10 decibels at 2000 Hertz this year in comparison than that last year. He reports he wears his hearing protection consistently and denies any sudden exposure to noise. Upon re-repeat test, no STS is noted despite no change in exposure or hearing protection. So he has the hearing loss in comparison. You repeat, there's no loss. Next year, it happens again. He has a reoccurrence of STS, but now it's 15 decibels. Even when you repeat it, there's been no exposure, no new exposure to his knowledge. He's wearing his hearing protection consistently. So you do the extended questionnaire and you do the noise exposure history. You send them to an audiologist. What are some reasons that he could have this questionable test? So first off, it could be a true work-related STS. Could be that simple that he may not be wearing the correct hearing protection and may not be consistent. He may be overexposed. So he does have a hearing loss. So it could be a simple work-related. He could have impacted cerumen. No one checked the ears. So that could be the reason why he has the hearing loss. Due to the improvement and the significant shift, further evaluation may be needed. He may have an acoustic neuroma. He may have another physiological reason for the hearing loss that has nothing to do with his hearing. So always remember that there are other reasons why patients can have hearing loss. You know, I mentioned lead exposure. I mentioned some medications can affect the hearing. So that's where you wanna look at the full picture. So in summary, OSHA standards, they began in 83. They've been re-evaluated in 2003 to begin to look at how we can prevent occupational hearing loss and monitor noise. It applies to all employees who have been exposed to noise greater than or equal to 85 decibels over an eight-hour of working or otherwise call an eight-hour TWA, time-weighted average. Program administrators should weigh the risk versus the benefit of booth versus wireless headphone testing. So determine that benefit before you go buying. So if the boothless system sounds like the easiest, cheapest, best way to do it, that's the worst to go through all the process and creating the program and buying everything and setting everything up and finding out it's just too noisy, you can't do it. Or your internet service is inconsistent, so it wouldn't work. Employees identified for the program have their hearing monitored through baseline and annuals. So make sure that they know how to put a baseline into the system because that will cause confusion. Remember that an STS definition is an average shift of 10 decibels or more at two, three, and 4,000 Hertz in either ear. Next, if an STS is identified or confirmed with the retest, determine work relatedness, utilize the extended questionnaire. I can't stress that enough because that helps put the picture together. Investigate, look at their job description, make sure that they have a true exposure, get all of that information before you refer them to your medical director or audiologist so they have the tools that they need to make that determination. If you're going to work with an audiologist and not a physician, make sure that they're knowledgeable, once work-related loss is determined, it is OSHA recordable in the respected ear. So if you're maintaining the OSHA log, it should go in the OSHA log if it's determined work-related. And then lastly, as a healthcare provider, it is important because it allows employers and employees to be proactive in preventing work-related hearing loss. So at the end of the day, it's not the most, I guess you could say the most exciting of programs, but as we get older, think about your role in protecting the hearing of your employees. You know, I will share as we close, you know, my mother worked in a loud area and did not wear hearing protection. And just watching the result as, you know, as she aged of not having good hearing, it's unfortunate because it could have been prevented. So we as clinicians, we know that we're advocates for our patients and we're advocates of all health systems and hearing is one of them. So my recommendation to you is to make sure that you have a solid program, that you look at the components in this discussion today and make sure that you have all the components in place. If you're simply just doing the tests, recording and filing them, then you may be missing pieces of what really truly makes a successful program and how to really support employees in making sure that they are protected. And sometimes, unfortunately, if you're doing it right, and I say unfortunately, because sometimes if you're doing it right, you will detect other reasons. And those examples of, you know, some form of acoustic neuroma, for example, or some kind of other lesions in the brain that can result in hearing loss and the way it's detected is that it doesn't fit. You know, it doesn't fit as to why they would have the significant loss and recognizing that it's not work-related and you're a part of that process. So I thank you for hanging in here with me today. I hope that you found the information helpful. And if anything, I hope that it helped you to confirm that you're providing a solid program or there may be pieces that you may want to tweak to make sure that you are effectively supporting a strong program. So thank you for your time and I'm sure I'll see you soon at some point.

Hearing Conservation Program

Occupational Hearing Loss

Noise Exposure

Monitoring Noise Levels

Audiometric Testing

Booth vs Booth-less System

Standard Threshold Shifts (STS)

Work-relatedness

Employee Hearing Protection