Audiology Service Delivery Considerations in Health Care During COVID-19

ASHA is aware that the audiology community is facing challenging job requirements that may have you providing care to patients/clients without personal protective equipment (PPE), comprehensive patient/client screening protocols, or appropriate physical distancing measures. ASHA continues to advocate for your safety and welfare related to clinical and professional issues with lawmakers, governing bodies, and employers, and will update this page as new information becomes available.

View the recording from the COVID-19 Audiology Town Hall.

On this page:

Job Classification of Audiologists: Essential/Non-Essential
In-person Audiology Services
Teleaudiology Practice Assessment
Limited Access to Personal Protective Equipment (PPE)
Documentation of Delays/Gaps in Services
Job Responsibilities Outside of Scope of Practice
Return to Work After Exposure to COVID-19
Additional Resources

Job Classification of Audiologists: Essential/Non-Essential

Members have been asking about the classification of essential/non-essential worker regarding the COVID-19 pandemic. Typically, positions are designated as essential/non-essential worker on a contractual, seasonal, or situational basis (e.g., in the event of a weather-related emergency or a public health crisis). Worker classification, if included, is commonly addressed in the employee contract signed upon hire. Please refer to your own setting’s employee handbook for specific guidance.

The designation of an essential or non-essential worker is usually assigned by one or more of the following entities:

An employer
An employee union
The federal government during a national emergency: For example, specifically in response to COVID-19, the U.S. Department of Homeland Security’s Cybersecurity and Infrastructure Security Agency (CISA) has issued guidance in the document "Essential Critical Infrastructure Workers" [PDF] in an advisory to state/local governments (page 5)

Note: While “Essential Critical Infrastructure Workers” does not explicitly list audiologists in the examples, the list is not exhaustive of all essential workers. The list of provided examples of a “caregiver” could reasonably include other caregivers, such as audiologists, who play a critical role in providing necessary services to patients, and who are involved in the continuity of care.

To the audiologists not identified as an essential/non-essential worker by nature of their work contract, and who are not employers, not part of a union, and who don’t interpret the CISA information [PDF] as being inclusive of audiologists, please note the guidance below.

We all must do what we can to help decrease the spread of COVID-19. If audiologists can physically isolate without denying essential patient services, they should do so. If audiologists can provide services for those in critical need while using every precaution at their disposal (e.g., enhanced infection control, physical distancing, PPE) for reducing COVID-19 spread, they should continue those necessary services.

Familiarize yourself with ASHA’s Code of Ethics. Every audiologist should make decisions that are the most appropriate for themselves, for their patients (see Code of Ethics, Principle I, and Principle I, Rule H), the facility at which the audiologist works, and the state regulations in place where the audiologist is licensed.

In-Person Audiology Services

The Centers for Disease Control and Prevention (CDC) recommends that each facility and type of practice setting completes its risk assessment to establish guidelines regarding the provision of services. The CDC encourages health care facilities to explore alternatives to face-to-face triage and visits. ASHA encourages audiologists to discuss patient and provider risks of service delivery with their employers to determine the best course of action for in-person services. State licensure laws regulate audiologists, and their worker classification is determined by their employer, setting, or state; therefore, ASHA is unable to provide broad national directives related to this issue.

ASHA recognizes that many members who work in health care settings are in situations in which they are expected to see patients with suspected coronavirus/COVID-19, or those who are at a high risk for contracting it. Audiology services are critical for individuals with communication disorders, which include hearing loss, vestibular disorders, and other auditory disorders.

While the welfare of the patient is paramount, ASHA’s Issues in Ethics: Client Abandonment states, “No clinician is ever ethically required to work...in physical danger in order to offer client care.” The CDC offers guidance for staff who may be at higher health risk (see this CDC resource on COVID-19 and pregnant women); your employer may consider alternatives to reduce the potential exposure to clients/patients/students who are ill. Depending on the current CDC Travel Health Notice information, you may want to ask clients/patients/students and families about their recent travel plans and consider a waiting period for in-person encounters in the interest of everyone’s safety. For information about COVID’s impact on children, please refer to the CDC’s Information for Pediatric Healthcare Providers.

See ASHA’s full list of telepractice resources, including research articles from Perspectives of the ASHA Special Interest Groups made open access.

Prioritizing Patient Care

COVID-19 has had unprecedented impacts on service delivery, affecting health care workers, and the patients they serve. ASHA maintains that decisions about patients’ care should be made based on the clinician's professional judgment and clinical expertise, per the ASHA Code of Ethics and Audiology Scope of Practice.

Every patient presents with unique characteristics and medical situations. Therefore, if clinicians face dilemmas prioritizing patients, decisions should be made using a team approach. Clinicians should seek guidance from administrators for facility-specific policies.

The Centers for Medicare and Medicaid Services’ (CMS) “Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED)” [PDF] offers additional recommendations, stating that “facilities should maintain a person-centered approach to care. This includes communicating effectively with residents, resident representatives, and/or their family, and understanding their individual needs and goals of care. Facilities experiencing an increased number of respiratory illnesses (regardless of suspected etiology) among patients/residents or healthcare personnel should immediately contact their local or state health department for further guidance.”

The American Medical Association (AMA) recommends “health care facilities and clinicians prioritize urgent and emergency visits or procedures now and for the coming several weeks."

Other AMA recommendations include:

Delay all elective ambulatory provider visits
Reschedule elective and non-urgent admissions
Delay inpatient and outpatient elective surgical and procedural cases
Urge patients to postpone routine dental and eye care visits

Audiologists’ Role in Newborn Hearing Screening

Many audiologists have been seeking advice on how soon a newborn would need to be tested after a “fail” result on the universal newborn hearing screening—whether the determination to perform a retest should wait until the environment is safe, or if the 1-3-6 guidelines should take precedence. There is no one universal answer for every facility. The American Academy of Pediatrics (AAP) issued Guidance on Newborn Screening During COVID-19. AAP states, “Clinical best practices advise that infants be screened by 1 month of age, are diagnosed for hearing loss by 3 months of age and enter into early intervention services by 6 months of age. Continued adherence to these standards amid COVID-19 is essential to ensure healthy and appropriate development.” Ultimately, the decision would be made by the hospital/facility according to the state guidelines it follows. It is ideal to have the retest performed as soon as safely possible. The best course of action would be to contact your state’s Early Hearing Detection and Intervention (EHDI) coordinator for guidance. The National Center for Hearing Assessment and Management (NCHAM) provides a valuable list of contacts for each state.

Infection Control

ASHA provides infection control resources for audiologists and speech-language pathologists, with updated information about COVID-19. All health care workers should follow infection control recommendations from the CDC and WHO [PDF].

ASHA provides guidance on best practices for disinfecting audiology equipment in the following chart: Infection Prevention and Control for Audiology Equipment [PDF]. ASHA also has an on demand webinar: Infection Prevention and Control in Audiology Practice Settings.

For those who employ audiologists and audiology personnel, please refer to OSHA recommendations: “Employers of healthcare workers are responsible for following applicable OSHA requirements, including OSHA's Bloodborne Pathogens (29 CFR 1910.1030), Personal Protective Equipment (29 CFR 1910.132), and Respiratory Protection (29 CFR 1910.134) standards.” See OSHA standards and directives for additional information on OSHA requirements.

Per OSHA recommendations, health care workers should “follow the manufacturer’s instructions for the use of all cleaning and disinfection products (e.g., concentration, application method, and contact time; PPE).”

The following manufacturers have provided instructions for the care and cleaning of their hearing devices during COVID-19:

Hearing Aids

Cochlear Implants

Note: Inclusion on this list does not imply endorsement by ASHA. For more information about this page, please contact audiology@asha.org.

Teleaudiology Practice Assessment

Many audiologists have considered offering audiology services remotely, via telepractice, but prior to COVID-19, few had actually implemented them. Teleaudiology encompasses many forms that are currently available today, from remote hearing aid programming through an app on a smartphone to comprehensive remote evaluations with patient and provider at distant sites. When planning to implement a full-service remote teleaudiology program, a good place to start is with an honest assessment of your needs, your goals, and your practice’s readiness.

Here are a few essential questions to consider:

Should you expand your availability in order to serve your patients/clients better?
Is your market area in need of more access to your services?
What do your patients/clients need?
Did you carefully review state laws and regulations, payment and coverage in your area, and other compliance issues—including privacy and security of protected health information?
Do you have policies and procedures in place?
Have you budgeted for the expense?
Do you have the proper equipment?
Do you have a plan for appropriate IT support, and have you secured a qualified team to embrace technology advances?
How will you measure the effectiveness of your teleaudiology services?

When considering your practice needs, your patients’ needs, and whether teleaudiology services are right for you, ASHA offers resources to guide you in examining state laws and regulations [PDF], payment and coverage in your area, and other compliance issues, including ensuring the privacy and security of protected health information.

The Agency for Healthcare Research and Quality (AHRQ) has developed a useful decision guide to consider as you approach innovation in your practice.

American Telemedicine Association (ATA) resources may be helpful as you explore offering tele-audiology services. You can receive ATA’s Quick-Start Guide to Telehealth During a Crisis by providing contact information on the website.

Limited Access to Personal Protective Equipment (PPE)

The following resources provide relevant information specifically related to access and use of PPE during the COVID-19 pandemic:

The Joint Commission provides guidance on managing critical shortages of PPE during declared emergencies.
The U.S. Department of Labor Occupational Safety and Health Administration (OSHA) provides “Guidance on Preparing Workplaces for COVID-19” [PDF], including access to PPE.
The World Health Organization outlines the rights, roles, and responsibilities [PDF] of health workers and their employers for occupational safety and health in light of the COVID-19 outbreak.
The CDC offers “Strategies for Optimizing the Supply of PPE,” as well as contingency plans for when supplies are limited and/or have run out, which include cancelation or delay of non-urgent services. Some states and facilities have chosen to interpret this as inclusive of rehabilitation services.

If audiologists and their colleagues are unable to access appropriate PPE for service delivery during COVID-19, they are encouraged to voice their concerns to OSHA and local departments of health and human services (HHS) after appropriate engagement with their employers.

Many audiologists are concerned about client abandonment if they refuse to provide services without appropriate PPE. ASHA’s Issues and Ethics Statement on Client Abandonment states that some disruptions of clinician-client relationships are involuntary. As such, “clinical relationships may also be interrupted if an organization decides to close a program or when natural disasters occur. It is expected that even in these types of situations, practitioners would hold paramount the welfare of the clients they serve; however, no clinician is ever ethically required to work without pay or to place themselves in physical danger in order to offer client care.”

Documentation of Delays/Gaps in Services

Because of this national emergency, there may be unavoidable delays in care, or instances when audiologists cannot provide care. In cases where a clinician is unable to see the patient, those specific reasons should be documented in the patient’s medical record and communicated to the patient’s health care team, while providing alternate solutions for whenever possible.

If there are interruptions to clinical services that delay continued access to care, here’s some additional guidance:

Review patients’ plans of care and consider making any updates or modifications that may be necessary to account for patient access issues related to COVID-19 (e.g., contacting the family by phone for discharge planning, providing treatment only in the patient’s room, following CDC guidance for PPE while providing services, etc.).
Communicate with patients and their families to help them understand the situation and assure them that you are doing all that you can to provide (or resume) services.
Ensure that all members of the care team are documenting in the medical record their efforts to adhere to the patient’s plan of care, including all refused attempts to see patients in-person and all alternative methods used to perform patient visits (e.g., virtual visits via telepractice or e-visits).

Job Responsibilities Outside Audiology Scope of Practice

Several audiologists have reported that during COVID-19 their employers have asked them to engage in tasks not directly related to their scope of practice (multiskilling). Multiskilling is often used in an attempt to enhance cost-effectiveness, efficiency, quality, and coordination of services.

The Audiology Scope of Practice is written in broad terms, and specific activities an audiologist may be asked to perform may not be mentioned. ASHA's Code of Ethics states that clinicians must be competent by virtue of training, education, and experience to perform any activities. Thus, appropriate training and support are necessary for an audiologist to undertake any activity in which they are not already competent. Your facility should develop a written policy that addresses the level of involvement and training that audiologists should have, and a mechanism for verifying their competency. ASHA has a position statement and a technical report on multiskilling that offer additional guidance. During COVID-19, it’s essential to note that states may issue executive orders that can override ASHA or employer policies.

Please check your own state’s executive orders for the latest guidance on the issue.

Return to Work After Exposure to COVID-19

The CDC has established “Criteria for Return to Work for Healthcare Personnel With Confirmed or Suspected COVID-19.” Employers are expected to make appropriate risk assessments for their staff and patients before permitting re-entry of employees suspected to have exposure to coronavirus into their facilities.