Cochelar Implants 003

Quality Standards
Cochlear implants for

children and young people
Guidelines for professionals working
with deaf children and young people
Joint revision by:

The National Deaf Children’s Society
and
British Cochlear Implant Group
and the British Cochlear Implant
Group would like to thank Advanced
Bionics (www.cochlearimplants.com),
Cochlear Ltd (www.cochlear.com) and
Med-El (www.medel.com) for kindly
providing photographs (and
permission for use) that have been
used throughout this publication. We
would particularly like to thank the
parents, children and young people
featured in these photographs and in
those provided by NDCS.
Contents
Statement by Susan Daniels and John Graham 5
1. Notes to readers 6
2. Introduction 7
3. Children and young people – key considerations 8

3.1 Appropriate candidates 8
3.2 Adolescent programmes 8
4. Local services and support 10

4.1 Local services for deaf children and young people 10
4.2 Newborn hearing screening programme 11
4.3 The local health service 11
4.4 The local specialist education service 11
4.5 The local social care services 12
4.6 Support groups and voluntary organisations 12
5. Supporting the child, young person and family 13

5.1 The need for accessible information 13
5.2 Communication 14
5.3 The need for multi-disciplinary working 14
5.4 Partnership and parental responsibility 14
5.5 Involving the child in their own care 15
5.6 Involving the young person in their own care 16
5.7 Contact with peers and families 16
5.8 Children with additional complex needs 17
Quality standards and good practice guidelines: Cochlear implants for children and young people
6. The paediatric/adolescent cochlear implant programme 18
6.1 The cochlear implant team 18
6.1.1 The audiological scientist (clinical scientist) 18
6.1.2 The ENT surgeon 19
6.1.3 The audiological physician 19
6.1.4 The speech and language therapist 19
6.1.5 The teacher of the deaf 20
6.1.6 The co-ordinator (or cochlear implant service manager) 20
6.1.7 The key (link) worker 20
6.2 Additional specialist support 21
6.3 Training requirements 21
7. Clinical and surgical facilities and accommodation 23

7.1 Hospital and clinic accommodation 23
7.2 Audiological testing and assessment 24
7.3 Surgical equipment 24
8. The referral and selection procedure 25

8.1 Attendance and commitment by the child and family 25
9. Assessment for a cochlear implant 27

9.1 Prior to the appointment at the clinic 27
9.2 The process and procedures 28
9.3 Funding requirements 28
9.4 A co-ordinated approach to multi-disciplinary assessment 29
9.5 Local professionals and the assessment process 29
9.6 Assessment in the home and at school 30
9.7 The audiological assessment 30
9.8 The teacher of the deaf assessment 31
9.9 The speech, language and communication assessment 31
9.10 The medical assessment 32
9.11 CT/MRI scans 32
9.12 Ophthalmic assessment 33
9.13 BCIG and other safety guidelines 33
9.14 Pneumococcal meningitis vaccination 33
9.15 Otitis media 34
10. The outcome of the assessment 35
10.1 Consent and confidentiality 35
10.2 Establishing funding commitment for long-term NHS care 36
10.3 Preoperative care 36
11. Surgery and postoperative care 38

11.1 The cochlear implant device 38
11.2 Nursing care prior to and at surgery 38
11.3 Surgery and care 38
11.4 Following surgery 39
11.5 Discomfort, unexplained changes or swelling of the surgical site 40
11.6 Contact details for support 40
11.7 Revision surgery 40
11.8 Device failure 40
12. Programming, follow-up care and support 42

12.1 Prior to programming 42
12.2 Fitting the implant device and programming 42
12.3 Records of measurements 42
12.4 Specialist contact sessions with the child, family and
local professionals 43
13. Ongoing evaluation of benefit 44

13.1 Habilitation for the young person 44
13.2 Cochlear implant equipment 45
13.3 Contralateral hearing aid provision 45
13.4 Personal FM equipment 46
13.4.1 Routine maintenance and monitoring 47
13.4.2 Assistive devices, leads and accessories 47
13.5 Battery safety 47
13.6 Insurance and replacement guidelines 47
13.7 New developments 48
14. Transfer of care 49
14.1 Transfer to an alternative paediatric or adolescent service 49
14.2 Transfer to adult care 49
15. Service planning, evaluation and audit 52

15.1 Complaints procedure 52
16. Acknowledgements 53
17. Appendix 1 54
Alphabetical listing of key professionals working with the child,
family and cochlear implant team
18. References 55
Driving up standards for deaf children and young
people with a cochlear implant
The National Deaf Children’s Society (NDCS) and the British Cochlear Implant
Group (BCIG) have jointly produced Quality standards and good practice
guidelines in cochlear implants for children and young people.
The aim of this joint review by NDCS and BCIG is to define good practice
and drive up standards of care for children and young people who are
considered for, or who receive, a cochlear implant.
We believe that this document provides a valuable tool and reference point
for all service providers, purchasers and commissioners of services to help
them to deliver quality care for deaf children and young people with a
cochlear implant. Its aim is to give busy professionals the framework in which
to provide the best possible support and long-term care.
We are proud that these guidelines have been developed through a strong
partnership between NDCS and BCIG. We would like to thank everyone
involved in the development of this work. The document has had crucial input
from cochlear implant teams across the UK, audiology and education services,
community professionals, parents and lay people involved with deaf children.
Susan Daniels, NDCS Chief Executive John Graham, BCIG Chairman
April 2005
The National Deaf Children's Society is the only UK organisation solely

dedicated to the support of deaf children, deaf young people, their families,
carers and professionals working with them.
The British Cochlear Implant Group is committed to the enhancement and

promotion of the best possible quality of service provision for children,
young people and adults who receive cochlear implants in the UK, and
welcomes with great enthusiasm the opportunity to work with NDCS in the
publication of this document.
Quality standards and good practice guidelines: Cochlear implants for children and young people 5
1. Notes to reader
1.1 We use the term ‘child’ or ’children’ to include babies and younger children,
and ‘young person’ to define older children and young adults. However, the
term ‘child’ or ’children’ is used to include young people, unless specifically
stated otherwise.
1.2 The term ‘young person/people’ is used to identify those most likely to
benefit from an adolescent programme.
1.3 We use the word ‘deaf’ to cover all types of deafness, including temporary
deafness such as glue ear.
1.4 The phrase ‘all deaf children’ includes children who have additional needs,
who are from minority ethnic communities or who are from families that find it
difficult to gain access to services.
1.5 We use the term 'parent(s)' and 'family' to include the child's carer with
parental responsibility. If the child is a ward of court, or in the care of a social
services department, appropriate permission must be sought before medical
or surgical procedures take place.
1.6 The document is intended for use by all cochlear implant programmes
throughout the UK (however, not all references and/or legislation cited in the
text may be relevant).
1.7 The abbreviation QS is used to denote factors which define a quality

standard that can be used in a clinical audit of services.
6 Quality standards and good practice guidelines: Cochlear implants for children and young people
2. Introduction
This document has been produced in partnership between The National Deaf
Children’s Society (NDCS) and the British Cochlear Implant Group (BCIG). It
replaces Quality Standards in Paediatric Audiology: cochlear implants for
children, Volume III, June 1999 (which superseded the original BCIG
document, 1994). This revision took place following consultation with
paediatric and adolescent cochlear implant teams, other interested
professionals, parents and young people across the UK.
More than two children a day in the UK are born with significant permanent
hearing loss (Fortnum et al, 2001; Hall, 2004). A study by Fortnum et al
(2001) estimated that a further 0.6-0.9 per 1000 children will develop hearing
loss by 10 years of age (due to illness, progressive hearing loss or late onset
of deafness). Of the 840 children born deaf each year (Summerfield &
Marshall, 1995) more than one quarter will receive a cochlear implant in their
early years.
Early identification and appropriate management lessens
the impact of hearing loss on the child, the child’s family,
and on society (Kuhl et al, 1992; Markides, 1986;
Meadow-Orlans, 1987; Ramkalawan & Davis, 1992;
Yoshinaga-Itano, 1998; Sharma et al, 2002; McConkey
Robbins et al, 2004).
Providing a child with a cochlear implant requires a
dedicated multi-disciplinary team who understand the
complex needs of each child and the impact any
intervention will have. The paediatric and, where relevant,
the adolescent team must be able to assess their
individual needs, be fully conversant with specialised
equipment and be capable of providing long-term
habilitative support to the child and to their family until
they transfer to an adult cochlear implant programme.
The provision of a cochlear implant requires NHS
commitment of life-long care for the user.
We believe that parents play a central role in the care of their deaf child, and
it is crucial for implant teams and local services to work closely with them
and with the child and/or young person and involve them in every step of the
procedure. Optimal habilitation for the child can only occur when parents are
considered and valued as equal members of the team. All services should
work with and encourage young people to be fully involved in decisions
relating to their own care and in their long-term care plan.
This document identifies guidelines for good practice that will help service
professionals to maintain and improve standards and quality service provision
for deaf children and young people. It will also provide purchasers and
commissioners with clear and balanced guidance on the different processes
and procedures involved when commissioning cochlear implantation services.
3. Children and young people – key considerations
Providing a child with a cochlear implant involves the surgical insertion of an
electrode array into the cochlea to provide direct stimulation of the auditory
nerve. It can provide severe to profoundly deaf children with a sensation of
hearing and, through a careful and consistent process of auditory habilitation,
many can achieve functional spoken language and a greater understanding
of environmental sounds.
3.1 Appropriate candidates

The referral criteria for cochlear implantation are constantly evolving. A
cochlear implant may be a suitable procedure for a young child who has
received very limited or no benefit from hearing aids. In addition, older
children and young people with a severe to profound hearing loss, and those
with progressive and sudden onset hearing loss, who show evidence of using
sound in their daily lives, may also be considered.
Around 40% of deaf children will have additional needs, such as ophthalmic
problems (Guy et al, 2003), or developmental delay. Deaf children with
complex needs, who meet the referral criteria, should be considered for
cochlear implantation assessment.
A cochlear implant should only be offered following efficient and effective
multi-disciplinary assessment by the cochlear implant team working with local
services. This detailed assessment will usually take some weeks to complete.
However, in certain circumstances, such as following meningitis and where
there is a risk of ossification this period of time is likely to be less.
3.2 Adolescent programmes

‘Individual specialist disciplines … should provide specifically for the needs of
young people, and, where numbers justify, develop a separate young
people’s service. They should also ensure that social, psychological,
education and employment needs are addressed.’
(Department of Health, 2003)
Cochlear implantation is no longer in its infancy in the UK and children who
received a cochlear implant some years ago are now young people. As a
result some teams have developed an independent ‘adolescent’ programme,
or service within their paediatric programme, to cater for older children and
teenagers who are still in full time education.
Young people will need a smooth transfer from the paediatric/adolescent
programme to the adult programme (see ‘transfer of care’, 14.2, page 49),
with one-to-one intervention provided outside the paediatric environment.
This specialist service should establish close liaison with local education and
other services.
4. Local services and support
‘At any stage, the care pathway may need to link in social care, education
and other services. It is essential that robust relationships and arrangements
are developed within and between organisations to ensure that the child’s
experience is as ‘joined up’ and seamless as possible’
(Department of Health, 2003).
4.1 Local services for deaf children and young people

The ‘local service’ refers to those services (health, education or social care)
based in the child’s local hospital, school or community, who will liaise with
the cochlear implant programme to provide day-to-day support. This would
include specialist education and therapy services.
The care pathway for a deaf child means that their first professional support
is likely to be from the ‘local health, education and/or social care services’. It
is important that purchasers and commissioners of NHS cochlear implant
services recognise this and that the management of a child involves
integrated multi-disciplinary care and support.
QS 01 Once a child has been identified as having a permanent

hearing loss the assessment targets outlined in the NDCS
Quality Standards in Paediatric Audiology Volume IV (under revision) and
NDCS Quality Standards in the Early Years (2002) will need to apply.
Local services should ensure that the family is given the opportunity to
discuss and explore issues relating to their child’s deafness. They should:
• promote equal opportunities for all children supported by the service
• ensure the child has every opportunity to develop their full potential
• raise the level of awareness of deafness with teachers and peer groups
to maximise the child’s potential.
Local services should be fully conversant with cochlear implant referral criteria
and current thinking on policy and procedures. Following implantation, local
services will need to work closely with the cochlear implant programme to
ensure effective ongoing habilitation for the child.
QS 02 Local and specialist multi-disciplinary teams should work

together to ensure a co-ordinated and efficient approach to
each child’s assessment and ongoing care.
Families with a disabled child can gain valuable support from other parents
with a disabled child (see ‘contact with peers and families, 5.7, page 16).
Therefore, it is important that local services provide families with the
information and opportunities they need to make contact with other families
with a deaf child.
4.2 Newborn hearing screening programme

Newborn hearing screening should be fully implemented throughout the UK
by the end of 2005 (see www.nhsp.info). Newborn babies will have their
hearing screened during the first few weeks after birth. If a baby does not
show a clear response to this screen they will be referred to the local
audiology service for assessment. Babies born with congenital or perinatal
deafness will be referred from screen to audiology in the first days of life,
although the hearing loss will take longer to confirm.
Newborn hearing screening will make it possible for families and
professionals to work together to take very early action on behalf of the
child and to intervene before language and communication deficit has
become established.
4.3 The local health service

Local audiological and medical services are responsible for the assessment,
diagnosis and audiological management of the child.
The audiology service will manage and treat any middle ear pathologies, in
partnership with the local ENT service. They should work closely with the
family and other local education and health services to ensure that suitable
support is given, appropriate hearing aids are fitted and maintained, and that
the hearing aids are effectively evaluated in use.
4.4 The local specialist education service

Specialist education services (for example teacher of the deaf, educational
audiologist, etc) will work with the child and family from the point of
confirmation of deafness. They will also work closely with the local health
services in providing multi-disciplinary advice, care and support to the family.
Prior to a child having an implant, the local education service should support
hearing aid use in order to assess functional hearing, maximise residual
hearing and develop communication. They will need to provide specialist
equipment for the child to use at home and at school, eg personal FM
system, and to ensure that all equipment has the appropriate accessories
and meets the individual needs of the child.
4.5 The local social care services
The role of the social care services team in relation to deaf children and their
families is identified in Deaf Children: positive practice standards in social
services (Association of Directors of Social Services et al, 2002).
It is important that a working partnership exists between social care, health
and education services to improve deaf children’s assessment for
communication equipment and its provision (ADSS et al, Standard 5.3,
2002). (This document was written in relation to services specific to England,
it is largely applicable to Wales but not to Northern Ireland or Scotland where
different legislation may apply.)
4.6 Support groups and voluntary organisations

Support groups and voluntary organisations are able to provide parents with
support and guidance on all aspects of hearing loss. They can provide useful
information on new and changing technological developments for the deaf
child, including information relating to cochlear implants. The cochlear implant
programme should provide families with written details of how to contact
local and national support groups, such as the Cochlear Implant Children’s
Support group (CICS) at www.cicsgroup.org.uk, NDCS at www.ndcs.org.uk
and local DCS group, etc.
QS 03 Information about voluntary sector services must be given to

the family at the time of assessment, at key stages throughout
the child’s life, and when requested by the family
5. Supporting the child, young person and family
‘Children and young people should receive care that is integrated and co-
ordinated around their particular needs, and the needs of their family. They,
and their parents, should be treated with respect, and should be given
support and information to enable them to understand and cope with the
illness or injury, and the treatment needed. They should be encouraged to be
active partners in decisions about their health and care, and, where possible,
be able to exercise choice’ (Department of Health, 2003).
In order for parents to make an informed choice it is essential that they be
fully informed with regard to the health and educational development of their
child. The implant team should ensure that the child and family understand
the nature and cause of the child’s hearing loss, as well as the management
options available to them.
Services will need to obtain appropriate consent prior to any intervention.
They will also need to obtain consent before passing details of the care of the
child or young person to others (see section on ‘consent and confidentiality’,
10.1, page 35).
5.1 The need for accessible information

Parents and young people need balanced and unbiased information so that
they can make an informed choice. Information should be clear, accurate and
accessible, and provided in spoken and written form, for example leaflets that
can be taken away (Department of Health, 2003). All information should be
available in other languages, including sign language, and other formats such
as large print, audio, videotape or Braille.
The cochlear implant team will need to provide information on:
• the assessment process
• the surgical procedure
• realistic outcome targets and benefits
• the need for long-term habilitative care with implantation
• types (and choices) of equipment available
• communication modes available after implantation.
QS 04 Families and young people must have equal access to

information in their preferred language.
5.2 Communication
QS 05 The cochlear implant team must provide the family and/or

young person with information on the audiological and
communicative developmental needs so that they can make an informed
decision about cochlear implantation.
All members of the team should be aware of the principles of

family-friendly services (for example, Baguley et al, 2000) and
these principles should be reflected in the written protocols as
well as the clinical delivery of services.
The cochlear implant team and local professionals will need to
work with the family in developing skills to help their child,
over time, to develop listening and spoken language skills.
Those involved in the cochlear implant team should be able to
communicate effectively and sensitively with the deaf child,
young person and the family. This should include signing if this
is the most appropriate communication method.
QS 06 Sign language and/or spoken language interpreter(s) must be

provided for all visits to the hospital or clinic, as required.
5.3 The need for multi-disciplinary working

(see Section 9.4, page 29)
‘The evidence strongly favours a holistic health-promoting approach, which
crosses agencies and disciplines, rather than a narrow defect-detecting
programme.’ (Hall & Elliman, 2002).
Children, young people and parents are part of the multi-disciplinary team
and they will be involved with a number of professionals from different
disciplines. Good multi-disciplinary working can effectively reduce
disruption to their family life, and good communication between personnel
within the team will help to establish their needs allowing them to be
addressed holistically.
Clear communication and co-ordination between agencies should reduce the
number of meetings and appointments that parents have to attend, for
example by arranging joint visits
5.4 Partnership and parental responsibility
Parents have a pivotal role to play in the assessment and influence of their
child’s progress and the needs of their child, and the implant team has a duty
to work in partnership with them and to provide the support they need to
carry out this role of care and responsibility.
With support from local services, the implant
team should work with parents and children
to ensure they understand how important it is
that the implant device is worn consistently
and the equipment maintained in good
working order. The implant team will need to
work with them to ensure they understand
they have a responsibility to:
• follow through with daily practice of
therapy goals
• attend the cochlear implant clinic for all
appointments, both pre- and post-surgery
and until transfer to the adult service
• prepare the child for hospital procedures
• ensure consistent and effective use of the
implant and related equipment
• provide effective feedback on their child’s
or their own development
• monitor, care and maintain the equipment
and surgical site on a daily basis
• commit to a programme of
aural habilitation.
5.5 Involving the child in their own care

Children have a right to be involved in
decisions about their own care (UN
Convention for the Rights of the Child, 1989).
It is essential that parents and professionals
providing services and support to children
seek, wherever possible, to obtain the views
of the child. Where a child is considered to
be old enough to make an informed choice
their consent should be obtained, and their
views should be respected.
Communication and information should be
culturally appropriate, age appropriate and at
a level, and by means, best suited to the
child’s stage of development and degree of
understanding (Department of Health, 2003).
5.6 Involving the young person in their own care
Young people must be fully involved in their own care, in the decision making
process, and in the development plan for their long-term care. They need to
fully understand the implications of having a cochlear implant before they
consent to surgery. Young people should be provided with the necessary
encouragement to take full responsibility for their own care (Department of
Health, 2002).
Regardless of whether the young person is cared for by a paediatric or
adolescent cochlear implant programme, it is important that they are given
culturally appropriate and age-related support and information.
5.7 Contact with peers and families

Parents, children and young people value contact with
other families in order to share experiences and learn
from one another (Dettman et al, 1996; McCormick &
Archbold, 2003).
Such shared experiences will be very valuable to
families during the assessment and decision making
phase. However, peer support following surgery and
during the ongoing habilitation of the child is equally
important. The implant team should work with local
services, support groups and voluntary organisations,
to ensure this is facilitated and proves a useful
experience for the child and family.
QS 07 It is the responsibility of the implant programme to work with

local services to ensure there are established and accessible
opportunities for the child and family to meet others, with and without an
implant, during the assessment phase.
Finding appropriate families and peers will take time and careful consideration
and requires the full consent of both parties. Once a contact family has been
identified and a meeting arranged, the implant programme should not have
any further involvement in the discussions between the families unless invited.
Patient confidentiality must always be observed and respected.
Implant teams should run ‘family days’. This will enable them to meet families
who are considering an implant for their child, as well as other families with a
child who already has a cochlear implant.
Young people should be offered contact with other deaf young people with
and without a cochlear implant, and given details of internet-based support
groups, such as www.ci4-teenz.com.
5.8 Children with additional/complex needs
‘Many children have complex needs that cross speciality boundaries and they
will need access to a whole range of services. Staff need to collaborate
closely to ensure that children and their families are receiving consistent and
co-ordinated support, and the NHS locally will need to design services to
achieve this’ (Department of Health, 2002; 2003).
Cochlear implant staff, and ideally all those working in local health and
education services, should have the knowledge and expertise that enables
them to work effectively with children with a range of complex needs, in
addition to hearing loss. They need to understand the referral pathways to
other specialised teams so that the child receives appropriate habilitation to
meet their individual needs. Strategies and protocols should be developed to
provide seamless service provision.
The impact of hearing loss on the child and family should be viewed in the
context of the child’s whole development, including that of health,
educational and social care development. It is the responsibility of both
health and education to ensure that all staff involved with a deaf child with
additional needs are fully informed and have a full understanding of the good
practice guidelines produced by other agencies and organisations supporting
such children.
6. The paediatric/adolescent cochlear implant
programme
The ‘cochlear implant programme (or service)’ refers to the team responsible
for assessment, surgery and habilitation of the child being considered for or
with a cochlear implant. This team may not be based in the child’s local
hospital or community and may be a tertiary centre. The service, working in
conjunction with the child’s local services, is responsible for advice and co-
ordination of the child’s care.
6.1 The cochlear implant team

‘To deliver hospital services that meet the needs of children, young people
and their parents, and provide effective and safe care, through appropriately
trained and skilled staff working in suitable, child-friendly, and safe
environments’ (Department of Health, 2003).
Providing a cochlear implant service involves the formation of a skilled, multi-
disciplinary team that works closely with the child, their family and local
professionals who work with the child. Team members need to allow
sufficient time to collaborate on joint working and planning, and to engage in
training. This will ensure the development of true multi-, inter- and intra-
disciplinary working and shared clinical knowledge. New personnel will need
to be given training, supervision and support by relevant experienced
members of the cochlear implant team. Key members of the team are:
6.1.1 The audiological scientist (clinical scientist):
QS 08 Audiological support and assessment must be undertaken by

staff with the necessary skills to perform and interpret testing.
Key scientific staff must be appropriately trained at postgraduate level (for
example MSc, or equivalent in audiology, supplemented by suitably
assessed practical experience) and state registered with the relevant body.
No audiological member of the team with less than 2 years experience in
paediatric audiology should work unsupervised.
The audiological scientist will review the child's hearing aid fitting and perform
detailed behavioural hearing assessments and objective hearing assessments
where necessary. They are usually responsible for testing the implanted
device during surgery.
During the habilitation period, to ensure that optimum fitting and use of the
device is maintained, the audiological scientist will establish thresholds and
comfort levels of stimulation and, in consultation with other members of the
implant team, select appropriate speech processing strategies and
parameters. The audiological scientist will be responsible for ongoing
adjustments and maintenance and for ensuring the child and family
understand how the cochlear implant works and is used.
6.1.2 The ENT surgeon:
QS 09 The ENT surgeon will have an FRCS qualification. They will be

a NHS consultant paediatric otolaryngologist/otologist with
appropriate accreditation and training in implant surgery. They will have had
a minimum of two years experience in adult cochlear implant surgery before
undertaking paediatric cochlear implant surgery.
The surgeon, in collaboration with the consultant anaesthetist, is responsible

for assessing the child's medical fitness for cochlear implant surgery. The
surgeon will perform the cochlear implant surgery and with the anaesthetist
will have overall responsibility for the child’s medical and clinical care.
6.1.3 The audiological physician:

In some centres the audiological physician may carry out some of the
medical and audiological care of the child (Papsin et al, 1997).
QS 10 The audiological physician must have the necessary skills to

carry out this work and be on the audiological medicine
specialist register. They should be qualified to MSc in audiological medicine.
They must be trained and have experience of working with children.
6.1.4 The speech and language therapist (SLT):
QS 11 The SLT must have a degree and licence to practice, including

registration with The Royal College of Speech and Language
Therapists and Health Professional Council. The SLT must have two years
generalist speech and language therapy experience (RCSLT, 1997), and have
at least two year’s experience of working with deaf children. They must have
attended relevant postgraduate training.
The SLT will assess and evaluate the child's communication development
and competence, including their speech and language skills and social
development. This will be in collaboration with other team members. They will
work closely with the rest of the team, the parents and local professionals in
advising and reviewing the implementation of appropriate communication
goals (Implant Centre Speech and Language Therapists, 1998).
6.1.5 The teacher of the deaf (TOD):
QS 12 The TOD will have a DfES QTS qualification and a mandatory

qualification as a TOD. They will have at least 2 years
experience of teaching deaf children. Experience in a variety of educational
settings, to include pre-school peripatetic work with young children and
their families, is required. It is desirable that they have further relevant
post-qualification training
The TOD will assess and evaluate a child’s functional hearing aid use,
listening and communication skills in collaboration with other team members.
The TOD will work closely with the team, family and local professionals in
identifying and advising and reviewing the implementation of appropriate
auditory and communication goals. They will liaise between the cochlear
implant team, the child’s home and school to ensure consistent sharing of
information during the assessment, surgery, device programming and
rehabilitation processes (ICTOD, 2003).
6.1.6 The co-coordinator (or cochlear implant service

manager):
The co-ordinator will have a high degree of organisational, leadership and
professional skills. They will ensure that appropriate services are provided for
each child throughout all phases of the cochlear implant process and
procedure. It is the co-ordinator’s responsibility to ensure that any
recommendations are made to the child’s local services to establish and/or
maintain quality provision of care.
6.1.7 The key (link) worker:
QS 13 ‘One professional should take on the role of key worker in

order to provide a single point of contact and co-ordination for
the family’s care package’ (Hall & Elliman, 2002).
The cochlear implant team should assign each child with a key (sometimes
known as the link) worker who will work with the child's family, co-ordinating
their care and acting as their first point of contact, and who will ensure there
is effective contact with the child’s local health and education professionals.
The family must know who their key worker is and have the ability to change
their key worker if they so desire. The key worker must be accessible to the
child and family and be flexible in their approach to their needs. It is their
responsibility to ensure that there is continuity in the information provided to
all those involved with the child.
6.2 Additional specialist support (see Appendix 1)
In addition to the expertise of the core team, and to local services, there may
be a need for others with specific expertise to be involved in the care of the
child. Additional support will depend on the individual needs of the child.
Wherever possible those providing additional support should have experience
of working with deaf children and their families.
Children with multiple sensory impairment may need further specialist input to
meet their complex needs.
6.3 Training requirements

‘All staff treating or caring for children and young people should have
appropriate training, and should undergo regular updating and refreshment of
skills. This training should cover both the technical clinical skills and the
personal and communication skills necessary to treat children and their
parents’ (Department of Health, 2003).
Children should receive appropriate high quality, evidence-based care,
developed through clinical governance and delivered by staff with the right skills.
Experienced members of the team have a duty to provide new personnel
with appropriate training, supervision and support. Training needs should be
identified and strategies in place to support and develop skills that will
ultimately improve overall performance of each team member and the team
as a whole, as well as achieve and maintain a quality service to deaf children.
To ensure a responsive child and family-centred service, training in issues
relating to childhood deafness, deaf awareness, sign language and finger
spelling is essential for all key staff. The implant team should be trained in the
necessary communication skills to enable them to work effectively with
children, young people and families and to support them in being active
partners in decision-making. Staff should also receive training in disability and
cultural awareness, and customer care including listening skills. Text
telephone facilities should be available and training given in their use.
QS 14 It is essential that there are clear procedures in place

for monitoring the professional performance of implant
team members.
Staff induction must include attendance at team meetings, multi-disciplinary
clinics, surgical procedures, specialist assessment appointments and joint
working with experienced staff.
All staff working within the cochlear implant programme must attend
recognised skill appropriate training, and have an agreed plan for continued
professional development and skills.
Joint training of staff from different disciplines should be encouraged, as this

can lead to co-ordinated services and well-informed personnel.
7. Clinical and surgical facilities and accommodation
‘Care will be provided in an appropriate location and in an environment that is
safe and well suited to the age and stage of development of the child or
young person, that is, child-friendly hospitals and hospitals that are safe and
healthy places for children’ (Department of Health, 2003)
Care should be delivered in a safe, suitable and child-friendly environment
(NHS Estates,1994, 2003; 2004). They should have a good understanding of
what it means to be cared for in a child and family-friendly environment,
following the philosophy of Baguley et al (2000).
7.1 Hospital and clinic accommodation
QS 15 The multi-disciplinary clinic must take place in a paediatric

hospital or other suitable paediatric setting that conforms to
the Hospital Standard: Quality of setting and environment (Department of
Health, 2003), and to Children’s Surgery – a First Class Service (Royal
College of Surgeons, 2000), and to the British Association of
Otorhinolaryngologists/Head and Neck Surgeons guidance.
Facilities for children should be accessible, safe, suitable, and family friendly,
and located either within the cochlear implant centre or within the hospital's
paediatric ENT/audiology department. In clinics where children are seen
alongside adults there should be some geographical separation, for example
through partitioning waiting areas (Department of Health, 2003). Careful
consideration must be given to the needs of young people.
QS 16 Children should not be cared for in adult clinics or on adult

wards, but in facilities that are appropriate for their age and
stage of development.
Ideally, there should be separate ‘adolescent’ units, but where this is not
possible, separate sections within the paediatric unit should be made
available to meet their needs.
Facilities will need to be made available for parents and siblings, with
suitable provision for overnight stay. These facilities should include access
to meals and relaxation, and must respect the privacy of parents.
7.2 Audiological testing and assessment
To assess children for a cochlear implant, the following will need to
be available:
• tympanometry
• pure tone, warble tone and visual response audiometry
(including insert earphones)
• speech discrimination assessment
• objective test measures, including otoacoustic emissions, auditory brainstem
evoked response (ABR), electrical ABR, neural response telemetry
• real ear in-situ hearing aid measurement
• cochlear implant processor programming equipment.
QS 17 Audiological testing should be performed in soundproofed

accommodation to BS EN ISO 8253-1 (1998) and BS EN ISO
8253 - 2 (1998) standards for acoustic test methods suitable for children.
All equipment must be calibrated at least annually using acceptable methods
on equipment whose own calibration is traceable to nationally recognised
standards, in accordance with BS EN ISO 8253-1 (1998).
7.3 Surgical equipment

Equipment used for otological surgery should be appropriate and of the
highest quality. In addition to routinely used otological equipment, an
appropriate micro drill system is needed. Backup systems must be
immediately available for all essential equipment and drills.
8. The referral and selection procedure
The referral criteria should be regularly reviewed by cochlear implant teams in
line with published research and identified good practice in the field. The
implant team should provide local services with a summary of the criteria for
referral to their programme and an assessment protocol. Local audiology and
ENT services should be familiar with the routes of access to the cochlear
implant programme and be aware of the referral criteria. Prior to referring a
child for assessment, the local audiology service should ensure that the child
and family understand that a cochlear implant is not a suitable procedure for
every child.
In the case of sudden onset of deafness, for example following meningitis, or
where deafness has progressed rapidly, the time taken for the referral
procedure and assessment may need to be shortened.
In order for a child to be considered for assessment, a written letter of referral
from the consultant otolaryngologist or audiological physician at the child’s
local service, should be sent to the consultant ENT surgeon or the co-
ordinator of the cochlear implant programme. Occasionally referrals may be
made by the child’s GP, a paediatrician or by a senior clinical scientist. The
referral should include all relevant medical and audiological details.
QS 18 A reply will be sent to the referrer within 2 weeks to confirm

acceptance of a referral.
The cochlear implant team will send information brochures to the child's
family within 3 weeks of the receipt of the referral.
If for any reason a referral is deemed inappropriate the implant team will
send the referrer an explanatory letter within 2 weeks of receipt of referral.
The referrer has a responsibility to pass such information on to the family as
a priority.
The cochlear implant service will need to liaise with the purchaser to ensure
that appropriate funding is in place.
8.1 Attendance and commitment by the child and family

It is important for the cochlear implant team to ensure that the family have
realistic expectations of their child’s audiological, speech and language,
educational and general development, and the level of impact that a cochlear
implant system may have on these.
As part of the assessment process, the child and family must understand
that they will be expected to attend the hospital or clinic for regular
appointments as part of the assessment, the surgical intervention and follow-
up care, and for long-term habilitation. The family need to be committed to
encouraging the child to use their speech processor consistently during
home, social and educational activities and take responsibility for daily
checking and maintenance of the system.
It is crucial that parents and young people understand that they have a
responsibility to report and where relevant take action when any problems
occur, such as swelling of the surgical site, or problems with the speech
processor. Such incidences could result in the need to attend the cochlear
implant centre, hospital outpatient department, or their GP, at short notice
for treatment.
9. Assessment for a cochlear implant
The cochlear implant programme, throughout all aspects of service delivery,
should work within the aims and objectives of Getting the right start: National
Service Framework for Children, Standard for Hospital Services (Department
of Health, 2003), and to the aims and objectives of the cochlear implant
team’s employing trust.
QS 19 The NHS quality standards for outpatient clinic consultation

waiting times should be adhered to for children who are
referred for cochlear implant assessment.
Once a child has been referred for assessment, the implant team will gather
information from the child's local health and education services. In order for
the assessment to be comprehensive and appropriate this information
should be received before the assessment takes place. Information will need
to include:
• the child’s medical history (including the full developmental history and
identification of any additional disabilities)
• their history of hearing loss, including aetiology (see BAAP/BACDA
guidelines, available from: www.baap.org.uk/Guidelines/guidelines.html,
www.bacda.org.uk/ or www.nhsp.info/
• the results of all audiological assessments
• type of hearing aids, and their use (previous and current)
• the communication method(s) used, for both the child and the family/carer
including sign language and other spoken language needs
• their speech and language development
• their educational support and placement
• the support that parents and carers have had and are being given.
The following sections (9.1 to 9.12) describe the assessment procedure,

but the order of procedure may vary.
9.1 Prior to the appointment at the clinic (see ‘supporting the

child, young person and family’, Section 5, pages 13-17)
Parents need clear information about their child’s audiological and
communication needs to enable them to make an informed decision
about whether a cochlear implant, or alternative provision, is the most
appropriate intervention.
As soon as the child has been accepted for assessment, the team should
provide them with written information on cochlear implant devices, on the
assessment procedure and on the tests that may be carried out. Accessible
information must be provided.
9.2 The process and procedures

The cochlear implant team has a duty to ensure that the child and family, and
all those working with the child, are fully involved in the assessment and
decision making process. As part of the assessment, the child and family
must be given realistic expectations of the expected outcomes with a
cochlear implant.
To enable the cochlear implant service to provide a comprehensive
assessment, a number of different assessments will be carried out which
may take some time to complete. Parents should be made aware of how
frequently their child will need to attend appointments if they proceed to a
cochlear implant.
QS 20 The initial appointment to begin the assessment process must

be undertaken within 13 weeks of referral.
9.3 Funding requirements

There is a clinical need for a timely and efficient assessment for a child who is
being considered for a cochlear implant. Clinical evidence (McConkey
Robbins et al, 2004) suggests that performing implantation in children with
profound hearing loss at the youngest age possible allows the best
opportunity for them to acquire communication skills that approximate those
of their normally hearing peers.
QS 21 Authorities responsible for funding cochlear implant provision

must agree funding for the initial cochlear implant clinic visit
within 4 weeks of receiving a request for funding from the cochlear implant
centre.
Authorities must also agree to fund the further assessment, the surgery and
habilitation, without delay, if the cochlear implant programme recommends
implantation as an appropriate intervention for the child.
Where there is a risk of ossification of the cochlea and where there is clear
medical opinion that bilateral implantation would be appropriate, additional
funding for bilateral implantation should be made available.
9.4 A co-ordinated approach to multi-disciplinary assessments
(see ‘the need for multi-disciplinary working’, Section 5.3,
page 14)
A co-ordinated approach will help to reduce disruption to family life and avoid
duplication of hospital appointments. Joint appointments should be arranged
whenever possible.
There should be effective liaison with other specialist paediatric multi-
disciplinary teams, so that children attending other clinics at the same
hospital can have linked appointments wherever possible (Department of
Health, 2003). This approach will ensure that all members of the multi-
disciplinary team, including the child and family, share information and
outcomes, and avoid duplication of case history and information gathering.
The cochlear implant team will need to obtain baseline measures of speech
production, speech perception and language and communication skills. Some
baseline measures will be made in educational settings and social situations.
QS 22 Multi-disciplinary assessment of the child by the implant team

must include information on a range of areas including:
• speech and language and communication development
• play, early social skills and emotional development
• hearing aid use and benefit.
Assessments should include the use of parent observations, the development

and progress of their child, and the impact of their child’s aiding on these.
They should be audio and video recorded, with consent.
QS 23 To ensure equal access to information, spoken and/or sign

language interpreters must be provided when required.
9.5 Local professionals and the assessment process

In order to support a child and their family effectively during the assessment
period, local education and health professionals will need to be given detailed
information by the cochlear implant programme.
As the decision to provide a cochlear implant has long-term impact, it is
important that all local carers contribute to the assessment procedure. This
collaboration will establish a basis for future co-operative relationships.
9.6 Assessments in the home and at school
Cochlear implant team members (such as the TOD, SLT) will visit the child’s
home and education establishment, based on individual need, in order to:
• provide detailed information about cochlear implants in children including
the range of possible outcomes, alternative forms of management, and
detailed safety and user guidelines
• discuss expectations with the family, so that expectations of their child's
development with a cochlear implant are realistic
• emphasise the nature of the commitment required, particularly from the
child's family, teachers and local support services
• evaluate the child's general development and communicative, social and
learning style in everyday situations
• evaluation of functional listening skills
• offer contact with other deaf children (with and without an implant) and
their families
• establish links with local professionals responsible for providing support for
the child, both pre and post cochlear implant
• review the child's educational support
• evaluate the effectiveness of parental support.
Such visits will help all those involved with the child to understand the:
• potential offered by cochlear implantation
• issues concerning the possible social and emotional impact of the device
• communication issues
• education provision issues
• long-term technical support and care required.
9.7 The audiological assessment

(see ‘audiological testing and assessment’, 7.2, page 24)
As part of the assessment, the audiological scientist will evaluate the child’s
hearing status, and their hearing aid provision, which may require audiological
modifications to hearing aids and earmoulds. It may be necessary to
undertake further audiological and functional assessments with revised
hearing aids and earmoulds to maintain consistent hearing aid use.
All tests performed on the child must comply with the current version of the
British Society of Audiology (2003) recommended procedures* and meet the
guidelines laid down in the current version of the NDCS Quality Standards in
Paediatric Audiology (under review).
Because of changes to specifications and the rapid development of new
technology, equipment should ideally be no more than five years old, with a
5-year rolling programme of replacement.
QS 24 Testing should be carried out to professionally accepted

protocols and procedures (British Society of Audiology, 2003;
BS EN ISO 8253-1 and 8253-2, 1998)*.
Audiological testing should be performed in audiometric test rooms to
(BS EN ISO 8253-1, 1998) standards for acoustic testing methods suitable
for children*.
All equipment should be calibrated at least annually using acceptable
methods on equipment whose own calibration is traceable to national
standards (in accordance with BS EN ISO 8253-1, 1998)*.
Accommodation must conform to standards outlined in NHS Estates
(2003; 2004)*.
Ideally, there should be a 5-year rolling programme of replacement of
audiological test equipment.
To support behavioural assessment of the child’s auditory function the

cochlear implant team will perform auditory brainstem response testing
if required.
The child’s ability to be able to participate behaviourally in the future
programming of the speech processor will also be assessed.
9.8 The teacher of the deaf assessment

In liaison with the cochlear implant team, the family and local professionals,
the TOD will assess management of amplification, functional use of hearing
and communication skills. This may include parent and professional reports,
direct observation and use of more formal measures. The assessments may
be undertaken in the home, pre-school and/or educational settings. This will
involve close liaison with local education services relating to the child’s
educational needs, progress and support requirements.
9.9 The speech, language and communication assessment

The assessment of communication skills and the development of spoken
language may take the form of observation, subjective description and
objective evaluation of hearing, spoken and sign language development. The
assessment procedure will take into account the developmental age, hearing
status and case history of the child, and should include receptive and
expressive skills in spoken, signed and written language form including:
• pre-verbal skills
• comprehension
• social skills
• semantic and pragmatic aspects of communication
• vocabulary
• syntactic analysis
• phonetic and phonological analysis
• airstream mechanisms
• voice
• resonance.
9.10 The medical assessment

The child's general medical health will be assessed and taken into
consideration when making a decision to offer a cochlear implant. If the
referring team has not already carried them out, tests to establish the
aetiology of the child's deafness may be requested by the clinician.
Assessments, including developmental assessment and identification of
additional disabilities will be requested and take place under the supervision
of the ENT surgeon or audiological physician.
In accordance with British Association of Audiological Physicians (BAAP)
policy document (1990) assessment will be carried out, where appropriate,
by a cardiologist, paediatrician and other specialists.
9.11 CT/MRI scans

CT/MRI scans will be performed in order to demonstrate the suitability of
each cochlea for insertion of the electrode array and to look at the condition
and viability of the hearing nerve. Scans may be performed with or without a
general anaesthetic or other sedation depending on the age and general
health of the child undergoing assessment. The ENT surgeon will be
responsible for checking the CT/MRI scans and will discuss the results with
the radiologist where necessary.
QS 25 The results of the CT and MRI scans will be notified to the
implant team.
child's family within 5 working days of receipt by the cochlear
9.12 Ophthalmic assessment
Optimum vision is crucial to the deaf child, yet more than 40% of all deaf
children will have ophthalmic problems (Guy et al, 2003). Therefore, the
cochlear implant team, must ensure that the child has had their vision
assessed by an ophthalmologist, or arrange for them to be referred to the
ophthalmology department. Deaf children and young people should be re-
referred throughout their development for eye assessments, as outlined in
‘Vision care for deaf children and young people’ (NDCS & Sense, 2004).
QS 26 ‘Following the identification of a permanent hearing loss the

child should be referred for a full ophthalmic assessment, and
where appropriate at key stages of their development’ (NDCS & Sense, 2004).
9.13 BCIG and other safety guidelines

As part of the assessment process, the cochlear implant team will provide
the family and other carers (such as those supporting the child in nursery or
school) with updated (BCIG, 2004) safety guidelines and safety information
provided by the cochlear implant device manufacturer.
9.14 Pneumococcal meningitis vaccination

A small percentage of deaf children, young people and adults may have
congenital abnormalities of the inner ear, which predispose them to
meningitis. Other predisposing factors may include such things as acute
middle ear infection (acute otitis media), immune-deficient status, and a prior
history of meningitis.
It is possible that the cochlear implant electrode array can act as a conduit
for the spread of infection from the middle ear to the cochlea and thus cause
meningitis. Because the surgically implanted equipment is a ‘foreign body’
this may act as a nidus for infection when a patient has a bacterial illness.
Prior to surgery, it is the responsibility of the lead clinician on the cochlear
implant team to determine the pneumococcal vaccination status of the child
or young person, and ensure that the appropriate pneumococcal vaccine, in
line with current Department of Health policy (Medical Devices Alert,
2004/046) is (or has been) provided. Other vaccinations should be carried
out in line with Department of Health policy.
QS 27 The lead clinician must ensure the child has received the
appropriate vaccination cover against meningitis, and they are
also protected by the appropriate vaccination programme.
All occurrences of meningitis in cochlear implant patients should be reported
to the Medicines and Healthcare Products Agency providing details of the
implant manufacturer and model.
As part of the assessment and ongoing care of the child, parents must be
provided with written information of the signs and symptoms of meningitis,
and provided with clear instructions to follow if they feel their child is at risk.
9.15 Otitis media

Prior to implantation, the clinician should check the child or young person for
otitis media and provide appropriate medical treatment (such as antibiotic
treatment) if required. Consideration should also be given to prophylactic
antibiotic treatment prior to implantation.
Post implantation, children or young people who develop symptoms or signs
of acute otitis media should be treated with appropriate antibiotics as a
matter of urgency to prevent the spread of infection to the cochlea.
QS 28 The consultant ENT surgeon on the implant team must be
implanted ear.
informed if a child develops signs of acute otitis media in the
10. The outcome of the assessment
Following the assessments, the implant team will meet to decide whether a
cochlear implant is the most appropriate intervention for the child. The
parents and child will be invited to attend a meeting with the implant team
where the team decision will be explained. The family must be provided with
the opportunity for detailed discussion with the team.
Children have a right to be involved in decisions about their care, and they
must be given sufficient time to fully understand the short and long-term
implications of having a cochlear implant. Communication should be at a
level and method appropriate to their stage of development and degree
of understanding.
These outcomes of assessments will be recorded in ‘The Children’s Implant
Profile’ (ChIP) (Hellman et al, 1989), or similar.
QS 29 The child (wherever possible), parents and the cochlear

implant team should discuss and agree the decision whether
to implant or not. Following this meeting, the family should be notified in
writing within 10 working days of the outcome of the assessment, including
any concerns, which may affect suitability of a cochlear implant.
A written report and other relevant information will be sent within 10 working
days to the child’s referrer, their GP and local health and education services
and all other service providers known to the cochlear implant team, advising
them of the outcome of the assessment and of the family's decision.
Where it is demonstrated that the child is not likely to benefit from a cochlear
implant, a report will be sent within 3 weeks to the local audiology and
education services, the referrer, and to the child's family regarding the
outcome of the assessment. The report should include:
• reason why a cochlear implant is considered to be unsuitable for the child
• recommendations for change of hearing aid provision if appropriate
• recommendations for future management, if considered necessary.
Parents must be given the opportunity to have face-to-face discussions with
the team on the background to the decision not to offer a cochlear implant
to their child.
10.1 Consent and confidentiality

‘Children, young people and parents need valid, relevant, accurate, up-to-
date, easily accessible and well-presented information, that is appropriate to
their level of understanding, before they can decide whether to consent to, or
refuse, treatment’ (Department of Health, 2003).
The cochlear implant team should be familiar with and follow the Department
of Health guidance on consent (2004) (see also British Medical Association,
2000) and confidentiality (Department of Health, 2004).
Services will need to obtain appropriate consent prior to any intervention.
Children and parents need to be fully informed before they can decide
whether to consent to, or refuse, treatment. Information they will need
should cover:
• what the treatment will involve
• benefits and risks
• immediate and long-term implications of not having treatment
• what alternatives may be available
• who will be administering the treatment.
QS
to others.
30 Services will need to obtain consent from the child or parent
prior to any intervention and before passing details of care
10.2 Establishing funding commitment for long-term NHS care
QS 31 There must be an agreed commitment by the funding authority

for the long-term support of the child.
The long-term funding commitment by the NHS must include the ongoing
costs of staff involved in the child’s care. It must also cover the upgrading of
the device, replacement in case of device failure, loss, irreparable damage,
repairs of equipment, and provision of accessories.
Some equipment (such as personal FM systems) may be a shared
responsibility with the local services.
10.3 Preoperative care
QS 32 Prior to cochlear implant surgery there will be a minimum of

one visit to the child’s home and to their educational setting to
assess the child’s progress, provide feedback and give advice about
habilitation plans by the cochlear implant team's key worker(s).
The preparatory stage will vary depending on the individual needs of the child
and their age. However, preparing children for surgery should include the use
of books, photographs, and toys to help them understand the admission
process to hospital and to prepare them for the operative procedure. Play
specialists can provide expertise for children who face operative procedures
and complex assessments.
To prepare the child and family for admission to hospital, a preoperative visit
to the children’s surgical ward should always be offered to the child and the
family so that they can meet the nursing staff.
11. Surgery and postoperative care
11.1 The cochlear implant device:
QS 33 The cochlear implant equipment should have a proven track

record for safety and reliability in children, with CE approval,
and conform to the recommendations of the Medicines and Healthcare
Products Agency.
11.2 Nursing care prior to and at surgery
QS 34 The liaison nurse or key worker (or other designated team

member) should provide the child and family with information
regarding hospital admission and care before and after surgery. On the day of
admission to hospital they will visit the child and family to offer them support
during their hospital stay.
The liaison nurse or key worker (or other designated team member) should
be available for telephone contact prior to surgery, offering the child and
family support and guidance. It is the responsibility of this person to refer the
family to other team members if they are concerned or anxious about any
aspect of their child’s surgical procedure or their care.
QS 35 To facilitate communication with children who use sign

language as their main means of communication, a minimum
of one member of the nursing staff on the surgical ward should have skills in
sign language to a minimum of CACDP stage 1.
11.3 Surgery and care

Because cochlear implant surgery is a major procedure it is the responsibility
of the ENT surgeon to ensure that all potential risks involved with having an
anaesthetic, undergoing surgery and post surgical complications are clearly
explained to the child and family.
The implant surgery will be performed under general anaesthesia, and the
operation site should be prepared when the child is anaesthetised. It is
crucial that the facial nerve activity is monitored closely throughout the
surgical procedure, as it can be at potential risk of damage.
QS 36 The facial nerve activity must be monitored throughout the
surgical procedure.
The ENT surgeon and the audiological scientist will ensure that the electrode
array is functioning correctly. This can be achieved by using one or more of
the following tests whilst the child is still anaesthetised:
• electrical auditory brainstem response
• electrical stapedial reflex thresholds
• neural response telemetry or equivalent test
• integrity testing, where appropriate
• impedance/voltage telemetry.
Performing postoperative radiology can also assess the position of the
electrode array. If this is not carried out at the same time as the surgery, then
it should be completed before the child is discharged home, or before the
processor is switched-on.
The cochlear implant team will need to maintain contact with the child and
family throughout the hospital stay and facilitate maximum care and support
in conjunction with the nursing and medical staff. The surgeon will discuss
the outcome of the operation with the child and parents’ as soon as it is
feasible following surgery.
Prophylactic antibiotics may be given. Children must be monitored carefully
for postoperative wound infection.
The number of days that the child is likely to stay in hospital will vary,
however, at the time of print, the routine postoperative hospital stay is
between 1 and 3 days.
11.4 Following surgery

Before discharge from hospital, the child and family will need to be given
clear guidance about care of the wound site and scalp. They will need to be
provided with clear written guidance on action to take if the child has a head
injury or specific medical problems that will need to be identified to them by
the cochlear implant team.
QS 37 Following discharge from hospital a summary of the surgery
within 3 days.
and outcome will be sent to the child’s GP and to the referrer
11.5 Discomfort, unexplained changes or swelling of the
surgical site
Any child who experiences any discomfort and unexplained changes, or any
swelling of the surgical site must have direct access to the appropriate ENT
professionals. The contact details must be clearly identified and provided to
the family (and young person). The emergency appointment may include
medical, audiological and electrophysiological staff as appropriate.
QS 38 The child and family must have emergency access to an ENT

specialist who has an understanding of the cochlear implant
process and the potential complications.
11.6 Contact details for support

The child and family should be provided with appropriate and written contact
details for the implant team so that they have quick and easy access during
normal working hours.
If they have any concerns, out of normal working hours, it is essential that
they have access to the appropriate on-call medical professionals. Therefore
telephone contact details must be provided in writing by the implant team.
Such information will need to be updated and replaced as required.
QS 39 The child and family must be given contact details of the

on-call medical professionals at the hospital.
11.7 Revision surgery

Any decision regarding the surgical removal or replacement of the cochlear
implant device, should it be necessary, will be made in close collaboration
with the child, the child's parents, the surgeon, and members of the cochlear
implant team.
11.8 Device failure

If there is a suspected internal device failure the cochlear implant
manufacturer should be informed so that they can carry out further integrity
testing of the device function. The cochlear implant team will need to be kept
informed of these results (Medicines and Healthcare products Regulatory
Agency, 2005)
On rare occasions, additional surgery may be required, for example because
of a fault in the internal components of the cochlear implant system. Should
this occur, the reason for the replacement will need to be clearly explained to
the child, their family, their GP before the revision surgery takes place.
12. Programming, follow-up care and support
12.1 Prior to programming
Prior to the initial programming session the child and family should be
provided with an up-to-date copy of the safety guidelines, produced by the
BCIG Safety Working Group.
QS 40 Before the processor is switched-on, a key member of the

team will meet with the family to provide information and to
further familiarise them with the external equipment in preparation for the
fitting and tuning session.
12.2 Fitting the implant device and programming

Medical checks will need to be carried out before the initial programming
session by the cochlear implant team surgeon or audiological physician.
QS 41 Following surgery the speech processor will be fitted and

initially programmed between 4 and 5 weeks post surgery.
Speech processor programming involves establishing which electrodes

produce useful hearing sensations and, for each electrode, measuring levels
of electrical stimulation. Initial programming may need to be adjusted in the
early stages of activation. The choice of an appropriate mode of stimulation,
speech processing strategy, and the correct setting of parameters for
electrical stimulation, are essential to this process.
In very young children, electrophysiological measurements obtained intra-
operatively may be used to guide initial stimulation levels.
The audiological scientist will check the function of the cochlear implant via
integrity testing.
12.3 Records of measurements
QS 42 Records of measurements of all programmes installed in the

software, and of all tests performed, must be kept on file.
Audiological records and measurements should be available on request and
provided, with consent, to other parties who may have a legitimate reason
for using them, eg education, health services, etc.
12.4 Specialist contact sessions with the child, family and
local professionals
QS 43 The level of specialist contact sessions must be based on the

individual needs of the child and their family. This will also
depend on the needs of local service professionals.
The audiological scientist should regularly monitor and adjust the

programming of the speech processor. In the initial stages this will require
regular visits to the implant centre by the child and family. These visits should
be scheduled to coincide with the auditory habilitation sessions wherever
possible. Over time, visits are likely to reduce but this will vary in accordance
with each individual child’s needs.
QS 44 The recommended framework for a young congenitally deaf

child should be:
Year 1 2 3 4/onwards
Habilitation support: 10 6 6 1
Speech processor programming: 5 1 1 1
Specialist surgeon The child should be seen at least
once each year
It can be expected that additional support and input will be required for a
child with additional special needs. However, less support may be required
for the older child and young person.
If the audiological scientist needs to carry out programming of the device
away from the implant centre, this should be carried out in a suitably quiet
and comfortable child and family-friendly environment.
QS 45 If there are concerns regarding the function of the internal

cochlear implant the audiological scientist must arrange for
integrity testing to take place as a priority and without delay.
The implant team will provide face-to-face contact with the child and family.
They will work together to provide appropriate developmental listening,
language and communication targets specific to the child (see ‘partnership and
parental responsibility’, section 5.4, pages 14-15). During the follow up care
when the child is being monitored and reviewed it is crucial that the implant
team liaise closely with local services to share information regarding the child’s
progress and current habilitation targets. They will also need to work with local
service professionals to plan and implement relevant training packages.
13. Ongoing evaluation of benefit
QS 46 The following areas will need to be monitored using

appropriate assessments. In the first year these will be carried
out at a minimum of 6 month and 12 month stages. Subsequently, they will
be completed at least annually.
• Use of the cochlear implant in various settings
• Soundfield warble tone thresholds
• Awareness, discrimination and recognition of environmental sounds
• Awareness, discrimination and recognition of speech
• Development of functional listening skills
• Development of functional communication skills
• Development of expressive and receptive language
• Shift in modality of communication
• Quality of life/well being of child and family
• Emotional and social development.
Information on the results of these assessments will be sent to the child's
family and local services within 3 weeks of completion.
13.1 Habilitation for the young person

In addition to setting listening and language targets that are of an appropriate
level of interest to the young person, specific packages of habilitation support
should be offered. These packages can be carried out with individual
cochlear implant users, or it may be more appropriate to offer them in a
group setting with other young people with hearing impairment, for example:
• communication skills
• telephone training
• speech intelligibility
• social skills.
It may be more appropriate, and therefore more effective for the young
person, for packages to be offered during school holidays.
Young people should be given information about self-help support groups,
and other information to help them make contact and communicate with
others of a similar age, for example www.ci4-teenz.com,
www.earfoundation.org.uk and www.cicsgroup.org.uk websites.
13.2 Cochlear implant equipment
The child's parents and local audiology and education service professionals
will need to be provided with the following information:
• how to use the cochlear implant equipment
• how to care for and maintain the speech processor and all
related accessories
• operating instructions for the speech processor
• what they should do if there is a need for a replacement speech processor
leads, microphone, battery packs, and batteries, etc
• up to date safety instructions.
The implant team should ensure that they have a sufficient supply of
spare speech processors, microphones, other equipment, and batteries
readily available.
Equipment, leads and batteries must be provided free of charge and
despatched by the implant team on the day they receive the request
for replacement.
QS 47 The cochlear implant team will issue (or despatch)

replacements for faulty external equipment, within 1 working
day of notification being received that a fault has occurred.
Each child will be provided with a minimum of one set of spare leads and
batteries, recommended for use with the child’s implant device, and ensure
that further supplies are readily available.
13.3 Contralateral hearing aid provision

Where it is appropriate for a child to continue to wear a hearing aid in the
contralateral ear, the hearing aid should be supplied and maintained by the
cochlear implant team, or by a hearing aid centre in the same trust as the
cochlear implant programme, or, if considered more convenient, by a more
local hearing aid centre if that centre agrees. Where agreement cannot be
reached, to allow bimodal fitting to go forward, it is the ultimate responsibility
of the cochlear implant programme to supply and maintain hearing aids for
the contralateral ear.
However, it is crucial that children and parents are included in discussions
about provision of care, including whom they would prefer to provide,
maintain and support the provision of a contralateral hearing aid.
QS 48 It is the responsibility of the cochlear implant programme to
ensure appropriate provision and maintenance of the
contralateral hearing aid for children with a cochlear implant (BCIG, policy on
contralateral hearing aid provision, 2004).
The contralateral hearing aid provider has responsibility for supplying
replacement batteries free of charge to the user.
13.4 Personal FM equipment

The decision to fit an implant user with a personal FM system should be
based on the opinions of, and liaison between, local service professionals
and the cochlear implant team. Children and parents must be involved in this
decision making process. An appropriate time for fitting will be when the child
has a stable map, is a reliable user of their implant and wherever possible
can report on sound quality.
The implant team will make recommendations with regard to the FM system
transmission frequency, the most appropriate wearing position and how to
minimise the risk of interference between the implant processor and the
personal FM system. The child should be encouraged to trial the FM system
at home and in the classroom. If it is proven to be beneficial and long-term
use is indicated, the personal FM system should be provided and maintained
by the child’s local education service.
Records of objective and subjective measurements of the combined devices
must be obtained at the time of issue of the personal FM system, and at any
subsequent change of equipment or operating parameters. At the time of
writing there is no nationally agreed FM fitting protocol, although this is at the
development stage. When it becomes available consideration should be
given to its adoption.
Audiological information must be made available to other parties (ie local
health and education services), with consent.
QS 49 Children with a cochlear implant should have the opportunity

to trial and assess a personal FM system. The equipment will
need to be fitted by a fully trained member of the cochlear implant team in
liaison with the local education service.
The implant processor/FM combination must be performance-checked
against the audiological-recorded measurements at intervals of no longer
than 1 year, and additionally when any equipment is replaced or repaired.
A personal FM system is potentially the most effective way of improving the

signal to noise ratio for cochlear implant users in the classroom and in other
difficult listening situations. However, well-fitted classroom soundfield
systems can also be beneficial and can be used in conjunction with a
personal FM system.
13.4.1 Routine maintenance and monitoring

Parents and teachers (or other responsible adult) must be trained and take
responsibility for simple maintenance checks of the cochlear implant
equipment and FM combination. This should include both visual checks of
the equipment including any leads and adaptors and subjective listening
checks (where possible). The nominated persons should be issued with
accessories to enable them to carry out these tasks.
13.4.2 Assistive devices, leads and accessories

The team will need to liaise closely with the child and family, and the local
education service, so that all those involved can provide the support needed
regarding equipment used in conjunction with the child's cochlear implant
equipment, for example for use with:
• audio equipment (eg personal stereo, television, etc)
• telephone
• personal FM system (see ‘personal FM equipment’,13.4, page 46)
• soundfield system.
13.5 Battery safety

The implant team has responsibility to ensure that the child and family
understand that all batteries should be stored safely and that used batteries
should be disposed of in a safe manner. The family will need to be provided
with clear guidelines as to what action they should take if the child, or others,
swallow a battery (NDCS, 2003).
13.6 Insurance and replacement guidelines

Cochlear implant equipment and hearing aids are given to the child on loan
and remain the property of the NHS. Should loss or damage occur, hearing
aids, including cochlear implant equipment, should be replaced immediately
to ensure continuity of care for the child (NCPA, 2003; NDCS, 2003).
Department of Health guidelines provide audiology departments with the
opportunity to charge users or parents for the cost of replacement of a
hearing aid that has either been lost or maliciously damaged by the child or
their parent. If the audiology department wishes to make a charge against
them, then the user or parent has a right to insist on a panel of at least three
people who will meet to discuss issues surrounding the alleged lost or
maliciously damaged hearing aid. This panel will provide the trust with their
findings and a decision will then be taken as to whether a charge can be
made and what that charge will be.
QS 50 If a dispute arises relating to loss or damage it is essential that

the child is provided with replacement equipment of the same
make and model, and without any delay, whilst the dispute takes place.
Children and parents have a right to be kept fully informed of any action and
to contest the legality of the decision of the trust. The Department of Health
guidelines also state that they would deplore any occasion where a health
authority insisted that parents insure their child's hearing aids. Providing
information or advice on insurance policies or schemes could be construed
as ‘encouragement’ to insure.
13.7 New developments

Over the next few years it can be expected that advances in cochlear
implantation will increase the benefit to severely to profoundly deaf children.
In addition, further developments in implant design should lead to smaller
devices that are better suited to children, especially very young children.
However, totally implantable devices are likely to be some years away.
Bilateral implantation is currently being investigated in children. In the UK
bilaterally fitting children is primarily carried out where there is a risk of
ossification following meningitis. For other children, any additional benefit
from bilateral implantation should be considered alongside the loss of their
residual hearing (which may restrict choices in later life) and the need for
surgical procedures.
14. Transfer of care (see NDCS 2000: Guidelines on
transition from paediatric to adult healthcare)
QS 51 The cochlear implant team should have clear written policies

detailing the transfer of care pathway to another service.
These policies should cover arrangements for:

• transfer between services
• the transfer of notes (electronic or paper)
• access and direct self-referral systems.
The implant team should provide detailed written information to the child,
parent and young person informing them what action they should take if
problems occur during transfer between services.
14.1 Transfer to an alternative paediatric or adolescent service

When a child or young person needs to transfer to an alternative service, it is
the responsibility of the existing provider to ensure that smooth transfer takes
place, and that they fully understand the process involved. They should be
informed in writing of details relating to the new service and they and the
accepting cochlear implant programme must be provided with the
information listed in item 14.2 below, ‘transfer to adult care’.
QS 52 The existing service provider will need to arrange an

appointment with the new service prior to transfer and the
child, family and/or young person notified in writing.
14.2 Transfer to adult care

Young people with long-term conditions need preparation for the move from
the child or adolescent service to the adult service.
QS 53 All young people with ongoing health needs should have a

plan developed with them for the transfer of their care to adult
services (Department of Health, 2003).
Where there is a separate adult and paediatric service, arrangements should

be in place for the smooth transfer of ongoing care, with a system in
operation for the transfer of notes. A clear transfer policy should include a
strategy for the maintenance of the cochlear implant equipment, identified
age of transfer (and how this might change depending on circumstances)
and services for young adults in further and higher education.
Details given to the adult programme will need to include the following, and
copies of this information must also be provided to the young person/family:
• date of first appointment required at the adult programme
• dates of surgical procedures
• surgical and post-fitting complications
• audiological test results
• attendance record
• list of local services working with the young person/family
• ongoing recommendations.
It is the responsibility of the paediatric/adolescent team to ensure that the
young person understands the implications, policies and procedures involved
when transferring from their existing service to an adult service.
The paediatric/adolescent service must make an appointment with the adult
cochlear implant programme before the young person is discharged, and
notify the young person in writing that this appointment is to take place. The
local audiology service and GP should also be notified in writing of this
transfer and of the new appointment date with the adult programme.
QS 54 The paediatric/adolescent programme should request an

appointment for the young person to attend the adult cochlear
implant programme to take place no later than 6 months after discharge.
The adult programme should acknowledge receipt of the transfer information
in writing to the paediatric/adolescent programme, the young person and
family and the young person’s GP, within 2 weeks of receipt.
In addition, the young person and parent should be provided with the
following before completion of the transfer to the adult service:
• written advice and information about their transfer
• details of the clinic and contact details, address and telephone
numbers etc
• details and contact numbers of social service facilities
• details and contact numbers of voluntary agencies and support groups
• information on the regularity of appointments and the importance of
attending the clinic.
During the first months following transfer it is important that the young person
is encouraged to contact the paediatric/adolescent team to discuss any
issues of concern regarding their transfer of care.
Teams with an all-age-service should have protocols, which recognise that
the young person should be encouraged to be independent and take
responsibility for their own care. For example, assessments, surgical
procedures, habilitative care should be directly with the young person, with
copies of all letters and reports being sent directly to them.
15. Service planning, evaluation and audit
‘Children, young people and their parents should participate in designing
NHS and social care services that are readily accessible, respectful,
empowering, follow best practice in obtaining consent and provide effective
response to their needs’ (Department of Health, 2003).
Children, young people and families should be routinely involved in the
planning and improvement of services. Guidance on seeking the views of
children and young people can be found in the Children’s and Young
People’s Unit (2001) document.
Multi-disciplinary child-specific clinical audits should be undertaken in all
specialities in which children are treated (Department of Health, 2003).
The cochlear implant service should carry out an annual audit to evaluate the
effectiveness and family-friendliness of the service, as well as identifying and
implementing changes to improve service provision. As part of this audit, the
views and experiences of users, ie children, young people and families, must
be gathered.
QS 55 Each cochlear implant centre should produce an annual report

for internal and external use that should detail:
• clinical activity
• surgical complications
• number of device failures and the possible cause of such failures
• measures of children's progress, to include informal assessment of
social and emotional development
• soundfield warble tone thresholds and speech discrimination
measurements
• research findings.
15.1 Complaints procedure

It is the responsibility of the cochlear implant service to ensure that the child
and family understand the standard hospital complaints procedure, should
they wish to make a complaint. There should be written policies and
protocols to follow in the case of a complaint, and these should follow
national guidelines.
16. Acknowledgements
The National Deaf Children’s Society and the British Cochlear Implant
Group would like to thank all those involved with the development of this
revised document.
The document was sent for consultation to:
• Cochlear implant programmes throughout the UK
• BCIG Council
• NDCS trustees and staff
• The Cochlear Implant Children’s Support Group
• Parents and young people
• The membership of the NDCS Children’s Hearing Services Working Group
• The National Committee of Professionals in Audiology
• The BSA Paediatric Audiology Interest Group
• Key organisations within health, education and social care
• Leading professionals working with and influencing services for deaf
children and young people
• Cochlear implant manufacturers in the UK.
As part of the consultation process the draft document was placed on

the NDCS website calling for comments from professionals, parents and
young people.
All comments received have been considered as part of the editorial process.
The editorial group was:
• Barbara Homer, Deputy Director UK Services, NDCS (Co-ordinator)
• John Ford, Head of Department, Advisory Teachers of the Deaf, RNTNE
Hospital, London
• Vicki Kirwin, Audiology Specialist, NDCS.
Further information or comments relating to this quality standards

document should be sent to Barbara Homer, NDCS, 15 Dufferin Street,
London EC1Y 8UR, or email Barbara@ndcs.org.uk
17. Appendix 1
Alphabetical listing of key professionals working with the
child, family and cochlear implant team.
In addition to the expertise of the core team and those working within health
and education at a local level, there may be a need to request specialist input
and support from others to contribute to the assessment and habilitation of
the child. This additional support will depend on the individual needs of the
child and their family.
Wherever possible such specialist staff should have experience of working
with deaf children and their families:
• class teacher/teaching assistant
• clinical psychologist
• communication support worker
• community paediatrician
• educational audiologist
• educational psychologist
• general practitioner
• genetic counsellor
• geneticist
• health visitor
• liaison nurse
• occupational therapist
• ophthalmologist, consultant
• paediatric anaesthetist
• paediatrician, consultant
• physicist, consultant
• physiotherapist
• radiologist, consultant
• sign/spoken language interpreter
• social worker/social worker for deaf people
• special educational needs coordinator (or advisor in Scotland).
18. References
Association of Directors of Social Services (ADSS), British Deaf Association
(BDA), Local Government Association (LGA), National Children’s Bureau
(NCB), The National Deaf Children’s Society (NDCS) & Royal National Institute
for Deaf People (RNID) (2002) Deaf Children: Positive practice standards in
social services. (NDCS/RNID).
Baguley D, Davis A & Bamford J (2000) Principles of family-friendly hearing
services for children. BSA News, 29 35-39.
British Association of Audiological Physicians (ongoing review) Policy
documents relating to the investigations for children with a bilateral
sensorineural hearing loss. Available from:
www.baap.org.uk/Guidelines/guidelines.html
British Association of Community Doctors in Audiology (ongoing review)
Policy documents relating to the investigations for children with a bilateral
sensorineural hearing loss. Available from: www.bacda.org.uk/
British Cochlear Implant Group. (1999) NHS Supplies National Tender
Specification
British Cochlear Implant Group (2004) Recommended guidelines on safety for
cochlear implant users. Available from www.bcig.org/
British Cochlear Implant Group (2004) Policy on contralateral hearing aid
provision. Available from: www.bcig.org/
British Medical Association (2000) Consent, rights and choices in health care
for children and young people, December.
British Society of Audiology (BSA) (2003) Recommended procedures for
puretone audiometry. Available on: www.thebsa.org.uk
BS EN ISO 8253-1 (1998) Acoustics. Audiometric test methods – Part 1:
Basic pure tone air and bone conduction threshold audiometry. Available on:
http://www.npl.co.uk/acoustics/techguides/audiometry/standards/
BS EN ISO 8253-2 (1998) Acoustics. Audiometric test methods – Part 2:
Soundfield audiometry with pure tone and narrow-band test signals. Available
on: http://www.npl.co.uk/acoustics/techguides/audiometry/standards/
Children and Young People’s Unit (November, 2002) Learning to Listen:
Core principles for the involvement of children and young people,
DfES Publications.
Department of Health (2002) Listening, hearing and responding; Department
of Health Action Plan: Core principles for the involvement of children and
young people. The Stationary Office.
Department of Health (2003) Getting the right start: National Service
Framework for Children, Standard for hospital services. Available on:
www.doh.gov.uk/nsf/children/gettingtherightstart.htm.
Department of Health (2004) Seeking consent: working with children.
Available on: www.doh.gov.uk/consent
Department of Health (2004) Information Authority. Confidentiality – codes of
practice for NHS staff. Available at:
www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/PatientConfidentiality
Dettman S J, Barker E J, Rance G, Dowell R C, Galvin K L, Sarant J Z,
Cowan R S C, Skok M C, Hollow R, Larratt M & Clark G M (1996)
Components of a rehabilitation programme for young children using the
Multichannel cochlear implant. In: Allum D J (ed) Cochlear implant
rehabilitation in children and adults. Whurr Publishers, London.
Fortnum H, Summerfield A Q, Marshall D, Davis A, Bamford J (2001)
Prevalence of permanent childhood hearing impairment in the United
Kingdom and the implications for universal neonatal hearing screening:
questionnaire based ascertainment study. British Medical Journal, 323.
Guy R, Nicholson J, Pannu S S & Holden R (2003) A clinical evaluation of
ophthalmic assessment in children with sensorineural deafness. Child: Care,
Health and Development 29:377-384.
Hall D (2004) Children’s audiology services – a multi-professional review in
partnership with NHSU. Report of a seminar held on March 23rd 2004 at
RCPCH.
Hall D M B & Elliman D (2002) Health for All Children. (4th edition) Oxford
University Press.
Hellman S A et al. (1991) The Development of a Children’s Implant Profile
Implant Centre Speech and Language Therapists (1998) Guidelines for Good
Practice: working with clients with cochlear implants.
Implant Centre Teacher of the Deaf (ICTOD) (2003) Working with children with
cochlear implants (available from BCIG).
Kuhl P, Williams K, Lacerda F, Stevens K & Linblom B (1992) Linguistic
experience alters phonetic perception in infants by 6 months of age. Science,
Vol 255, No 5044, 606-608.
Markides A (1986) Age at fitting hearing aids and speech intelligibility. British
Journal of Audiology, 20, 165-167.
McConkey Robbins A, Burton Koch D, Osberger MJ, Zimmerman-Phillips S
& Kishon-Rabin L (2004) Effect of age at cochlear implantation on auditory
skill development in infants and toddlers. Archive of Otolaryngology Head and
Neck Surgery, Vol 130, May, 570-574.
McCormick B & Archbold S (eds) (2003) Cochlear implants for young children
(2nd edition) Whurr Publishers, London.
Meadow-Orlans K (1987) An analysis of the effectiveness of early intervention
programmes for hearing-impaired children. In: Guralnick M & Bennet F (eds)
‘The effectiveness of early intervention for at-risk and handicapped children’.
Academic Press, 325-358.
Medicines and Healthcare products Regulatory Agency (2005) Reporting
adverse incidents and disseminating medical device alerts. Available at:
http://devices.mhra.gov.uk/mda/mdawebsitev2.nsf/981591cd2aa346660025
6a7600410666/eefc0c0e8d90135c80256f720055834f/$FILE/MDA-2005-
001.pdf
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charging for lost or damaged hearing aids in NHS audiology departments-
A questionnaire survey and development of a new protocol, BSA News.
The National Deaf Children’s Society (2000) Quality Standards in Paediatric
Audiology Volume IV; Guidelines for the Early Identification and the
Audiological Management of Children with Hearing Loss.
The National Deaf Children’s Society (2002) Quality Standards in the Early
Years: Guidelines on working with deaf children under two years old and
their families.
The National Deaf Children’s Society (2003) Insurance and replacement of
hearing aids and cochlear implant equipment – NDCS policy statement.
The National Deaf Children’s Society (NDCS) (2003) Hearing Aids: A Guide
pp 23.
The National Deaf Children’s Society (NDCS) and Sense (2004) Quality
standards in vision care for deaf children and young people. NDCS & Sense.
The National Deaf Children’s Society (2005) Guidelines on transition from
paediatric to adult health care.
NHS Estates (1994) Health Building Note 12(3), ENT and audiology clinics
hearing aid centre, refer to www.nhsestates.gov.uk.
NHS Estates (2003) Improving the patient experience – friendly healthcare
environments for children and young people. The Stationery Office.
NHS Estates (2004). Hospital accommodation for children and young people:
Health Building note 23.
Papsin B C, Sirimanna T K S, Albert D M and Bailey C M (1997) Surgical
experience with bone anchored hearing aids in children. Laryngoscope, 107,
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intervention on some language metrics in young hearing-impaired children.
British Journal of Audiology, 26, 97-107.
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Communicating Quality (2nd edition), RCSLT.
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class service, Report of the Paediatric Forum of the Royal College of
Surgeons of England.
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development of the central auditory system in children with cochlear
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1990-1994
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Registered office:
15 Dufferin Street, London EC1Y 8UR
NDCS Freephone helpline: 0808 800 8880 (voice and text)
open Monday to Friday from 10am to 5pm
Phone: 020 7490 8656
Fax: 020 7251 5020
Email: helpline@ndcs.org.uk
Website: www.ndcs.org.uk
Registered Charity No 1016532
April 2005

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Quality Standards

Cochlear implants for

Joint revision by:

3. Children and young people – key considerations 8

4. Local services and support 10

5. Supporting the child, young person and family 13

7. Clinical and surgical facilities and accommodation 23

8. The referral and selection procedure 25

9. Assessment for a cochlear implant 27

11. Surgery and postoperative care 38

12. Programming, follow-up care and support 42

13. Ongoing evaluation of benefit 44

15. Service planning, evaluation and audit 52

Susan Daniels, NDCS Chief Executive John Graham, BCIG Chairman

The National Deaf Children's Society is the only UK organisation solely

The British Cochlear Implant Group is committed to the enhancement and

1.7 The abbreviation QS is used to denote factors which define a quality

3.1 Appropriate candidates

3.2 Adolescent programmes

4.1 Local services for deaf children and young people

QS 01 Once a child has been identified as having a permanent

QS 02 Local and specialist multi-disciplinary teams should work

4.2 Newborn hearing screening programme

4.3 The local health service

4.4 The local specialist education service

4.6 Support groups and voluntary organisations

QS 03 Information about voluntary sector services must be given to

5.1 The need for accessible information

QS 04 Families and young people must have equal access to

QS 05 The cochlear implant team must provide the family and/or

All members of the team should be aware of the principles of

QS 06 Sign language and/or spoken language interpreter(s) must be

5.3 The need for multi-disciplinary working

5.5 Involving the child in their own care

5.7 Contact with peers and families

QS 07 It is the responsibility of the implant programme to work with

6.1 The cochlear implant team

6.1.1 The audiological scientist (clinical scientist):

QS 08 Audiological support and assessment must be undertaken by

6.1.2 The ENT surgeon:

QS 09 The ENT surgeon will have an FRCS qualification. They will be

The surgeon, in collaboration with the consultant anaesthetist, is responsible

6.1.3 The audiological physician:

QS 10 The audiological physician must have the necessary skills to

6.1.4 The speech and language therapist (SLT):

QS 11 The SLT must have a degree and licence to practice, including

QS 12 The TOD will have a DfES QTS qualification and a mandatory

6.1.6 The co-coordinator (or cochlear implant service

6.1.7 The key (link) worker:

QS 13 ‘One professional should take on the role of key worker in

6.3 Training requirements

QS 14 It is essential that there are clear procedures in place

Joint training of staff from different disciplines should be encouraged, as this

7.1 Hospital and clinic accommodation

QS 15 The multi-disciplinary clinic must take place in a paediatric

QS 16 Children should not be cared for in adult clinics or on adult

QS 17 Audiological testing should be performed in soundproofed

7.3 Surgical equipment

QS 18 A reply will be sent to the referrer within 2 weeks to confirm

8.1 Attendance and commitment by the child and family

QS 19 The NHS quality standards for outpatient clinic consultation

The following sections (9.1 to 9.12) describe the assessment procedure,

9.1 Prior to the appointment at the clinic (see ‘supporting the

9.2 The process and procedures