Hearing loss is one of the most pervasive occupational health problems in America today. Approximately 30 million workers are exposed on their jobs to noise levels or toxicants that are potentially hazardous to their hearing. Fortunately, noise-induced hearing loss can be reduced, or often eliminated, through the successful application of occupational hearing loss prevention programs.

A successful hearing loss prevention program benefits both the company and the affected employee. Employees are spared disabling hearing impairments and evidence suggests that they may experience less fatigue and generally better health. Ultimately, the company benefits from reduced medical expenses and worker compensation costs. In some cases there may be improved morale and work efficiency.

The existence of a hearing loss prevention program (even one that complies with government standards) does not guarantee the prevention of occupational hearing loss. Experiences with successful hearing loss prevention programs show that management needs to develop and adhere to certain policies from the start. These policies cover the integration of the hearing loss prevention program into the company's safety and health program, designation of a key individual (a "program implementor") with ultimate responsibility for the overall conduct of the program, standard operating procedures for each phase of the program, the proper identification and use of outside services, and the purchase of appropriate equipment.

This guide, developed by those having long, varied experience in hearing conservation practices, presents some of the important attributes of successful hearing loss prevention programs. Concepts and action items are presented in terms of the responsibilities of three groups of personnel: those representing management, those who implement the hearing loss prevention programs, and those who are affected by exposure to noise or ototoxic chemicals. Checklists are provided in the appendices to assist in evaluating hearing loss prevention programs on a step-by-step basis.

As presented in the original edition of "The Practical Guide," the seven basic components of a hearing loss prevention program consist of: (1) noise exposure monitoring, (2) engineering and administrative controls, (3) audiometric evaluation, (4) use of hearing protection devices, (5) education and motivation, (6) record keeping, and (7) program evaluation. To these, we now add an eighth: hearing loss prevention program audit.

Hearing Loss Prevention Program Audit

Ideally, a carefully conducted audit should be performed before any program to prevent hearing loss is put into place, or before any changes in an existing program are made. The audit should be performed on the system as it exists or doesn't exist. While it is not difficult to conduct an audit, it may require time to assemble the materials necessary to fully answer audit questions. The questions in Appendix B, Program Evaluation Check List, can serve well for an audit, although for an initial audit the check list should be reordered. It is best to perform the audit from the top down with administrative issues addressed first. Administrative issues concern corporate responses to regulations, to good safety and health practices, to the need to develop or modify program policies, to assuring adequate resources, and to providing the necessary authority to those persons responsible for the day-to-day operation of the program. Aspects of hearing assessment, implementation of engineering and administrative controls, and supervisor involvement in the program should be considered. The system for monitoring audiometry and record keeping requires close attention since how the records of audiometry and other aspects of the program are maintained can make or break the program. Employee and management education should be planned and past successes and failures should be addressed. When noise cannot be reduced to the point where it is no longer a hearing hazard, a program for providing, fitting, training in the use of, and maintaining hearing protectors must be established. The hearing loss prevention program audit should be revisited annually so that strengths of the program may be identified and weaknesses may be addressed.

Monitoring for Hearing Hazards

As with any health hazard, it is important to characterize the hazard accurately and to identify the affected employees. Management should define the specific goals of the sound survey and make sure that operating procedures, as well as resources, are available for collecting and evaluating measurements of ototraumatic exposures. Since noise is the most widespread ototraumatic agent, this section will focus on noise exposure monitoring. However, other agents known to effect the auditory system, or to interact with noise should also be monitored. In the case of ototoxic chemicals, analytical procedures that specify the collection media, sample volume and chemicals analysis can be found, for an extensive number of compounds, in the NIOSH Manual of Analytical Methods (1994). The results of the noise and other measurements must be reported to the hearing loss prevention program implementor and to the employees in an understandable format. Hearing loss prevention program implementors need to coordinate closely with production employees to make sure that the measurements represent typical production or processing cycles and that noise and toxicant levels are adequately sampled. The program implementor should see that those who make the measurements closely follow the policies and procedures established by management, that the report explains the results clearly, and that employees are apprised of the results. Employees have the responsibility of sharing their knowledge about the production environment, the machinery, and specific operations with those who measure the exposures.

Engineering and Administrative Controls

Ideally, the use of engineering controls should reduce ototraumatic exposure to the point where the hearing hazard is significantly reduced or eliminated. It is especially important for companies to specify low noise levels when purchasing new or refurbished systems and equipment.

Management needs to identify controllable exposure sources, set goals for their control, and prioritize allocated resources to accomplish these goals. Managers should also explore potential administrative controls, such as scheduling that will minimize exposure to noise and other ototraumatic agents, and providing quiet, clean, and conveniently located lunch and break areas. Program implementors must ensure that communication channels are open between management, noise control personnel, and production workers. The workers, in turn, need to communicate their concerns to management and those in charge of engineering control, and must learn to work safely in their environment by taking full advantage of the available controls.

Audiometric Evaluation

Audiometric evaluation is crucial to the success of the hearing loss prevention program, since it is the only way to determine whether occupational hearing loss is being prevented. Management must allocate sufficient time and resources to the audiometric program to allow accurate testing; otherwise, the resulting audiograms will be useless. Management should also select audiometric technicians and professional consultants with demonstrated competence in relating to employees as well as in performing their duties in the audiometric program. The program implementor must monitor the audiometric program including scheduling, testing, equipment maintenance and calibration, audiogram review, feedback to the employee, and referral. Effective communication and coordination among company personnel, health services, and employees are of utmost importance. Employees need to disclose information about ear problems and prior noise or toxicant exposures, or problems encountered in taking the audiometric test. They also need to follow up on any recommendations for treatment or further medical or audiologic evaluation.

Personal Hearing Protection Devices

In the absence of feasible engineering or administrative controls, personal hearing protection devices (often referred to as hearing protectors) remain the only means of preventing hazardous noise levels from damaging one's hearing. Unless great care is taken in establishing a hearing protector program, employees will often receive very little benefit from these devices. Each employee can react differently to the use of such devices, and a successful program should respond to individual needs. The primary managerial responsibilities are: to facilitate the procurement of appropriate hearing protection devices, to demonstrate commitment to the program (e.g., by modeling the use of these devices in appropriate situations), to provide the personnel and facilities to train employees in the proper and optimum use and care of hearing protection devices, and to enforce the use of hearing protectors. Program implementors need to be knowledgeable in the details of hearing protector evaluation, selection, and use, and must be able to impart this information and enhanced daily use skills to employees. Implementors need to encourage employees to ask questions and must help them solve any problems that may arise. Program implementors also should perform periodic on-site checks of the condition and performance of hearing protectors including availability of replacement devices as well as component elements that tend to deteriorate with use (such as earmuff cushions).

Employees must take responsibility for being fully informed about the need for hearing protection, wearing their hearing protectors correctly at all times, seeking replacements as necessary, encouraging co-workers to use these devices, and communicating problems to their supervisors.

Education and Motivation

Education and motivation sessions are valuable for both management and employees so they will understand that a successful hearing loss prevention program takes commitment, communication, and cooperation. Management should set a high priority on regularly scheduled training sessions, and select articulate, knowledgeable, and enthusiastic instructors. The program implementor, or those who present the sessions, need to make their presentations short, simple, and highly relevant to employees and management. They need to encourage questions and open communication, and they must make sure that all problems receive prompt attention. Employees must contribute to their own education by raising questions and concerns, and by informing program implementors when specific procedures are impractical, suggesting alternatives when possible. If hearing loss prevention program personnel fail to provide adequate consideration or follow-up, employees should communicate their concerns to higher levels of management.

Record Keeping

Effective record keeping requires a committed and consistent approach. Each element of the hearing loss prevention program generates its own type of record (e.g., noise survey forms, audiograms, and medical histories), and much of this information needs to be integrated into the employee's health record. Historical record keeping is vital because injuries to hearing due to over exposures are rarely as evident as other types of occupational events; i.e., noise-induced hearing loss takes place very slowly over time. Therefore, complete documentation becomes vitally important when evaluators attempt to construct longitudinal records that pertain to an individual's long-term exposures to noise and effectiveness questions concerning prevention and control measures.

Management's responsibility is to provide adequate resources for efficient record processing, review, and storage in addition to training program implementors and procuring outside services if necessary. Management must ensure that confidentiality of personal data is maintained, that hearing loss prevention program records are available to program implementors and government inspectors, and that each employee has access to his or her own files. Program implementors must see that the information entered into the records is accurate, legible, complete, and self-explanatory. They also should ensure that records are standardized, cross-referenced, and properly maintained. Employees should take advantage of the record keeping system by inquiring about their hearing status, especially at the time of the annual audiogram.

Program Evaluation

A thorough evaluation of all the hearing loss prevention program's components is necessary to determine the extent to which the hearing loss prevention program is really working, or if there are problems, which elements or departments need improvement. There are two basic approaches: (1) to assess the completeness and quality of the program's components, and (2) to evaluate the audiometric data. The first approach may use checklists, such as those found in Appendices A and B, and the second consists of evaluating the results of audiometric tests, both for individuals and for groups of employees exposed to hearing hazards. Management should dedicate resources for hearing loss prevention program evaluation (i.e., trained individuals and computer facilities). In addition, managers must be willing to acknowledge and solve problems that arise. If program implementors are not knowledgeable in the mechanics of database analysis, the company should obtain training for the implementor or hire someone with these skills. Program implementors must also be committed to seeking out elusive information, and interacting with all members of the hearing loss prevention program team to identify and correct any deficiencies. As with many other aspects of the hearing loss prevention program, the employee's responsibility with respect to program evaluation is to provide feedback on the program's merits or shortcomings to the program implementor and management and to participate in the implementation of the improvements.

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