Activities, detailed actions, decision nodes, workflows, roles, environmental conditions have to be identified and specified. More specifically key issues are reported.
The typology and the number of tests, and the healthcare setting in which performing the examinations (before or after the discharge) – The program needs to be well balanced for sensitivity, specificity, coverage of the population and costs per subject identified. E.g., Kennedy et al. [
25] reported to have changed their protocol using unilateral failure on aABR, rather than bilateral failure on Transient Evoked OAEs (TEOAEs) testing, as the second step; this change was associated with a reduction in the screen-failure rate from 2.4 % (95 % CI 2.2–2.6) to 1.3 % (1.1–1.5) of babies screened.
The presence of specific protocol for neonates at higher risk (e.g., aABR for NICU staying in NICUs for more than 5 days instead of TEOAEs) [
17] - Such neonates, in fact, are at risk of having neural hearing loss (auditory neuropathy/auditory dyssynchrony) which is not detectable with TEOAEs
. The set of examinations for the full audiological evaluation – E.g., the one recommended by the JCIH [
17].
The tasks to be performed to increase the percentage of enrolment and to reduce the lost to follow up (neonates referred to further examinations that do not show at the planned appointments) - With reference to the former, it has to be noted that specific actions should be done for an appropriate communication with families creating the conditions for an informed consent. With reference to the latter, a survey conducted in USA [
26] shows that only 62 % of all newborns who need a diagnostic evaluation actually did it and, out of them, only 52 % by the age of 3 months (as recommended by the JCIH). The lost to follow-up at all stages of the EHDI process continues to be a serious concern also for the World Health Organization (WHO) [
27] that states the importance, for its success, of monitoring and implementing all the phases of the screening (responsibilities, training, information campaign, procedures of quality assurance).
The surveillance program for early identification of infants and children with late onset (especially in presence of high risk factors) – It is recommended to perform regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status to for all infants, together with an objective standardized screening of global development, at 9, 18, and 24 to 30 months of age or at any time if the health care professional or family has concern [
17].
The cooperation among all the involved operators, services and institutions - The identification of the key roles is an essential step for an appropriate management of the entire process and for monitoring purposes.