Historical Role of IOM for the Audiologist

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Neurophysiologic Intraoperat ive Monitoring Page 1 of

American Speech Language Hearing Association

Position StatementNeurophysiologic Intraoperative Monitoring

d Hoc Committee on dvances in Clinical Practicebout this Document

This was prepared by the American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee onAdvances in Clinical Practice: Donald E Morgan, chair; Carol M. Frattali, ex officio; Zilpha T. Bosone;David G. Cyr; Deborah Hayes; Krzysztoflzdebski; Paul Kileny; Neil T Shepard; Barbara C. Sanies; JaclynB. Spitzer; and Frank B Wilson. Diane L Eger, 1991-1993 vice president for professional practices, andTeris K Schery, 1988-1990 vicepresident for clinical affairs, sewed as monitoring vice presidents. Thecontributions of the Execuiive Board, select widespread peer reviewers are gratefully acknowledged.The Legislative Council approved the document as official policy of he Association at its November 1991meeting (LC 51 F-91).

Table of Contents I. Introduction

ll BackgroundIll Purpose

IV. Scope of Practice V Education and Training VI. Precautions VII. Roles and Definitions VIII. Knowledge and Skills References Notes

I. IntroductionSpeech-language pathology and audiology are dynamic and expanding professions with constantlydeveloping technological and clinical advances. Before conducting procedures involving such advances,

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Neurophysiologic Intraoperative Monitoring Page of7

practitioners must have acquired the knowledge, skills, education, and experience necessary to perform themcompetently. This policy statement is one of seJen documents III developed by the Ad Hoc Committee onAdvances in Clinical Practice. Each statement expresses the position of he American Speech-LanguageHearing Association ASHA) concerning specific clinical procedures within the scope of practice ofspeechlanguage pathology or audiology, most of which have developed only within the last few years. Eachstatement further provides guidelines for practitioners performing these procedures. The guidelines considerthe knowledge and skills normally associated with the required competencies, the clinical settingsrecommended for the procedure, and t e appropriate involvement of personnelfrom other disciplines.Clinical certification by ASHA ensures that practitioners have met the education, knowledge, and experiencerequirements established by the Association foryroviding basic clinical services in the professions of speechlanguage pathology or audiology. Certification in the appropriate profession is necessary, but not sufficient to

i perform the specific clinical procedure(s) discussed in this statement. The procedure(s) addressed in thisdocument requires the practitioner to obtain education and training beyond that necessary for ASHAcertification. Practitioners are bound by the ASHA Code ofEthics to maintain high standards of professionalcompetence. Therefore, practitioners should engage only in those aspects of he p ~ o f e s s i o n s that are within thescope of heir competence, considering their e ~ e l of education, training, and experience.In promulgating this policy statement, there is no intention to imply that the practitioner holding ASHACertification is prepared to conduct the procedure(s); nor is it incumbent on any certified professional toprovide the procedure(s) merely because the practitioner holds certification.The following document is intended as guidelines for the practitioner to ensure the quality of care, welfare,safety, and comfort of those served by our p r o f ~ s s i o n s .

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II ackgroundNeurophysiologic intraoperative monitoring involves continuous direct or indirect electrophysiologicmeasurement and interpretation of myogenic and neural responses to intraoperative events or o d a l i t y ~specific, controlled stimulation in the course of surgery on or in the vicinity of hose structures. An importantaspect of intraoperative monitoring is the on-line, moment-to,moment correlation between changes inneurophysiologic responses and intraoperative events. The purpose of intraoperative monitoring is to facilitatethe maintenance of the functional and structural integrity of neural structures, at risk for iatrogenic injury.The principal objectives of neurophysiologic intraoperative monitoring are: (a) to avoid intraoperative injuryto neural structures; b) to facilitate specific stages of he surgical procedure; {c) to reduce the risk of

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Neurophysiologic Intraoperative Monitoring Page 3 of

permanent postoperative neurological injury; and d) to assist the surgeon in identifYing specific neuralstructures.As this clinical procedure has developed over the past several years, a variety of disciplines have beeninvolved in its development and practice. Prominently figuring among such disciplines as neurology,neurophysiology, anesthesiology, and others is the profession of audiology. Therefore, in many clinicalsettings, audiologists deliver or are expected to deliver this clinical service .t is important to note that neurophysiologic intraoperative monitoring is an interactive process involving

close collaboration and interaction between the surgical and the monitoring team. Therefore, it is onlyieffective ifboth parties are knowledgeable and in agreement about the limitations and goals ofintraoperative

monitoring.Return to Top

III PurposeThe purpose of this position statement is to assist audiologists who are involved in, and those who plan to beinvolved in, intraoperative monitoring. Speciiically, the purposes are: a) to inform audiologists thatperforming nel rophysiologic intraoperative monitoring is within the scope of practice of audiology; (b) todefine the procedure known as neurophysiologic intraoperative monitoring; c) to advise audiologists of heeducation, training, circumstances, and precautions that should be considered prior to undertaking this clinicalactivity; d) to provide guidance. for audiologists as to the knowledge and skills required to performneurophysiologic intraoperative monitoring; and e) to educate health care professionals, consumers, and thegeneral public of the services offered by audiologists as qualified health care providers.

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IV Scope o PracticeIt is the position of the American Speech-Language-Hearing Association (ASHA) that neurophysiologicintraoperative monitoring is within the scope of practice of audiologists with the appropriate knowledge baseand skills. The purpose of neurophysiologic intraoperative ,monitoring is to assist surgeons to minimize oravoid altogether the occurrence ofintri10perative injury to neural structures at risk due to the nature ofthepathology and their proximity to the surgical field. The practice ofneurophysiologic intraoperativemonitoring by an audiologist requires knowledge in neuroanatomy and neurophysiology, with specialemphasis in neurodiagnostic techniques and their intraoperative applications. In addition, familiarity with thesurgical procedure, effects of surgical manipulations and pharmacologic agents on neurophysiologic events,and the ability to recognize those events also is required.

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If practitioners choose to perform these procedures, indicators should be developed, as part of a continuousquality improvement process, to monitor and evaluate the appropriateness, efficacy, and safety of theprocedure conducted.

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V ducation and TrainingAppropriate education and training are the cornerstones of involvement in intraoperative monitoring byaudiologists. These should include relevant and appropriate academic training, followed by extensive clinicaltraining in a setting providing the opportunity to be involved in a sufficient number of cases, under thesupervision of experienced and competent professionals. t is the practitioner s responsibility to determinewhether he/she has obtained the appropriate type and sufficient degree of education and training to becompetent in the performance of neurophysiologic intraoperative monitoring. The specific education andtraining may vary for each type and modality of intraoperative monitoring. For instance, appropriatebackground and experience in monitoring posterior cranial fossa surgical procedures does not automaticallyensure competence in the monitoring of somatosensory evoked potentials during spinal-cord surgery.

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VI PrecautionsEach practitioner should consider the following precautions or circumstances prior to undertakingintraoperative monitoring:

1. Inform institutional and/or regulatory bodies, such as state licensure boards, about these procedures aswithin the scope of practice;

2. Check with appropriate state licensure boards to ensure that there is no limitation imposed on the scopeof audiology practice that restricts the performance of neurophysiologic intraoperative monitoring;

3. Check professional liability insurance to ensure that.there is no exclusion applicable to this procedure;4. Follow the universal precautions to prevent the risk of disease from blood-borne pathogens contained in

the Centers for Disease Control Morbidity and Morlalily e e k ~ v Reporl (June 24, 1988, Perspeclive nDisease Prevenlion and Hea/Jh Promo/ion 37 (24), 377-388 or ASHA s AIDS/HIV Update Asha,1990);

5. Know whom to contact in the event of a medical emergency;

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6. Obtain the informed consent of the patient/client, and maintain complete, and adequate documentation.

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VII Roles and DefinitionsThe audiologist has the responsibility of preoperative patient preparation, including placement and securingrecording electrodes and stimulators or transducers to avoid interfering with or being dislodged during thesurgical procedure. If subdermal needle electrodes are used for recording or stimulus purposes, theirplacement may be the responsibility of the audiologist or of a surgeon, as dictated by each institution spolicies and procedures: The audiologist is responsible for determining, prior to sterile draping, that therecording electrodes have adequate low impedances and that the stimulators or transducers are delivering theappropriate stimuli in an undisturbed fashion.The audiologist is also responsible for operating the electrophysiological equipment used in intraoperativemonitoring, including its proper maintenance, function, and calibration. The selection of appropriaterecording and stimulus parameters is also the responsibility of the audiologist, including safe stimulation,whether or not stimulus modality is acoustic or electric. The audiologist-is also responsible for providing safe,effective, high7quality, artifact-free, interpretable recordings.The on-line intraoperative interpretation ofthe recorded neurophysiologic responses or events and theircorrelation with relevant intraoperative surgical events is also the responsibility of the audiologist. This needsto be carried out by means of close interaction and collaboration with the surgical and anesthesia team. Theaudiologist must apply knowledge of he effects of anesthetics and other intraoperatively administeredpharmacologic agents and the knowledge of he surgical procedure to carry out this responsibility, whichinvolves the capability of making on-line distinctions between relevant and irrelevant neurophysiologicchanges and with a good understanding ofthe limitationsimposed by the surgical procedure, to communicatethis information to the surgical team in anticipation ofsteps taken by the surgeon to correct the problem. Theaudiologist also needs to communicate to the surgical team when a potential problem has been corrected sothat surgery may proceed at an optimal pace.At times neurophysiologic monitoring involves direct electrical stimulation of the neural or surroundingtissue for the purposes of identification and the determination of morphology topography, and functionalstatus. The electrical current stimulus may be delivered by means of a hand-held probe by the surgeon or bypreviously attached surface electrodes. t is the audiologist s responsibility to ascertain that appropriate, safecurrent levels are being delivered. This implies that the level has to be adjusted to be effective but notpotentially damaging.

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VIII. nowledge and SldllsIn order to be effective in the performance of intraoperative monitoring, audiologists should have thefollowing knowledge base and skills:

1. Fundamental knowledge in basic and applied neuroanatomy and neurophysiology;2. Fundamental and applied 1..-nowledge in the measurement of bioelectric signals;

3. Fundamental and practical knowledge in electronic instrumentation used in clinical neurophysiologyapplications;

4. A practical working knowledge of clinical neurophysiology/neurodiagnostic procedures, includingtechnical and interpretive/diagnostic aspects, particf larly those related to the neural systems to bemonitored in the operating room;

5. A basic knowledge of medical and surgical considerations as they pertain to the procedures to bemonitored. The audiologist needs to have a good theoretical knowledge of the specific surgicalprocedure, anatomical structures encountered, and risk factors specified to the particular surgicalprocedures; '

6. A fundamental understanding of anesthesia and tl1e effects of pharmacological agents used in theoperating room .on the electrophysiologic events and responses monitored during surgery:7. A solid understanding of he biological mechanism involved in the electrical stimulation of neural

tissue, safe limits of stimulation, and the identificalion offalse-positive and false-negative outcomeresulting from electrical stimulation. When the electric stimulus is applied manually by the surgeon bymeans of a handheld monopolar or bipolar probe, it is the audiologist's responsibility to control thestimulus delivery, including rate and intensity.

8. Direct supervised experience in neurophysiologic intraoperative monitoring, prior to independentlymonitoring surgical procedures, is necessary. The audiologist should also have a thoroughunderstanding of operating room conditions, sterile fields, and general operating room etiquette.

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ReferencesAmerican Speech-Language-Hearing Association. {1990, December). Report update. A DS/H V:Implications for speech-language pathologists and audiologists. Asha 32 46-48.Centers for Disease Control. (1988). Aforbidity and mortality weekly report: Perspectives in diseaseprevention nd health promotion 37 377-388.

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Notes[lj The documents include position statements and guidelines for balance system assessment, electricalstimulation for cochlear implant selection and rehabilitation, evaluation and treatment for tracheoesophagealfistulization/puncture, external auditory canal examinatior; and cerumen management, instrumental diagnosticprocedures for swallowing, neurophysiologic intraoperative monitoring, vocal tract visualization and imaging.

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Index terms monitoring, assessmentRefeteneethis material as: American Speech-Language:Hearing Association. 1992). Neurophysiologicintraoperative monitoring [Position Statement]. Available from www.asha.org/policy.Copyright 1992 American Speech-Language-Hearing Association. All rights reserved.Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for theaccuracy, completeness, or availability of hese documents, or for any damages arising out of he use ofthedocuments and any infonnation they contain.doi: 0.1 044/policy.PS 1992-00036

1997-2013 American Speech-Language-Hearing Assoc.iation

Historical Role of IOM for the Audiologist

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