Even in the population-dense region of Southern California, sleep labs used to be rare. When compared to 2011, sleep apnea awareness in the 1980s significantly trailed other conditions.
Officials at Hoag Memorial Hospital Presbyterian in Orange County, Calif, recognized early on that there was a need for a specialized center to evaluate and treat sleep disorders. The Judy & Richard Voltmer Sleep Center, backed by the resources at Hoag, filled this void back in 1987 in Newport Beach, Calif. More recently, the center moved to gleaming new quarters in an effort to modernize and accommodate more patients.
With considerable resources, expertise, and referrals flowing from Hoag, the state-of-the-art 8-bed facility never lacks for patients. Paul Selecky, MD, FACP, FCCP, FAASM, long-time medical director of the Voltmer Sleep Center, has tirelessly spread the message of sleep health among his colleagues. The result is that clinicians from diverse specialties appreciate the value of healthy sleep, and they don’t hesitate to ask for help when they need it.
Under the umbrella of Hoag Neurosciences Institute, the Voltmer Sleep Center is seamlessly integrated within the continuum of care. Sleep is not an afterthought. Neurologists, ENTs, pulmonologists, endocrinologists, and primary care physicians all readily send patients to the center.
Colleagues on Board
The evidence for the sleep/health connection seems to build each year, with ever-more co-morbidities related to poor sleep. The more apt question these days is what is not affected by sleep.
When the American Society of Anesthesiology (ASA) came out with its 2006 guidelines on peri-operative management of patients with known or suspected sleep apnea, clinicians at Voltmer Sleep Center were ready. “Our anesthesiologists asked if we could help them develop a program to screen patients who were coming in for elective surgery,” says Selecky. “That protocol has now grown, and nearly every admission coming into Hoag is evaluated for the risk factors of sleep apnea.”
Hoag has taken a proactive approach, and patients who come in for other ailments benefit from the extra attention. “About 70% of stroke patients have sleep apnea,” says Selecky. “It’s a chicken-egg type of thing, but at least they get sent here to lower that risk. Others who come in for total knee, hip, chest pain—we ask them about sleep and the patient is educated about serious breathing problems.”
Not surprisingly, about 90% of all referrals to Voltmer Sleep Center come from Hoag, but outside referrals are growing. If a patient is referred by a Hoag neurologist for sleep problems related to that neurologic problem, a neurologist working on staff at Voltmer Sleep Center is the one to see that patient.
If COPD was the primary problem, a pulmonologist would visit with the patient. “This is not just an independent sleep center,” explains Trish Stiger, BBA, RPSGT, CRT, manager of the Voltmer Sleep Center. “It is part of Hoag, and they refer from the Diabetes Center, the Cardiovascular Institute, and more. Even obstetricians are reminded that a snoring pregnant woman should not be ignored as if she merely has nasal congestion, as this can lead to complications of pregnancy.”
In line with the large body of evidence linking sleep apnea and congestive heart failure, Voltmer Sleep Center clinicians provide information and education to all Hoag cardiologists. “A lot of them have gotten the message,” says Selecky. “They ask every congestive heart patient, ‘Do you snore?’ If the patient snores, and has other features of sleep apnea, he comes to us.” Cardiologists will also send patients whom they are treating for resistant hypertension, as is recommended by the American College of Cardiology and American Heart Association because of the link with untreated obstructive sleep apnea.
Much the same can be said for diabetes management. Endocrinologists who prescribe several different medications for diabetes have referred their patients to the Center, again because of the link between diabetes management and sleep apnea . “The first thing that should be done is to rule out sleep apnea,” says Selecky.
Education and Follow-up
Every physician takes patients to the lab bedrooms to explain the diagnostic tests and procedures, and these in-person consultations provide vital information. Despite all the media attention on sleep, Selecky admits that some convincing is often part of the job. “Sometimes there is too much negative information out there,” laments Selecky. “People come in and say, ‘I don’t want that breathing machine. I know somebody that hated it.’ It gets a bad rap, so we must provide a lot of education.”
When it comes time to dispensing the actual CPAP machine, Selecky and Stiger work closely with trusted durable medical equipment (DME) providers who are known for their good service. “If they don’t provide good service, we don’t refer to them—it’s that simple,” says Selecky. “That means excellent follow-up, because if patients don’t have a positive experience in the first few weeks of CPAP use, they are more likely to abandon it. Nationally, the average for CPAP users is that 50% drop it by the end of the first year. We have several of the DME RTs spend time in the Center so patients can try a dozen different masks. It’s like buying a pair of shoes. If it doesn’t fit well, you are not going to use it.”
In addition to the familiar sleep apnea/CPAP combination, officials at Voltmer are keen to address all sleep disorders and treatments. “Insomnia is not a huge percentage of our patient population at this point, but it’s significant enough and our physicians treat it,” says Stiger. “Patients may need extensive cognitive behavioral therapy, sometimes with the aid of psychologists.
In addition to CPAP for apnea, we embrace dental sleep medicine as a valid option. “Oral corrective devices have been used throughout our history with the help of local dentists who started treating some of our milder patients, or those who could not tolerate CPAP,” adds Selecky.
Unlike the 1980s, Selecky says it seems as though these days there is a sleep lab on every corner. Favorable demographic trends suggest that won’t change, despite the furor caused last year when Medicare approved home sleep studies—much to the chagrin of lab owners. “People said that might be the end of all sleep centers,” says Selecky. “But as time has gone on, that has not occurred at all. Part of it is that reimbursement for home sleep studies is low. However, it has made every lab consider whether it should be involved in home sleep studies. The answer is yes for certain populations.”
In 2011, Selecky believes the keys to success looks a lot like the keys of the past. Education, clinical excellence, follow-up, and compliance must be the driving forces. As understanding of sleep medicine grows and physicians know more about it, they will inevitably order more sleep studies.
Those who have worked to be a full service center will remain in the black as they gain the trust of physicians and patients alike. “There is a difference between establishing yourself as a sleep center vs a sleep lab,” adds Stiger. “A center deals with everything. You educate, go out and teach the community, and work with all the other specialties to care for patients—which should always be the number one goal.”
Tradition of Excellence
Hoag Memorial Hospital Presbyterian is accredited by the Joint Commission on Accreditations of Healthcare Organizations (JCAHO), and home to Centers of Excellence in cancer, heart, orthopedics and women’s health services. Orange County residents named Hoag the “Hospital of Choice” in a National Research Corporation poll, as well as the county’s top hospital in a a local newspaper survey.
The Voltmer Sleep Center is an accredited member of the American Academy of Sleep Medicine, and features a Web site (http://www.hoag.org/services/neurosciences-institute/voltmer-sleep-center) where potential patients can view online sleep assessments, photos of the sleep center, and information about the physicians. “Many people simply don’t realize that an adequate night’s sleep is needed to maintain good health and stay fully alert throughout the day,” says Selecky. “We are excited about the opportunity to use the Internet to educate the public and to let them know there is help nearby.”
The new Out of Center Sleep Testing (OCST) in Adult Patients AASM Accreditation requirements were recently released. Although it does contain some very practical requirements for an entity wishing to be an AASM Accredited provider of OCST, it also contains some requirements (or some say, lack of requirements) when it comes to who will be scoring these recordings.
Of concern to many RPSGT’s is the lack of reference to the RPSGT credential anywhere in the document. In B-9 it does specify that CPSGT’s and other “non-specified” board or sleep certifications are “appropriate” to score OCST recordings. Also mentioned are holders of the respiratory “SDS” endorsement. Perhaps omitting the “RPSGT” credential is just an oversight by the AASM?
Furthering the controversy is F-4 which provides a pathway to exclude all scoring techs, regardless of credential, from scoring OCST recordings.
Below are paragraphs from the newly released standards. WHAT ARE YOUR THOUGHTS? Post a comment here
Standards for Accreditation of
Out of Center Sleep Testing (OCST) in Adult Patients
Appropriate scoring technical personnel include sleep technicians, sleep technicians with the CPSGT certification or other board approved (non-specified boars) certifications, sleep technologists, respiratory therapists with the sleep disorders specialist (SDS) certification, or electroneurodiagnostic technicians with additional sleep certification.
If used, computer-assisted scoring of OCST recordings must be reviewed and edited for accuracy by a board certified sleep physician.
Here is the link to read the entire OCST Standards:http://www.aasmnet.org/resources/pdf/OCSTstandards.pdf
I know that there are many opinions about the validity of doing OCST recordings. This editorial does not focus on that controversy. We will leave that for another day. However, many of the sleep professionals that have contacted me are very concerned that there is no mention of the RPSGT credential in the acceditation requirements and the seemingling acceptance of auto scoring. Combine this with the recent announcement that there will soon be a fourth (RPSGT + CPSGT + Respiratory SDS + new ABSM) tech sleep credential and many RPSGT’s are feeling threatened by these recent events.
Many are asking “where is the AAST in all this?” I have begun to hear rumblings from many techs that feel they have wasted their $100 annual dues for representation they feel is not happening. I dont have an answer for you. Each RPSGT, CPSGT, and sleep professional needs to come to their own conclusions about the direction that our field is moving in. As an editorial writter I would very much like to hear from you.
In order to be properly represented you need to make your desires known. Staying silent whether against or in favor of any position does not send a clear message to those we pay to represent us.
No matter what your indivdual thoughts are, the industry deserves to hear from you. Let your thoughts be known to those that care to listen Join the discussion on the Sleep Scholar Linkedin site
If you have not seen the latest from the AASM that directly impacts working sleep techs, I have included the letter below. What are your thoughts about the AASM deciding the value of your RPSGT Credential, allowing Auto Scoring for Home Sleep Studies, and now supporting a routine 3:1 ratio of patients to tech?
Please post your opinion (agree or disagree). If you have no opinion then you should say nothing when the industry changes.
“Dear Accredited Sleep Disorders Center,
Over the past year, selected sleep disorders centers accredited by the American Academy of Sleep Medicine participated in an assessment of current laboratory procedures to identify areas for improved patient care and safety as well as efficiency. The report resulting from this year-long assessment has assisted the Board of Directors in making strategic decisions related to policy for the diagnosis and treatment of sleep disorders.
After reviewing the final report, the Board of Directors amended Standard B-7 of the Standards for Accreditation of Sleep Disorders Centers. To ensure the highest quality of care and patient safety the standard continues to recommend a patient-to-technologist ratio of 2:1 for attended polysomnography, and now allows for a maximum ratio of 3:1. The revised standard states:
|B-7 – Sleep Technicians and TechnologistsAASM accredited sleep facilities must maintain appropriately trained, supervised, and, where required by state law, licensed sleep technologists. Technologist staffing must be adequate to address the workload of the sleep facility and assure the safety of patients. This includes a recommended patient to technologist ratio of 2:1 and a maximum patient to technologist ratio of 3:1 under usual circumstances for attended polysomnography.|
A complete version of the current Standards for Accreditation of Sleep Disorders Centers may be downloaded at www.aasmnet.org/accreditation.aspx. “
Sleep affects how children feel and function. By helping your child to get the recommended amount of sleep, you can improve your child’s health, psychological well-being, and safety. Sleep is key to your child’s growth and development as well as his/her ability to learn.
The chart below provides general guidelines showing how your child’s need for sleep changes with age. There may be individual differences between children:
|Daily Sleep Need|
|Preschool aged children||10-12 hours|
|School-aged children||At least 9 hours|
|Adolescents (Teens)||9 hours|
Unlike preschoolers who may need naps, school-aged children usually get all of their sleep at night. Teens need more sleep than adults. In addition, adolescent body clocks shift to a later sleep-wake cycle, making it hard for most teens to either fall asleep or wake up as early as they once did, or as early as younger children and adults. This shift is due to changes in teen brains and bodies and is what makes it hard for many teens to fall asleep much before 11:00 p.m.
Why Is Sleep Important? What Happens During Sleep?
Adequate sleep is a central part of a healthy lifestyle. During sleep, your body and your brain actively work to support healthy brain and body function.
Sleep helps your child focus and remember what he or she has learned. Memory is improved with sleep. Sleeping seems to enhance learning as if it were extra practice,iv whether your child is learning an academic subject like algebra, new physical skills like playing a musical instrument, dance steps, plays in sports, or how to drive a car.
Sleep also is vital for your child’s physical health. As one example, sleeping well supports the immune system, which helps fight infections, and thus sleep may decrease your child’s risk of getting sick.
What Happens When My Child Doesn’t Get Enough Sleep?
Sleep loss appears in younger age groups but is more common in teens. One national study showed that teenagers, on average, obtain 1.5 hours less sleep each school night than the 9 hours they need to function best.
Even repeatedly losing an hour of sleep per night can be harmful to your child’s function. This is because such nightly sleep loss accumulates (adds up) and produces a sleep debt. Performance and function decrease with each added night of sleep lost. Your child may tell you that they are used to a lack of sleep—this feeling has little to do with reality in terms of true daytime ability.
Young people who do not get enough sleep may be overly active, misbehave, have problems paying attention, or suffer declines in school performance. Sleep deprivation is sometimes misdiagnosed as attention deficit hyperactivity disorder.ii Sleep-deprived young people may have difficulty getting along with others, may be angry and impulsive, or lack motivation. Shorter sleep durations in adolescents and later parental set bedtimes (after midnight) have been linked with depression and increased suicide ideation. There also may be a link between sleep loss and risk-taking behavior. Sleep loss is of particular concern in teens as they are already inexperienced drivers. Research has linked decreased sleep (even 25 minutes less on school nights) to lower grades in adolescents.
Sleep loss may lead to increased weight gain and obesity. One study of teenagers showed that, for each hour of sleep lost, the odds of becoming obese increased. Sleep helps maintain the healthy balance of a number of hormones, including the ones that control appetite. Thus, loss of sleep may lead to increased appetite, overeating, and unhealthy weight gain.
Sleep loss may have life and death consequences for your teen driver. Drowsy driving causes more than 100,000 crashes a year, resulting in 40,000 injuries and 1,550 deaths and these numbers are considered conservative for many reasons including under-reporting by police of sleep as a cause of crashes. More than half of all fall-asleep crashes involve young drivers between the ages of 16 and 25.
How Can You Help Your Child Develop Healthy Sleep Habits?
It is important for your child to understand that getting enough sleep is a vital part of a healthy lifestyle. Make sleep a top priority and help your child to set a schedule that allows enough time for sleep. Developing a relaxing bedtime routine may help. Your Guide to Healthy Sleep provides tips to build healthy sleep habits: http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf. As always, if you have a question about your child’s or teen’s sleep, a good place to start is with his/her primary doctor.
Remember, even children who have established healthy sleep habits can be sleep deprived when schedules limit time for sleep or the time available conflicts with a child’s natural sleep cycle.
Posted By The Viginia Academy of Sleep Medicine.
For complete references, please visit: www.vasleepmedicine.org
This years meeting is in New Orleans and is March 24-27. Come and support a regional sleep society that supports the sleep professional and has done so since 1978. Additional information and registration can be found at: http://www.southernsleepsociety.org/index2.asp
Beyond boil and bite – T. Shumard
One of my favorites by James Joyce, a gentleman and scholar – T. Shumard
The voice of the winter
Is heard at the door.
O sleep, for the winter
Is crying “Sleep no more.”
My kiss will give peace now
And quiet to your heart — –
Sleep on in peace now,
O you unquiet heart!
In the last several weeks there seems to be a lot of buzz surrounding the AASM/ABSM’s announcement that they will be developing and administering a new credentialing exam for professional sleep techs sometime later this year.
As we are all trying to understand the reasoning behind this “surprising” pathway, we are being told by the AASM/ABSM that their reasons for adding a fourth sleep credential include low pass rates with the existing RPSGT exam and complaints from sleep center/lab physicians that the new crop of RPSGT’s do not have the skills needed to meet the labs needs regarding patient care and professional processes.
Now I know that I am just a mere educator and simply hold multiple credentials in a variety of related professions, which includes being a proud registered sleep tech for about 15 years, so maybe I am not smart enough to understand this reasoning by the AASM/ABSM. But what stands out in my mind is where is the representation I have always paid for, and expected, from the AAST?
After finding out about this new credential pathway I did some of my own investigation to try and find the answers to some questions that my elected AAST leadership has yet to answer. I called numerous sleep centers accross the country and spoke with many center/lab physicians and techs and without failure each and every one of them had “no such complaints” as explained to us by the AASM/ABSM. Maybe I just did not ask the right people, after all I am “only” a sleep tech and educator.
Now I admit that I have limited resources and time and could not possibly contact everyone to ask their opinion. So I asked myself who could do this for me, for us. Who has the resources to contact some 17,000 RPSGT’s and thousands of accredited sleep facilities and physicans to ask the same questions that I asked when I contacted just a few dozen.
From what I am reading in the blogs, and Facebook, and other cyber space sites is that many of you are asking the same question and most of you are coming to the same conclusion: the AAST, the AASM, and the ABSM. After all, isnt this why we have paid year after year of membership fees, supported annual meetings, and donated our time to further the cause of sleep professionalism. My expectation, maybe your expectation as well, was that my membership dollars and my donated time was not only to futher the cause of sleep professionalism but was to also protect my credential. Doing both would protect my livelihood as well.
As I said in the beginning of this rant, maybe I am just not smart enough to understand where my representatives have been on this matter, much less where they stand today. I also dont understand why nobody asked me my opinion about any of this over the last several years. And the same concern was expressed to me when I called upon the physicans and techs that I have spoken with over the last week or so.
The actions taken by the AASM/ABSM/AAST may be based on valid reasoning and concerns. I have no way of knowing one way or the other. So far they have only told us what they want us to know and have not released any valid data to support their decision. However what I do know is that the actions, or lack of action, by all three entities have thrown this profession into chaos. And the statement by the AASM/ABSM that I will be able to “grandfather my RPSGT” to their new credential means that at some near point in time my RPSGT credential will be worthless.
Its important to also remember that many of our representatives in these organizations are volunteers. They too have donated massive amount of their personal time and energies to support our profession. But it is also important to understand that their are also many “paid” representatives and staff that depend on the survival, and expansion, of these organizations for their income and in some cases, their positions of power and authority.
How each of you react to this chaos that was thrown upon us is a personal decision. I have read and heard that many or you are cancelling memberships and others are cancelling plans to attend the national meeting and opting instead to pay their dollars to state and regional meetings. Still others are taking the “wait and see” approach to see where the AAST “publically” stands when they eventually do take a stand either way for the development and testing of the new credential.
Whatever action you take or dont take I suggest that you stay informed and do your homework. Talk to each other, send emails to your elected industry and organization representatives. Make an informed decision on what action you take as an individual. For me, its pretty simple personal decision; since I am not smart enough to be asked my opinion I will be attending the Southern Sleep Meeting in New Orleans where I can be with other RPSGT’s who may actually think that I have something of value to say.
Joseph Anderson, RPSGT, RPFT, CRT-NPS, RCP