Tag Archives: AASM

AASM Announces a New 3:1 Tech to Patient Ratio

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. “

Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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Demystifying the Accreditation Process for Sleep Labs

The president of The Compliance Team seeks to demystify the accreditation process for sleep labs.

After meticulously building a solid reputation in the world of DME accreditation, Sandra Canally is determined to bring her simplified approach to sleep labs. As president of The Compliance Team Inc, based in Spring House, Pa, Canally has long worked on the premise that excellence in health care delivery is best achieved by dramatically simplifying quality standards.

In Fall 2006, The Compliance Team (TCT) got a chance to implement this philosophy in a big way when the Centers for and Services () formally granted the company deemed status to accredit providers of all types of DME, prosthetics, orthotics, and supplies (DMEPOS). Beyond the mandates that often accompany accreditation, Canally believes the entire process ultimately boosts patient care and improves business practices.

While TCT continues to actively accredit home care providers, these days company officials are also targeting that may be looking for an alternative to the (). “I created the sleep center program quite a few years ago,” says Canally, who launched the Exemplary Provider™ accreditation programs more than a decade ago. “I created it because DMEs were expanding and adding —and doing a lot of business with sleep labs.”

With “deemed” status for DME now long established, Canally can accredit sleep labs that wish to “self dispense” CPAP units. “We can package the and CPAP sales together and you are fully approved to bill Medicare,” says Canally. “The major national sleep organization [AASM] is not able to do that because they are not CMS approved for DMEPOS.”

Beyond the Medicare scenario, TCT can offer accreditation for sleep labs that encompasses all aspects of the lab’s operations. “A big misconception is that the major national sleep organization is the only player, and the same thing can be said of hospitals when it comes to the Joint Commission,” says Canally. “We provide an alternative that is not all about the minutia and jumping through hoops. We believe in simplification. We have led the movement within DME and other markets, and we are introducing these accreditation concepts for sleep centers. Simplification leads to clarity, and clarity allows the provider to focus on what matters most—safety, honesty, and caring.”

These three principles are all part of what TCT officials call the “Exemplary Provider” brand. “The word ‘exemplary’ means you are setting yourself apart from other providers that are just doing the minimum,” says Canally. “To accredit, you need to score 90% or better. So already we are setting the bar higher as our minimum standard.”

These days, TCT is opting to renew accreditation on a 3-year term, as opposed to the old 1-year process. During the 3-year span, providers still send in required items such as updated quality initiative plans, licensure documents, and proof of annual training.

In-person visits can be expected at least once during the 3 years, perhaps twice depending on the product lines. Second visits are focused only on patient care. “Since patients come in to a sleep lab in the evening, the sleep labs that we have accredited thus far have required night visits,” says Canally. “For one company that had three locations, we went in during the evening and stayed through the night and into the morning to see the whole process.”

With other sleep labs, TCT members have instead gone in extremely early in the morning. With this method, they could still see patients waking up and were able to ask questions about the night before, as well as take a peek at the sleep study. “We are not bound by Medicare to do unannounced visits on sleep labs,” explains Canally. “Unlike us, the AASM puts their complete focus on the medical director and the sleep study itself—all the technical aspects.

“My belief, and this is at the foundation of our program, is that the full evaluation should encompass operational excellence,” adds Canally. “Operational excellence leads to clinical excellence. You are not going to have the very best sleep study if you are not doing things right operationally—and that is the big difference between us and the AASM. We are looking at the whole picture of the organization, and they are looking at a small picture.”

If providers, including sleep labs, do not want to get accredited, or don’t need to do it for Medicare, there are other payors out there too. “A lot of the private pay organizations in managed care require accreditation to get on their network,” says Canally, who still maintains her active RN license. “A lot of the state Medicaid organizations are going toward accreditation. It’s just good business practice.”

Accreditation usually takes between 3 and 4 months, and most of the time it is a relatively pain-free process. Canally attributes the lack of pain to simplified standards that are written in plain language. “Providers are more compliant because there are no surprises,” says Canally. “We want their focus to be on improving operations and better serving patients.”

BRPT members stunned by ABSM announcement to Launch New Exam for Sleep Technologists

has been notified that the Board of Directors of the () has decided to develop a certification exam for sleep technologists to be administered through the American Board of Sleep Medicine (). The has indicated that the exam will be developed over the next six to twelve months.

Read Letter to BRPT President from ABSM announcing AASM Board decision

Read BRPT response to ABSM

Will the new credential be good for the field of technologists or the beginning of a controversial struggle for control.

View BRPT discussion forum

East Coast Lab Preps for Potential

Image1 East Coast Lab Preps for Potential

New York-based Winthrop Center made the difficult decision to switch database vendors in an effort to remain a step ahead of progress.

By any measure, the Winthrop Sleep Disorders Center, Garden City, NY, brings a wealth of experience to the relatively young field of sleep medicine. As Associate Director of the Winthrop Sleep Disorders Center, Claude Albertario, RPSGT, has helped the academic facility evolve from modest roots in the late 1980s to its current position as a respected laboratory in the Northeast.

Leveraging their knowledge and experience gained over more than two decades, the hospital recognized the need to expand in 2006. Albertario seized the opportunity to take a long, hard look at equipment needs. The investigation led the 26-year sleep veteran to only consider systems with database constructs that could change with the times.

Expand and Integrate

Later in 2008, the () came out with the H5 guideline that requires all , even for those not getting a study, to be amassed in a central database. As a result, going beyond a mere “ acquisition” system suddenly became a top priority. “As an academic institution, we typically like to keep things in-house, so we did not go with a web-based design,” says Albertario. “However, we did want the ability to interact from the outside through the Internet.”

Narrowing it down to two major database systems was relatively easy, since virtually everything else was cobbled together using third party databases. “We wanted something integrated and cohesive,” says Albertario. “The push over the edge was the solidarity of what the vendor showed us they could provide. The Grael High-Definition /EEG system and their nexus system had what we wanted, as well as the potential to grow as technology changed.”

As the first accredited and paperless laboratory in the world (1990), Winthrop officials knew early on that patients in the population-dense Long Island region wanted not only the best, but the latest. Cutting edge technology kept people coming back and fueled an expansion from four beds at the turn of the century, to eight beds in their new facility—with all recordings digitally recorded and managed. “Our institution has allowed us to plug into the archiving infrastructure used for and Cardiology, thereby allowing digitized, seamless, online archiving”, says Albertario.

Keeping the door open for new millennium technology gave Compumedics the slight advantage in a competitive market. Vendor representatives simply could not “fake it” at Winthrop. “They had to know their stuff,” confirms Albertario. Albertario questions vendors with vigor, because he knows that better equipment/database management leads to real-world results, such as decreased turnaround time for patients, while strongly appealing to referral sources. With Compumedics, the idea is to adapt to whatever challenges the industry may throw, while continuing to evolve technologically.

“You have to know sleep, and Compumedics has a good clinical understanding of what we do,” says Albertario. “We have not even finished installing all of the elements, such as digital audio and next-level digital video. The cameras are installed, but the higher-grade software is not written as of yet. I see where they are going with multi-screen video capabilities— one screen zoomed into the face, one into the legs, and all synchronized. They offer it in their EEG platform, so I know it is on the horizon as promised,” says Albertario.

Like a Hotel

Even though the market changes and reimbursement changes with it, Winthrop officials are poised to help the 7.5 million patients on geographic Long Island. Moreover, when these residents show up, the facility they walk into does not look like a laboratory in the slightest. “We literally built a hotel,” says Albertario. “One of the inspectors upon opening the door to a bedroom said, ‘You literally built the Winthrop Hotel.’ And, anybody who visits says the same thing.”

In a state that boasts “The city that never sleeps,” it is appropriate to also open “the hotel” for daytime guests. “We realized that a special segment of our market, and one that not many facilities touch upon, is the shift-worker market,” explains Albertario. “We staff the laboratory around the clock, and every day we have the ability to perform daytime PSGs for patients who sleep and work in this 24 hour New York market.”

Added services and capabilities mean that more in-depth clinical trials are on the horizon for Winthrop, a prospect that officials welcome in the coming years. “We believe we are perfectly poised to help the academic world, and the clinical realm of those New Yorkers who seek treatments and understanding of sleep disorders,” adds Albertario. “In fact, those who have recently visited from Australia and Europe, realize how much thought we have actually put into this facility and comment on our ability to keep all of the technology in the background, thusly allowing the design team’s calming and soothing accents and highlights to shine through. It has truly been a labor of love for all parties involved, says Albertario, a once-in-a-career kind of thing.

Claude Albertario, RPSGT, is associate director of the Sleep Disorders Center, Winthrop-University Hospital, Mineola, NY. Albertario began his career in Sleep Medicine at New York Hospital’s Institute of Chronobiology, after obtaining his undergraduate training in Psychobiology at SUNY Purchase. He obtained his RPSGT credential in 1990. As an early advocate of digital recording methods, he spearheaded the effort to become the first accredited, paperless sleep center in the world (1990). He helped form the New York State Society of Sleep Medicine in 1998, and presently serves as its secretary. His research interests revolve around his invention, z-ratio, a unified metric of sleep/wake (http://www.zzzratio.com). Albertario is also a sleep apnea sufferer.

Man vs. Machine

Giving Automatic Scoring a Second Thought

Changes in technology have been exponential over the last two decades. The industry has advanced significantly by software innovation. In our to wholeheartedly welcome these enhancements to our processes, we sometimes forget that technology in the form of automation is meant to assist, not replace, our skilled technologists.

To automate or not to automate the scoring of sleep studies remains an ongoing debate in our industry and with software giants looking for ways to expand service offerings, the discussion is unlikely to end any time soon. While the notion of computerized analysis holds the promise of decreased staffing costs and increased efficiency, the reality of this premise is far less simplistic. One would no doubt question the rationale behind the insistence that a plane does not require a pilot in light of autopilot technology. Yet there exists a movement that would apply such logic, resulting in the ultimate redundancy of scoring technologists.

Whether as a primary or secondary resource, a registered technologist is essential for an accurate analysis of a patient study—period.

Sleep medicine is still very much a human-centered industry. With over 80 different currently documented, nothing comes close to replicating the and contextually- reliant assessments made possible by intensive, real-life training and experience.

Any sleep facility or homecare company that are uses automatic scoring as a one-for-one alternative to human analysis is neglecting the clinical aspect of patient care. What begins as a well-intentioned, cost-cutting measure emerges as a practice that risks undermining the credibility of an entire industry.

Like every industry, efforts to streamline business and make processes leaner are present in sleep medicine. What we are seeing, however, are moves to market such software as a turnkey solution—completely undermining the specialized nature of sleep scoring and the skills, knowledge and training that go into delivering this process. Laboratories that wish to remain reputable should take a critical look at automated scoring and question whether the absence of registered technologists involved in this process is putting patient care in jeopardy.

The Reality of No Regulations

None of this is to say that automated scoring is without value. On the contrary, it can prove to help the technologist become a more effective clinician—especially as automation matures and is improved.

Early detection, of irregularities, cost-efficiency and timely performance are just some of the benefits that automated systems bring to the table. To ignore these benefits would be denying progress for the sake of it. However, as the sleep industry is itself still coming of age, it remains vulnerable to unscrupulous business models that risk tarnishing an entire sector by making patient care an after thought.

Discount scoring services have gained significant traction with unsustainably low price points underwritten by unregistered and clinically inexperienced scoring staff. What such practices fail to respect is that scoring is far more than an objective matter of computation. There are qualitative factors that only trained, registered and clinically experienced technologists can assess.

With minimal regulation of the effects of automatic scoring currently in place, the credibility of an entire industry rests on education and best practices. While sleep medicine awaits increased governance to prevent such fly-by-nights from infiltrating a valuable healthcare service, automation could aid in the standardization of certain scoring processes. As long as laboratories incorporate the technology primarily as a labour- cutting device, it may prove to be detrimental.

Assist not Replace

Another area of concern lies in the homecare and sectors. Level III sleep studies are being conducted and automatic analysis is being used for diagnosing patients going against the recommendation to have a secondary review by a Registered Technologist.

In such a case, automated scoring is not only the primary but the solitary mode of analysis. But scoring software can never comprehensively analyze a Level III study—results must be reviewed and assessed against clinical correlation. Software should be viewed as serving a complementary function in that it assists an RPSGT, who later verifies the automated scores manually and cross-references them with clinically-obtained observations.

Furthermore, one must consider the long-term impact of reliance on scoring software. Crucial information is gathered in the RPSGT’s current role as a front-line, integrated health- care professional. The knowledge and skills that arise from working with different patients and various symptoms and conditions could be lost should technologists be removed from the equation.

Know What You’re Getting Into

Pharmacists have also found their profession impacted by automated “advances”. The automated dispensing model they were recently introduced to have raised questions about accountability as dispensing errors can put patients (and businesses) at risk.

It goes without saying that human error can, has and will occur in any facet of healthcare. To be certain, accuracy is one of the dominant selling points of many automated systems used in other fields. However, the rush to market this form of technology may fail because the underlying technology is immature and needs time to evolve as it finds a permanent home within the sleep medicine industry. Even if automatic scoring technology matures to the point that algorithms can account for most variables, it still cannot contend with even the common clinical problems and complexities that come with sleep disorders in order to perform accurate scoring.

This is not to say that automatic scoring has no place in the streamlining of sleep laboratory operations. On the contrary, as time progresses and automated software has been tried and tested perhaps this may well become a fixture in sleep facilities.

But with no current regulations governing the use of such software, it is imperative that we consider the following disclaimer: automatic scoring exists to assist technologists, not replace them.

Natalie Morin, RPSGT is president and CEO of Sleep Strategies Inc., a provider of professional scoring and consulting services for sleep disorders facilities worldwide.

BRPT members stunned by ABSM announcement to Launch New Exam for Sleep Technologists

has been notified that the Board of Directors of the American Academy of () has decided to develop a certification exam for sleep technologists to be administered through the American Board of (). The has indicated that the exam will be developed over the next six to twelve months.

Read Letter to BRPT President from ABSM announcing AASM Board decision

Read BRPT response to ABSM

Will the new credential be good for the field of technologists or the beginning of a controversial struggle for control.

View BRPT discussion forum

Positional Apnea in a 73-Year Old Male with Atrial Fibrillation

This is the case of a 73-year old male who was diagnosed by the local heart institute with atrial fibrillation. The patient was under outpatient care of both a cardiologist and family doctor. Bedpartner interview did not report a history of snor- ing nor any history of breathing difficulties during the night. However, the patient reported awakening nightly around 0300 to 0400 with the inability to return to sleep because of height- ened arousal. The patient underwent a procedure at the heart in- stitute which induced normal cardiac sinus rhythm, but atrial fibrillation returned within two weeks. The patient is currently taking Coumadine (warfarin). Based on this history, and the known association between obstructive sleep apnea and atrial fibrillation,1 the patient agreed to a simple home sleep apnea screening test using the MediByte Jr.

Home Sleep Screening
The MediByte Jr. is an easy-to-use Type 3 home sleep apnea recorder which complies with new guidelines by using the same technology in the comfort and convenience of the home as is used in sleep laboratories worldwide. The MediByte Jr. records blood oxygenation and pulse rate using transmission SpO2, oro- nasal airflow via internal pressure transducer, snoring vibrations from airflow, thoracic respiratory effort using RIP technology, and importantly, body position. The raw data is fully disclosed, identical to that recorded in , and there is no data processing using proprietary black-box algorithms. The device is capable of recording for one nine-hour night or two consecutive nine-hour nights. Cost per study is approximately seven dollars and published data have found high sensitivity, specificity and correlations of 0.92 between the MediByte and PSG.2

A registered polysomnographic technologist (RPSGT) spent approximately seven minutes instructing the patient in how to apply the MediByte Jr recorder and biosensors. All home sleep apnea data was scored by an RPSGT using scoring guidelines published by the American Academy of Sleep Medicine.3 Total recording time for the baseline night was six hours and 45 minutes. Contrary to subjective reports, the patient had severe obstructive apneas and hypopneas while supine, but was within normal limits during nonsupine sleep. The supine respiratory disturbance index (RDI) was 45.5 and the nonsupine RDI was 1.5 (see Figure 1). The patient slept 49.2% of the night sleeping on his back. Although time between 90% to 100% SpO2 was 99.9% of the entire night, there were 112 SpO2 desaturations of ␣ 4%. The results of the study were explained to the patient and also provided to both the family doctor and cardiologist. Treatment options were discussed with the patient. The patient had no desire to use CPAP therapy and opted to initially attempt positional treatment.

Fig 1CS1 Positional Apnea in a 73 Year Old Male with Atrial Fibrillation

Positional Therapy
Positional therapy involved sewing two street hockey balls (cost about three dollars) into the back of a shirt. Positive feedback about treatment was received from the patient during a follow-up phone call 72-hours post baseline recording. The patient reported he was now sleeping through the night awakening at 0600 rather than during the middle of night. A subsequent home sleep apnea recording with treatment was performed approxi- mately three weeks after the baseline test. It was originally hoped that the positional treatment would reduce the RDI to a mild or moderate level, at which point therapy could be combined with oral appliance treatment (the patient was adamantly opposed to CPAP therapy). However, the results of treatment were striking in their effectiveness and are shown in Figure 2. Total recording time was six hours and 19 minutes. The supine respiratory disturbance index (RDI) dropped to 0.0 (from a baseline of 45.5) with the patient spending 0% of the night sleeping on his back. Total nonsupine RDI was 4.0 which was within normal limits. Time between 90% to 100% SpO2 was 100% of the entire night, but more importantly the number of SpO2 desaturations of ␣ 4% plummeted to one (from a baseline of 112). The patient reported better sleep, increased energy, and overall satisfaction with treatment. Additional follow-up recordings will be performed to monitor continued treatment success.

Fig 2CS Positional Apnea in a 73 Year Old Male with Atrial Fibrillation

Successful Outcomes
This case study illustrates the cost-effective approach to successful home sleep apnea screening. It also shows the vital importance of recording body position and how subjective reports may be qualified using objective, empirical data. Home diagnosis and monitoring of` sleep apnea is a valid tool which should be used with a suitable patient population to extend sleep medicine practice into the community. The successful outcomes associated with positional therapy are not surprising, and are consistent with a recent study which concluded “positional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA, with similar effects on sleep quality and nocturnal oxygenation.”4

Richard A. Bonato, Ph.D., Co-Founder and CEO, Corporation, Kanata, Ontario,
Learn about MediByte Jr. at www.braebon.com


1. Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation scientific statement. Circulation. 2008; 118:1080 –1111.
2. Driver, HS, Bjerring KA, Toop F, Pereira E, Stewart SC, Munt P, Fitzpatrick MF. Evaluation of a Portable Monitor Compared with Polysomnography for the Diagnosis of Obstructive Sleep Apnea. Poster presentation at Sleep 2009: Seattle.
3. Iber, C, Ancoli-Israel, S, Chesson, A, Quan, SF. The Manual for the Scoring of Sleep and Associated Events: Rules, Terminology, and Technical Specification, 1st ed, American Academy of Sleep Medicine, Westchester, Illinois 2007.
4. Permut, I, Diaz-Abad, M, Chatila, W, Crocetti, J, Gaughan, J, D’Alonzo, G, Krachman, S. Comparison of Positional Therapy to CPAP in Patients with Positional Obstructive Sleep Apnea. Journal of Clinical Sleep Medicine. 2010; 6: 238–243.

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