Tag Archives: American Academy of Sleep Medicine

California Dreaming

bed California DreamingOfficials at the Orange County, Calif-based Judy & Richard Voltmer Sleep Center make sleep health a priority throughout the many specialties at Hoag Memorial Hospital.

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 , the Voltmer Sleep Center is seamlessly integrated within the continuum of care. Sleep is not an afterthought. Neurologists, ENTs, pulmonologists, endocrinologists, and 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 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 . “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.” 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 machine, Selecky and Stiger work closely with trusted (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.

The Future

Unlike the 1980s, Selecky says it seems as though these days there is a on every corner. Favorable demographic trends suggest that won’t change, despite the furor caused last year when Medicare approved studies—much to the chagrin of lab owners. “People said that might be the end of all ,” says Selecky. “But as time has gone on, that has not occurred at all. Part of it is that reimbursement for studies is low. However, it has made every lab consider whether it should be involved in 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 , 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.”

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.