CleveMed Blogs

This week, we continue our video series of Q & A with Dr. Joseph Golish on Current & Emerging Trends in Sleep Medicine. Here’s the BIG question: Will Home Sleep Testing Replace the Sleep Center?

Dr. Golish, is a board-certified specialist in sleep medicine and author of more than 300 publications on sleep. He is a member of the Sleep Steering Committee for the ACCP. After 35 years as a professor in The Cleveland Clinic and Co-Director of Sleep Medicine, he has left academic medicine to advance a new paradigm in sleep medicine, focusing on accessibility and affordability. His goals are the proper use of HST and fostering continuity of care, in an efficient and cost-effective manner, while preserving high quality. He is currently the Medical Director of Cleveland Medical Devices (CleveMed) and Director of Sleep Center, North Coast Clinical Trials, in Cleveland, Ohio.

As the market changes it is rapidly becoming important to offer flexible solutions for collecting sleep studies at varied locations. With the entrance of Wireless Polysomnography, sleep study setups outside of the lab become more feasible. A comprehensive sleep diagnostic service can now come to the patient instead of the patient having to come to the lab for a PSG. Wireless PSG also brings several benefits to the traditional in-lab setting. Here’s a quick introduction to the traditional and new & upcoming, non-traditional settings for a polysomnography.

Traditional Setting:

In-lab sleep facilities offer onsite sleep techs, medical equipment, and a full bedroom set. This is an expensive set-up, but wireless PSG completely eliminates the cost of running cables throughout the facility with its ability to transmit data through multiple walls. Also, there are typically fewer components with wireless devices and lower risk of individual component failure. Sleep labs will also benefit from expanding their sleep services to include non-traditional off-site testing. Sleep labs volume will not diminish but their patient mix will differ. Typically overcrowded labs will only have deal with those who strictly require in-lab testing, and they can service a larger total volume of patients (since they do not all need to be onsite). Each patient population can then receive a faster diagnosis and therefore faster treatment initiation, cutting out the need for long waits or investing in additional beds for the lab.

Non Traditional Settings:

Home Sleep Test: While some extreme conditions strictly require in-lab sleep testing, many patient populations are well suited for home sleep diagnostic testing, like those tested for occupational reasons, or the home-bound suffering from chronic pain. Home Sleep Testing (HST) allows patients the comfort of home and a familiar environment. It is also increases affordability by cutting out the facility costs of the sleep lab, and the costs involved in moving a patient to the sleep lab which can be expensive in some cases.

Hospital Inpatient PSG: Hospital networks, wireless or intranets are used to transfer sleep studies from the bedside to the sleep lab. Technicians can monitor and respond to problems, yet the patient is still under the immediate supervision of skilled nurses. Since Sleep Disorders Breathing is a complicating factor in many surgeries, the ability to conveniently conduct a sleep study in those settings may avoid complications intraoperatively and postoperatively (particularly for bariatric and cardiac surgery patients)

Hotels: Sometimes sleep labs use hotel rooms to conduct sleep studies because of reduced costs. Some patients are better able to relax in this more familiar setting, and benefit from a reduced first-night-effect.

CleveMed offers the technologies that can expand the reach of sleep services with its wireless systems that are suitable for both HST, follow-up and in-lab sleep studies. This post draws on the experience of several experts at CleveMed and the following web page: www.clevemed.com/PSGAnywhere

As sleep techs, we analyze the sleep of our patients to ultimately help guide them to improved overall quality of sleep throughout their life both in and out of the sleep center. In order to accomplish this, I have listed a few tips that the sleep tech should keep in mind:

1. Being Considerate of Patient’s Needs

This means accommodating the patients’ own sleep schedules as much as possible, using a bundling of wires that makes them feel as comfortable as possible, assisting when needed, to give them an utmost sense of ease during the study. It is ideal for the Tech to control the environment but allow the patient a measure of his/her own sense of control.

2. Determining the Use of “Tools”

The prudent tech recognizes that no matter what comforts are offered, the patient is still outside their natural sleeping environment, fitted with electrodes and wires, and hence may not as comfortable as they wish to be. It helps to remember that beyond the basic amenities, every comfort offered to the patient during a study is a tool. It is better to not offer the patient every tool all at once, because in doing so, it leaves the tech with fewer tools to work with if things go bad. For example, automatically starting all patients with humidity might not be the best approach. It is better to talk with the patients first to feel what their comfort levels are. Another example of this could be Respironics’ C-flex feature. If the tech uses it without needing to, and the patient still has a difficult time, it is one less tool the tech can offer. It is best to use the minimum number of tools until deemed necessary.

3. Knowing Expectations

Know the expectations of your facility, doctors, and supervisors. Having worked in a wide variety of centers myself (Hospital, IDTF, Physician Owned, Privately Owned, PRN, FT, Nights, Days, Management) it is apparent that expectations vary by site. In order to provide the best patient care, there needs to be excellent communication and delivery of expectations. This goes both ways, so let your supervisors know what you expect from them, keeping an open working relationship.

4. Continuing Learning

It is most important to recognize that the field of sleep is rapidly changing, and the only way to keep up with these changes is through ongoing education. If you do not receive this from your current center/lab, take it upon yourself to seek out education whenever & wherever possible. Some good sources for this are binarysleep.com, aastweb.org, brpt.org (from the sleep tech’s perspective), and cpaptalk.com (from the patient’s perspective). Push yourself to new experiences. The more knowledge and experience you have, the more bargaining power you have. For example, many techs don’t like to score studies at night. Not only does this make you more valuable as a tech, but it makes you more aware of the patient condition and the sleep study in its entirety. If you offer to help out more, you could find yourself learning something along the way as well as perfecting your skills.

Sleep techs, you are welcome to add to this article with your comments.

In this week’s post we decided to write about one of the more popular topics suggested by our readers: definitions of types of sleep studies devices according to CMS (the Center for Medicare & Medicaid Services) and AASM (the American Academy of Sleep Medicine). Hope these quick summaries help in understanding these terms better. CleveMed currently has three devices that fall within these defined categories for the purposes of sleep (Type I - Sapphire PSG, Type II - Crystal Monitor PSG, and Type III - SleepScout).

Definitions according to Center for Medicare & Medicaid Services (CMS) Guidelines

Type I – Attended studies (Sleep studies that are preformed with the oversight of a sleep technologist.) with full sleep staging (Sleep staging monitors the transition through the sleep stages. Traditionally with the use of EEG electrodes that monitor the brain). Type I devices must includes the following channels:

• EEG
• EOG
• ECG/Heart rate
• Chin EMG
• Limb EMG
• Respiratory effort at thorax and abdomen
• Air Flow from nasal canula thermistor and/or X-Flow (AASM re- commends RIP technology
• Pulse Oximetry
• Additional channels for CPAP/BiPap levels, CO2, pH, pressure, etc.

(CPT #95810 Baseline PSG, 95805 MSLT, 95811 Titration)

Type II – Home sleep study test (HST) with type II portable monitor, unattended(Sleep studies that are preformed without the oversight of a Sleep Technologist.); minimum of 7 channels. Type II devices must includes the following channels:

• EEG
• EOG
• ECG/heart rate
• EMG
• Airflow
• Respiratory effort
• Oxygen saturation

(HCPCS #G0398)

Type III – Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels. Type III devices must includes the following channels:

• 2 respiratory movement/airflow
• 1 ECG/heart rate
• 1 oxygen saturation

(HCPCS #G0399, CPT 95806)

Type IV – Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels. Type IV devices must allow channels that allow direct calculation of an AHI or RDI as the result of measuring airflow or thoracoabdominal movement. Alternatively devices that record other information to derive AHI or RDI must be approved by CMS through the review of published peer-reviewed medical literature.
(HCPCS #G0400)

Definitions according to American Academy of Sleep Medicine (AASM) Guidelines

Type I - Monitoring devices perform in-laboratory, technician-attended, overnight polysomnography (PSG) and are discussed separately. (CPT #95810 Baseline PSG Study, CPT #95805 MSLT Study and CPT #95811 Titration Study (CPAP))

Type II – Monitoring devices can perform full PSG outside of the laboratory. The major difference from type 1 devices is that a technologist is not present. These devices are called comprehensive portable devices. (CPT #95807)

Type III – Monitoring devices do not record the signals needed to determine sleep stages or sleep disruption. Typically channels include:

• Four physiologic variables are measured including:
• Two respiratory variables (eg, respiratory movement and airflow)
• Cardiac variable (eg, heart rate or an electrocardiogram)
• Arterial oxygen saturation
• Some devices may have other signals including a monitor to record snoring, detect light, or a means to determine the body position.

(CPT #95806)

Type IV – These devices are called continuous single or dual bioparameter devices. Monitoring devices record one or two variables and can be used without a technician. Typically channels include:

• Arterial oxygen saturation
• Airflow