Sleep Coordinator Review History of the sleep coordinator. - PowerPoint Presentation

Sleep Coordinator Review

History of the sleep coordinator. Organizational ChartJob DescriptionSleep Coordinator Process (A day in the office)VocabularyWhat is sleep apnea and why the strong focus. Introduction of the Screening ToolScoring the screening tool Session 1

Session 2 Introduction to Patient Interaction Techniques HST vs In-Lab studyConsultation 1 (Role Play)How Sleep Apnea is quantified and reportedReview of the Home Sleep Study SystemsHome Sleep Study Report ReviewPhysician Recommendations and Patient ChoiceConsultation 2 (Role Play)

Session 3 Treatment Options Flip Chart ReviewSmart SheetEntering patients and alarms into the SmartSheetContinuum of care over timePractice IntegrationBalancing the schedule (screening times vs. follow-up time)

Session 4 PAP What is sleepSleep Hygiene and Sleep DebtTeam Building Exercise

Sleep Coordinator – A step back in time I was hired to work in a sleep lab that was a side practice to a Cardiology Practice Sleep physician was concerned that patients were coming through the Cardiology office that she felt for sure had sleep apnea and who were not being identified.Cardiologist felt that the sleep physician was just trying to fill her beds.The literature that was emerging was strongly suggesting that heart failure patient with sleep apnea had increased rate of morbidity and was increasing the cost of providing care to CHF patientsThe sleep coordinator position was created as a means of identifying those patients with increased probability of having sleep disordered breathing.If you will she functioned as a peace maker between the two entities in the same practice.

The sleep screener initially was the Epworth sleepiness scale Dr. Murray Johns was the Founding Director of the Sleep Disorders Unit at Epworth Hospital, Melbourne, Australia. He developed the ESS initially so he could assess the daytime sleepiness of patients in his own private practice of Sleep Medicine. The ESS was first published in 1991 0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozingSITUATIONCHANCE OF DOZINGSitting and reading____________ Watching TV ____________ Sitting inactive in a public place (e.g. a theater or a meeting) ____________ As a passenger in a car for an hour without a break ____________ Lying down to rest in the afternoon when circumstances permit ____________ Sitting and talking to someone ____________ Sitting quietly after a lunch without alcohol ____________In a car, while stopped for a few minutes in traffic____________

The form evolved over time Though the Epworth Sleepiness Scale is useful in determining the level of daytime sleepiness for a person, it cannot rule out other contributing factors that can and do contribute to daytime sleepiness. The practice began to look at body habitus as well after all that was the measure that the sleep physician was using anecdotally as she looked pointed and boldly stated a bet that person there has sleep apnea.

The practice advanced to using a form that looked something like this. Height WeightBMINeckSnoringESSCongestive Heart FailureObserved falling asleep during a procedure or in the waiting room.

The form continued to progress over time to include issues that were appropriate as indicated by medical literature

While working in this sleep lab with cardiac patients it became clear that not all patients would accept PAP. Our response was to reach out to a dentist in our area and known to our Medical Director the cardiologist to join our team. Dr. Weisfogel would come into our sleep clinics regularly and would consult and take molds for oral appliances.The majority of our patients were successful with use of the oral appliance where they had failed with PAP. Co-founder of Dental Sleep Masters

That’s Where the sleep coordinator position started Over time sleep coordinators were placed in cardiac practices around the country. Laboratory based sleep programs were developed in these same practices.

Sleep Coordinator Today

Organizational Chart Dental Sleep Masters (DSM) – Professional organization which has developed forms and processes that enhance a dentists’ ability to practice dental sleep medicine. DSM has members from all over the country. DSM monitors changes in the sleep community and makes changes needed to all forms and processes when appropriate. Forms and processes that are used are licensed through membership in the DSM program. Dental Practice(Member of Dental Sleep Masters) Medical Practice(Working relationship with The Dental Sleep Co) Dental Sleep, LLC (Created by Dental Practice) Sleep Coordinator (Employee of Dental Sleep LLC)

Job Description Review Break and Review the document from within the packet

Performance Expectations

Proprietary Information All practices, policies and forms provided to you for the performance of your job as a sleep coordinator are licensed and proprietary and are to be used for the sole purpose of doing your job. They are not to be reproduced, altered or shared for any other purpose.

Confidential Information Information regarding the HST company’s clients, patients and employees must be held in the strictest confidence. Under no circumstances may employees discuss or disclose the HST company’s confidential information, including but not limited to patient information, with a relative, friend or anyone else outside of the HST company. Employees are not permitted to make public statements to the press or other news media which in any way involve the Company, its customers or its employees without express consent and approval from the Company.

Conflict of Interest No employee shall accept gifts from any person or firm doing or seeking to do business with the HST company under circumstances from which it might reasonably be inferred that the purpose of the gifts is to influence the employee in the conduct of the HST company or its business with the donor. This prohibition of accepting gifts from customers, clients and suppliers of the HST company is necessary in order to avoid not only a potential conflict of interest but also the appearance of impropriety. Such gifts should be returned with a note of explanation. However, employees are not prohibited from accepting advertising novelties such as pens, pencils, and calendars, or gifts of nominal value when circumstances clearly show that the gifts are offered for reasons of personal esteem and affection, or where refusal would appear discourteous.

Work Rules You are in the Medical Practice as a guest. Make sure that your behavior is professional at all times even if the practice employees are perhaps engaging in behavior that is less than professional. Avoid Unsatisfactory job performance. (sitting idle, delaying patient contacts, delays in returning phone calls)Theft. (do not take their pens, pencils, post-it pads, avoid using their office machines unless arrangements have been made between the dentist and the practice).Insubordination (If there is conflict between you and the office manager, a doctor or a staff member take it back to your boss for review.Disclosing business information of a confidential nature including, but not limited to, patient information to unauthorized persons. Don’t complain about your job or your home circumstances to the staff.Ignoring safety rules or common safety practices. (If you are stuck in a corner do not run an extension cord across a hallway to power your machine).

Work Rules Avoid Unexcused or excessive tardiness or absence or failure to observe working schedule. Find out who you should contact in the practice to let them know if you have an unavoidable delay in getting to work in time.Leaving work during scheduled hours for any reason. If you are in and out randomly it will appear that the services are not consistently available and can lead to customer dissatisfaction.Smoking in unauthorized areas.Engaging in criminal conduct, whether or not job-related. Damaging Company/Practice property.Activities that can be considered Sexually Harassing. (no dirty jokes, no body physique comments)

Work Rules Avoid Possession of firearms or other dangerous weapons on Company/Practice premises.Unauthorized use of office equipment, time, materials or facilities.Possessing, consuming or working under the influence of alcohol or illegal drugs during working time or on company premises.Fighting or horseplay.Personal use of the company’s phone and computer systems, including email, Internet applications, games and voicemailPersonal cell phone use during company time, including personal phone calls, email, Internet applications, games and voicemail.Altering patient documents including screening tool, test results and/or the medical record.

Practice Resources The Practice phone and computer systems, including e-mail, Internet applications and voice mail, and any information transmitted, reserved or stored therein, are the property of the Practice. Such systems are to be used for business purposes only by the practice employees. The Sleep Coordinator is a guest in the practice and not an employee and must only use resources as pre-approved.

Daily Duties Responsibilities

Daily Duties and Responsibilities Provide Screening tools to all patients within the affiliated practice.Score the screening tool and correctly identify patients with high probability for having sleep disordered breathing.Accurately determine the need for HST vs. Sleep Facility TestingObtain prescription for sleep testingEnsure insurance authorization is obtained when requiredProvide the home sleep testing system according to manufacturer guidelinesUpload Patient data per manufacturer guidelines 

Daily Duties continued Clean and process testing units for next patient. Track test results through the HST computer system and provide copy to physician for patient chart.Obtain prescription for treatment when indicated.Make referral for indicated treatment including all documents required (i.e., copy of sleep study report, demographics, insurance card, letter of medical necessity)Maintain medical record (Smartsheet) with documentation of every patient encounter including phone calls, in person interactions, interactions with test results, physicians and dentist and other office staff when it relates to a patient. Ensure that there is an alarm set for ever patient from intake to discharge from service.

Daily Duties Continued Ensure that that appropriate alarms are set for future services, visits, follow-up and/or testing. Maintain communication with the medical practice and the managing director of the Home Sleep Testing company.Inform the managing director of the Home Sleep Testing company of all conflict, successes and need for process change. Never make changes without consent. Never engage in conflict or conflict resolution without input from the managing director of the Home Sleep Testing company.Scan all documents into the medical recording including all test results, consult reports, and compliance reports. Track and maintain the appropriate supplies required to maintain patient testing systems.

A DAY IN THE OFFICE Work flow

A day in the office Arrive early and perky. Check your email for alarms this how you know what is scheduled.Gather your screens and have them ready for the patients.Every ½ hour or so go to the desk to see if there are screens to be scored.Expect some positives that will be sent to you for considerationPee Break and a sip of coffeeReceive the returned units and connect the first to the computer to upload.While its uploading go check the screeners again.Upload 1 is completed now plug that unit in to charge and clean and prep it to go out.Don’t for get to plug returned unit 2 in to upload andAhh it is 10:30 am Mrs. Hammer is coming in to get her HST unit. Take about 20 minutes to review the unit and the paperwork and send her on her way. Enter a note in the smart sheet that the unit went out. Enter an alarm for when the unit is to come back.

A day in the office Plug Unit number 3 in to upload and plug number 2 into charge (don’t forget clean number two Mr. Bell will be in at 11: 30 for it. Dr. Spoke wants you to talk to Miss B. In less than 5 minutes let Miss B know that Dr. Spock wants a recording of her breathing and heartrate during sleep and you would like to set that up to be done tonight. Miss B. is wondering why the answer is simply the way you sleep can effect your health and she has several health problems such as hypertension and diabetes both of which can be negatively impacted by disorders of sleep. Enter Miss B into the Smartsheet and make sure there is a note regarding todays interaction, She agrees to the unit, have her wait for unit 3 to be ready to go. You clean it and otherwise prepare it and teach her how to use it now. Put a note in the Smartsheet that the unit went out. Put an alarm in in the Smartsheet so you know when it is expected back.Mr. Bell is here for his unit. It should take about 10 minutes to show him how to use the unit. Don’t forget to give him you cell number so he can call if he has any problems.It is now 11:50. Time to see if any of your prior sleep studies are through the interpretation process.

Vocabulary

Apnea Without breath

Sleep Apnea Periods where breathing stops for 10 or more seconds during sleep. 3 typesCentral – breathing stops for 10 or more seconds.Obstructive – breathing stops for 10 or more seconds because the airway is occludedMixed – Breathing stops for 10 or more seconds the initial portion of the event is central and then the effort to breathe returns and the airway occludes.

Diabetes Disease in which the body doesn’t produce or properly use insulin, leading to hyperglycemiaType 1 the body does not make enough Insulin.Type 2 the body is resistant to the insulin that it does make.

Hyperglycemia Hyperglycemia, or high blood sugar is a condition in which an excessive amount of glucose circulates in the blood plasma.

Pulse Oximetry Transmissive - A sensor device is placed on a thin part of the patient's body, usually a finger tip or earlobe, toe, or in the case of an infant, across a foot. The device passes two wavelengths of light (LED’s)one red and the other infrared through the body part. Absorption of light at these wave lengths differs significantly between blood loaded with oxygen and blood lacking oxygen. Reflectance - Reflectance pulse oximetry may be used as an alternative to transmissive pulse oximetry described above. This method does not require a thin section of the person's body and is therefore well suited to more universal application such as the feet, forehead and chest, but it also has some limitations. Vasodilation and pooling of venous blood in the head due to compromised venous return to the heart, as occurs with congenital cyanotic heart disease patients.

Oxygen Saturation (SpO2) A blood-oxygen monitor displays the percentage of blood that is loaded with oxygen. More specifically, it measures what percentage of hemoglobin, the protein in blood that carries oxygen, is loaded. Acceptable normal ranges for patients without pulmonary pathology are from 95 to 99 percent at see level with a normal temperature.Oxygen Saturation readings can be skewed:with some nail polishes.If finger nails are too long to allow for proper probe fit.If the hands are too coldIf there is a very shallow pulse

Hypertension The blood pressure recording, measures pressures within the arteries at two different times. The first reading, the systolic pressure, measures the pressure when the heart is pumping blood to the body through the arteries. The second reading, the diastolic pressure, measures the pressure within the arteries when the heart is receiving blood returning from the body.

Congestive Heart Failure Heart Failure sometimes called Congestive Heart Failure: The inability of the heart to keep up with the demands on it. In heart failure of the heart is unable to pump enough blood to the body’s tissue. With too little blood being delivered the organs and other tissues do not receive enough oxygen and nutrients to function properly

Coronary Artery Disease When the arteries of the heart — the major blood vessels that supply the heart with blood, oxygen and nutrients — become damaged or diseased. Cholesterol-containing deposits (plaque) in your arteries and inflammation are usually to blame for coronary artery disease.When plaques build up, it narrows the coronary arteries, decreasing blood flow to your heart.

Obesity BMI of 30 or more

Heart Atria - Upper chambers of the heart Ventricle – Lower chambers of the heart

Cholesterol Cholesterol is found in every cell in our body and without it our bodies would not function properlyCholesterol plays an important role in our body's digestion. Cholesterol is used to help the liver create bile which aids us in digesting the food that we eat.Within the cell membrane, cholesterol also functions in intracellular transport, cell signaling and nerve conductionWithin cells, cholesterol is the precursor molecule in several biochemical pathways. In the liver, cholesterol is converted to bile, which is then stored in the gallbladder. Bile contains bile salts, which solubilize fats in the digestive tract and aid in the intestinal absorption of fat molecules as well as the fat-soluble vitamins, A, D, E, and K.

LDL - HDL LDL - BAD Cholesterol Cholesterol can't dissolve in the blood. It must be transported through your bloodstream by carriers called lipoproteins, which got their name because they’re made of fat (lipid) and proteins. The two types of lipoproteins that carry cholesterol to and from cells are low-density lipoprotein, or LDL, and high-density lipoprotein, or HDL. HDL- Good Cholesterol

Sleep Disordered Breathing What and why the focus

Respiratory Events Apnea – Without breath for at least 10 seconds Hypopnea – reduction in breathing that last for at lest 10 seconds and results in at least a 4% oxygen desaturation.Respiratory Effort Related Arousal (RERA) – arousal caused by changes in breathing.

POTENTIAL HEALTH CONSEQUENCES OF SLEEP DISORDERED BREATHING - OSA Short-TermAutomotive accidentsExcessive sleepinessDecreased quality of lifeNeurocognitive and performancedeficitsLong-TermHypertensionHeart attackArrhythmiasStrokeHeart FailureImpaired glucose tolerance-Diabetes

Respiratory Event Quantification Apnea Hypopnea Index (AHI) – The number of times that breathing is compromised per hour during sleep.Mild 5-14 events per hourModerate 15-30 events per hourSevere >30 events per hour Respiratory Disturbance Index (RDI) - number of apnea, hypopneas and RERA’s per hour Respiratory Event Index (REI) - number of respiratory events scored per hour of perceived sleep during a home sleep study (October 1 2015)

AHI Calculation Worksheet with 30 samples to calculate

AHI Worksheet Instructions Hours (Sleep) = minutes divided by 60 A+H (Apneas and Hypopneas) = number of apneas plus the number of hypopneas  AHI (Apnea Hypopnea Index) = A+H divided by the hours of sleep.RDI (Respiratory Disturbance Index) add the A+H to the RERA’s then divide by hours. 

Sleep Screener 30 screeners with worksheet for scoring

ESS Section SectionSection TotaHomeLab Score One Two Three Score Study Study Weisfogel Screener Worksheet Instructions ESS Score – add all the selections from the top section on the form. Section One – if the score is 8 or greater on the ESS enter a 1. If the score is less than 8 enter a zero. Section Two – enter 1 point for every item checked yes. Section Three – enter 2 point for every item check yes. Total Score – add the scores for Section one, section two and section three. If the total of section One and Section Two equals three or more a study is indicated. If the score of all three sections is at least 4 a study is triggered. ESS Score – add all the selections from the top section on the form. Section One – if the score is 8 or greater on the ESS enter a 1. If the score is less than 8 enter a zero. Section Two – enter 1 point for every item checked yes. Section Three – enter 2 point for every item check yes. Total Score – add the scores for Section one, section two and section three.   If the total of section One and Section Two equals three or more a study is indicated. If the score of all three sections is at least 4 a study is triggered.

Teach Back Video

Patient Consultation And Patient Education

Patient Teaching Patient teaching is defined as a system of activities intended to produce learning. In our case patient teaching is a dynamic interaction between the sleep coordinator (teacher) and the patient (learner). Both the teacher and the learner communicate information, emotions, perceptions, and attitudes to the other. Before learning can occur, a relationship of trust and respect must exist between the teacher and learner. The learner trusts the teacher to have the required knowledge and skills to teach and the teacher respects the learner's ability to reach the goals. The goal of patient teaching is the patient's active participation in health care and his/her compliance with instructions.

First Consultation Goals Review the screening toolProvide a home sleep testing systemSchedule a return visit to return the Home Sleep Testing unitSchedule a return visit to for the results.

Second Consultation Goals Discuss results of the findings of the Home Sleep TestReview treatment OptionsAssist the patient with the transfer to the treatment phase.

Sleepy people have short attention spans and poor memories. Apnea Education

Use all available sources of information. Review the patient’s medical records. Read the history of medical problems as well as diagnoses and physical examinations. If there are comorbidities be prepared to bring them into the conversation.Be Prepared

Evaluate whether learner objectives have been met . There are several ways to do this. Observation. Observe the patient to verify that he has put the information that he learned into practice. (b) Patient's comments. The patient will usually state whether or not he or she understands the information being taught. (c) Direct questions. Ask the patient a question requiring a response, which reflects his or her level of knowledge about the topic. (d) Return demonstration. Have the patient perform the procedure as it was demonstrated. This is an excellent method of evaluating proficiency in psychomotor skills. Learning Objectives

Compliment on a attribute of the person (e.g., clothes, hair, car ),Inquiring about a person's family (e.g., birthday observed, anniversary, graduation, pets, health, etc.)Asking about an event the person recently experienced (physicians visit)Commenting on something newsworthy - community, sports, weather ("What did you think about...?").Your goal is to appear genuinely concerned about the person.

Role Play Consultation 1

Home Sleep Testing Systems Review

Ares

WatchPAT

Nomad

Respironics - Alice PDX

Apnea Link Air - ResMed

Cleaning and Preparing for the Ares for use

Uploading the Ares Study

Home Sleep Study Report Introduction

Important Test Findings AHI – (5-14 Mild, 15-29 Moderate, 30 + Severe) RDI – RDI significantly increased over AHI element of upper airway resistance presentREI – respiratory events in sleep on a home sleep study, new requirement by the AASM not recognized by Medicare and may not be recognized by other providers yet.Time with Saturations below 90%SaO2 Nadir – lowest saturation 78% or less may indicate an increased risk for death during sleep.Treatment Options – what is the physician recommending as options for treatment?Quality of Recording – Does the physician indicate a need for repeat study?

Breakfast has been moved back to the restaurant. Same as yesterday.Sorry for the misinformation. Thanks, Sheila

HST Report Review 40 studies with a work sheet to practice

Reviewing the sleep study AHI - Mild, Moderate or Severe SaO2 Nadir – Lowest Oxygen SaturationPercent of time with Oxygen less than 90%Was the study time and quality adequateRecommendation – CPAP, Oral Appliance, Other

Your conversation with the patient should include the following: Nature of the problemProposed treatment to address the conditionAlternative treatmentsAnticipated benefits of each treatment option Risks and side effects of each treatment option Consequences of no treatmentAssessment of the patient’s understanding of the proposed treatmentRisk Management suggests that d Patient Choice

Sample Conversation Nature of the problem – you have been diagnosed with sleep apnea. Your airway is either completely or partially closing ___times per hour.Proposed treatment to address the condition – the physician who interpreted your sleep study is recommending that you be referred to a sleep lab for a CPAP titration.Alternative treatments – an alternative to the CPAP might be a dental device that you wear at night when sleepingAnticipated benefits of each treatment option – either of these two option may be effective at controlling your airway. With the CPAP you will know immediately if the mask controls your airway. You will have a second home study after a period of wearing your dental device to determine the level of airway control it provides.Risks and side effects of each treatment option – success with either of these devices is primarily based on your acceptance and your willingness to persevere until you’ve adjusted to the treatment of choice.Consequences of no treatment – lack of treatment increases your risk for cardiac disease, development of type 2 diabetes and risk of daytime accidents.Assessment of the patient’s understanding of the proposed treatment – Can you please tell me what your choice is and why? Document patient choice using the patients words in your notes.

Documentation Tips for Reducing Malpractice Risk Document physician recommendation/s. Document your discussion with the patient.Document patient choice – use the patient’s words to document their choice.Do not make any referral without a prescription.If the patient totally refuses treatment have them follow-up with the practice physician.

Referral Process Dentist and/or Sleep Specialist

Dental Referral Cover letter including request for documentation of consultation and treatment progress and outcomes. Demographic InformationCopy of Insurance CoverageHST ReportCopy of the last visit notesLetter of Medical NecessityTreatment Choice Form

Sleep Lab Referral Cover letter including request for documentation of consultation and treatment progress and outcomes. Demographic InformationCopy of Insurance CoverageHST ReportCopy of the last visit notesTreatment Choice Form

Flip Chart Review

Smartsheet 5 patients each to enter with demographic worksheets and alarms to be entered.

Alarm Opportunities Set-up HSTReturn HSTLook for HST Report (48 hours)Scheduled HST ReportSent HST to physician for signature set tag to look for the report1 week follow-up to see if they've made contact with the dentist or the sleep specialist1 month follow-up has the study been completed or do they have their appliance45 day follow-up after insertion of OAT or starting PAPGet download from the DME companyRepeat HST with OAT3 month. 6 month or yearly going forward60-90 day follow-up after papEvery patient should have an alarm set unless they’ve refused treatment or have died and are discharged from service

Practice Integration

New HST Guidelines October 1, 2015

New HSAT terminology and definitions Monitoring time (MT) - Total recording time minus periods of artifact and time the patient was awake as determined by actigraphy, body position sensor, respiratory pattern, or patient diary. 
Respiratory event index (REI)-Total number of respiratory events scored × 60 divided by monitoring time (MT).

DOCUMENTATION As with full attended polysomnography, the sleep technologist is responsible for ensuring that all required documentation (history, physical exam, previous test results, referral and insurance information, physician’s orders, etc.) is available and reviewed prior to dispensing the PM device for testing.

PAP

Goals Obtain the information needed to be able to apply an Auto-PAP machine for the purpose of home titration of positive airway pressure and then to convert that information to home PAP therapy.

Breathing Patterns Single Breath Differing Breath Rates

PAP Delivery System Includes: Blower, Tubing and Interface

PAP Blower Types

CPAP Continuous Positive Airway Pressure Single level of pressure set.Device attempts to maintain that level of pressure through all parts of the breath.

Auto PAP Single level of pressure within each breath. The level of pressure may vary from time to time throughout the night as more or less pressure is required.Breathing deficits are recognized and then the machine responds by changing pressures.APAP Systems control breathing by responding to;Inspiratory flow limitationSnoring Apnea

BiPAP Bilevel Positive Airway PressureTwo levels of pressure within each breath delivered.Machine maintains a single level of pressure during exhalation and at rest and provides a higher level of pressure during inhalation.

Auto BiPAP Bilevel Positive Airway PressureTwo levels of pressure within each breath delivered.Machine maintains a single level of pressure during exhalation and rest and provides a higher level of pressure during inhalation.Levels may vary from time to time throughout the night as needed.

BiPAP ST Bilevel Positive Airway PressureTwo levels of pressure within each breath delivered.Machine maintains a single level of pressure during exhalation and rest and provides a higher level of pressure during inhalation.Machine triggers the IPAP pressure in the absence of patient triggered breath.

ASV Therapy designed to treat Central Apnea.

Delivery Devices 6 Types

Nasal Mask Nasal CPAP masks seal around your nose in the shape of a triangle. Are held in place by a four point headgear. Original type of CPAP mask and remain the most popular. Come in silicone, gel, or cloth styles. IndicationsFor persons who breathe through the nose only.Persons who have a heightened sense of claustrophobia with the presence of the nasal mask.

Full Face Mask Seals around your nose and mouth in the shape of a triangle.Are held in place by four point headgear. Indicated for people who breathe through their mouth.For persons who breathe through both the nose and the mouth.Those who have not been successful with nasal mask and chin strap combos

Nasal Pillows – Nasal Prongs Soft pillows that seal around the base of the nostril.Held in place by headgear.May be irritating to their naresIndicationsNose breathersPersons with odd shaped noses that are hard to fit with a nasal mask.When there is difficulty maintaining a seal with a nasal maskWhen a proper seal cannot be kept because of a mustache or beard.Note may not be tolerable at high levels of PAP pressure.Not suitable for persons prone to frequent nose bleeds.

Functions like a full face mask however less bulky. The hybrid combines the seal of nasal pillows at the nostril openings and a cushion that seals over the mouth. Used for those who breathe through both the nose and the mouthCombo therapy with bite blocks or other dental devices.Some denture wearers like to sleep with dentures in and find the pressure of a nasal mask to cause pain to the gums. A hybrid mask may be more acceptable.Hybrid Face Mask

Oral CPAP Mask Oral CPAP masks use an oval cushion to seal around the mouth and deliver air through two inlets inside the mask. An inside flap rests between your teeth and lips and a second curls over your lips to keep the mask stable. This design is great for users who experience frequent nasal congestion. IndicationsPersons with chronic nasal congestion who breathe through the mouth only.

Total Face Mask Total Face CPAP masks seal over the entire face including the nose, mouth and eyes. Are held in place by four point headgear. IndicationsFor persons who have air leaks through the eyes when using positive pressure.

Titration Grading System An optimal titration reduces RDI <5 per hour for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings.A good titration reduces the overnight RDI ≤10 per hour or by 50% if the baseline RDI <15 per hour and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure.An adequate titration is one that does not reduce the overnight RDI ≤10 per hour but does reduce the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressureAn unacceptable titration is one that does not meet any one of the above grades Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea Positive Airway Pressure Titration Task Force of the American Academy of Sleep Medicine

CPAP Delivery System

CPAP Therapy Indications/Contraindications

Treatment with continuous positive airway pressure (CPAP) is appropriate for a patient aged 19 years or older when both conditions below are met:Home or lab based sleep study demonstrates one of the following: Apnea–hypopnea index (AHI) greater than or equal to 15 AHI 5–14 with any of the following: excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, treatment-resistant hypertension (persistent hypertension in a patient taking three or more antihypertensive medications), ischemic heart disease, history of stroke

AND Appropriate CPAP level has been determined from one of the following: Split-night sleep study Whole-night lab based titration study following a study where the CPAP level was not determined during the therapeutic portion or the patient has obstructive sleep apnea (OSA) but did not meet criteria for positive airway pressure (PAP) titration during the study Whole-night lab based titration study in a patient in whom auto-titrating positive airway pressure (APAP) is contraindicated (e.g., congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD]) APAP titration trial Whole-night lab based titration study when home, unmonitored APAP titration was unsuccessful.

APAP Therapy Indications/Contraindications

Treatment with APAP is appropriate when a patient meets conditions A and B; A. Home or lab based sleep study demonstrates one of the following: AHI greater than or equal to 15 AHI 5–14 with any of the following: excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, treatment-resistant hypertension (persistent hypertension in a patient taking three or more antihypertensive medications), ischemic heart disease, history of stroke

AND B. The patient has none of the following contraindications to the use of APAP: Age 18 years or younger CHF COPD Central sleep apnea Neuromuscular disorders (e.g. muscular dystrophy, myasthenia gravis)

PAP Systems Smart Technology

Machine Technology In addition to providing pressure many of the machines have the ability to record breathing and usage of the machines. The data can be downloaded and a report created.Information within those reports can be used to determine the appropriate level of pressure needed to stabilize the patients airway.New machines coming out that allow constant web communication.

Downloaded Data What does it mean? How is the information used?

Converting Auto-PAP to CPAP

Patient name; Description of item(s) to be dispensed; Prescribing practitioner’s National Provider Identifier (NPI);Ordering physician’s legible signature; andDate of the ordering physician’s signature. CPAP Prescription

Medicare Approved Sleep Study A positive diagnosis of OSA for the coverage of CPAP must include a clinical evaluation and a positive:a. attended PSG performed in a sleep laboratory; orb. unattended HST with a Type II home sleep monitoring device; orc. unattended HST with a Type III home sleep monitoring device; ord. unattended HST with a Type IV home sleep monitoring device that measures at least 3 channels

Table 2. Initial Coverage for HCPCS Codes E0601 and E0470 Device Code Criteria Detailed Order HCPCS code E0601 A face-to-face clinical evaluation by the treating physician before the sleep test to assess the patient for OSA.A Medicare-covered sleep test that meets one of the following: The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events ; Or The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; orHypertension, ischemic heart disease, or history of stroke.The patient and/or their caregiver received instructions from the supplier of the PAP device and accessories in the proper use and care of the equipment.A face-to-face encounter during the 6-month period preceding the written order . Objective evidence of continued need and continued use.

The treating physician must perform a clinical re-evaluation after the 31st day, but before the 91st day after initiating therapy, which documents the following:A face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of OSA are improved; andObjective evidence of adherence to use (defined as use of PAP devices for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use) of the PAP device, reviewed by the treating physician.NOTE: Documentation of adherence to PAP therapy must be determined through direct download or visual inspection of usage data with written documentation provided in a report to be reviewed by the treating physician and included in the patient’s medical record.

are eligible to re-qualify for a PAP device but must have both:A face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy; and 2. A repeat sleep test in a facility-based setting (Type I study).Patients who fail the initial 12-week trial

and are seeking Medicare coverage of either rental of the device, a replacement PAP device, and/or accessories, both of the following coverage requirements must be met :The patient had a documented sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the patient seeks Medicare coverage of a replacement PAP device and/or accessories; andThe patient had a face-to-face clinical evaluation, following FFS Medicare enrollment, by the treating physician who documented in the patient’s medical record that:The patient has a diagnosis of OSA; andThe patient continues to use the PAP device.If either criterion is not met, the claim will be denied as not medically necessary. For patients who received a PAP device prior to enrollment in FFS Medicare

BiPAP Coverage Meets coverage criteria for CPAP A CPAP has been tried and proven ineffective based on a therapeutic trial conducted either in a facility or in a home setting. Ineffective is defined as documented failure to meet therapeutic goals using a CPAP device during the titration portion of a facility-based study or during home use despite optimal therapy (such as, proper mask selection and fitting and appropriate pressure settings).

Patient 1 A-Flex Compliance Summary11/18/2014-12/17/2014 (30 days)Date Range20Days with Device Usage10Days without Device Usage66.7% Cumulative Usage 4 days, 14 hrs. 39 min. 33 secs. Maximum Usage (1 Day) 3 hrs. 41 mins. 19 secs. Average Usage (All Days) 5 hrs. 31 mins. 19 secs. Minimum Usage (1 Day) 2 hrs. 48 mins. 3 secs. Percent of Days with Usage >=4 hours 60.0% Percent of Days with Usage <4 hours 40.0% Total Blower Time 4 days, 14 hrs. 39 min. 33 secs. AUTO CPAP Summary   Auto CPAP Mean Pressure 11.7 cmH2O Auto CPAP Peak Average Pressure 14.0 cm H2O Average Device Pressure <= 90% of time 14.6 cm H2O Average Time in Large Leak Per Day 2 mins. 21 sec. Average AHI 22

Patient 2 A-Flex Compliance Summary1/2/2015-2/2/2015 (32 days)Date Range32 daysDays with Device Usage0 days Days without Device Usage100.0% Cumulative Usage 12 days 16 hours. 37 mins. 20 secs. Maximum Usage (1 Day) 15 hrs. 16 mins. Average Usage (All Days) 9 hrs. 31 mins. 10 secs. Minimum Usage (1 Day) 3 hrs. 13 mins. 19 sec. Percent of Days with Usage >=4 hours 96.9% Percent of Days with Usage <4 hours 3.1% Total Blower Time 12 days 17 hours 21 mins 55 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 7.1 cm H2O Auto CPAP Peak Average Pressure 9.2 cm H20 Average Device Pressure <= 90% of time 9.1 cm H2O Average Time in Large Leak Per Day 22 sec Average AHI 11 Min Pressure5 cm H2OMax Pressure20 cm H2O

Patient 3 A-Flex Date Range6/17/2015-7/16-2015 (30 days)Days with Device Usage29 DaysDays without Device Usage1 dayPercent of Days with Device Usage96.7% Cumulative Usage 7 days. 1 hrs. 51 mins. 5 secs. Maximum Usage (1 Day) 13 hrs. 15 mins. 16 secs. Average Usage (All Days) 5 hrs. 39 mins. 42 secs Minimum Usage (1 Day) 13 mins. 23 secs. Percent of Days with Usage >=4 hours 83.3% Percent of Days with Usage <4 hours 16.7% Total Blower Time 9 days 2hrs. 19 mins. 35 secs. AUTO CPAP Summary   Auto CPAP Mean Pressure 9.0 cm H2O Auto CPAP Peak Average Pressure 12.5 cm H2O Average Device Pressure <= 90% of time 10.5 cm H2O Average Time in Large Leak Per Day 1 hrs. 38 mins. 10 secs. Average AHI 19 Min Pressure5 cm H2OMax Pressure20 cm H2O

Patient 4 A-Flex Compliance Summary Date Range6/21/2015 - 7/20/2015 (30 days)Days with Device Usage22 daysDays without Device Usage8 days Percent of Days with Device Usage 73.3% Cumulative Usage 2 days 7 hrs 10 mins 7 sec Maximum Usage (1 Day) 7 hrs 52 mins 46 secs Average Usage (All Days) 1 hr 50 mins 20 secs Minimum Usage (1 Day) 2 hrs. 30 mins 27 sec Percent of Days with Usage >=4 hours 6.7% Percent of Days with Usage <4 hours 93.3% Total Blower Time 20days 7 hrs 10 mins 44 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 9.6 cmH2O Auto CPAP Peak Average Pressure 13.2 cmH2O Average Device Pressure <= 90% of time 11.3 cmH2O Average Time in Large Leak Per Day 11 secs Average AHI6Min Pressure20 cmH2OMax Pressure6 cmH2O

Patient 5 Auto-BiLevel Compliance Summary Date Range6/22/2015 - 7/9/2015 (18 days)Days with Device Usage18 daysDays without Device Usage0 days Percent Days with Device Usage 100.0% Cumulative Usage 5 days 8 hrs 42 mins 47 secs Maximum Usage (1 Day) 9 hrs. 51 mins 49 secs Average Usage (All Days) 7 hrs 9 mins 2 sec Average Usage (Days Used) 7 hrs. 9 mins 2 secs Minimum Usage (1 Day) 13 mins 23 secs Percent of Days with Usage >=4 hours 94.4% Percent of Days with Usage <4 hours 5.6% Total Blower Time 5 days 14 hrs 59 mins 18 secs AUTO BiLevel Summary   Maximum Titrated IPAP Pressure 22.0 cm H2O Average Device IPAPPressure <= 90% of time 20.1 cm H2O Maximum Titrated EPAP Pressure 18.0 cm H2O Average Device EPAPPressure <= 90% of time15.8 cm H2OAverage Time in Large Leak Per Day13 mins 53 secsAverage AHI6

Patient 6 A-Flex Compliance Summary Date Range6/17/2015 - 7/16/2015 (30 days)Days with Device Usage29 daysDays without Device Usage1 days Percent Days with Device Usage 96.7% Cumulative Usage 7 days 1 hrs 51 mins 5 secs Maximum Usage (1 Day) 13 hrs. 15 mins 16 secs Average Usage (All Days) 5 hrs 39 mins 42 sec Average Usage (Days Used) 5 hrs. 51 mins 25 secs Minimum Usage (1 Day) 13 mins 23 secs Percent of Days with Usage >=4 hours 83.3% Percent of Days with Usage <4 hours 16.7% Total Blower Time 7 days 2 hrs 19 mins 35 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 9.0 cmH2O Auto CPAP Peak Average Pressure 12.5 cmH2O Average Device Pressure <= 90% of time 10.5 cmH2O Average Time in Large Leak Per Day1 hr 38 mins 10 secAverage AHI19Min Pressure20 cmH2OMax Pressure8 cmH2O

Patient 7 A-Flex Compliance Summary Date Range6/16/2015 - 7/15/2015 (30 days)Days with Device Usage23 daysDays without Device Usage7 days Percent Days with Device Usage 76.7% Cumulative Usage 4 days 18 hrs 44 mins 49 secs Maximum Usage (1 Day) 8 hrs. 51 mins 59 secs Average Usage (All Days) 3 hrs 49 mins 29 sec Average Usage (Days Used) 4 hrs. 59 mins 20 secs Minimum Usage (1 Day) 24 mins 22 secs Percent of Days with Usage >=4 hours 66.7% Percent of Days with Usage <4 hours 33.3% Total Blower Time 4 days 18 hrs 45 mins 49 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 10.1 cmH2O Auto CPAP Peak Average Pressure 12.2 cmH2O Average Device Pressure <= 90% of time 11.5 cmH2O Average Time in Large Leak Per Day 7 mins 16 secAverage AHI2Min Pressure20 cmH2OMax Pressure10 cmH2O

Patient 8 Auto-PAP Compliance Summary Date Range6/20/2015 - 7/19/2015 (30 days)Days with Device Usage29 daysDays without Device Usage1 days Percent Days with Device Usage 96.7% Cumulative Usage 4 days 6 hrs 52 mins 11 secs Maximum Usage (1 Day) 5 hrs. 45 mins 59 secs Average Usage (All Days) 3 hrs 25 mins 44 sec Average Usage (Days Used) 3 hrs. 32 mins 50 secs Minimum Usage (1 Day) 30 mins 13 secs Percent of Days with Usage >=4 hours 33.3% Percent of Days with Usage <4 hours 66.7% Total Blower Time 4 days 13 hrs 22 mins 32 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 8.4 cmH2O Auto CPAP Peak Average Pressure 10.2 cmH2O Average Device Pressure <= 90% of time 10.5 cmH2O Average Time in Large Leak Per Day52 secsAverage AHI2Min Pressure20 cmH2OMax Pressure5 cmH2O

Patient 9 Auto-PAP Compliance Summary Date Range6/14/2015 - 7/13/2015 (30 days)Days with Device Usage29 daysDays without Device Usage1 days Percent Days with Device Usage 96.7% Cumulative Usage 8days 2 hrs 21 mins 50 secs Maximum Usage (1 Day) 8 hrs. 57 mins 29 secs Average Usage (All Days) 6 hrs 28 mins 43 sec Average Usage (Days Used) 6 hrs. 42 mins 7 secs Minimum Usage (1 Day) 4 hrs 42 mins 51 secs Percent of Days with Usage >=4 hours 96.7% Percent of Days with Usage <4 hours 3.3% Total Blower Time 8 days 2 hrs 41 mins 38 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 8.4 cmH2O Auto CPAP Peak Average Pressure 8.6 cmH2O Average Device Pressure <= 90% of time 9.3 cmH2O Average Time in Large Leak Per Day0 secsAverage AHI0Min Pressure20 cmH2OMax Pressure8 cmH2O

Patient 10 Auto-PAP Compliance Summary Date Range5/5/2015 -6/5/2015 (32 days)Days with Device Usage30 daysDays without Device Usage2 days Percent Days with Device Usage 93.8% Cumulative Usage 7 days 16 hrs 1 mins 10 secs Maximum Usage (1 Day) 8 hrs. 54 mins 22 secs Average Usage (All Days) 5 hrs 45 mins 2 sec Average Usage (Days Used) 6 hrs. 8 mins 2 secs Minimum Usage (1 Day) 3 hrs 47 mins 8 secs Percent of Days with Usage >=4 hours 90.6% Percent of Days with Usage <4 hours 9.4% Total Blower Time 7 days 16 hrs 1 mins 10 secs AUTO CPAP Summary   Auto CPAP Mean Pressure 5.3 cmH2O Auto CPAP Peak Average Pressure 5.9 cmH2O Average Device Pressure <= 90% of time 6.1 cmH2O Average Time in Large Leak Per Day0 secsAverage AHI0Min Pressure20 cmH2OMax Pressure8 cmH2O

SLEEP Physical State? Psychological State? Both ?

What is sleep? According to the Webster’s Seventh New Collegiate Dictionary sleep is: The natural periodic suspension of consciousness during which the powers of the body are restored.A state of torpid inactivity as in deathSleep may be best described as a state of arousable unconsciousness. In sleep we do not see, hear or experience happenings around us in a logical manner. Our body is relatively immobile.

Possible benefit of sleep Body and Brain tissue restoration Energy ConservationAdaptationMemory Reinforcement and consolidationSynaptic and neural network integrityThermoregulation Clinical Companion to Sleep Disorders Medicine Second EditionSleep deprivation can deteriorate the bodyRepairing products are produced during sleep: protein production, growth hormone, etc.the more physical exercise an animal does, the more sleep an animal will have Evolutionary or Energy conservation theoryHedonistic theory – we sleep because we like itLearning and memory consolidation

When do we sleep? Circadian Rhythm - biological clock; controls the rise and fall of physiological responses such as temperature, and even sleep.

Circadian Rhythms Experiments designed to determine the length of the circadian rhythm place subjects in environments with no cues to time of day. Results depend upon the amount of light to which subjects are artificially exposed.Rhythms run faster in bright light conditions and subjects have trouble sleeping.In constant darkness, people have difficulty waking.Remains consistent despite lack of environmental cues indicating the time of dayCan differ between people and lead to different patterns of wakefulness and alertness.Change as a function of age.Example: sleep patterns from childhood to late adulthood

Rhythms of Waking and Sleep Mechanisms of the circadian rhythms include the following: The Suprachiasmatic nucleus.Genes that produce certain proteins.Melatonin levels.The suprachiasmatic nucleus (SCN) is part of the hypothalamus and the main control center of the circadian rhythms of sleep and temperature.Located above the optic chiasm.Damage to the SCN results in less consistent body rhythms that are no longer synchronized to environmental patterns of light and dark.

SCN The SCN is genetically controlled and independently generates the circadian rhythms. Single cell extracted from the SCN and raised in tissue culture continues to produce action potential in a rhythmic pattern.Various cells communicate with each other to sharpen the circadian rhythm.

Two types of genes are responsible for generating the circadian rhythm. Period - produce proteins called Per. Timeless - produce proteins called Tim.Per and Tim proteins increase the activity of certain kinds of neurons in the SCN that regulate sleep and waking.Mutations in the Per gene result in odd circadian rhythms.

Melatonin The SCN regulates waking and sleeping by controlling activity levels in other areas of the brain. The SCN regulates the pineal gland, an endocrine gland located posterior to the thalamus.The pineal gland secretes melatonin, a hormone that increases sleepiness.Melatonin secretion usually begins 2 to 3 hours before bedtime.Melatonin feeds back to reset the biological clock through its effects on receptors in the SCN.Melatonin taken in the afternoon can phase-advance the internal clock and can be used as a sleep aid.

Circadian Rhythm The purpose of the circadian rhythm is to keep our internal workings in phase with the outside world. Light is critical for periodically resetting our circadian rhythms.A zeitgeber is a term used to describe any stimulus that resets the circadian rhythms.Exercise, noise, meals, and temperature are others zeitgebers.Jet lag refers to the disruption of the circadian rhythms due to crossing time zones. Stems from a mismatch of the internal circadian clock and external time.Characterized by sleepiness during the day, sleeplessness at night, and impaired concentration.Traveling west “phase-delays” our circadian rhythms.Traveling east “phase-advances” our circadian rhythms.

What happens during sleep? Is sleep like being unconscious? Not exactly. We can continue to process the external world while asleep.Infants cryingEnvironmental events can become incorporated into our dreams.We can continue to process our internal world.We wake up when we have to use the restroom or get sickEvents of the previous day become incorporated into our dreams.

What happens to the brain and body during sleep? EEG: Electroencephalogram – measures overall activity patterns of neurons in the brain.

2 types of Sleep REM Non-REM

4 Stages of Sleep Stages other than REM are referred to as non-REM sleep (NREM).When one falls asleep, they progress through stages 1, 2, and 3 in sequential order.After about an hour, the person begins to cycle back through the stages from stage 3 to stages 2 and than REM.The sequence repeats with each cycle lasting approximately 90 minutes to 120 minutes.Stage 3 sleep predominate early in the night. The length of stages 3 decreases as the night progresses. REM sleep is predominant later in the night.Length of the REM stages increases as the night progresses.REM is strongly associated with dreaming, but people also report dreaming in other stages of sleep.

Stage N1 EEG activity is of higher amplitude and lower frequency than during waking People awaken from Stage 1 claim to have not been asleep

Stage N2 The EEG is higher in amplitude and lower in frequency Contains strange firing bursts K-complexes Sleep spindles

Stage N3 Waves are slower and higher in amplitude, indicating greater cortical synchrony

REM: Rapid Eye Movement Sleep The EEG is that of an awake individual Muscle activity ceases completelyHeart rate returns to the level it had at the start of sleepEyes dart back and forth together underneath the closed lids

Sleep Architecture

New OCST or HST Guidelines October 1, 2015

Contraindications for OCST OCST is not appropriate and is contraindicated for pediatric patients, patients with comorbid medical conditions including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure, and patients suspected of having other sleep disorders, including central sleep apnea, periodic limb movement disorder (PLMD), insomnia, parasomnias, circadian rhythm disorders, or narcolepsy.OCST is also contraindicated for patients with medical or cognitive issues that impact the safety of a patient using the device unattended . OCST should not be used for general screening .

Initializing the PM Device Most PM devices require re-charging or replacing the batteries, and previous study results must be cleared before a new recording can be acquired. Once the device is connected to a computer and the manufacturer’s software, patient information can be entered and the device initialized to collect new data. Devices can be set to start at a preset time, or can be manually started by the patient at bedtime. It is important to know the maximum recording time capability, which might range from one to seven or more nights of recording time. When chain of custody features are required to verify the identity of the patient’s data that is recorded, a security cable, nonremovable sensor, or other feature may need to be applied on site.

METHODOLOGY FOR PATIENT EDUCATION AND INSTRUCTION The visit in which the patient picks up the PM device and is instructed how to apply it at home is an opportunity to engage them in their sleep health. Providing information on OSA symptoms, health consequences, and the benefits of treatment can help set the stage for a successful test and acceptance and compliance with treatment.

Demonstration The instruction on how to apply the PM device can be performed using multiple modalities. Written instructions with pictorial diagrams of each component and step in the process should be given to the patient to take home. Many manufacturers provide video instruction accessible online or on a pre-recorded disk. A demonstration on video or by the technologist educator can be followed by having the patient apply the device and sensors themselves. This allows for questions to come up and for the technologist educator to correct anything that is incorrectly applied.

Dispensing Dispensing the device, patient education and complete instruction can be performed using one to one instruction, in a group setting, or by mail if the patient is unable to get to the sleep center. Face to face patient interaction is preferable to mail to home, because it allows for physical exploration of the device and components, and the opportunity for the patient to ask questions. When devices must be mailed, all information normally supplied by the technologist educator, should be made available in printed and/or recorded materials.It is important for the patient to be given a 24-hour access phone number for technical support if any questions r problems arise.

DOCUMENTATION As with full attended polysomnography, the sleep technologist is responsible for ensuring that all required documentation (history, physical exam, previous test results, referral and insurance information, physician’s orders, etc.) is available and reviewed prior to dispensing the PM device for testing.

INSURANCE VERIFICATION Patient ID verification and insurance verification should be completed at intake , as well as the documentation that the privacy notice was made available to the patient. The sleep center may require the patient to sign a return agreement stating when and where to return the device that includes device replacement or late fee terms.

QUESTIONNAIRE A form that includes pre-sleep and post-sleep questions should be dispensed to the patient with the device and returned for the interpreting physician’s review.

Data base A comprehensive database should be kept to track OCST procedures, diagnosis codes, turnaround time, and failure rates. Optimally, this data should be tied to patient outcomes.

DEVICE RETURN AND DATA UPLOAD Timely return of the device is desired to enable it to be available for subsequent use, and to expedite test interpretation, diagnosis, and treatment. If possible, the data should be checked for minimal adequacy (required signals recorded for a minimum time set by the center) and re-dispensed at the same visit when a failure is detected. The device is connected to the manufacturer’s software and uploaded for manual review by the scoring technologist. The raw data may also be made available remotely on a secured website or server.

Training of Sleep Technologists All technical personnel must be trained by the Medical Director of the sleep center, a board certified sleep specialist, or a registered sleep technologist with the RST or RPSGT credential.

EQUIPMENT SAFETY Equipment and sensor use and maintenance should meet manufacturer standards. All equipment used for OCST must be visually inspected and maintained, and those actions must be regularly logged and documented by a sleep technologist. Electronic equipment used in conducting OCST must be tested for safety by a credentialed biomedical engineer or electrician at least annually.