March 2016 | Volume 25 | Number 1

� Obstructive Sleep Apnea and Atrial Fibrillation

� Are All Policy and Procedure Manuals Created Equal?

� Dealing With the Deaf Patient in the Sleep Center

� Normal" Sleep Across the Ages: A Comparative Study of Sleep in Three Contemporary Pre-Industrial Societies

� Risk Management in the Sleep Center

� Dreaming and Encounters With the Alternate Self (Part 1)

A Publication of the American Association of Sleep Technologists

"

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Annual Meeting38Colorado Convention CenterJune 12-14, 2016

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A2 Zzz 25.1 | March 2016

An organization’s mission is its driving force and helps to focus its purpose and its decision making. It concisely defines what an organization is all about. The American Association of Sleep Technologists (AAST) Board of Directors recently adopted a new mission statement that more accurately reflects what our organization is trying to accomplish.

Our new mission is to promote sleep wellness and lead the sleep technology profession through education, resources, and advocacy.

Now, on to the current issue of A2Zzz. In this issue, in addition to the usual continuing education articles (CEC) articles, we have included some additional articles. Check out the very first “Ask the President” column which answers a question about recertifying your sleep credential. This issue also includes an interview with Cameron Harris, the 3rd AAST President (1991-1993). In addition, the first in a series of state sleep society interviews that we will be highlighting is featured.

An Update on the AAST Educational Taskforce is also included in this issue; the next meeting is coming up so stay tuned for additional information on that front. Carolyn Winter-Rosenberg brings sleep technologists up to speed on the Centers for Medicare & Medicaid Services (CMS) durable medical equipment (DME) prior authorization program established in December of 2015. A final additional article by Auburne Hutchins and Mary Ellen Wells issues a call to action for sleep technologist education.

In addition, this issue contains all the usual A2Zzz articles and features.

Our CEC articles include Regina Patrick discussing research that suggests a strong correlation between obstructive sleep apnea (OSA) and atrial fibrillation, and Reg Hackshaw takes an intriguing look at the study of autoscopic hallucinations before modern sleep technology. Sleep center policy and procedure manuals (P&Ps) are a workplace mainstay and Tamara Sellman shares an article on whether all P&Ps are created equal. Throughout your time working as a sleep technologist you will run into many different types of patients, each with their own special needs. Lisa Bond provides some tips for dealing with the deaf patient in the sleep center. Rui de Sousa takes an interesting look at “normal” sleep across the ages. Also, just in time for the spring course, Tamara Sellman covers risk management in the sleep center.

We sincerely hope you enjoy this expanded issue of A2Zzz, as well as our newly redesigned website.

TABLE OF CONTENTSFrom the President ...........................................................6

Continuing Education Credit Offering..........................7

Ask The President .............................................................8

An Interview With Cameron Harris ......................10-11

Iowa State Sleep Society: An Interview With Brandon Butters .....................12-13

Obstructive Sleep Apnea and Atrial Fibrillation ..14-16

Are All Policy and Procedure Manuals Created Equal? ...........................................................17-18

Dealing with the Deaf Patient in the Sleep Center .......................................................19-21

"Normal" Sleep Across the Ages: A Comparative Study of Sleep in Three Contemporary Pre-Industrial Societies .............................................22-24

Risk Management in the Sleep Center ...................26-29

Dreaming and Encounters with the Alternate Self (Part 1) ........................................30-31

An Update On The Educational Taskforce ..........32-34

A Call to Action for Sleep Medicine ......................35-37

CMS Establishes A DME Prior Authorization Program ........................................38

In the Moonlight .............................................................39

Certification Update (BRPT).........................................40

MARCH 2016 | VOLUME 25 NUMBER 1FROM THE EDITORRita Brooks, MED, RST, RPSGT, REEG/EPT

Submit an original article for publication in A2Zzz. See page 5 for details.

September 2010 | Volume 19 | Number 3

Possible Neuronal Loss with Insomnia

Nitric Oxide, Obstructive Sleep Apnea and Upper

Airway Inflammation

Risk Management Strategy and Techniques for Sleep Facilities

The A, B, C of PAP

Second Generation “DIY EEGT” and the Pursuit of the

Alpha Rhythm

A P u b l i c a t i o n o f t h e A m e r i c a n A s s o c i a t i o n o f S l e e p T e c h n o l o g i s t s

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A2 Zzz 25.1 | March 2016

editorials in this magazine are solely those of the authors thereof and not of the American Association of Sleep Technologists (AAST); the American Academy of Sleep Medicine (AASM), which provides management services for the AAST; or of either organization’s officers, regents, members or employees. The appearance of products and services, and statements contained in advertisements, are the sole responsibility of the advertisers, including any descriptions of effectiveness, quality or safety. The Editor; Managing Editor; AAST; AASM; and each organization’s officers, regents, members and employees disclaim all responsibility for any injury to persons or property resulting from any ideas, products or services referred to in articles or advertisements in this magazine.

Mission: The American Association of Sleep Technologists (AAST) promotes sleep wellness and leads the sleep technology profession through education, resources, and advocacy.

Vision: The American Association of Sleep Technologists (AAST) will play a key role in setting the standard for professional excellence in the evolving practice of sleep healthcare.

Purpose: To provide a voice for the professionals who ensure the safe and accurate assessment and treatment of sleep disorders.

2510 North Frontage RoadDarien, IL 60561Phone: (630) 737-9704Fax: (630) 737-9788E-mail: A2Zzz@aastweb.org | Web: http://www.aastweb.org © 2016 American Association of Sleep Technologists

ABOUT A2Zzz

A2Zzz is published quarterly by the American Association of Sleep Technologists (AAST), 2510 North Frontage Road, Darien, IL 60561.Learning Objectives: Readers of A2Zzz should be able to do the following:

• Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options

• Interpret this information to determine how it relates to the practice of sleep technology

• Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments

• Apply this knowledge in the practice of sleep technology

Submissions: Original articles submitted by AAST members and by invited authors will be considered for publication. Published articles become the permanent property of the AAST.

Permission to Use and Reproduce: A2Zzz is published quarterly by the AAST, all rights reserved. Permission to copy or republish A2Zzz material is limited by restrictions. Visit www.aastweb.org to view the full A2Zzz permissions and use policy.

Advertising: Advertising is available in A2Zzz. Please contact the AAST national office for information concerning A2Zzz rates and policies, or find more details online at www.aastweb.org.Disclaimer: The statements and opinions contained in articles and

OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION OF SLEEP TECHNOLOGISTS (AAST)

CONTRIBUTORS

Share your expertise with colleagues in the profession of sleep technology by submitting an original article to A2Zzz. Read the A2Zzz Writer’s Guidelines at http://www.aastweb.org/publication-info. To propose an article topic or to get more information, send an e-mail to A2Zzz@aastweb.org.

A2Zzz publishes articles that relate to the profession of sleep technology and informs members about recent and upcoming activities of the American Association of Sleep Technologists (AAST).

SUBMIT AN ARTICLE TO A2Zzz

EDITORRita Brooks, MED, RST, RPSGT, REEG/EPT

MANAGING EDITORLynn Celmer

SENIOR WRITERSReg Hackshaw, EdD, RPSGTRegina Patrick, RST, RPSGT

CONTRIBUTING WRITERSLisa Bond, RST, RPSGTRita Brooks, MED, RST, RPSGT, REEG/EPTRui de Sousa, BSC, RPSGT, RSTJoel Glass, RPSGTYoona HaAuburne Hutchins, MHA, RPSGTLaura Linley, CRT, RST, RPSGTTamara Sellman, RPSGT, CCSHMary Ellen Wells, MS, RPSGT, R.EEG T, R.NCS TCarolyn Winter-Rosenberg

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elcome to a busy 2016! This is an important year for sleep technologists. The Board of

Directors of the American Association of Sleep Technologists (AAST) is aware that many AAST members are up for recertification this year. We have heard your concerns about the increased cost of recertification and completing your continuing education credits (CECs). We are sensitive to this and I can assure you that the AAST is committed to providing real value for your membership

and did not increase membership dues this year in an effort to offset recertification cost.

An RPSGT credential holder must apply for recertification on or before their expiration date to avoid any late fees and penalties. Recertification expiration date is five years from the date the certificate was issued, and requires the credential holder to complete 50 continuing education credits (CECs) within the five year period. We have more information on how to recertifiy on our website.

Sleep technologists can meet their continuing education requirements by participating in live courses hosted by the AAST, reviewing presentations and completing activities in the AAST Online Learning Center or by reading A2Zzz, the official publication of the AAST. Members can also find live and prerecorded CEC activities offered by CEC providers posted in the AAST CEC Calendar. For more information about getting your sleep technologist CECs, check out this article on the AAST blog.

The AAST will also offer special CEC bundles to make it more convenient for sleep technologists to complete their recertification requirements; stay tuned for more information on that. Another membership benefit we offer is maintaining an educational transcript for members that can be downloaded. No need to search for your certificates of completion; if you took a course that included AAST education credits we have that information logged for you.

Another upcoming educational opportunity is the AAST spring course on Risk Management in the Sleep Center. The course will be held in Louisville, KY March 11-12, 2016. This course is relevant for sleep technologists, sleep center managers, nurses, physician assistants and physicians seeking the knowledge necessary to ensure safety, privacy and proper accommodation of their patient population. This course will be presented with

a problem based learning format and is offering interactive workshops. I hope to see you there!

I am also proud to announce that the AAST Board of Directors recently adopted updated organizational mission and vision statements to reflect the goals of the organization as we embark on another exciting year.

Our mission: The American Association of Sleep Technologists (AAST) promotes sleep wellness and leads the sleep technology profession through education, resources, and advocacy.

Our vision: The American Association of Sleep Technologists (AAST) will play a key role in setting the standard for professional excellence in the evolving practice of sleep healthcare.

Hopefully by now you have all noticed the completely redesigned and updated AAST website with many new features and ease of access. Some of the new features include:

• Mobile optimization: Whether you are using your smart phone, browsing with your tablet or on your desktop, the new AAST website can be viewed without squinting your eyes or having to pinch and enlarge your screen to view.

• Streamlined home page: We have significantly cut out the clutter on our homepage.

• Built-in search feature: No longer do you have to click through a maze on our site to find what you are looking for.

• Mouse hover: All you have to do is move your mouse over an item and you will see what's indexed behind it.

• A2Zzz is now completely ungated: We've unlocked all of the future, current, and past A2Zzz articles for anyone to view.

• Online educational offerings: The AAST has a ton of resources available online that, until now, were sometimes difficult to find.

Keep your eyes posted for a tutorial video to help you navigate. We hope you like the new design and functionality!

FROM THE PRESIDENTBy Laura Linley, CRT, RST, RPSGT

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AAST PRESIDENT LAURA LINLEY, CRT, RST, RPSGT

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INSTRUCTIONS FOR EARNING CREDITAAST members who read A2Zzz and claim their credits online by the deadline can earn 2.00 AAST Continu ing Education Credits (CECs) per issue – for up to 8.00 AAST CECs per year. AAST CECs are accepted by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT).

To earn AAST CECs, carefully read four of the designated CEC articles from the list below and claim your credits online. You must go online to claim your credits by the deadline of June 2, 2016. After the successful completion of this educational activity, a confirmation letter acknowledging that you have earned 2.00 AAST CECs will be sent to the email address that you have on file with the AAST.

COSTThe A2Zzz continuing education credit offering is an exclusive learning opportunity for AAST members only and is a free benefit of membership.

STATEMENT OF APPROVALThis activity has been planned and implemented by the AAST Board of Directors to meet the educational needs of sleep technologists. AAST CECs are accepted by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT). Individuals should only claim credit for the articles that they actually read and evaluate for this educational activity.

STATEMENT OF EDUCATIONAL PURPOSE/OVERALL EDUCATIONAL OBJECTIVES A2Zzz provides current sleep-related information that is relevant to sleep technologists. The magazine also informs readers about recent and upcoming activities of the AAST. CEC articles should benefit readers in their practice of sleep technology or in their management and administration of a sleep disorders center.

Readers of A2Zzz should be able to do the following: • Analyze articles for information that improves their understanding of sleep, sleep disorders,

sleep studies and treatment options • Interpret this information to determine how it relates to the practice of sleep technology • Decide how this information can improve the techniques and procedures that are used to evaluate

sleep disorders patients and treatments• Apply this knowledge in the practice of sleep technology

You must go online to claim your CECs by the deadline of June 2, 2016.

Read and evaluate four of the following articles to earn 2.0 AAST CECs: Page #

Obstructive Sleep Apnea and Atrial Fibrillation ............................................................................................................... 14-16 Objective: Be aware of the increased prevalence of obstructive sleep apnea among people with atrial fibrillation. Are All Policy and Procedure Manuals Created Equal? ...................................................................................................... 17-18 Objective: Understand the importance of a having a policy and procedures manual in the sleep center.Dealing With the Deaf Patient in the Sleep Center ........................................................................................................... 19-21 Objective: Understand how to provide the best care to patients in the sleep center who are deaf or significantly hard of hearing.“Normal” Sleep Across the Ages: A Comparative Study of Sleep in Three Contemporary Pre-Industrial Societies ............... 22-24Objective: Understand the differences in sleep in three contemporary pre-industrial societies.Risk Management in the Sleep Center ............................................................................................................................. 26-29Objective: Be aware of potential risks in the sleep center and understand how to properly manage those risks.Dreaming and Encounters With the Alternate Self (Part 1) ............................................................................................... 30-31 Objective: Understand how autoscopic hallucinations during dreaming were studied before modern sleep technology..

CONTINUING EDUCATION CREDIT OFFERING

CLAIM CEC CREDITS FOR A2ZZZ ONLINEClaiming continuing education credits (CECs) by reading A2Zzz is now easier than ever: AAST Members can claim credits online through the AAST website – no need to mail, email or fax your completed evaluation form! Visit the AAST website and claim your CECs today!

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A2 Zzz 25.1 | March 2016

LAURA LINLEY, CRT, RST, RPSGT

Laura A. Linley is VP of Clinical Operations for Advanced Sleep Management, LLC. She has implemented DME in an IDTF and Multi-Specialty Clinical settings and presently sits on the AAST Board of Directors and is the Board Liaison for the CoA PSG.

ASK THE PRESIDENTKEEP THAT CREDENTIAL CURRENT: CERTIFICATION AND RE-CERTIFICATIONBy Laura Linley, CRT, RST, RPSGT

There are many pathways to becoming a registered sleep technologist, and once you have attained that credential

you will want to keep it current. Certification and education requirements for sleep technologists vary from state to state and provider to provider, so as a sleep technologist you need to be aware of regulations outlined by licensure practice acts, state governing boards, local Medicare requirements and insurance provider requirements that affect you. The American Association of Sleep Technologists (AAST) has compiled a directory of legislative information for each state, which is available on our website. Using this directory, you can review the statutory language for sleep technologists and coverage policies for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea as well as find information about state sleep societies to review their issues and updates.

Every five years it is required that you recertify your sleep credential. Recertification is a best practice in all allied health fields. Investing in continuing education and maintaining your competency year after year will assure that you meet the state and federal requirements for certification that allow you to practice in the sleep technology field.

For many, recertification is right around the corner. Make sure that you know what is required to maintain your credential and what continuing education credits (CECs) are accepted for recertification.

To assist our members with this process, the AAST has provided links to the American Board of Sleep Medicine (ABSM) recertification requirements as well as the Board of Registered Polysomnographic Technologists (BRPT) requirements. You can check your credential expiration date by searching the directories on the credentialing bodies’

websites. To view information for registered sleep technologist (RST) recertification, including guidelines and an application, visit the ABSM website. To view information for registered polysomnographic technologist (RPSGT) recertification, including an application and a recertification handbook, visit the BRPT website. Make sure your contact information is up to date in the credentialing organization databases so you don’t miss out on important reminders.

As a benefit of AAST membership, you can access an online transcript of the continuing education credits (CECs) that you have earned through programs that were AAST approved. This transcript is printable, and may be downloaded and used to demonstrate that you have completed the continuing education requirements for maintenance of your certification. We have compiled your credits for you so you do not need to scramble to find the information needed to log events such as:

• Date earned

• Course title

• Course ID

• Number of credits earned

For more information visit the CEC Educational Transcript page on our website.

AAST transcripts validate the continuing education credits (CECs) awarded to our members by educational providers that offer AAST continuing education credits. The transcript is recognized and accepted for re-credentialing by the American Board of Sleep Medicine (ABSM) and the Board of Registered Polysomnographic Technologists (BRPT).

The AAST is here to assist you in meeting the requirements for maintaining your credential. Don’t forget to take advantage of your FREE member CECs every month. We also list upcoming opportunities for educational programs that offer AAST continuing education credits. In addition, we provide numerous online learning modules on current topics of importance to sleep technologists. If you missed the Advanced Therapies course held in Branson last fall you will want to check out these new modules!

AAST ONLINE LEARNING MODULESNEW

https://go.aastweb.org/LearningCenter/Home.aspxAASTAmerican Association of Sleep T echnologist s

®

� e AAST Online Learning Center gives you new and a� ordable opportunities each month to earn continuing education credits (CECs) while you sharpen your professional skills and understanding. Each narrated presentation allows you to learn at your own pace and from the convenience of your home or o� ce.

VISIT THE AAST ONLINE LEARNING CENTER FOR THE LATEST LEARNING MODULES IN EACH OF THESE SERIES:

Each month a new module reviews a case dealing with topics such as proper and improper titration, di� cult decisions associated with split-night studies, and normal sleep study variants. Tips on scoring and reporting are provided with each presentation. Recent modules include:• Neonatal Sleep Staging• Treatment of Chronic Low Oxygen

Saturation

• PAP Titration in a Patient Needing Extra Attention to Improve Adherence

• ASV Titration for Central Sleep Apnea

CASE OF THE MONTH

� ese learning modules will help you stay up to date on the latest developments in sleep technology and sleep medicine. Each module contains a video discussion with the author of a recent article published in a sleep journal. � e full text of the article is included with purchase. Recent modules include:• Barcelona Sleepiness Index• Circadian Rhythm Sleep Disorders

• PAP Adherence• OSA and Depression

JOURNAL CLUB

FALL COURSE 2015 MODULES

In October 2015 the AAST’s fall course “Beyond OSA: Diagnosis, Comorbidities and � erapy of Sleep Related Breathing Disorders” focused on advanced therapies for sleep disordered breathing.Several presentations from the course are now available as learning modules:

• Upper Airway, Lungs and the Control of Breathing

• Central Sleep Apnea• Moving Beyond the Basics

• Therapy for Respiratory Rhythm Disorders

• Neuromuscular Disease• Monitoring Adherence and Outcomes

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CAMERON HARRIS, MED, RST, RPSGT, REEG/EPT, THIRD AAST PRESIDENT, SCORES A PAPER POLYSOMNOGRAM (PSG) CIRCA 1991.

Cameron started his career at the Mayo Clinic as an electroencephalographic (EEG) technologist in 1977. An

ear, nose and throat (ENT) surgeon was working on a master’s thesis project looking at the effect of nasal breathing during sleep and needed somebody to work all night doing sleep studies. Cameron knew how to do the EEG recording, so he volunteered. Shortly after that Mayo Clinic expanded from doing some daytime nap studies for sleep apnea patients to creating a sleep laboratory, and Cameron became the first sleep technologist at the Mayo Clinic in 1980.

Regarding learning polysomnography in the 1980’s Cameron says:

“In those days we didn’t have the Internet so it wasn’t easy to find information. Hours were spent in the library finding books and papers that described sleep disorders and techniques for diagnosing them. I recall three books that encapsuled the knowledge of sleep medicine at the time. Two books were published in 1978 (coincidentally corresponding in time with the formation of the APT). Sleep Disorders: Diagnosis and Treatment

AN INTERVIEW WITH CAMERON HARRIS, 3RD AAST PRESIDENT (1991-1993)By Yoona Ha and Rita Brooks, MED, RST, RPSGT, REEG/EPT

was edited by Robert Williams and Ismet Karacan from Baylor. Curiously, this book had only one chapter on sleep apnea, but four on penile tumescence. The second 1978 book was Sleep Apnea Syndromes edited by Christian Guilleminault and William Dement from Stanford. As the name implied, this book covered the current state of knowledge about sleep apnea, but it had only a seven page appendix addressing the topic of diagnostic testing. In 1982 Dr. Guilleminault edited Sleeping and Waking Disorders: Indications and Techniques. With contributions from Mary Carskadon, Sharon Keenan and Cynthia (Bollinger) Mattice, this book became the de facto standard reference for clinical and technical sleep medicine.”

In the early days of sleep technology the level of monitoring performed during sleep studies was more invasive than it is today. We routinely placed a radial artery line to monitor blood pressure and secure blood gas samples. An esophageal balloon was used to measure intra-thoracic pressure and a pneumotachograph was used for airflow. When I first started in sleep medicine, treatment for obstructive sleep apnea (OSA) was primarily tracheostomy. This sounds like a drastic measure today, but the patients we saw then were severely impaired by their OSA and responded dramatically to the treatment. In 1982 and 1983 the concept of treating OSA with continuous positive airway pressure (CPAP) was being pioneered by Colin Sullivan in Australia, but there were no commercial systems available. The challenge of treating sleep apnea at the time was to build custom CPAP systems for each patient.Cameron explains, “There were various sources for flow generators but we had to build an interface with a resistor system to vary the delivered pressure. It wasn’t a matter of using a remote control to set or change the pressure, we had to enter the room and and manually adjust the resistor circuit. The masks were another issue because we had to custom make a mask for each patient.” Each patient was sent home with a system that had been tailored to their needs. Even then the issue of patient compliance with treatment was a challenge. Crafting a mask that the patient was comfortable with was the technologist’s job. But there was no objective data for measuring patient compliance. There was much more personal interaction with patients then, and there weren’t any durable medical equipment (DME) vendors so the technologist did it all.

Things began to change rapidly in 1985 when Respironics came out with the first commercially available CPAP system. It took about a decade, but sleep medicine evolved into big business. This eventually led to conflicting scopes of practice among respiratory care and sleep technology professionals. Issues erupted regarding respiratory care licensure, ultimately leading to licensing for sleep technologists in a number of states.

A2 Zzz 25.1 | March 2016

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What goes around, comes around. Early on, we did some home sleep apnea testing. There wasn’t the plethora of technology we have today, but there were portable recording devices that could be used to monitor a patient’s breathing overnight. Because there was limited availability of in-lab testing beds in the early 1980s, Mayo Clinic resorted to ambulatory sleep apnea testing. As lab resources became more available, the ambulatory testing was abandoned. Even with ambulatory testing to establish a diagnosis, an in-lab therapeutic trial was necessary to titrate CPAP, even after commercial systems became available. The volume of patients was such it quickly became apparent we couldn’t test and treat every patient if they had to spend two nights in the sleep laboratory, so we developed the technique of splitting the study for patients with unequivocal confirmation of a diagnosis in the first half of the night. This led to another innovation, so-called “online scoring”. We actually did that back in the day when studies were recorded on paper and scored by hand. A big innovation was the personal computer, and Excel which greatly facilitated tabulation of data and calculation of summary statistics.

Peter McGregor was the initial organizer of the Association of Polysomnographic Technologists (APT) in 1978, and the first President. The Board of Registered Polysomnographic Technologists (BRPT) started about the same time, as a committee of the APT, and the first Registered Polysomnographic Technologist (RPSGT) registry examination was given in 1979. Sharon Keenan was president for several years following Peter, and at that time leadership was totally voluntary. Cameron was Vice President under Sharon Keenan when the board of directors (BOD) determined there was a need for a professional grade credential. The APT BOD contracted with Applied Measurement Professionals (AMP) to develop a professional examination for the RPSGT credential. As VP Cameron also

BY TAMARA SELLMAN RPSGT, CCSHYOONA HA

Yoona Ha, a graduate of Northwestern University’s Medill School of Journalism and Weinberg College of Arts and Sciences, is a web content manager for the American Association of Sleep Technologists.

BY TAMARA SELLMAN RPSGT, CCSHRITA BROOKS MED, RST, RPSGT, REEG/EPT

Rita Brooks MED, RST, RPSGT, REEG/EPT is the President of the American Association of Sleep Technologists. She is the Director of Diagnostic Services for Capital Health in Trenton, N.J.

worked with an attorney in Minnesota to make the APT a legal entity, incorporated the APT, and is proud to have been the representative who signed the articles of incorporation.Cameron was the third president for the organization, and his primary focus was to attain tax-exempt status for the APT, organize the finances, and guide the creation of a professional organization. Part of that organization required acquiring staff and an executive director for the APT, which resulted in a management contract with AMP and bylaws revisions that defined the structure of the board and officers and outlined an orderly progression of leadership.

The AAST today mirrors many other professional organizations in allied health, representing grassroots technologists who fulfill essential and evolving roles. Technology has changed things, there are fewer technologists attending meetings and interacting in person, and there is much communication on social media. This phenomenon is by no means unique to sleep technology; all membership societies are struggling today and some organizations are losing membership due the fact that many organizational functionsare no longer critical.

One of the challenges for professional organizations is to maintain value for members and this means providing continuing education to large extent. The AAST is the main provider of education for sleep technologists and is charged with keeping technologists abreast of changes in the field, whether that be by presenting valuable experiences through courses and meetings, or developing online modules and professional guidelines and competencies. Today the AAST is doing all of this and is on target to keep technologists informed of the rapid changes occurring in our field.

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IOWA STATE SLEEP SOCIETY: AN INTERVIEW WITH BRANDON BUTTERSBy Yoona Ha and Rita Brooks, MED, RST, RPSGT, REEG/EPT

Yoona Ha, Content Manager for the American Association of Sleep Technologists (AAST), recently began interviewing

state sleep society representatives across the country to gather information for sleep technologists seeking professional support in their states and local educational opportunities. This is the first in a series of interviews that we will be highlighting in A2Zzz.

The Iowa State Sleep Society was formed nine years ago, and has approximately 100 members throughout the state of Iowa. The society was formed to develop a consolidated voice for sleep professionals in Iowa.

Brandon Butters is the current president of the Iowa State Sleep Society. He first joined the society as a board member, was elected president and is currently serving his second term in that capacity.

One of the major issues facing the Iowa State Sleep Society was licensure for sleep technologists. That effort has been a major undertaking for the society over the past five years. The Iowa Respiratory Care Practice Act previously contained exemption language that allowed sleep technologists to practice in the state. However, the Iowa State Sleep Society championed licensing for sleep technologists in Iowa and submitted a proposed licensing

bill to the legislature in March 2014. Their substantial efforts were worthwhile; this resulted in the Iowa legislature establishing polysomnography as an independent licensed profession within the Board of Respiratory Care and Polysomnography effective January 1, 2017. The board includes a sleep technologist representative and as of the effective date of this law, anyone performing sleep technology in Iowa must be licensed. This was the culmination of the substantial efforts of the Iowa State Sleep Society.

One of the requirements for licensing in Iowa, as in other states with sleep technologist licensing acts, is continuing education. Membership in the Iowa State Sleep Society is an affordable $40 and the society hosts an annual education conference in September. In 2015, the 8th annual conference was held on September 25th and included an open session for discussion of the recently enacted licensing bill. The conference is primarily focused on education for sleep technologists and includes topics that are current and relevant.

Regarding the educational conference Brandon says “We are trying to create value for the technologist by covering topics like motivational therapy and continuous positive airway pressure (CPAP) compliance.” The program includes physician speakers

BY TAMARA SELLMAN RPSGT, CCSHYOONA HA

Yoona Ha, a graduate of Northwestern University’s Medill School of Journalism and Weinberg College of Arts and Sciences, is a web content manager for the American Association of Sleep Technologists.

BY TAMARA SELLMAN RPSGT, CCSHRITA BROOKS MED, RST, RPSGT, REEG/EPT

Rita Brooks MED, RST, RPSGT, REEG/EPT is the President of the American Association of Sleep Technologists. She is the Director of Diagnostic Services for Capital Health in Trenton, N.J.

A2 Zzz 25.1 | March 2016

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and varied topics. At the most recent conference an associate professor in neurology discussed what goes on in the brain during different sleep stages, and another speaker focused on the power of sleep and naps from a physician’s perspective. Brandon indicates the Iowa society’s educational endeavors target topics beyond obstructive sleep apnea (OSA) and mirror the AAST’s focus on better preparing sleep technologists to fulfill more advanced roles within the sleep community. Their educational programs have also included Board of Registered Polysomnographic Technologists (BRPT) examination review sessions for those preparing for Registered Polysomnographic Technologist (RPSGT) registry.

A major challenge for state sleep society leadership is making the society relevant to everyone’s interest. As a respiratory therapist who has been involved in both sleep and respiratory national and state societies for 20 years, Brandon believes professionals must care about their profession and support and participate their regional and national professional societies. The primary goal of the Iowa State Sleep Society is to provide a voice for sleep professionals. Now that the huge licensing hurdle for Iowa sleep technologists is resolved the society is focused on

877.735.6827 MVAPMED.COM

preparing technologists to do their jobs well. One of the major benefits of being a state sleep society member is the low cost for quality education and the ability to maintain essential continuing education credits (CECs) without incurring airfare and hotel costs. Support from the national organization is important to state sleep societies. These interviews are part of a renewed effort by AAST leadership to contact state sleep society leadership to determine what resources AAST can provide. The AAST is expanding the website to list state sleep society meetings and making efforts to provide an AAST representative as a speaker at state sleep society meetings upon request. Assistance with developing committees and managing social media accounts were identified as additional support needs for state societies. Another suggestion the AAST is making efforts to support was to provide a contact at the national level who can help local leaders keep their society members abreast of the AAST vision of the future for sleep technologists. AAST leaders are committed to supporting the state sleep societies and we hope that all state sleep society leaders will provide information that we can disseminate to AAST members to support local activities and needs.

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Regina Patrick, RST, RPSGT, has been in the sleep field for more than 20 years and works as a sleep technologist at the Wolverine Sleep Disorders Center in Tecumseh, Michichigan

REGINA PATRICK, RST, RPSGT

OBSTRUCTIVE SLEEP APNEA AND ATRIAL FIBRILLATIONBy Regina Patrick, RST, RPSGT

Atrial fibrillation is a heart arrhythmia characterized by an irregular and often rapid heartbeat (typically 110–140 beats/

min, but it can rise as high as 170 beats/min). Some research1,2 indicates an increased prevalence of obstructive sleep apnea (OSA) among people with atrial fibrillation. After treatment for atrial fibrillation, people with OSA are at a higher risk of recurrence, compared to people without OSA. Scientists are uncertain whether OSA contributes to or causes atrial fibrillation. However, the findings of a recent study suggest that OSA may cause, rather than simply be correlated with, atrial fibrillation.3

During a normal heartbeat, the atria normally contract virtually in unison in a coordinated manner to push blood into the ventricles; the ventricles similarly contract to push blood to the lungs. During an atrial fibrillation episode, the atria contract in an uncoordinated fashion (i.e., different parts of the atria contract independently), and consequently several atrial contractions can occur before the ventricles contract. Most episodes of atrial fibrillation are asymptomatic but many people experience symptoms such as palpitations, dyspnea (i.e., difficulty breathing), fatigue, dizziness, angina (i.e., chest pain), and heart failure (i.e., inability of the heart to pump blood efficiently). Atrial fibrillation can be treated by medications that control the heart rate (e.g., beta blockers such as propanolol) or that can convert the heart rhythm back to normal (e.g., amiodarone, quinidine, disopyramide), by cardioverter devices (e.g., defibrillator, implantable cardioverter-defibrillator, external cardioverter-defibrillator), or by surgery through procedures such as pulmonary vein isolation that discretely destroys tissues associated with triggering atrial fibrillation.

In OSA, the upper airway muscles relax excessively during sleep, which allows tissues such as the tonsils and adenoids to be drawn into the airway and block airflow. The person makes increasingly stronger respiratory movements in an effort to restore airflow, to no avail. With airflow blocked, the blood oxygen level falls, which ultimately triggers a brief arousal. On arousing, the upper airway muscle tone is restored, which allows the upper airway to open, and the person is able to take a few deep quick breaths to restore the

oxygen level to normal. Once the oxygen level is restored, the person resumes sleep, which may set the stage for another apnea event.

The interrelations between the heart and respiratory system may explain the correlation between atrial fibrillation and OSA. For example, the sympathetic nervous system is activated, resulting in a rapid heart rate, when a person arouses to take a few breaths after an episode of apnea. Some research has found that a sudden surge in sympathetic activation followed by an abrupt shift to vagal activation occurs immediately before the onset of an atrial fibrillation episode.4 It may be that the OSA-related surges in sympathetic activity could set the stage for atrial fibrillation in some people.

Other researchers have focused on nerves on or near the heart as the trigger for episodes of atrial fibrillation, which may become activated during an OSA episode. For example, Tan and colleagues5 used a canine model of paroxysmal (i.e., sudden) atrial fibrillation to examine whether blocking the stellate ganglia (which have a role in heart rate variability6) and the superior cardiac branch of the vagus nerve (which mediates the interplay between respiration and heart rate and blood pressure [i.e., cardiorespiratory coupling ]7) would prevent or reduce atrial fibrillation episodes. After blocking these nerves, Tan artificially induced atrial fibrillation intermittently in the dogs for several weeks. Episodes of atrial fibrillation would normally continue after the removal of the stimulus. However, these dogs had no episodes of atrial fibrillation once the stimulus was removed. By contrast, in another group of dogs in which these nerves remained intact, episodes of atrial fibrillation, premature atrial contractions, or atrial tachycardia continued after the stimulus had been removed.

In a canine model, Muhammad Ghias and colleagues8 focused on the role of the ganglionated plexi (i.e., a network of nerves on the atria around the pulmonary vessels) in apnea-induced atrial fibrillation. They ablated ganglionated plexi by the right pulmonary artery. Before the plexi were ablated, the dogs, whose breathing was controlled by a respirator, underwent simulated apnea while atrial fibrillation was artificially induced. In most dogs, atrial fibrillation occurred in response to the signal. The ganglionated plexi were then ablated and the dogs underwent the procedure again. This time atrial fibrillation could not be induced during the apnea. Ghias concluded that ablation of the ganglionated plexi inhibited apnea-induced atrial fibrillation.

Another factor that may contribute to atrial fibrillation is the changes in intrathoracic pressure during an OSA episode. As a person struggles to breathe through the obstructed airway,

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the intrathoracic pressure decreases substantially (i.e., the intrathoracic pressure becomes negative). With the resumption of breathing the intrathoracic pressure quickly rises. The sudden swings in the intrathoracic pressure result in large changes in the heart’s transmural pressure (i.e., the pressures exerted on the heart internally and externally). When the intrathoracic pressure (i.e., pressure exerted on the heart externally) is low during an apnea, the pressure exerted from blood inside the heart is greater, which can cause distension of the ventricles and atria. In addition, hypercapnia, hypoxia, and apnea-induced arousals activate the sympathetic nervous system and result in large surges in blood pressure, which also can contribute to excess intracardial (i.e., within the heart) pressure. These OSA-related factors may contribute to structural changes of the heart such as increased left ventricular mass and increased left atrial volume that have been reported in the literature.9,10

Surgery is sometimes used to treat people with atrial fibrillation for whom drug therapy and other treatments have been unsuccessful. One procedure is pulmonary vein isolation. Four pulmonary veins arise from the left atrium (two veins take unoxygenated blood to the left lung, and two veins take unoxygenated blood to the right lung). In pulmonary vein isolation, discrete areas on the left atrium that encircle the base of each vein are ablated by radiofrequency or cryoablation (i.e., freezing). Some research has implicated these sites as a trigger for atrial fibrillation.11 For many people, episodes of atrial fibrillation cease after this procedure. However, people with OSA are more likely to have a recurrence of atrial fibrillation, compared to people without OSA who have undergone this treatment.

The impact of OSA treatment on atrial fibrillation recurrence after treatment has not been examined in depth. Therefore, Thomas Neilan and colleagues12 investigated whether therapy for OSA (e.g., continuous positive airway pressure [CPAP]) could have a beneficial effect on cardiac structural remodeling in patients with atrial fibrillation, and thereby reduce or eliminate the recurrence of atrial fibrillation episodes after pulmonary vein isolation in people with OSA. In their study, they questioned patients who were to undergo pulmonary vein isolation about whether they had OSA. The patients who reported having OSA had previously undergone a formal sleep study. After the procedure, all patients were followed up. A patient was considered to have a recurrence of atrial fibrillation if an electrocardiogram or prolonged cardiac monitoring showed episodes of atrial fibrillation occurring 3 months or later after the procedure. (The patients were followed monthly for the first 3 months and then

at 3- to 6-month intervals for the first 2 years.) The sleep apnea group was divided into two groups: treated (i.e., the patients used CPAP for 4 hours or more nightly) and untreated OSA (i.e., the patients used CPAP for fewer than 4 hours nightly).

Neilan found that between the treated and untreated OSA groups, recurrence of atrial fibrillation after 3 months was higher in the untreated OSA patients (68 percent) than in the treated OSA patients (35 percent). On comparing the OSA groups collectively to the non-OSA group, Neilan found that 51 percent of patients with OSA had a recurrence of atrial fibrillation after 3 months, compared to 30 percent of patients without OSA. Neilan suggests that OSA treatment has a very strong impact on the recurrence of atrial fibrillation.

Other phenomena Neilan noted were increased left ventricular mass (i.e., thickened ventricle, which can lead to heart failure), enlarged left atrium and right ventricle, and reduced right ventricular function in people with OSA, compared to people without OSA; people whose OSA was treated had a lower left ventricular mass and a reduced left atrial size, compared to people with untreated OSA; and a large number of patients (20 percent) who had been referred for pulmonary vein isolation also had OSA. Neilan encourages more work on the impact of OSA treatment on atrial fibrillation treatment. Daniel Gottlieb,3 citing the work of Neilan and other researchers, believes that such findings may implicate OSA as a cause of atrial fibrillation. However, Gottlieb cautions that the design of Neilan’s study does not allow one to determine conclusively whether CPAP therapy truly reduced the risk of recurrence of atrial fibrillation since the patients’ heart dimensions were measured only once before the pulmonary vein isolation procedure. Gottlieb suggests that had the heart structure of the patients with OSA been measured soon after they had begun CPAP therapy (the patients had been on the therapy approximately 18–31 months) but before the study, it would have been easier to distinguish the true extent of treatment-related remodeling of their heart structure, and the extent to which such remodeling reduced the risk of recurrent atrial fibrillation.

Some people with refractory (i.e., treatment-unresponsive) atrial fibrillation may have undiagnosed OSA. If scientists determine that OSA is a cause of atrial fibrillation, then physicians may need to consider assessing patients with atrial fibrillation sooner for OSA. It may be that treating OSA could improve the response to or reduce the need for medications or could improve treatment outcome in patients who undergo ablation surgery.

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REFERENCES1. Monahan K, Storfer-Isser A, Mehra R, et al. Triggering

of nocturnal arrhythmias by sleep-disordered breath-ing events. Journal of the American College of Cardiology. 2009;54:1797-1804.

2. Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110:364-367.

3. Gottlieb DJ. Sleep apnea and the risk of atrial fibrillation recurrence: Structural or functional effects? Journal of the American Heart Association. 2014;3:e000654.

4. Bettoni M, Zimmermann M. Autonomic tone variations before the onset of paroxysmal atrial fibrillation. Circula-tion. 2002;105:2753-2759.

5. Tan AY, Zhou S, Ogawa M, et al. Neural mecha-nisms of paroxysmal atrial fibrillation and paroxysmal atrial tachycardia in ambulatory canines. Circulation. 2008;118:916-925.

6. Yokota S, Taneyama C, Goto H. Different effects of right and left stellate ganglion block on systolic blood pressure and heart rate. Open Journal of Anesthesiology. 2013;3:143-147.

7. Campbell HA, Egginton S. The vagus nerve mediates cardio-respiratory coupling that changes with metabolic demand in a temperate nototheniod fish. Journal of Experi-mental Biology. 2007;210(Pt 14):2472-2480.

8. Ghias M, Scherlag BJ, Lu Z, et al. The role of ganglionated plexi in apnea-related atrial fibrillation. Journal of the Amer-ican College of Cardiology. 2009;54:2075-2083.

9. Chami HA, Devereux RB, Gottdiener JS, et al. Left ventricular morphology and systolic function in sleep-dis-ordered breathing: The Sleep Heart Health Study. Circula-tion. 2008;117:2599-2607.

10. Cloward TV, Walker JM, Farney RJ, et al. Left ventricular hypertrophy is a common echocardiographic abnormality in severe obstructive sleep apnea and reverses with nasal continuous positive airway pressure. Chest. 2003;124:594-601.

11. Jais P, Haissaguerre M, Shah DC, et al. A focal source of atrial fibrillation treated by discrete radiofrequency abla-tion. Circulation. 1997;95:572-576.

12. Neilan TG, Farhad H, Dodson JA, et al. Effect of sleep apnea and continuous positive airway pressure on cardiac structure and recurrence of atrial fibrillation. Journal of the American Heart Association. 2013;2:e000421.

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TAMARA SELLMAN, RPSGT, CCSH

Tamara Kaye Sellman RPSGT, CCSH is a science journalist and sleep health activist. She is currently writing a book on sleep hygiene for mainstream audiences which she hopes to launch in 2016. She is curator of the sleep health information clearinghouse, SleepyHeadCentral.com, and staff writer for Somnosure, Inc. and InBoundMed.com.

ARE ALL POLICY AND PROCEDURE MANUALS CREATED EQUAL? By Tamara Sellman, RPSGT, CCSH

Sleep center policy and procedure manuals (P&Ps) are a workplace mainstay. Or at least they should be. It might be

surprising to learn that, in some sleep centers, no such manual exists, or if it does, it is grossly out of date, hard to access, or literally falling apart at the seams.

Just because we, as sleep technologists, work in the dark doesn’t mean we should be kept in the dark regarding policies and procedures.

WHY HAVE A P&P?The P&P is the single best resource for ensuring all employees are “on the same page” regarding workplace protocols and the shared goals of a sleep center: to provide quality diagnostics and therapeutics for patients with sleep disorders. The P&P not only provides guidance but offers users a measure of legal protection; after all, the first course of legal action in a situation involving staff or protocol is to consult the P&P. It is also consulted during regulatory compliance audits and is required for American Academy of Sleep Medicine (AASM) accreditation.

However, the P&P isn’t just a bureaucratic compilation meant only for administrators. It provides sleep technologists with real-world, hands-on guidance—like recipes in a cookbook, if you will—for addressing variations in protocols while on the job.

A typical P&P is a large ring-bound file housing the sleep center’s core policies (“the rules”) and procedures (the “how to” of “the rules”). Today’s sleep centers may also use electronic formats residing on dedicated computers or a network for quick access.

WHAT’S IN THE P&P?P&P documents could include:

• Detailed flowsheets for specific tests• The latest AASM practice parameters and clinical/”best

practice” guidelines • Sleep center safety rules

• Key phone number lists for after-hours calls• Codes of ethics and the sleep technologist “Scope of Practice”• Master copies of shareable patient form blanks and

education media• Manufacturer manuals, data sheets, charts, diagrams• Emergency procedures• Equipment cleaning and maintenance instructions• Human resources FAQs and administrative documents• Electronic health record (EHR) instructions• HIPAA requirements • Legal documents

Influential policies and procedures also come from outside the sleep center—The Joint Commission, Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and affiliate hospitals—and should be included.

When started at ground zero, most P&Ps are generated by customizing a generic template, such as one offered by the AAST, to the specific language and priorities of the medical director. Some P&Ps are written entirely in original language, while others are a collage of referenced sources, or a combination of both.

Reviews should be a yearly undertaking, led by the medical director or sleep center manager, with updates made in a timely fashion following changes in protocol or AASM parameters. All changes must be made in writing, added to the P&P directly, approved by the medical director, and promptly disseminated to all users as photocopies or via email links.

ARE ALL P&PS CREATED EQUAL?They are equal in that they ideally provide guidance, protection, and clarity for the sleep center staff. But they are always imperfect “works in progress.” While most sleep centers typically follow AASM practice parameters, even these offer wiggle room for customizing protocols. By their very nature, P&Ps will vary because their focus and content reflect the perspectives and priorities of individual medical directors.

For example, one sleep center’s split-night protocol might require 2.5 hours of recording time before switching from nocturnal polysomnography (NPSG) to titration, while another may require only 2 hours. This doesn’t mean the P&P is wrong, but it does mean sleep technologists need to know what their P&P requires.

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P&Ps may not be equal, however, for other reasons.

Consider the assembly. Poor bindings, lack of tabs and contents pages, and missing content render a P&P useless. Same with vague documentation that’s too generic for real-world application.For example, apnea–hypopnea index (AHI) rules to qualify a patient for split-night protocols vary from sleep center to sleep center. However, some sleep centers count central apneas as part of AHI; some do not. It’s up to the P&P to clarify this protocol. If the P&P doesn’t, the technologist should address this omission with their superiors, who should then update the P&P accordingly.

Whatever happens, do not work against written protocol, and document conflicts as they arise. Common sense means placing phone calls to the on-call supervisor to clear up any discrepancies. If they don’t call back, and you feel the P&P is not addressing your specific situation, you may wish to default to AASM guidelines—just be prepared to “show your work” later.

IN CASE OF P&P FAIL Congratulations! You have a new job! But you discover that the P&P at your sleep center is:

1. Impossible to use (poor binding, missing or unreadable content)

2. Out of date3. Lost or inaccessible4. Nonexistent

What do you do? 1. Request an upgrade to make it user-friendly.

A simple request is not out of line. Meanwhile, attach sticky notes where you suspect missing content; flag indiscernible content as you find it. If it’s just a matter of replacing the binding, and you have the time and inclination, you might volunteer to do this yourself if they’re willing to provide or reimburse for materials.

2. Request an update. Example: Old guidelines for scoring hypopneas by desaturation (3% versus 4%) may conflict with newer guidelines. Show your superiors the latest information to support your request. Maybe those in charge are unaware of updates or haven’t made P&P updates a priority. Your request may move it to the top of their to-do list.

3. It it’s lost, ask for a new one. At the thought of the work involved, someone might magi-cally make it reappear. Or, if it’s located, but never kept in the same place, request it be kept on a shared community shelf. A P&P is useless if it can’t be found. If a digital P&P becomes lost to security lockouts or corrupted files, inform your sleep center manager immediately. A printed backup of the elec-tronic P&P may be in order.

4. Request a new one. It’s in everybody’s best interest to not only have a P&P, but to use it. If you can’t request this of your medical director, try the day manager instead. If you’re met with indifference or resistance, approach human resources with your concern.

P&P, FOR THE WIN!Try these suggestions for building or improving your sleep center P&P:

• Work directly with your sleep center manager or medical director to develop one. You could glean important experience for a future role in management, and the needs of technologists might be better met through your advocacy.

• Strive for organization. Use a contents page, sections and subsections, color-coded tabs, and an intuitive navigation system.

• Build it to be easy to update later. • For large sleep centers: Designate identical copies for the

technologists, the front office, and management.• At sleep technologist meetings, include “P&P updates” in

your agenda.• Create a collaborative document where suggestions and

observations are posted by technologists for review by the medical director during updates.

• Don’t forget discussions about insurance requirements, especially when they contradict sleep center protocols.

• Use relevant, pertinent information.

REFERENCESAmerican Academy of Sleep Medicine. (n.d.) “Accreditation FAQ.” Retrieved from http://www.aasmnet.org/accred_centerfaq.aspx

American Academy of Sleep Medicine. (November 7, 2014.) “Standards for Accreditation.” Retrieved from http://www.aasmnet.org/resources/pdf/accreditationstandards.pdf

American Association of Sleep Technologists. (n.d.) “2014 Policy & Procedure Manual Templates.” Retrieved from https://go.aastweb.org/store/product.aspx?pid=1015

Trimble, M. (August 9, 2013.) “Establishing Policies and Procedures within the Sleep Center.”

Kansas Association of Sleep Professionals. Retrieved from http://www.kansas-sleep.com/KASP%202013%20presentations/Melinda%20Trimble%20Kansas%20Policies%20and%20Procedures%208-19-13.pdf

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LISA M. BOND, RST, RPSGT

Lisa M. Bond RST, RPSGT, has been in the healthcare field since the late 1980s and the sleep field since the early 1990s. She currently works as a contract scoring technician.

DEALING WITH THE DEAF PATIENT IN THE SLEEP CENTERBy Lisa M. Bond, RST, RPSGT

Throughout your time working as a sleep technologist you will run into many different types of patients, each with their own

special needs. Sometimes those needs are challenging; but with a little direction and a few tips you can successfully navigate any issue and provide quality patient care for all of your patients.

One type of special need you may see in the sleep center is a patient who is either deaf or so significantly hard of hearing they are classified as deaf. Your ability to communicate effectively with these patients is vitally important; as the sleep technologist caring for the deaf patient you need to be able to explain what they should expect during their sleep study and what you will need them to do to assure they receivean excellent study and appropriate care.

First and foremost, did you know that by law you are requiredto provide an interpreter for a deaf patient? It is not the patient’s responsibility to bring someone along to interpret. Even if they do bring a family member or friend, unless the patient refuses in writing, a professional interpreter must be available, either in person or via technological means.

Having family in the sleep center with the patient has the potential to be either a boon or a bane with every patient. It is

great when family is there to provide support and help the patient to remember things afterwards, or even to ask for some additional clarification when the patient may be hesitant to ask. However, when a patient has special needs such as deafness, you need a professional who can sign the complicated words and medical terminology that we use and assure that the patient understands. There is also always the delicate issue of asking the patient questions that the family may not wish to ask, or the patient may not wish to answer, due to embarrassment. Privacy is always a concern, and is a key reason that we have laws that require that we offer an interpreter.

I have had the good fortune to be able to work frequently with an actual on-site interpreter. This is always preferable but is not always practical.The alternative is a video remote interpreter (VRI) but there are many technical issues your information technology (IT) department will have to resolve before you plan to use one. They are also a bit bulky and when you are hooking a patient up, frequently in a small space where you are moving around and blocking the patient’s view of the device, it is not nearly as convenient or quick as a human being who can also move around and keep within the patient’s view. I have found that working with an on-site interpreter caused little disruption and involved nearly no extra time for setting the patient up. However, using a VRI as an interpreter requires significantly more time for hook up, so be sure to plan for the additional time needed when using this technology.

A VRI is a viable alternative for remote areas where you may not have available an onsite interpreter. They do provide real time interpretation. However, it is important that you take into account

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that the screen needs to be large enough for the patient to see well and consider placement of the device carefully; it must be located where the patient can see it at all times. The screen needs to be large enough and of sufficient quality to clearly display the interpreter’s face, arms, hands and fingers. You will also need to make sure that there is no lag or delay in the communication, which requires adequate bandwidth. The sound microphone needs to be of high quality as well so that the interpreter can hear what you, the caregiver, are saying. So as mentioned previously, your IT department will have to make sure that your system is set up properly and meets all the standards for such a device. Staff using this device will also need training in order to quickly and properly set up and use the device. Again, it is of utmost importance that the patient can see it all times; and that requires remembering not to block the patient’s view or place the equipment where they have to constantly turn to be able to see the device. This may mean you having to move the device periodically to keep it in the patient’s view and adjust how you do your hook up as well, to not block that view. Hence the reason more time should be set aside if you are going to use this device.

You may be wondering if you are going to need that interpreter for the entire night. I have not generally found that to be necessary. Normally, after the patient has been hooked up, we have completed bio-calibrations, and the patient is ready to sleep the interpreter can be sent home to return in the morning for the unhook process and to provide follow-up instructions. During the night pen and paper will usually be sufficient communication tools. Make sure you have completed any and all desensitization, fitting, and explaining of the mask and positive airway pressure (PAP) devices well before the patient goes to bed and while your interpreter is still present in case you need to perform a split-night study.

The patient should be comfortable with a communication plan prior to the interpreter leaving; I never allow the interpreter to leave if the patient feels uncomfortable and thinks they may need them during the night. To date I have not had any patient that felt they needed someone there while they slept when they knew the interpreter would be back first thing in the morning, shortly before they would be awakened. Pen and paper has always been sufficient for the middle of the night run to the bathroom or other communication needs during the night.

There are a few protocols that should be observed when you are working with an interpreter. First and foremost, talk to the patient! It is our natural instinct to look at the person talking, however when you are dealing with an interpreter you must always look at the patient and talk to the patient, not the interpreter. Just as when you are working with any other patient, you want to make sure you maintain eye contact with your patient while you are working,

talking, and demonstrating. Do not talk to the patient with your head down or turned away and do not mumble.

Here are some helpful tips for patient hook up. There are times during the hook up that you will need to move around behind the patient. Make sure you tell the patient what you are going to do and make sure that the interpreter is keeping up and informing the patient of what you will be doing. With a deaf patient it is more important than ever to let them know what you are going to be doing before you move out of their sight. I have developed a system that works well for me. I explain what I will be doing, and that I will tap their shoulder before proceeding to the next step. For example, I tell the patient about the electroencephalogram (EEG) placement and show him the leads while standing in front of him, and explain that before each lead placement I will be tapping his shoulder. This way, though I was behind him, the interpreter in front of him could sign that I was going to put another electrode on the scalp. I tap the patient’s shoulder before actually placing each lead. I have found that using this method my patients quickly begin to relax and to trust me. The extra moment taken to tap the patient’s shoulder before I start touching his head is well worth the effort in assuring patient comfort.

Keep in mind when working with the deaf patient that there is no need to speak loudly, or exaggerate your mouth or lip movements. For those that read lips, you will only make it more difficult for them to understand you, not less so. It is also important to make sure that the room is well lit so that the patient is able to clearly see the interpreter and what is going on around them.

An important thing to discuss with your patient while an interpreter is available is how they wish to be approached if you need to enter their room during the study. It is vital that you talk about this. Whereas with another patient you might slip into a room and fix something quietly without waking the patient and simply slip back out, that is not going to happen with a deaf patient. The deaf patient is much more attuned to their surroundings with their other senses. Sneaking into the room of a deaf patient is likely to be a frightening experience. My patients have all stated that if I would simply tap or jostle the foot of the bed and briefly wake them that would be satisfactory.

Trust me if you have discussed this with the patient ahead of time, they are going to relax and go to sleep easier as they will trust that you are aware of and sensitive to this need. I also tell the patient that if I need to fix something during the night that once I woke them I would give them a thumbs down to indicate something was not working correctly and then point on myself to what area I needed to access to correct the issue. For example a thumbs down and then pointing to my own left leg would let them know that was the lead I needed to fix. I also always offer a night light for

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the patient; and I have found that mostpatientsprefer that it is left on for them. Keep a pen and paper near the patient and handy if communication during the night if necessary.

It is important to assure that the patient knows how to contact the technologist during the night. I inform my patient that at any point if they need me they should call out or simply clap their hands. When I have more than one patient I make a point of letting the deaf patient know that if I do not respond immediately I may be in the other patient’s room. The patient is instructed to wait a moment and then repeat the process. In addition, I instruct that if they need to go to the bathroom it is a good idea to sit up. Then, when I come out of the other patient’s room and see they are sitting on the side of the bed I would immediately know to come in and get them up to the bathroom. I explain this will reduce the wait time and the need for them to call out again or clap. Remember, the deaf patient is not able to hear you say “just a moment” over an intercom, so it is vital that you explain and work out how delays on your entering the room will be handled.

Award recipients are recognized at the Annual

Meeting. Each recipient receives a plaque,

complimentary registration to attend the

AAST Annual Meeting and reimbursement for

travel, hotel accommodations and meals.

For more information and to nominate, visit:

aastweb.org/awards.aspx

Know someone making a difference in the sleep

technology field?

Nominate them for an AAST Award:

AAST Leadership Award

AAST Service Award

AAST Professional Development Service Award

AAST Literary Award

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Every person having a sleep study feels vulnerable. The patient who has a hearing loss feels even more vulnerable. It is your job to make sure you do everything you can to make the deaf patient as comfortable as possible, and alleviate any fears they may have before lights out. Communicating with the deaf is much easier than you may think with the application of just a bit of forethought.

REFERENCESDisability Rights Section of the U.S. Department of Justice. Retrieved February 12, 2016 from http://www.justice.gov/crt/disability-rights-section

“Communicating with People with Hearing Loss.” UCSF Medical Center. Retrieved February 12, 2016 from https://www.ucsfhealth.org/education/communicating_with_people_with_hearing_loss/

Iezzoni LI1, O’Day BL, Killeen M, Harker H. (2004). Communicating about health care: observations from persons who are deaf or hard of hearing. Ann Intern Med. 2004 Mar 2;140(5):356-62.doi:10.7326/0003-4819-140-5-200403020-00011

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You don’t have to work in sleep for many years to first hear the question “So, how many hours of sleep do we REALLY

need?” And the answer is invariably 7.5 to 8 hours of sleep. And, if pressed for more information, one might have answered that it all depends on the age of the person, and the energy expended during the day, and whether they are healthy or sick. The young need more sleep, the elderly slightly less. More sleep is also required for the more active person, and for those that are sick or infirm. Sleep is restorative and repairs tissues and promotes health. Contemporary wisdom also suggests that we, in the west, are cutting ourselves short when it comes to a good night’s sleep. The advent of the electric light bulb, television, coffee machines (mmmmmm, coffeeeee), the internet, and now smart phones have lead to a significant reduction in the amount of time spent asleep compared to the time before we had such modern conveniences. Some studies showed a drastic reduction in sleep of about 2-3 hours from more primitive times to present day modern society.

However, recent anthropological findings are shedding new light on these concepts. Dr. Jerome Siegel and his team from the Semel Institute of Neuroscience and Human Behavior at UCLA, studied three pre-industrial traditional hunter-gatherer societies: the Hadza of Tanzania, the San of Namibia, and the Tsimane of Bolivia. The researchers recorded the sleeping habits of 94 individuals around the clock to collect data representing 1,165 days in all. These three groups represent the whole spectrum of human migration, and quite possibly evolution. The two African groups were closer to where we believe modern humans evolved, while the Tsimane of Bolivia were closer to the end point of the human global diaspora.

Dr. Siegel and lead author Gandhi Yetish, a PhD candidate at the University of New Mexico, have reported that it seems that we, modern humans, are sleeping just as much now, as we did

“NORMAL” SLEEP ACROSS THE AGES: A COMPARATIVE STUDY OF SLEEP IN THREE CONTEMPORARY PRE-INDUSTRIAL SOCIETIESBy Rui de Sousa, BSc, RPSGT, RST

millennia ago. He believes the notion that we sleep less than our hunter-gatherer cousins may be more fiction than fact. His study observed three modern-day hunter-gatherer societies, and concluded that Americans, on average, sleep as much—IF NOT MORE—than the individuals in these three pre-industrial civilizations. In fact, according to the study, people in these pre-industrial societies sleep a little under 6.5 hours a night, on average. They also did not nap and they did not go to sleep as soon as it got dark. This in itself is interesting, because we were always taught that ancient man prepared for sleep when it got dark and the advent of the light bulb changed the natural order of things. Modern sleep medicine dictates that humans evolved as diurnal creatures, awake and aware during the daylight hours, and asleep during the night, heading to “bed” soon after the sun went down.

We also see that both modern/western society and the three pre-industrial societies spent approximately the same amount of energy on a daily basis. Our current understanding would suggest that primitive societies might expend more energy, exercising more often, walking everywhere. This would lead to more sleep (remember, the more active you are, the more sleep you need) and better general health. Yet, this study confirms observations from previous research that shows these primitive societies were relatively fit and healthy, despite sleeping as much if not less, then we currently do in North America. Studies have also shown that the daily energy spent was about the same as that for most Americans, suggesting that physical activity was not the sole reason for their good health.

So, not only were these more “primitive” societies sleeping as much as we are now, but they were just as healthy. Established wisdom suggests that lack of sleep, independent of other factors like physical activity, is associated with obesity and chronic disease. And yet, we see these three societies were in relatively good health.

What hasn’t been studied or reported is any age differences between the two societies. Do the young and the elderly show similar sleeping patterns? We are tempted to assume this trend would continue, that the similarities would persist, but as we saw from Dr. Siegel’s seminal work however, these assumptions cannot be taken for granted.

BY TAMARA SELLMAN RPSGT, CCSHRUI DE SOUSA, BSC, RPSGT, RST

Rui de Sousa is a Canadian sleep technologist with over 20 years experience helping patients sleep better in and around the greater Toronto area.

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This latest research also weighs in on the established idea that natural sleep is divided into two halves of the night. From early pre-industrial writings, we knew that in the past man would sleep from sun down until midnight, and then from 2 or 3 am until sunrise, waking up in the middle of the night for 2-3 hours. Napping for an hour or so in the middle of the day was considered normal, even advisable. The accepted thought was that human sleep is not naturally consolidated into 7-8 hour episodes, that this “need” to sleep one solid block is a by-product of “modern” living. Our lifestyles (work and recreation) demand full participation in society from sun-up until bedtime, and with the invention of the electric light bulb, our bed times became progressively later and later, as work and recreation kept us awake longer and longer. Therefore, sleep had to become consolidated into one solid block to accommodate later and later bedtimes.

However, this study also debunked this concept. The observations from the current research showed that these hunter-gatherers also slept in one consolidated sleep period, mirroring our very own sleep patterns. So here we have three societies, without electric lights, without modern technological distractions, staying instinctively awake well into the night, roughly going to sleep and waking up at the same time (or even slightly earlier) than we do now, and sleeping throughout the night in one consolidated period.

Interestingly, even more recent evidence has come to light to bolster these results. The Jawbone UP®, a fitness tracker, has been compiling data on the sleeping habits of its Indian users, reporting that they rest less than many westerners. According to a released report compiled after analyzing data from Jawbone Up fitness trackers, sleep among Indian users was about 6.5 hours per night. Kolkata’s residents got the least sleep, averaging 6:16 hours, while those in Panaji slept 6:46 hours. Although this is a modern culture, it is decisively non-western, and we still see similar sleep requirements as those seen in the three pre-industrial tribes studies. Jawbone says it analyzed aggregated data from thousands of Up users throughout the year for their report, although no mention was made regarding quality of sleep nor overall health.

And yet, we complain, nay, obsess, over poor sleep, insufficient sleep, daytime sleepiness and insomnia in general. Why did these hunter-gatherers, sleepers very much like our modern-day, technologically connected western societies, feel that they sleept so much better than we do? Why did they rarely complain of insomnia? In fact, insomnia was so rare, that some tribes did not even have a word for it. How can that be? We sleep the same

amount, we have the same daily energy expenditure, we require roughly the same amount of sleep, so why are we so obsessed with our poor sleep?

The reason postulated for this is as profound as it is simple. Temperature stimuli are theorized to be the driving factor in sleep initiation and consolidation, superseding light cues.

We have always believed the notion that sleep and sleepiness were triggered by light cues, specifically the approaching darkness. As the sun set and darkness came, ancient man would yawn, signaling the sleep period. As the sun rose in the early morning, the light would wake us up and the day would start anew.

However, the current observations are more consistent with the concept that temperature is the main factor in initiating and maintaining sleep. As temperatures begin to fall, a few hours after the sun has set, sleepiness sets in. These societies went to sleep almost 3.5 hours after sunset. As the temperatures CONTINUED to drop, sleep continued unabated. This idea has important implications. Then as the ambient temperature reached its nadir, these people would wake up, just as the sun started to rise. Importantly, awake to get early morning sunshine.

So, despite the similarity in sleep patterns, why are our subjective experiences of sleep quality so disparate. Why do modern societies feel they sleep so little? Part of the problem may be due to what we define as a good night’s sleep. We are taught that we need 7.5-8 hours of sleep. So, we think, if we only get 6.5 - 7 hours, clearly we are cutting ourselves short. Quick!! Run to the doctor, we need sleeping pills; we are not getting enough sleep!! But in fact, this 7.5 - 8 hour requirement seems to have been originally meant as “time in bed”. The recommendation was given with the knowledge that periods of wakefulness may cut the true sleep time to the more normal 7 hours of sleep. This fact may have been “lost in the shuffle”.

There are other factors too, which may have significant impact on how we view and treat insomnia. Let’s explore the temperature factor a little further. If temperature is “the” important cue for sleep, then we have lost that variable in modern life. We have long counseled insomniacs to sleep in a cool room, to take a warm shower or bath, letting the body cool naturally to initiate sleep, some of us even have programmable thermostats that drop the house temperature a few degrees late at night. All of these are great practices. However, we still sleep in an environment characterized by a steady temperature. The ambient temperatures may have dipped initially late at night, but

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the house remains at a relatively steady temperature throughout the night. It is postulated that, perhaps, the temperature should CONTINUE to drop slowly throughout the night. This may have important implications for sleep architecture, as temperature may affect timing and amount of rapid eye movement (REM) sleep, for example. The continuing drop in ambient temperatures may also have been the wake-up cue for the three pre-industrial societies in the study. This resulted in an added benefit of waking up sleepers to witness the early morning sunshine. We know that exposure to early morning light is crucial in resetting our circadian clocks. Light continues to be the primary zeitgeber, the master clock synchronizer. Exposure to morning sunlight helps reset everyone’s circadian rhythms, and by the end of the day, we are ready to sleep.

It is important to note that this advice is consistent with current therapies for insomnia. What has changed is the emphasis on the importance of temperature, especially a dynamic temperature, rather than on light cues after sunset.

At this point, I think it is important to add that “insomnia” is not always a disorder of initiating sleep. We are well aware that sleep disorders such as periodic limb movements of sleep (PLMS) and obstructive sleep apnea (OSA) can result in “insomnia”, non-restorative sleep and daytime sleepiness. Although I cannot postulate on the relative incidence of PLMS in modern vs ancient man, I am more than comfortable asserting that obstructive sleep apnea is much more prevalent in modern times than at any previous point in human history. A combination of excessive food, sedentary lifestyles, and an older population, has made modern society especially susceptible to higher incidence of OSA. We also have to account for the 24-hour modern workday. Now, more than ever, we have growing numbers of people working throughout the nighttime hours. So insomnia is never something so easy to treat as telling someone

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be an additional tool to be used in treating some basic idiopathic insomnia cases.

I think it is reassuring to see, that no matter where we come from, primitive or modern, that as humans, we are more alike than we are different. Even in sleep, we see similarities in our sleep behaviors. We sleep about the same amount, we go to bed and wake up in the same manner, and I will bet we dream the same dreams. Dreams where we make a better life for our loved ones, and survive the next day dodging urgent emails in the office or evading tigers in the savannah or snakes in the forest.

REFERENCESYetish, g., Kaplan, H., Gurven, M., et al. Natural sleep and its seasonal variations in three pre-industrial societies. Current Biology, 25(21), 2862–2868. Accessed at: http://www.cell.com/current-biology/abstract/S0960-9822%2815%2901157-4

Hunter-Gatherers Do Not Get More Sleep Than People in Industrialized Societies Do. Published on October 20, 2015. Accessed at: http://www.sleepreviewmag.com/2015/10/hunter-gatherers-not-get-sleep-people-industrialized-societies/

O’Conner, A. Do we really need to sleep 7 hours a night? NY Times, Well, 10/15/2015. Accessed at: http://well.blogs.nytimes.com/2015/10/15/112251/

Van Boom D. Jawbone user data shows Indians sleep less than most westerners. Gadgets, November 10, 2015. Accessed at: http://www.cnet.com/news/jawbone-user-shows-indians-sleep-less-than-most-westerners/

Moore-Ede MC, Sulzman FM, Fuller CA. The clocks that time us: Physiology of the circadian timing system. February 15, 1984, Commonwealth Fund Publications.

http://www.resmed.com/us/en/healthcare-professional/products/masks/airfit-f10.html

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TAMARA SELLMAN, RPSGT, CCSH

Tamara Kaye Sellman RPSGT, CCSH is a science journalist and sleep health activist. She is currently writing a book on sleep hygiene for mainstream audiences which she hopes to launch in 2016. She is curator of the sleep health information clearinghouse, SleepyHeadCentral.com, and staff writer for Somnosure, Inc. and InBoundMed.com.

RISK MANAGEMENT IN THE SLEEP CENTER: WHAT WE CAN TAKE AWAY FROM RENEE LEWIS V. THE EMORY CLINIC, INC.By Tamara Sellman, RPSGT, CCSH

the negligence (some which will be assigned to Emory Clinic), with the DeKalb County EMT on the hook for 39 percent, and the sleep center director, Dr. David Schulman, assuming 1 percent liability.

The details of Harris’ lab experience were, as expected, a matter of great scrutiny. The audio-visual recordings and polysomnographic evidence both corroborated the patient’s distress and captured the actions of the sleep center staff. The technologists involved were characterized by the plaintiff ’s legal team as lax and underprepared, whereas they were depicted as following protocol by their defending counsel. (The raw video footage was disseminated on the Internet not long after, but has since been pulled due to legal concerns with the exception of fragments included in the WSB-TV link cited in the references)

It’s well understood that patients undergoing sleep studies rarely die. Deaths are usually due to comorbidities and not an outcome of the procedure itself. In the Harris case, it’s considered a sentinel event, defined by The Joint Commission (TJC) as “any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.” The Sentinel Event Policy adopted by TJC in 1996 was created to help healthcare providers undergoing serious adverse events to improve safety and to learn from sentinel events.

But with the odds so slim that this could ever happen again, should sleep technologists be concerned? Probably not, but the Harris case does offer a unique opportunity for us to learn ways to strengthen sleep center risk-management policies so critical to our success.

THE STORY OF BRANDON HARRIS

Twenty-five-year-old Brandon Harris died in January 2010 during a sleep study at the Emory Clinic Sleep Center in

DeKalb County, Georgia. He was there at the request of Dr Srinivas Bhadriraju, a sleep medicine specialist who suspected Harris might be suffering from obstructive sleep apnea. Multiple health issues composed Harris’ medical history, including cardiomyopathy, asthma, diabetes, hypertension, obesity, and mental deficits. During the night, Harris awoke, used the bathroom, expressed problems with breathing, and eventually collapsed. The technologists called 911, but local emergency medical technicians (EMTs) did not respond in time to resuscitate Harris.

Cause of death was listed as sudden cardiac arrest, but when Harris’ family pursued a wrongful death suit (Renee Lewis v. The Emory Clinic, Inc.), claiming negligence on the part of the attending lab technicians, they were granted awards totaling over $20 million, holding the clinic owner, Neurocare, responsible for 60 percent of

THE BRANDON HARRIS ACTFollowing the Emory Sleep Clinic incident, Georgia Senator Vincent Fort introduced state legislation that would further regulate sleep studies in the state of Georgia (beyond the current AASM guidelines) by requiring the following:

• The 24-hour on-site presence of a licensed sleep specialist or licensed nurse professional

• A consent form for patients to read and sign that expresses, clearly and conspicuously, the potential hazards and risks involved in undergoing a sleep study

• Continuing education and recerti-fication requirements for all sleep technologists

• Technologist access to a defibrillator in each patient room

• Required training and certification in basic life-saving techniques, including cardiopulmonary resuscitation

• Misdemeanor judgment for any person who violates or permits a violation of these additional regulations

• New protocols requiring sleep tech-nologists to immediately contact their patients’ emergency contacts in the event they experience “indi-cations of medical distress”

It’s worth nothing that AASM and BRPT guidelines already cover most of these requirements. Technologists who work in nonaccredited facilities or who have not yet become board registered, however, may want to make some changes in light of the Brandon Harris Act, which is still under discussion. This legislation can be found at: http://www.legis.ga.gov/Legislation/20112012/123098.pdf

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We already practice risk management: we ensure bathroom floors are not slippery, assist our patients to and from bed after hook up, or gauge their drowsiness prior to morning departure. Risk and risk management are major buzzwords in today’s clinic environment. It’s no longer as important to measure what’s working (the job of quality control), as it is to identify what’s not working.

Risk can be defined any number of ways, but in a healthcare setting, it starts with a very basic definition: The chance of suffering or encountering harm or loss. Risk managers develop sophisticated algorithms to measure potential errors and probabilities, but for sleep centers , risk management isn’t overly complicated. It involves identifying and assessing risk, with the goal of managing (or preventing) it. Individualized quality control plans can reduce risk by preventing errors from happening in the first place, by detecting and actively addressing the emergence of errors during a patient encounter, and by aiming to achieve the impossible—zero risk.

After all, Brandon Harris died. However unlikely, it could happen again.

What could go wrong? Errors can happen at any point in the continuum of care. Reviewing the continuum:

A WORD ABOUT SAFETYSafety issues are a risk-management priority in every healthcare setting, not only for patients but for workers.

For patients, it’s important to acknowledge a 21st century reality: sleep study patients today are sicker than they’ve ever been. The competency of sleep technologists has never been more critical to patient safety.

• Communication between technologists and patients must be clear and consistent, regardless of whether it is verbal, written, or behavioral.

• Emergency management should include comprehensive P&Ps, flowcharts to inform decision making, and quick access to critical phone numbers.

• Technologists should be assigned to patients based on their abilities and should not be overscheduled if they work solo; so-called “1:1” patient care should be available for complex patients.

• There should also be a worst-case scenario plan in place for solo technologists should they suffer their own medical emergencies while on duty.

• If calling 911 becomes necessary, access protocols for paramedics and EMTs should already be in place.

• Patients who require medications during testing should bring and take them as directed; technologists should remember it is not within our scope of practice to dispense medications.

• Finally, all patients must be assessed for their ability to drive before they leave the sleep center in the morning.

Safety for sleep technologists and sleep centers is also part of risk management.

• Sleep centers must have adequate building security and easy-to-access emergency devices.

• Technologists should have proper training in cardiac first aid, seizure first aid, mental health first aid, application of supplemental oxygen, and informed awareness of protocols regarding atrial fibrillation and fall risks.

• While technologists know that many patients are unwilling or resistant to testing, there needs to be a clear protocol established for difficult patients who are completely noncompliant to test requirements, who become physically threatening, or who behave in ways that suggest sexual harassment.

Sidebar continued on page 29

Let’s look more closely from a sleep technologist’s perspective.

(In the next two sections, comparisons with the Harris case are made. Please note: It is impossible to know how any other technologist might respond, and none of us were present at this particular test. Even with audio-visual evidence, other factors still come to bear on how any technologist acts in any given situation. The point here is not to pass judgment on the technologists involved, but to speculate on how we might improve our own risk management protocols.)

Potential pre-test errors that a sleep technologist could encounter include:

• Assuming a physician’s order exists without verifying proper documentation

• Poor transcription of the order, which risks misinterpretation or confusion

• Failing to communicate or consider a patient’s unique needs or medical history prior to the test

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hear, who have language barriers, or who practice poor sleep hygiene such as cellphone use after Lights Out)

Again, comparisons to the Harris case might be made, namely to the last three points. Harris is shown on the video calling for assistance numerous times without timely response by the technologist. There were questions about protocol when Harris’ oxygen saturation levels dropped to 80 percent (some say the technologist followed protocol, other say he didn’t). Harris voiced concerns about breathing problems that might have been underestimated by the technologist. When Harris eventually collapsed, it was shown that cardiopulmonary resuscitation (CPR) was not started right away—according to some reports, a pulse wasn’t even taken—and 17 minutes passed before 911 was called.

After the test, there are still opportunities for errors to occur:

• Data may not be properly acquired, saved or stored.

• The study may not be scored accurately or in a timely fashion.

• The study report may include unanswered questions that remain so even after the scoring is complete or the sleep center manager reviews it and signs off.

• Data entry in the EHR might be inaccurate, misspelled or otherwise unclear.

How to prevent or control errorsFortunately, the reason that sleep centers have so few cases with mortalities is due not only to the fact that the tests themselves are noninvasive and painless, but because it’s relatively easy to set up controls to prevent errors or to make them easy to fix them, should they arise.

Documents and communication are top of the list for controls that must be put into place and practiced with care and due diligence. These include accessible and updated collections of polices and procedures (P&Ps), updates and regular reviews of P&Ps, general reference books (EKG identification books, mask leak charts, basic equipment troubleshooting flowcharts) and, perhaps most importantly, meetings between all members involved in the continuum of care—from the technologists to the managers, directors, and physicians—to ensure everyone is on the same page.

Supporting staff for sleep technologists, who as night shift workers perform in the “trenches,” should include quality support from competent scoring technologists, on-call accessibility to sleep center managers and medical directors for patient or equipment concerns, a workplace environment that gives technologists permission to ask for help without fear of judgment, and a “tag team” climate in the sleep center, where technologists value teamwork over competition.

• Incorrectly identifying the patient either in person or via electronic health records (EHR)

• Patient ignorance about pre-test preparations regarding medications, caffeine use, napping, meals, behavioral expectations (whether this information was provided or not)

• Inability to adequately manage workflow (hookups, tech notes, cleanup, EHR updates, reports) in order to have adequate time to perform a complete study

• Assignment of an inexperienced technologist to a complex patient

• Referring the patient to a testing facility which may not adequately address their special needs

• Technologists working at a higher technologist/patient ratio than appropriate for the situation

• Rejecting the overnight presence of a caregiver when their assistance might be called for

In the case of Brandon Harris, a number of pretest errors are alleged: The physician’s orders may not have clarified the severity of his comorbidities; the technologists may not have fully understood Harris’ need to sleep in an elevated position; the physician may have erred in placing Harris in an outpatient facility rather than in a hospital based lab; and the presence of a caregiver was denied, but who knows if she might have been useful, given Harris’ mental challenges?

Errors that could happen during a test include:

• Failing to calibrate instruments or troubleshoot technical problems

• Performing the wrong procedure

• Mistakes in calculations required for decision-making “on the fly” (such as with split night polysomnography).

• Failing to fix problems caused by test interruptions (power failure, behavioral issues with patient).

• Overlooking room conditions that could interfere with data collection (adjustments for altitude, overwarm rooms, exterior noise from hospital helipad).

• Failing to respond to the needs of patients (by ignoring them, not paying attention, because they are tending to other patients, or taking a break).

• Failing to follow proper protocols regarding status changes in the patient (such as significant drops in oxygen saturation or complaints of feeling unwell or dizzy)

• Not ascertaining and meeting the patient’s special needs in order for the test to be a success (for patients with challenging mental or emotional behaviors, who cannot

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Quality measures in the sleep center help to raise competency levels among technologists. For scoring technologists, a regular review using interscorer reliability (ISR) ensures consistency in scoring. All technologists should be competent in utilizing the EHR and should follow established protocols for managing patient information consistently. Sleep centers should aspire to have highly trained technologists by offering reimbursement for continuing education and course registration fees as well as providing in-services or complex patient job shadow opportunities in clinical settings.

Finally, managing equipment integrity is at the heart of quality control. Regular instrument troubleshooting and upgrades should be the norm. The quality of audio-visual equipment should be reviewed periodically. Utilizing best practices for cleaning, sanitizing, and storing all equipment help preserve hardware functionality.

Could Brandon Harris’ death have been prevented? It’s impossible to say. On the one hand, there might have been errors during the patient encounter that could have been avoided. On the other hand, Harris was extremely sick with complicated health conditions that could have been the primary cause of his demise. Regardless, it’s important to review this sentinel event to see how we can better manage risk in our own sleep centers so it won’t—can’t—happen again.

• The sleep center should have evacuation protocols in place for both external and internal events, plus cancellation policies due to inclement weather.

• Equally, infection control practices should be standard practice and not the exception when it comes to handwashing, equipment sanitation, room disinfection, and laundry removal.

• Finally, a reminder: Many, if not most, sleep technologists suffer to some degree with shift work disorder. This is a job hazard, not a badge of honor. Sleep technologists cannot do their jobs well if they do not also practice good sleep hygiene and treat their shift work problems effectively. Working in any healthcare environment requires clear judgment, quick response time, and the ability to be attentive—especially during that last quarter of the third shift, when patients are most likely to code. Technologists should also have options available to avoid drowsy driving at shift’s end.

The Joint Commission has published National Patient Safety Goals to help prevent workplace errors and improve patient safety. Among their recommendations, they ask us to strive to improve communications among caregivers; to use written P&Ps that are updated regularly and disseminated in a timely fashion; to reduce the risks of acquired infection; to practice proper hand hygiene, equipment sanitization, and room disinfection; and to never assume that what we do is free of risk. An ounce of prevention is, indeed, worth a pound of cure.

Sidebar continued from page 27

REFERENCES1. “Are Sleep Studies Safe? A family sends a warning, after 25-year-old’s death.”

George, K. Examiner. (2015, February 11). Retrieved from http://www.examiner.com/article/are-sleep-studies-safe-a-family-sends-a-warning-after-25-year-old-s-death

2. “Brandon Harris Act.” Fort, Senator V. (2012, February.) Legislated introduced before the Georgia State Legislature. Retrieved January 24, 2016 from http://www.legis.ga.gov/Legislation/20112012/123098.pdf

3. “Manager’s Desk: Risk Management Strategy and Techniques for Sleep Facil-ities.” Barrett, D. A2Zzz Magazine (2010, September). Retrieved from https://go.aastweb.org/Resources/PDF/A2Zzz19_3/ManagersDesk.pdf

4. “National Patient Safety Goals.” The Joint Commission. (n.d.). Retrieved January 24 2016 from http://www.jointcommission.org/standards_information/npsgs.aspx

5. “Safety Considerations in the Sleep Laboratory - RT: For Decision Makers in Respiratory Care.” Whitman, R. RT Magazine (2012, May 30). Retrieved from http://www.rtmagazine.com/2012/05/safety-considerations-in-the-sleep-laboratory/

6. “Sentinel Event Policy and Procedures.” The Joint Commission. (n.d.). Retrieved from http://www.jointcommission.org/sentinel_event_policy_and_procedures/

7. “(UPDATE) Jury Awards $20.5 Million in Emory Clinic Sleep Center Wrongful Death Case.” Courtroom View Network. (2015, September 23). Retrieved from http://blog.cvn.com/emory-clinic-sleep-center-wrongful-death-case-continues-in-dekalb-georgia

8. “Emory to pay family $20.5M for death at sleep center.” WSBTV.com. VIDEO. (2015, October 1). Retrieved from http://www.wsbtv.com/news/news/local/emory-pay-family-205m-death-sleep-center/nnsNF/

9. “Lewis v. Emory Clinic Trial.” Courtroom View Network. VIDEO. (2015, September 21-23). Case Number 11-A-36471; Judge Alvin Wong, DeKalb County Courthouse, Jurisdiction State Court of Georgia, DeKalb County; opening arguments video and case summary. Retrieved from http://video.courtroomview.com/Mediasite6/Play/e12151214d-6c417eb1cf7c3a20c296161d?playFrom=169887&autoStart=true&popout=true

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DREAMING AND ENCOUNTERS WITH THE ALTERNATE SELF (PART I)By Reg Hackshaw, EdD, RPSGT

“Too late to go back to sleep. It’s time to trust my instincts. Close my eyes…and leap! It’s time to try. Defying gravity."

— From the Broadway Production, Wicked1

In many societies, nightly expeditions of the alternate self during dreams are believed to accrue valuable insights that offer reassurance and hopefulness about the future when self and dreamer reunite in the morning.6 In contrast, a sinister view of the alternate self surfaces in a short story by the nineteenth-century writer, Feyodor Dostoyevsky. The Double explores the downward spiral of the main character after a series of emotionally traumatic encounters with his alternate self during episodes of “waking dreams.”7

DREAMING OF A SELFIEAutoscopic hallucinations (AHs), the clinical term for out-of-body experiences, occur when subjective visuo-spatial perception appears to reside outside of the dreamer’s body. Instrumentation to detect the onset of dreams in real time was in use by the mid-twentieth century. Early sleep studies were reams of paper tracings showing brain waves, eye movements and muscle activity. Although Hans Berger had recorded human alpha waves by 1929, not until 1953 did Aserinsky and Kleitman report high correlations between rapid eye movement (REM) sleep and subjective accounts of dreaming.8, 9 Subsequently, Dement and Kleitman identified non-REM sleep stages based on the appearance of consistent patterns appearing in electroencephalogram (EEG), electrooculogram (EOG) and electromyogram (EMG) recordings.10

Contemporary studies of polysomnographs (PSGs) suggest that an intrusion of REM cognitions into Stage I of non-REM sleep may facilitate dreams of viewing one’s image from a distance.11, 12 A simultaneous reduction in external sensory processing occurs during drowsiness, which is a defining feature of stage N1 sleep. Surveys reveal that AHs are reported during episodes of lucid dreaming when subjects claim conscious control over dream content.12 Furthermore, lucid dreamers often recall sensations of “rising out of the body and floating above the bed.”12 As perception of our surroundings wanes due to drowsiness, “possibly we feel the cessation of gravity…and then feel that we are suddenly lighter and float up” continues Stephen LeBerge, founder of The Lucidity Institute, Inc., which offers workshops on conscious dreaming techniques.12 Autoscopia may be a normal result of sleep stage transitions and the experience is not necessarily an example of a neuro-degenerative disease, psychiatric disorder or a folkloric belief.12-14

WHEN A CIGAR IS JUST A CIGARSigmund Freud published The Interpretation of Dreams in 1900, over half a century before the connection between REM sleep and dreaming was discovered. The distinguished sage of the

Written works as well as oral traditions have described the disengagement of a consciously aware self from the physical

body during sleep. For example, Egyptian priests of antiquity believed the winged consciousness of an individual could detach itself and hover above the mummified remains which remained dormant in the tomb (see Fig. 1)2. In ancient Greece, priest-healers, known as the therapeutai, led dream incubation rituals that endeavored to release the consciousness from congregants who relaxed in the sleeping-halls of temples.3 A Native American community on the West coast of the United States has a tradition of humming a specific tune after waking that only one’s “shadow” knows so this alternate self can find a way home to the body after a night of extensive traveling.4 Similar ideas of one’s shadow as a name for the alternate self that leaves the host during a dream appear among indigenous populations spanning Brazil’s lowland forests to the highlands of Papua New Guinea.5, 6

REG HACKSHAW, EDD, RPSGT

Reg Hackshaw has been in the sleep field for over 20 years and presently works as a Mentor for students in the PSG Program at Thomas Edison State University. He gratefully acknowledges assistance from the Rare Book and Manuscript Library of Columbia University.

PAINTING FROM PHARONIC EGYPT SHOWING A WINGED CONSCIOUSNESS LEVITATING OVER A MUMMY (Fig. 1)2

A2 Zzz 25.1 | March 2016

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subconscious proposed that dreams are mental performance spaces where socially forbidden fantasies existing below conscious awareness produce dramas of symbolic imagery. In keeping with this theory, the self employs various ego defenses to reduce anxiety due to conflicts between the dreamer’s secret wishes and social norms.15

Some of Freud’s contemporaries questioned this assertion by claiming that no ego structure resided in the mind to “censor” the meaning of a dream and make it less anxiety provoking after the dreamer awakened the next morning.16 Lydiard Horton was an experimental psychologist and contemporary critic of Freud who argued that “dreams can be explained in terms of the perceptive processes in waking life.”16 Presumably, there were no fantasies hidden in the past to be uncovered through an intensive decoding of the dreamer’s autoscopic experiences.

Horton pioneered the use of case reports from human volunteers to investigate their claims of AHs.16 Specifically, he asserted that certain behavioral routines performed before bedtime could increase the chance of a “flying sensation or levitating illusion” often encountered during episodes of lucid dreaming.16

To be continued…

REFERENCES1. Schwartz S. Wicked: Piano/Vocal Selections. Winona,

MN: Hal-Leonard Corp. 2004:68.

2. Budge EAW. The Book of the Dead. NY: Dover Reprints, 1895/1967:227.

3. Hamilton M. Incubation; or the Cure of Disease in Pagan Temples and Christian Churches. London: Simpkin, Mar-shall & Co. 1906:1-2. Available from: https://archive.org/details/incubationorcur00hamigoog accessed on July 12, 2014.

4. Hobday MJ. Humming home your shadow. Parabola: Myth and the Quest for Meaning. 23:VII(1);1982.

5. Gregor TA. Far, far away my soul wandered: The dream theories of the Mehinaku Indians of Brazil. American Ethnologist. 1981;8(4):709-20.

6. Lohmann RI. The role of dreams in religious encultura-tion among the Asabano of Papaua New Guinea. Ethos. 2000;28(1):75-102.

7. Dostoyevsky F. The Double (Garnett C, trans). University of Adelaide, South Australia: Ebooks, 2015: Chap 6. Ac-cessed on 02/08/2016 from: https://ebooks.adelaide.edu.au/d/dostoyevsky/d72d/

8. Grass AM. The Electroencephalographic Heritage. Quincy, MA: Grass Instrument Co.1984.

9. Neylan TC. Fiftieth anniversary of the discovery of rapid eye movement (REM) Sleep. J Neuropsychiatry Clin Neu-roscience. 2003;15:453.

10. Dement WC. Some Must Watch While Some Must Sleep. New York: WW Norton, 1978.

11. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 2nd ed. Westchester, IL: AASM. 2005:170-2.

12. Levitan L and LaBerge S. Out-of body experiences and lucid dreams. Nightlight. 1991;3(2-3). Accessed on 02/08/2016 from: http://www.lucidity.com/NL32.OBEandLD.html

13. Christodoulou G.N. Syndrome of Subjective Doubles. Am J Psychiatry. 1978;135(2):249-51.

14. Droll J and Backrach B. Visions and psychopathology in the Middle Ages. J Nerv Mental Dis. 1982;170(1):41-9.

15. Day SX. Theory and Design in Couseling and Psychother-apy. Belmont, CA: Brooks/Cole, 2008.

16. Horton LH. The illusion of levitation: A General Presenta-tion. J Abnorm Psychol. 1918;13(1):42-53.

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The mission of the American Association of Sleep Technologists (AAST) is “To promote and advance the sleep

technology profession through the continued development of educational, technical and clinical excellence in sleep disorders.” In 2013 the AAST convened a summit of key stakeholders in an effort to assure that sleep technologists are informed and supported as they expand their role in sleep medicine and are prepared to meet new challenges that are impacting healthcare at all levels. Leadership quickly realized during the summit that there were broad areas of consensus, especially with regard to improving and updating educational offerings. Capitalizing on the momentum of the summit, a Taskforce focused on education was developed. The Taskforce, led by the AAST and with representation from the Committee on Accreditation for Polysomnographic Technologist Education (CoA PSG), Board of Registered Polysomnographic Technologists (BRPT), and sleep technology educators, first met in 2014. The group has continued to meet at least annually to develop consensus for a forward-thinking education plan for the profession. The Taskforce met twice in 2015, most recently in June at the AAST Annual meeting in Seattle. The next Taskforce meeting is scheduled for February 26th, 2016 and, we are happy to report, will include the addition of representation from the American Board of Sleep Medicine (ABSM).

At these Taskforce meetings discussion of the evolving role of the sleep technologist continues. More than two years after the AAST Summit, there is a consensus that sleep technologists are, as predicted, expanding their roles beyond performing PSG. We see that technologists are providing new and advanced therapies such as Adaptive Servo Ventilation (ASV), average volume assured pressure support (AVAPS), oral appliance therapy (OAT), and Trilogy ventilators, and are rapidly expanding into patient education and care management roles.

The Taskforce consensus is that these tasks require advanced training and education, as well as improved technical and critical thinking skills. Discussion at these meetings focuses on how to best prepare technologists for the future and what the educational

AN UPDATE ON THE AAST EDUCATIONAL TASKFORCEBy Rita Brooks, RST, RPSGT, REEG/EPT

requirements for a sleep technologist should be. The Taskforce felt that technology had already outstripped available training in advanced titration protocols and patient education processes. A collaborative approach is needed to provide technical guidelines for these new and advanced titration protocols. In addition to input from the CoA PSG, BRPT and ABSM, industry white papers would be useful to guide the development of education for technologists on new technologies. The AAST is also working with physicians and other health care providers to develop technical guidelines and education for technologists via courses and advanced online modules.

There is consensus that additional education will be needed for those currently working in the field and beginning to fill other roles in the sleep medicine arena. An example is the recent development of the Certification in Clinical Sleep Health (CCSH), which is intended to be an advanced level credential for those providing sleep health education that builds on an educational degree and a current credential. The AAST met with several educators and other stakeholders in June 2015, to discuss the production of a CCSH textbook as a learning tool for sleep technologists pursuing this career pathway. The AAST supports this project and has appointed a committee to begin to develop the standardized curriculum and education guidelines that are required in order for sleep health educators to be able to bill for these services in the future.

To further support the needs of those providing patient education, the AAST has updated a second edition of the Technologist’s Introduction to Sleep Disorders. The textbook is intended to provide a basis for understanding the diagnosis of sleep disorders, a review of how sleep disorders evolve over time, a survey of appropriate treatments and their efficacy; and knowledge for the sleep technologist who is providing patient education, addressing patient concerns and assisting the physician in improving patient adherence to treatment as a part of the patient’s care team.

At present, approximately 75 percent of the current sleep technologist work force is on the job trained (OJT). Accredited Sleep Technologist Education Program (A-STEP) and Sleep Technology Approved Resource (STAR) programs were initial steps on the road to standardized education and are the most commonly accepted avenues for credentialing examination eligibility, but were designed to provide a basic understanding of sleep technology. Professionalism is tied to education, and for sleep technology to become a recognized profession we need guidelines and industry-wide support for higher entry-level education requirements for sleep technologists. This means that we need

BY TAMARA SELLMAN RPSGT, CCSHRITA BROOKS MED, RST, RPSGT, REEG/EPT

Rita Brooks MED, RST, RPSGT, REEG/EPT is the President of the American Association of Sleep Technologists. She is the Director of Diagnostic Services for Capital Health in Trenton, N.J.

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Continued on Page 34

the Taskforce members, physicians, employers, and educators to agree to a consensus position on formal entry-level education requirements for sleep technologists. In order to move forward with a minimum educational requirement for sleep technologists, the pathway for credentialing examination eligibility must be cohesive and consistent, and the credentialing bodies will need to eliminate other pathways for eligibility over time.

Educational programs must meet goals in order to be sustainable and effective. Most educational programs utilize credentialing examination pass rates and a 70 percent or better positive employment rate for graduates as markers of a successful program. We must also show that formal education leads to a higher pass rate on credentialing exams. Thus, one of the key roles of the Taskforce is to reach a consensus on what sleep technologists need to know and develop a cohesive curriculum for all formal programs. Next, credentialing should reflect the formal education provided by Commission on Accreditation of Allied Health Education Programs (CAAHEP) accredited programs. The goals for accredited educational programs are for graduates to attain credentials and jobs.

The Taskforce has reached agreement that a higher basic education level for sleep technologists is needed. This is an essential goal for the profession; however implementation of educational minimums requires much thought and consideration. A variety of consequences must be weighed, including the impact on patient care, changes to legislation in states with licensure, and modification of existing educational and credentialing programs. Currently the majority of the CAAHEP accredited CoA PSG schools are certificate programs and these programs will require support and time to upgrade certificate programs to associate degree programs.

As a result of these considerations, there was much discussion as to whether an Associate’s Degree for entry level into the profession should be a requirement or a guideline. The Taskforce agreed that entry level for sleep technologists in the future must move toward requiring an Associate’s Degree for eligibility to attain a credential registered sleep technologist, registered polysomnographic technologist (RST, RPSGT) in sleep technology. The change would mirror other health technology professions. For example, the National Board of Respiratory Care (NBRC) already requires an Associate’s Degree for the RRT-SDS credential, and is moving toward a Bachelor’s Degree requirement.

This transition will require a thoughtful process as most current CoA PSG programs are currently certificate programs and will require support to move to the Associate’s Degree level. The Taskforce determined that a step-wise approach that first eliminates A-STEP and STAR programs and accepts CAAHEP certificate programs in the transition toward requiring an

Associate’s Degree program is the most viable plan. This is consistent with the AAST position statement on education that was developed with input from the Taskforce in October 2014, and the proposed timeline that was developed by the Taskforce at the March 2015 meeting.

The Taskforce is committed to supporting A-STEP and STAR programs that consider partnering with community colleges to become CAAHEP programs. The CoA volunteered to assist these transitions; recommend an educational partnership and provide a curriculum. The Taskforce suggested, and the AAST subsequently undertook, an A-STEP program survey to determine what programs might be interested in transitioning to formal programs.

The Taskforce survey and a proposed transition timeline were sent to the 32 A-STEP Programs listed as active. Fourteen programs that stated they were currently active responded to the survey. Four of those surveyed indicated they had more than 25 students complete their program; the remaining ten had less than 25 students graduate. Of those programs surveyed, none said they were currently transitioning into a CAAHEP accredited program. When asked how long it would take the program to transition into an Associate’s Degree program, six programs indicated they could complete the transition within a five-year timeline. Five programs indicated they already have an association or partnership with a community college or higher education program, eight indicated that they would be interested in partnering with an educational program, and one had no interest in creating a partnership. All programs felt it was extremely important to advance sleep technology education. Twelve of the 14 programs surveyed showed interest in participating in an Education Summit to discuss the advancement of sleep technologist education.

The AAST has committed to providing stakeholders with a forum for a group meeting at the AAST annual meeting and hosting a needs assessment survey that includes employers and gathers information on their educational requirements for employees. The Taskforce plans to review the surveys currently in use such as the CAAHEP graduate surveys and job task analyses used by credentialing bodies to assist in determining the need for higher education in the sleep technology profession and gaps in training that should be filled. The AAST will request support of the American Academy of Sleep Medicine (AASM) to distribute the needs assessment survey to accredited sleep centers and physicians to assure that all stakeholders are represented.

The Taskforce has developed through consensus a road map to get sleep technologists from where we are today to where the profession needs to be in the future. The issues and time needed to transition existing programs to an Associate’s Degree level were seriously considered and extensively discussed. It was determined

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that 1/1/19 would be the earliest that the certificate and ASTEP/STAR programs transitioning to Associate’s Degree programs could be transitioned and approved by the host institutions. The Taskforce also identified other issues that may arise with this change in credentialing requirements, including international and legislative issues.

As of October 2012, the California State License Requirement includes A-STEP or an AAS degree. A-STEP has been written into licensure in other states as well. Legislatively it was the consensus of the group that a higher educational standard should not cause a hardship in states where licensure is in place based on A-STEP educational programs. The Taskforce determined that educational requirement changes will only affect programs in the United States and will not affect international programs.

The Taskforce then worked backwards from the 1/1/19 date to identify the milestones that need to be met so that an associate degree is the only viable pathway for credentialing by 1/1/2021.

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timeline to all stakeholders and to work on an updated joint position paper that reflects the proposed timeline that was developed. To support the transition the AAST will provide website links to CAAHEP programs and the CoA PSG, spotlight online programs, develop blogs on the transition process and highlight programs that are developing bachelor degree programs in sleep technology.

The AAST will continue to provide educational opportunities for experienced sleep technologists seeking to learn new skills and advance to leadership positions. However, sleep technology will not become a profession until minimum entry-level education levels are established and consensus is reached on a standardized syllabus. January 1, 2021 is the target date for requiring an Associate’s Degree for eligibility for credentialing examinations. The Taskforce, led by the AAST, will continue to meet and work toward these goals, keeping the evolving role of the sleep technologist in the forefront of the discussion surrounding the current and future educational needs of sleep technologists and the sleep technology profession.

EXPLORE NEW CAREER OPPORTUNITIES by browsing through the AAST Job Board!

www.aastweb.org/Jobboard.aspx

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January marked a decision in respiratory therapy to mandate a minimum education requirement of a bachelor’s degree (The

National Board for Respiratory Care, 2016). This is a step higher than their currently required associate degree. Athletic trainers will soon be required to have a master’s degree to enter their field (National Athletic Trainers’ Association, 2016). In most states, physical therapists are required to have a doctorate (America Physical Therapists Association, 2016). Many professions in allied health are increasing their educational requirements in an effort to improve overall patient care and increase the minimum knowledge and skill levels of the professionals in their fields.

Sleep medicine is at a critical point in which we must rise to the call of requiring a minimum level of formal education for our entry-level technologists. With the changes in healthcare funding, the rise of home sleep testing, and the strengthened grip on reimbursement for testing and treatment options, many people have found themselves fearing for, or even losing their jobs. However, the advent these of new technologies and screening devices have created a shift in the acuity of the patients that are being evaluated and treated in sleep centers. Today, the patients we see in the sleep center are those that have significant comorbidities, complex health histories, and sleep disorders that require a higher-level skill set from the technologist. Therefore, the need for technologists with more education and at higher levels is more critical than ever. Only in recent years have sleep medicine fellowships for physicians, associate degrees for technologists, and add-on tracks to respiratory care and neurodiagnostic educational programs existed. The public’s recognition of sleep and sleep disorders is also on the upswing, with the advent of local and national media campaigns from organizations such as the National Sleep Foundation (NSF). Their recent changes to sleep recommendations were covered on national news as well as late night talk shows. It’s no secret that the 1/3 of our life we spend sleeping is absolutely critical to our health and well-being.

A CALL TO ACTION FOR SLEEP MEDICINE EDUCATION By Auburne Hutchins, MHA, RPSGT and Mary Ellen Wells, Ph.D., RPSGT, R.NCS T.

Currently, there are educational programs for sleep technologists accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Accreditation for Respiratory Care (CoARC). The breakdown of these programs by degree type and accreditor are as follows:

Accreditation Board

Certificate/Diploma Programs

Associate Programs

Baccalaureate Programs

CoA PSG (Polysomnographic Technology Programs)

25 17 1

CoA END (Add-on sleep programs to Neurodiagnostics programs)

5 8 0

CoARC (Add-on sleep programs to Respiratory Care programs)

0 7 0

A full list of these schools, their contact information, and instructions on how to apply can be found at www.caahep.com and www.coarc.com. Some of these programs are also available in an online format to help meet the needs of students that are unable to attend courses due to geographic constraints. However, there is also a need for more programs to be developed. If you are interested in learning more about becoming an educator or speaking with the administration at your local college about starting a Polysomnographic Technology program, there are many opportunities this year to participate in educational sessions on just these topics. The American Association of Sleep Technologists (AAST) is planning an Educator’s Forum at the SLEEP meeting in June and the Board of Registered Polysomnographic Technologists (BPRT) usually hosts an

BY TAMARA SELLMAN RPSGT, CCSHAUBURNE HUTCHINS, MHA, RPSGT

Auburne Hutchins, MHA, RPSGT is the Program Coordinator and Clinical Assistant Professor of the Neurodiagnostics and Sleep Science Bachelor’s Program at the University of North Carolina in Charlotte, N.C.

BY TAMARA SELLMAN RPSGT, CCSHMARY ELLEN WELLS, MS, RPSGT, R.EEG T, R.NCS T,

Mary Ellen Wells, MS, RPSGT, R.EEG T, R.NCS T, is the Program Director of the Neurodiagnostics and Sleep Science Program at the University of North Carolina School of Medicine.

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the fall. Watch for these meetings and contact the Committee on Accreditation of Polysomnographic Technologists Education (CoA PSG) at www.coapsg.org for more information.

EDUCATION: ONE STEP FURTHERIn addition to requiring a minimum degree from an accredited program for entry-level technologists prior to taking their board exams, there is also a need for the development of leaders in our profession that have even higher educational degrees. Investing in your education will not only make you more desirable in a competitive job market, but it can also better prepare you to be a more active proponent of the need for your skills as part of the complete healthcare team. With a more educated workforce, we have a much stronger voice in advocating for state licensure bills, increased reimbursement for services, and support for advanced patient care.

Prior to 2013, the highest formal degree available with a focus in sleep technology was the associate degree. In 2013, a new program was born – The Bachelor of Science program in Neurodiagnostics and Sleep Science (NDSS). This program is the first of its type in the world, and prepares graduates with the “knowledge, competence, and adaptive skills to fulfill educational, professional, and leadership positions in the field.” This program is offered through two world-class universities: the University of North Carolina at Charlotte with collaborative coursework through the University of North Carolina at Chapel Hill. The program offers students opportunities to enhance their professional skillset in preparation for leadership roles including management, research, entrepreneurship, teaching, graduate school and many other opportunities.

Students are able to complete this degree in five semesters (less than two years) and the program is available completely online. Financially, the NDSS program is a bargain compared to many bachelors degree programs in other concentrations with tuition at $588 per credit hour for out of state students and $143 per credit hour for North Carolina residents. Over $35,000 in program-exclusive scholarships are awarded each year. A total of 38 credit hours comprise the NDSS program, which includes the following areas of study:

• Pathophysiology of sleep, neurological, and related disorders

• Diagnostic and therapeutic methods and monitoring

• Advanced clinical procedures

• Information technology in healthcare

• Healthcare education

• Program administration

• Advanced physiological monitoring and data acquisition

• Leadership

Students in the program complete real world experiences while enrolled in the program through capstone projects, research, and a clinical practicum. These can all be done from the student’s current location, which makes the program a realistic option even for those not residing in North Carolina. Because the curriculum is designed with professionals in mind, most students are able to continue to work full time while completing their degree.

Many graduates obtain higher level positions or new career opportunities even before they graduate. Graduates consistently report that they are very satisfied in completing their bachelor’s degree and that doing so has created more professional opportunities for them that they would not have been otherwise qualified for. Investing in your own future will not only create a more fulfilling life for you, but will also impact your family, employer, colleagues and the entire community of patients that you help with the knowledge and experience you gain through your education.

ADMISSION INFORMATION AND CRITERIA The NDSS program starts in the fall semester of each year. Admissions are competitive and 25-30 students are admitted each year. Applications to the program open in September of each year for students wishing to begin the fall of the following year. The admission deadline is May 15, 2016 for the Fall 2016 semester admission. Applicants are encouraged to submit all application materials to the program as early as possible as it can sometimes take a significant amount of time for the admissions office to receive transcripts from other schools and process applications. Early application ensures adequate time to collect all required application materials for consideration of admission.

To be considered for admission to the NDSS program, ap-plicants must hold a current registration as either a registered Polysomnographic technologist (RPSGT) or registered electro-encephalographic technologist (R. EEG T.) and have training in sleep technology. Applicants must also have a cumulative grade point average (GPA) of 2.0 or better from a degree program that is from a regionally accredited institution. That degree must be an Associate of Science (AS), Associate of Arts (AA), or Associate of Applied Science (AAS) in either polysomnography, neurodiagnostics technology or respiratory therapy, or a bache-lors degree. And lastly, the student must earn at least a grade of C in all coursework taken by the end of the semester prior to the semester for which the application is made. It should be noted, however, that meeting these minimum requirements does not guarantee admission to the NDSS program.

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Whether you are looking to expand your current career options through an educational experience specific to your profession or just looking to blossom into the field of sleep medicine for the first time, choosing an education from an accredited institution is important. As our profession continues to grow and embrace technological and patient demands, a highly educated and motivated workforce is essential.

For more information on the UNC Bachelor’s Degree Program, visit http://www.med.unc.edu/ahs/ndss/bachelors-degree-program or to apply, visit http://distanceed.uncc.edu/programs/bs-neurodiagnostics-and-sleep-science.

For more information on CAAHEP accredited programs, visit www.caahep.org and search for programs. Each listed accredited program has a link to their individual website.

The Neurodiagnostics and Sleep Science Program is accredited by the Commission on Accreditation of Allied Health Education Programs (www.caahep.org) upon the recommendation of the Commission on Accreditation for Education in Polysomnographic Technology.

Consider furthering your education; you will be glad that you did!

REFERENCESAmerican Physical Therapists Association. (2016, January 25). Normative model of physical therapist professional education. CAPTE Fact Sheet: Physical Therapist Education Programs: 2012-13. Retrieved from: http://www.apta.org/PTEducation/Overview/

National Athletic Trainers’ Association. (2016, January 25). Retrieved from: http://www.nata.org/degree-change-frequently-asked-questions

The National Board for Respiratory Care. (2016, January 26). Retrieved from: https://www.nbrc.org/Pages/news.aspx

RISK MANAGEMENT IN THE SLEEP CENTER

Spring Course 2016

Register online at www.aastweb.org/course.aspx

The Seelbach Hilton | Louisville, KentuckyAAST CEC Credits: 13

MARCH 11-12, 2016

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CMS ESTABLISHES A DME PRIOR AUTHORIZATION PROGRAMBy Carolyn Winter-Rosenberg

On December 29, 2015, the Centers for Medicare & Medicaid Services (CMS) published a final rule establishing a prior

authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. The rule identifies continuous positive airway pressure (CPAP) devices as one of the items “potentially subject to prior authorization.”

The rule finalizes a previous CMS proposal for a prior authorization process, which was published in mid-2014. At that time the American Academy of Sleep Medicine (AASM) submitted a letter to CMS arguing against such a process for sleep-related DME. The AASM’s position was that prior authorization would threaten beneficiaries’ ability to obtain timely treatment for a serious sleep illness.

The final rule creates a “Master List” of 135 high-cost DME items “frequently subject to unnecessary utilization.” Both CPAP and respiratory assist devices without backup rate (RAD) are included on the Master List. However, presence on the Master List will not automatically require prior authorization.

CMS indicates in the rule that it will initially implement prior authorization for a subset of select items from the Master List, which will be assigned to a separate “Required Prior Authorization List.” CMS will publish a notice in the Federal Register indicating which DMEPOS items will be subject to prior authorization 60 days before implementation.

The final rule goes on to explain that in order to obtain prior authorization, DMEPOS suppliers will be required to submit documentation indicating that the order meets all requirements outlined in Medicare policy. This will include documentation described in the relevant DMEPOS Local Coverage Determination (LCD). CMS indicates in the rule that efforts will be made to process prior authorization requests within 10 business days.

The AASM will notify members as soon as CMS publishes additional information indicating whether or not CPAP and RAD will be included on the Required Prior Authorization List.

To join, visit the AAST website at www.aastweb.org

Questions? Contact the AAST Membership Department at (630) 737-9704 or AASTmembership@aastweb.org.

JOIN AAST TODAYInvest in yourself, your career and your profession by becoming a member of the American Association of Sleep Technologists. Join today and receive membership benefits including:

• Free CECs each month

• Discounts on a multitude of educational resources including AAST products, courses, annual meeting registration and more

• E-mail notifications about the latest news and developments affecting the field...from legislative updates to information concerning certification

• Career resources and CEC transcript

• And more!

AAST members will receive FREE access to two new online learning modules per month, a $960 value. Both modules are intended to sharpen the skills and advance the knowledge of experienced technologists.

!

BY TAMARA SELLMAN RPSGT, CCSHCAROLYN WINTER- ROSENBERG

Carolyn Winter-Rosenberg is the Director of Coding and Compliance at the AASM. She is a graduate of Boston University.

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In the MoonlightIn the Moonlight: Q&A with Joel R. Glass, RPSGT

For fun on days off from work I like to…spend time as an outdoorsman, sportsman, husband and father.

My favorite TV show is…anything on the Investigation Discovery (ID) Channel. I love those mysteries.

My favorite singer or musical group is…Sting.

The website I visit most often is…www.google.com.

The person I would most like to meet is…Theodore Roosevelt.

The biggest change I have seen in the profession since I started is…everything! I started on a Grass Model 78 polygraph. We have moved from being technicians to being technologists.

Words of advice I have for people who are new to the profession are…education, education, education. Not just in sleep technology but in networks, electronics, medical care and patient education. Those who are more rounded in the bigger picture will never be out of work. Learn how it all works and why, not just how to use it.

My professional goals for the next five years are…to give back the knowledge and skill I have been lucky to be given, by volunteering and educating those who ask and who will listen.

Sleep is…the lifeblood of society (and my career and profession).

“In the Moonlight” puts an American Association of Sleep Technologists (AAST) member in the spotlight, giving readers an opportunity to get to know one of their colleagues. This month A2Zzz asked Joel R. Glass, RPSGT, to complete the following statements. Glass has been in the sleep field since 1994. He is self-employed in Vernonia, Oregon, and is chair of the AAST’s Regulatory & Legislative Advisory Committee.

When I was young I wanted to grow up to be a…fireman.

I decided to become a sleep technologist because…it was at night and I thought I could study. Was I ever wrong!

I got my first job in sleep technology at…Legacy Good Samaritan Hospital.

I became an AAST member because… I liked the support it gave me, the CEC tracking, the A2Zzz magazine and the advocacy for the profession.

The person who has had the greatest influence on my career is…Gerald B. Rich, MD.

The most challenging part of my profession is…the recent transitions in the world of insurance companies,

authorization requirements and allowed testing modalities.

The thing I like most about my profession is…making a life changing difference in 12 hours.

The food I’m most likely to snack on while working is…chewy granola bars.

Would you like to appear “In the Moonlight”? Send an e-mail to A2Zzz@aastweb.org.

September 2010 | Volume 19 | Number 3

Possible Neuronal Loss with Insomnia

Nitric Oxide, Obstructive Sleep Apnea and Upper

Airway Inflammation

Risk Management Strategy and Techniques for Sleep Facilities

The A, B, C of PAP

Second Generation “DIY EEGT” and the Pursuit of the

Alpha Rhythm

A P u b l i c a t i o n o f t h e A m e r i c a n A s s o c i a t i o n o f S l e e p T e c h n o l o g i s t s

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UPDATE FROM THE BOARD OF REGISTERED POLYSOMNOGRAPHIC TECHNOLOGISTS

The BRPT Names Daniel D. Lane President of the Board of DirectorsThe Board of Registered Polysomnographic Technologists (BRPT) named Daniel D. Lane, RPSGT, CCSH, President of the Board of Directors. His two-year term as President began in January.

Lane has been a member of the BRPT Board since 2011 serving as Treasurer and working closely with the Exam Development Committee. Lane currently works as a Clinical Sleep Health Educator for Sleep Center Orange County in Irvine, CA.

“Daniel has been an integral member of the Board for a number of years – serving as BRPT’s Treasurer; playing an important role on the Exam Development Committee; spearheading our STAR program; working tirelessly each year on the annual Symposium, and so much more,” said BRPT Past-President Theresa Krupski, RPSGT, RRT. “Daniel brings a wealth of knowledge, expertise and energy and I look forward to continued collaboration with him in my role as Past-President.”

“I’m excited and energized to step into the role as President of the BRPT as I’m very passionate about sleep technology and patient-centered care,” said Daniel D. Lane, RPSGT, CCSH. “It’s incredibly inspiring to work alongside this team of motivated Directors, each of whom brings a different perspective and set of expertise. In 2016, I'd like to enhance and grow the BRPT’s role within the sleep community through a cohesive and collaborative approach that exemplifies the professionalism of the sleep technology and clinical sleep health fields.”

BRPT Shining Star Award Current Board member, Jessica Schmidt, MA, RPSGT, received the BRPT President's Shining Star Award in

November for her dedication and outstanding service to the organization. “Jessica joined the Board and truly hit the ground running,” said BRPT Past-President Theresa Krupski, RPSGT, RRT. She served as chair of the Government Relations/Legislative Committee and led the effort to create the Sleep Educator Reimbursement Guide. And, in 2016, Jessica is serving as BRPT Treasurer.”

BRPT Welcomes a New Board Member BRPT is very pleased to welcome Jomo Martin Nkunika, BSAST, CCSH, RPSGT, RST to the Board of Directors. Jomo is a Sleep Medicine Technologist at Sleep Services of America, a Johns Hopkins Health System company. He currently serves as a Program Coordinator and part-time Adjunct Faculty of the CAAHEP-accredited Polysomnographic Technology program at Montgomery College in Maryland, where he also serves on the program's CoA PSG advisory committee. Previously, Jomo held various per diem and contract roles at different sleep centers in Washington, D.C. and Maryland. Jomo holds the Certification in Clinical Sleep Health, the Registered Polysomnographic Technologist and the Registered Sleep Technologist credentials. He has a Bachelor of Science Degree in Applied Sciences and Technology, majoring in Health Services Technology. In addition, he holds Associate Degrees in Electronics Engineering Technology, Polysomnography, and General Studies. He also holds a Certificate in Sleep Medicine Technology. Currently, Jomo is pursuing a Master's Degree of Science in Healthcare Administration through the University of Maryland. Jomo has previously volunteered his graphics and multimedia skills with the Maryland Sleep Society and Washington D.C. Sleep Society. Prior to his career in healthcare, Jomo worked in mobile GSM telecommunications, computer/multimedia technologies and non-profit industries.