By Elise Maher, RPSGT, FAAST
Although the news surrounding the COVID-19 virus outbreak started to be reported in January and February, it was in mid-March that everyone started taking it seriously as cases started to bloom in the U.S. For many sleep centers, this meant closing indefinitely with a prompt ceasing of revenue. Many sleep physician clinics also closed until telehealth platforms could be launched. Even for centers that stayed open for office visits and testing, many patients chose to postpone their nonurgent medical care indefinitely. As important as sleep is to health, it is rarely considered an emergency. The American Hospital Association (AHA) estimates that because of canceled nonessential services, U.S. nonfederal hospitals stand to lose approximately $161.4 billion in revenue between March and June.
For employees, the COVID crisis generally meant one (or more) of four things: layoff, furlough, pay reduction or freeze, or redeployment. Many entities, especially large systems, offered financial and job security throughout shutdowns for sleep techs and managers. Although outpatient and elective procedures were suspended, there were novel tasks to do: screening employees, patients, and visitors for COVID symptoms, handing out PPE, cleaning ventilators, helping the cleaning staff with ramped up cleaning of high touch surfaces. At my hospital, the sleep techs were the superstars of the screener/greeter program because they were the only outpatient staff who were used to working overnight (and also because they are just great people).
Managers used to focusing on operations had to become HR specialists dealing with employees who had a natural fear of coming to work and going home to possibly infect family members, discomfort with new roles, earned time losses, benefits issues, and homeschool proctoring issues. Other new and needed skills for managers included PPE wrangling and planning new workflows for virus control.
The financial burden could be more challenging for smaller independent centers and hotel-based labs. While layoffs and furloughs lower staffing costs in the face of lost revenue, rent and other fixed costs remain. At least one hotel-based sleep center in New England chose to close when their contract for room leasing was up, and they will only provide home sleep testing going forward. Even at hospital systems with deep pockets, capital expense plans had to be shelved, and all nonessential spending ceased. Hospitals and larger entities have the benefit of volume discounts and availability of more sources for PPE; regardless, cost is an added burden for everyone.
The pandemic accelerated the rise of home sleep apnea testing (HSAT). Many centers offered HSAT during lab closure by mailing to home, offering curbside drop-off and pickup, and using a 72-hour equipment quarantine or partially or fully disposable equipment. With overnight lab beds closed, HSAT offered a reasonable temporary solution for patients who may have better benefitted from a more comprehensive test. For those tracking inconclusive HSAT results as part of AASM quality measures standards, you may have seen an uptick.
The lack of definitive advice on what pre-procedure testing was needed and what PPE was to be used to safely reopen sleep labs caused confusion early on, and policies varied widely depending on facility regulations, regional community infection rates, and availability of PPE. Safety and infection control are paramount to operations in the ongoing COVID-19 pandemic, and considerable planning and vigilance was and continues to be needed. Some operations and workflow changes may include, at least temporarily, entrance restriction and monitoring, mandated hand sanitizing and mask use, increased cleaning procedures, temperature checks, restricted visitor policies, increased use of urinals, inter-patient cleaning of shared restrooms, wiping carts and IV poles before exiting a patient room, shower restrictions, staggered arrival times, and escorted departures. Facility changes could include removal of magazines and pamphlets in rooms or waiting areas, careful spacing of chairs and check-in areas, removal of all nonessential objects from testing rooms (mannequin heads with interface displays, etc.), and restrictions on non-wipeable or fabric-covered furniture.
Around June, many sleep centers reopened with wait lists of patients to be prioritized and scheduled. Many centers now require COVID testing as a prerequisite to PAP titration studies due to the aerosolizing nature of the procedure; some require COVID testing for all procedures; some have not resumed PAP studies and rely on AutoPAP for titrations. An appropriate testing window that allows for both test processing and a short lag time for potential reinfection had to be determined and operationalized: What type of test would be accepted? What testing site would be safe and convenient? Who would order the test? Who would inform the patient of the result?
Pre-COVID capacity utilization may not be possible until the virus is contained by vaccination or other means. When pre-procedure testing is required, there are multiple checkpoints where a scheduled sleep study may need to be canceled, and timing may not allow for refilling that slot. Symptom checks should be done multiple times, and if on the day of confirmation—or worse, after arrival to the sleep center—a symptom is reported or an elevated temperature is detected, the patient will need to stay home or go home. Patients may miss their scheduled COVID test appointment, and some may have a change of heart and decide they do not want to be tested. Of course, some tests will come back positive, and staff may become symptomatic or contract the virus as well. Hospital-based labs have the benefit of occupational health and infection control experts to handle the logistics after an employee contracts the virus (temporary department closure, contact tracing, quarantine, etc.). Independent labs may look to the AASM, CDC, and state health departments for guidance.
Despite the financial losses, HR issues, patient care delays, and increased complexity in providing sleep medicine services, there is opportunity amid the upsets. One such side benefit is the widespread use of telehealth. Telemedicine was slow to gain acceptance in many regions due to lack of reimbursement, lack of technology and security, fear of the new, and lack of demand. The COVID pandemic offered a reprieve from worrying about reimbursement, malpractice, and privacy risk; demand went from 0 to 60; and the technology was already available and relatively easy to implement. At Mass General Brigham, a large New England health system and the largest employer in New England, telemedicine visits went from 0.2% to 62% in 2 months, reaching 1 million visits in August.
Technology is benefitting sleep centers in other ways. Getting everyone together for a staff meeting has always been difficult for practices that include shift workers. The ability to use Zoom or other web-based meeting platforms makes attendance easier and safer. In-services from vendors on new products can happen faster and reach more people. Sleep meetings and other professional development opportunities that may not have been feasible due to cost or travel time are now online and can be attended live or on-demand.
The COVID-19 pandemic also gave us all a newfound respect and gratitude for healthcare workers. Beyond respect, many sleep programs stepped up needed support programs like childcare assistance, work from home allowances, stress management programs, quarantine housing, financial grants, and many, many free food deliveries.
There are ways to offset reduced lab volumes, and this crisis may be the push needed to start an inpatient screening program, add revenue streams like contracting for HSAT outside of your geographic footprint and add compatible services like dental sleep medicine, EEG testing, corporate programs, or private sleep coaching.
There may be new challenges ahead, with an “echo” outbreak (an echo is never stronger than the original) and cold and flu season around the corner. Sleep services may be able to proceed even with a new outbreak now that safety protocols and workflows are in place. We have all gotten a crash course in managing and working through a pandemic, and I for one, believe it will be easier to handle whatever comes next.
Elise Maher, RPSGT, FAAST is manager of sleep and neurodiagnostic services at North Shore Medical Center in Salem, MA. She served two terms as director on the AAST Board and currently volunteers on the AASM Sleep Technologist and Respiratory Therapist Education Committee. This article appears in the Sept/Oct 2020 issue of Sleep Lab Magazine.