A long-time registered polysomnographic technologist details highlights from each era, as well as how techs can prepare themselves for the future.
By Robert L. Lindsey, MS, RPSGT
Over the last decade, the evolving role of the sleep technologist has been a topic of discussion among sleep professionals. The common denominator among the print articles and conference presentations I have seen on the topic is that change in our roles is inevitable.
Sleep and other neurology techs must advocate for ourselves and drive as much of that change as possible at every level of healthcare. My RPSGT credential means more to me than my master’s degree ever did. At the time I earned my credential—for which the effort to pass the 3-part exam was greater than the work of earning my master’s degree in psychology—I was one of fewer than 1,300 techs worldwide. Since then, I’ve enjoyed a career in varying roles including staff tech, educator, and administrator—like so many of you.
We must tell everyone who’ll listen what it is we can provide and where our talents can be most used to care for patients. Hopefully my perspective on our evolving role will cause you to ponder where you fit into the future of sleep medicine as a polysomnographic (PSG) technologist.
In The Beginning
Since the advent of CPAP in 1980,1 the impact of time and technology has propelled the role of the polysomnographic technologist from humble beginnings to more advanced and varying roles. While many aspects of polysomnography have been advanced by technology, other changes have been driven by insurance requirements. The advent of home testing and increased utilization of auto-titrating PAP devices are two leading influences that have forever impacted the traditional role of the PSG tech.
When asked about the current roles of the PSG tech compared to in the early days of sleep medicine, Meir Kryger, MD, FRCPC, noted the differences in the working relationships of physicians and techs. In the late 1970s and throughout the 1980s, physicians and technical staff had a much closer working relationship than today, he said. “These were the frontier days of sleep medicine.” Kryger, who I am thankful to for his pivotal contributions to sleep medicine from its beginnings, explained that many of the sensors and masks we today consider abundant were at the time frequently custom-made by physicians and techs in the sleep lab. “Very early on, techs were directly involved in designing sensors and they came from a lot of different areas,” he says. “At that time, when techs came into the field their backgrounds often included computer programming, engineering, or some other science.”2
Custom CPAP machines, masks, thermistors, effort belts, and all the adapters necessary to capture those signals onto paper machines are a few examples of items routinely created and assembled from scratch by early technologists.
Major Events That Impacted the PSG Tech Role
This timeline of how technologists’ roles have changed over the past 40+ years is not meant to cover everything but rather to align the major events that impacted or involved our role.
|Time Period||Highlights||Technologist’s Focus|
|1979 – mid-1990s||By the late 1980s, commercially available CPAPs for in-lab testing started to become available. Sullivan and Healthdyne were popular brands.|
3-part exam process for PSG techs, administered by Association of Polysomnographic Technologists (APT), precursor to AAST (name changed in 2007) and from which BRPT later spun-off (in 1999-2000).i
|Techs work closely with physicians on a day-to-day basis, such as custom designing CPAP masks, machines, and PSG interfaces (such as thermistors and plethysmography).|
Instrumentation and the need for frequent improvisation and technical aptitude are crucial for sleep studies.
Techs support a wide variety of paper machines and their ancillary inputs (such as oximetry and plethysmography).
Limited and regional organized education for techs. Most techs train on the job and don’t score while on shift.
|mid-1990s – 2007||BRPT becomes responsible for administering RPSGT exam.i|
Single written exam replaces 3-part RPSGT exam.
PC-based polysomnography increases as a way to record and archive sleep studies.
Increase in standalone/physician-owned sleep labs.
Newer digital platforms emerged with more A/C channels; use of expanded EEG during polysomnography widely adopted.
AASM rolls out A-STEP (Accredited Sleep Technologist Education Program) for sleep techs to receive standardized education (2006).ii
Adaptive servoventilation (ASV) first used in ICUs (1998); later ASVs used in lab for central sleep apnea, Cheyne-Stokes respiration, periodic breathing (early 2000s).iii
|With digital PSG, more and more techs were score during acquisition.|
Gradual decline in reliance on “day scorers.”
Some sleep labs start contracting with scoring techs outside of the country.
Tech’s role in patient education increases as the construction and expansion of labs tries to keep up with demand for sleep testing.
Techs need additional training and new skillsets to successfully perform advanced titrations using ASV.
|2007 – present||Improved digital PSG with expanded EEG and integral video capabilities.|
National Board of Respiratory Care implements Sleep Disorders Specialty add-on credential for respiratory techs/therapists (2007).iv
Centers for Medicare & Medicaid services revises its National Coverage Determination, allowing for use of home sleep testing in the diagnosis of obstructive sleep apnea and related therapy coverage of CPAP (2008).v
Expanding role of ASV in sleep labs.
American Board of Sleep Medicine begins offering Registered Sleep Technologist certification (2011).vi
BRPT launches Certification in Clinical Sleep Health (CCSH) exam (2014).vii
Consumer sleep trackers such as Apple Watch and FitBit appear in the marketplace.
Patients turn online to buy their CPAP devices, on legitimate sites that require prescriptions and on illegitimate sites that don’t.
Hospital inpatient OSA screening programs become more prevalent.
Since 1979, BRPT (or its precursor) has credentialed more than 22,000 RPSGTs in the United States, Canada, and 32 countries overseas.vii
|Colleges and major CPAP manufacturers offer enhanced titration skills and training programs.|
Techs no longer need to be experts on recording instrumentation.
With the rollout of home sleep testing, more techs hold “day” jobs.
With increasing in-lab patient acuity, greater than ever need for enhanced tech competencies to handle emergent situations and to properly care for sicker patients.
Increased utilization of techs in physician-owned labs to obtain preauthorizations.
Techs with the CCSH credential educate and see patients in offices to provide more detailed education. APAP trials and alternatives to in-lab testing being facilitated by the CCSH techs.
Emergence of technologists working in hospital inpatient roles as sleep navigators.
Home Testing’s Influence
In some states for nearly a decade now, authorizations for in-lab sleep testing (for suspected obstructive sleep apnea) are limited only to those patients who have one or more comorbidities, such as congestive heart failure, chronic obstructive pulmonary syndrome, a neuromuscular diagnosis, or other complex scenarios. For patients without these comorbidities, payors will only approve home sleep testing (HST). Around 2012, a 22-bed sleep center where I was working in Georgia closed about 25% of its in-lab beds due to the new insurance requirements brought about by home testing. In addition to some job displacement, the net effect on techs performing in-lab testing has been that they are now seeing mostly Medicare and the most complex patients.
While home testing requirements aren’t the same everywhere, where HST has been instituted as firstline testing, acuity of in-lab patients has forever risen.
Acuity levels on any given night may look like this: three heart failure patients, a patient with COPD and interstitial lung disease, and two others with obesity hypoventilation syndrome who present on 3-4 lpm of continuous supplemental oxygen and are in wheelchairs. And that COPD patient, who is seen by a pain management doctor, is on a maximum dosage of hydrocodone and the Fentanyl patch to boot. Welcome to in-lab sleep testing in the new age!
This climb in acuity calls for techs to respond decisively in emergent situations and intervene on the patient’s behalf when appropriate. The necessary critical thinking and problem-solving skill set was not necessarily sought by lab managers in years past but is now a recruiting standard in areas where home testing requirements have driven only the most fragile patients in-lab. When asked about what the future would probably look like for a tech in the average sleep lab in ten years, Kryger replied that it would “be like being an ICU nurse.” Continued development of commercially available screening devices will change the face of diagnostic testing as well, he added.
Inpatient Screening & Other Roles for Techs of the Future
During the past decade, hospital inpatient screening for sleep apnea and the launch of the Certification in Clinical Sleep Health (CCSH) credential has given rise to an even more expanded role for technologists. Grassroots efforts among sleep centers and respiratory departments have shown hospital administrators just how much undiagnosed sleep apnea truly impacts hospital length of stay, daily costs, and readmission rates. Enter the “sleep navigator” role.
A sleep navigator is typically a tech with a CCSH credential who is utilized for the purpose of screening, educating, and assisting hospitalists and other physicians with ordering sleep testing as part of discharge planning. Hundreds of thousands of apnea patients (most undiagnosed) are admitted and readmitted each year to America’s hospitals. In many cases patient readmissions are the result of, or exacerbated by, an underlying sleep disorder that has remained undetected and untreated. Inpatient screening programs appear straightforward, but implementation is a rockier road than most expect.3 Past articles and conference presentations of such programs cite initial roadblocks with administrations, nursing, information technology, and even hospitalist groups. Once the metrics begin to turn on readmissions, costs and lengths of stay, then impressions change and support often follows.
One such example is from a hospital system in Atlanta, Ga, led by T. “Massey” Arrington, RPSGT, MBA, RST, CCSH. Arrington, executive director of Wellstar Sleep Centers, said, “The greatest hurdle we had to overcome was time. We spent six months trialing this at one hospital. Finding team members with the CCSH credential was another hurdle, but that is improving as there are now more CCSH credentialed candidates in the market. Convincing senior leadership to support us was actually the easy part, once we presented them with our trial findings and identified the significant impact our inpatient screening was going to have on reducing readmissions. I would argue my biggest champions for the original idea to screen every single patient admitted were my medical director, Hitendra Patel, and our chief nursing officer, Jill Case-Wirth. Dr Peter C. Gay from Mayo also encouraged us after he learned of our unique approach.”4
Over its lifetime, the field of sleep medicine has moved from a diagnostic to more of an outcomes-based subspecialty. The role the PSG technologist plays and will play in supporting improved outcomes requires refined and improved competencies, increased formal education, and development of new work models. The best way to prepare is to distinguish yourself by a combination of:
- In and out of lab testing experience;
- Add-on certifications;
- Formal education; and
- Independent study.
I know my graduate degree has meant the difference in jobs that went to me versus other candidates at least four times in the last 30 years. Physicians and other licensed health professionals are taught early on that education is a career-long endeavor, and we should treat it the same way.
For much of this decade, it is this author’s opinion that we all can expect even higher acuity of in-lab patients, an increased utilization and role of respiratory-assist devices, greater access to self-administered apnea testing, and the need for improved interdisciplinary workflows among the total care team (including providers, durable medical equipment companies, hospitals, and independent sleep centers). Remember if you’re doing the same old thing and your competition is improving, then like it or not, you’re falling behind—sage advice for sleep programs and the evolving role of the PSG technologist.
Robert Lindsey, MS, RPSGT, is the director of Sleep Medicine and Neurophysiology at DCH Health System in Tuscaloosa, Ala, and has been on the Sleep Review editorial advisory board since 2004. He began his sleep career as a polysomnographic tech at CHI Memorial Healthcare in Chattanooga, Tenn, in 1991.
1. Sullivan CE. Nasal positive airway pressure and sleep apnea. Reflections on an experimental method that became a therapy. Am J Respir Crit Care Med. 2018 Sep 1;198(5):581-7.
2. Kryger M. Interview by author. 10 May 2021.
3. Arrington T, Gladden K. “The sleep navigator, defining world class sleep medicine delivery.” Virtual SLEEP 2020.
4. Arrington T. Interview by author. 13 Jul 2021.