Perspectives on staffing ratios at accredited sleep labs and the education requirements for technologists performing attended polysomnography.

By Robert L. Lindsey, MS, RPSGT, CCSH

Acknowledgments

I want to acknowledge and express thanks for the generosity of the sleep specialists and technologist leaders who helped make this article possible by sharing opinions and expertise. Physicians sharing their opinions herein are leaders in the field and serve as medical directors for large academic-based programs. Four out of the five, I’ve had the privilege of working with, or for, in some capacity: 

  • Nancy A. Collop, MD, director, Emory Sleep Centers, Emory School of Medicine
  • James G. Geyer, MD, medical director, DCH Health System, University of Alabama School of Medicine
  • Beth A. Malow, MD, MS, director, Vanderbilt Sleep Division, professor of pediatrics and neurology
  • Paula G. Williams, MA, MDiv, CRT, RPSGT, sleep educator and administrator
  • Byron Jamerson, RPSGT, CCSH, FAAST, clinical sales manager – US, Nox Medical

For many years the American Academy of Sleep Medicine (AASM) has recommended a “patient to technologist ratio of 2:1 under usual circumstances for attended PSG at facilities.”1

My experience is that responsible programs permitting more than the recommended ratio of patients per technologist do so only with well-defined criteria and policies that meet the intent of the recommendation—that is, one technologist is not working alone with more than two patients. 

Having worked in accredited sleep centers where the recommended ratio was regularly exceeded, the practice never included working alone nor disregarding patient safety. We all know that with the advent of home testing and various insurance limitations to attended in-lab testing, in-lab sleep patients now present with more comorbidities than ever. 

To be fair, it’s not just the insurance companies that have driven the increase in acuity. The clinical practice guideline for diagnostic testing of adult obstructive sleep apnea published in 2017 carefully describes the “absence of uncomplicated” conditions a home testing patient must not have, including, for example, “significant cardiopulmonary disease, potential respiratory muscle weakness due to neuromuscular disease, history of stroke, and chronic opioid medication use.”2

Most of us who’ve been in the field for a decade or more agree that our patients have been and are becoming more complex. Should it still be permissible for an accredited sleep center to routinely staff with a 3:1 ratio with one tech working alone? This author says no, not ever. Accreditation isn’t just a means of getting into an insurance network; it’s also a stamp of quality and patient safety. 

Patient-to-Tech Ratio Discussion Topics

What are the implications and issues around regularly exceeding a 2:1 patient-to-tech ratio with only one tech on shift? Our panel shared their opinions via a four-question survey:

  1. Given the average acuity of the present-day in-lab sleep patient, share your thoughts on the practice of a 3:1 patient-to-tech staffing ratio.
  2. Should the AASM revisit and refine its guidance of “under usual circumstances” 2:1 staffing for attended polysomnography, knowing that many accredited labs are regularly utilizing the 3:1 ratio (and greater) with only one onsite technologist?
  3. Are minimum formal education requirements for technologists (high school plus STAR or A-Step training) adequate preparation to care for the clinical presentations of current and future of in-lab patients?
  4. Would you be in favor of a whistleblower hotline maintained by the AASM and other accreditors for techs to anonymously report routine staffing ratios of 3:1 or greater (in an accredited lab) where a tech is offsite from a hospital and working alone? 

First Thoughts on 3:1 Patient-Tech Ratio

To question 1: all agreed that although possible, 3:1 is not the best idea on a routine basis. 

Malow and Collop both agreed that with advanced titrations and the ubiquity of split studies, a routine assignment of 3 patients is “excessive” and “a lot” to ask from one tech. In larger labs, Geyer shared that he believed techs could safely work together under a higher ratio occasionally only to handle special situations, such as a last-minute sick call out of a technologist.

The technologists polled all agreed that while possible, it doesn’t make sense to routinely schedule 3:1 (or even more patients to one tech) staffing ratios with the concurrent increase in complexity of most patients. 

‘Under Usual Circumstances’?

To question 2: Summarily, all agreed that it’s not a good idea to routinely have one tech working alone.

In greatest favor of clarification from the AASM on the topic of staffing ratios was Geyer. He stated that the language of “under usual circumstances” “should definitely be reevaluated.’’ He added, the “AASM should monitor the average scheduling ratios as a component of reaccreditation and establish reasonable variance. Any program outside of standard variance should be required to provide an explanation of the specific cases.” 

Technologist leaders both agreed that the language needs clarification. 

Sleep Technologist Education

Question 3’s emphasis on technologist education inspired a mixed bag of replies.

Physician concerns of how an increased educational requirement would impact an existing tech shortage was shared among all. However, Geyer went a step further and stated that the current and future complexity of patients warrants at least an associate degree in a health-related field. 

Despite the potential impact to the existing sleep tech shortage, both of our technologists agreed that the “current requirement is insufficient,” for techs to adequately care for our patients. 

Both technologists also agreed that the state of technologist education is the greatest systemic challenge we face at this time. Williams’ reply to the question of whether the high school diploma requirement is adequate yielded the response “absolutely not.”

As a long-time director of both large- and medium-sized programs, I’d say that the topic that we desperately need driven home to techs is cardio-pulmonary anatomy and physiology. Techs who have a better understanding of these dynamics almost always produce better titrations, especially advanced titrations. My closest peers and I have seen this repeatedly over the last three decades. 

Opinion of a Whistleblower Hotline

Opinions on having a hotline for reporting ongoing “3:1 ratios with a tech working alone” were three against and two in favor. 

In my opinion, Jamerson’s comment probably sums up the issue best: “When there are no clear guidelines, there can be no clear consequences.” 

Geyer opined, “In general I would be in favor of such a program,” but he further clarified that “specific guidelines to assess the appropriateness of 3:1 scheduling to avoid vindictive or inappropriate reporting” would be necessary. 

Sleep Technologists and Patient Complexity

The following opinions expressed by the author are my own and not necessarily held by the contributing professionals quoted earlier. 

Formal considerations of the increasing complexity of in-lab patients date back to at least 2014 when the Journal of Clinical Sleep Medicine published “The Future of Sleep Technology: Report from an AAST Summit Meeting” by Rita Brooks, MEd, RST, RPSGT, REEG/EPT, and Melinda Trimble, RPSGT.3

The article made repetitive references to the need for increased formal education for technologists entering the field. But as of 2024, the bar has only been moved to include alternative pathways whereby other degreed professionals and technicians can enter the field with virtually no experience in attended PSG.4 For example, did you know that included under BRPT pathway #2 (for the RPSGT) are chiropractors, certified hyperbaric technicians, certified athletic trainers, doctors of audiology, and registered exercise physiologists?

I concede some improvements have been made to the required curriculum; however, there is still no requirement for at least an associate degree in some sort of hard science for entry-level technicians. This is not only a clinical issue; the lack of the degree requirement drives down pay ranges for technologists. At the beginning of my career, I spent four years in healthcare and human resources as a compensation analyst. So I know that in healthcare, minimum formal education is a key (and usually the first) consideration in job evaluation and minimum pay grade assignment. 

If you’re a working RPSGT earning less than $25/hour for base pay, you can, in part, thank those of us who’ve been in the saddle for the last three decades and never required a degree of any sort for the RPSGT credential. Shame on us!

As a director of a 14-bed operation in 2002, I paid newly registered techs $21.50/hour. In many areas of the country, that base hasn’t changed much. Degree requirements have been discussed ad nauseum. Lack of a degree requirement negatively impacts our credibility among other allied health professionals. 

All of healthcare has its challenges. We’ve known about increasing patient acuity and the state of technologists’ education for a long time. Even considering artificial intelligence, home testing, and all other changes we’re undergoing, increased in-lab patient acuity and the lack of sleep tech education requirements remain. 

Yet under present language in the articles and requirements of accreditation, for at least the AASM and the Accreditation Commission for Healthcare, a technologist working alone is permitted to manage three patients. For those who may be less informed about the practice, (or in a state of denial) ask around at APSS or any other big sleep conference you go to, and you will find lone techs are being incentivized by employers to test three or more patients at a time. Again, for those of us who’ve been in the field for some time, we know from experience that sooner or later there will be a preventable sentinel event that results from this practice. 

Take Action on Patient Safety in Sleep Labs

Have your medical director advocate to the accrediting bodies for clarification and refinement around staffing requirements and the BRPT around minimum educational requirements, for patients and our future. Doing so will not only enhance the safety of our future patients but will ultimately improve the critical-thinking skills of staff everywhere. We owe this to patients and ourselves.

References

1. AASM Facility Standards for Accreditation. 2022 Jul;B-7:9.

2.  Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017 Mar 15;13(3):479-504.

3. Brooks R, Trimble M. The future of sleep technology: report from an American Association of Sleep Technologists summit meeting. J Clin Sleep Med. 2014 May 15;10(5):589-93.

4. BRPT. RPSGT Eligibility. RPSGT Pathway 2. Accessed 2024 Feb 10.

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