Across the United States, hospital and government/VA-run sleep centers are moving away from reusable equipment in favor of one-time-use thermistors, EEG electrodes, CPAP tubing, respiratory effort belts, and more. Three labs share how and why they switched.
The accelerating pace of sleep disorders centers that are switching to disposable supplies from reusables sparks timely questions in the psyches of neighboring sleep professionals. Clinicians ask: Why now? Should our lab switch? How can we prepare?
The popularity of one-time-use sensors, electrodes, CPAP masks and tubing, and other supplies that come into contact with patients seems to have occurred overnight, but in reality, the trend has been several years in the making.
Contributing factors include:
Increased emphasis on hospital infection control. Mainstream press reporting on healthcare-associated infection outbreaks has raised consumer awareness and upped pressure on infection control departments to take action. What’s more, providers risk not being reimbursed for services when a patient develops a healthcare-associated infection. United States Department of Veterans Affairs (VA) sleep labs in particular are trending toward disposables to mitigate the spread of germs between patients. This trend converges with sleep labs seeing sicker patients who are more likely to be immunocompromised in lab (as healthier patients without comorbidities opt for home sleep testing), meaning added pressure to investigate options for lowering the potential for contamination.
Disposables seen as an easier way to earn (re)accreditation if infection control protocols are of concern, particularly for Joint Commission-accredited hospitals. The trend toward disposables is more salient in hospital-based sleep centers than in independent ones, according to anecdotal reports from multiple sensor manufacturers. The reason relates in part to accreditation specifics. Hospital-based sleep labs tend to be accredited by the Joint Commission, an accreditor known for placing a large focus on patient safety and infection control procedures, whereas independent sleep labs usually opt for other accrediting organizations that may emphasize sleep-specific protocols (such as sleep scoring reliability). As some independent labs are purchased by hospitals, staff need to be prepared for a possible switch to disposables. Joint Commission accreditation is valid for 3 years, so some of the recent changes are spurred by hospitals planning for renewal surveys.
High-level disinfection protocols for reusables can be expensive. Sleep supplies that touch mucus membranes or non-intact skin must undergo high-level disinfection before being used on another patient. So reusable thermistors that go inside the nose and even electrodes used on abraded skin fall into this category. Sleep labs report that accreditors, again particularly the Joint Commission, are enforcing disinfection requirements and manufacturer-provided instructions strictly. Some labs find that the money and time for disinfecting supplies, as well as the risk for breakage, make disposables the path of least resistance. Even for devices that are reusable, some labs report more closely tracking how many times an item is used to dispose of it at the manufacturer-recommended time (for example, a CPAP humidifier chamber may be rated for 60 uses).
Generally, there are more, better, and less expensive options for disposable sleep supplies than ever before. Though not in every category—CPAP masks being noted by some as an exception—in general, more options with more features are available in disposables. For example, gold disposable EEG electrodes and MRI-compatible disposable electrodes are now readily available. Also, costs continue to decrease—a key factor as the initial financial outlay is historically the number-one barrier cited by facilities considering a switch.
The confluence of these factors in 2017 and 2018 is driving increasing numbers of labs to purchase disposables. Here, three hospital-based sleep centers that recently switched some reusable product lines to the disposable counterparts share their experience and advice with Sleep Review’s audience.
Morton Plant Mease Healthcare, Florida
Part of the BayCare Health System in the Tampa region of Florida, Morton Plant Mease Healthcare has 19 beds across 5 sleep centers. To prep for an upcoming Joint Commission reaccreditation survey, the sleep centers were visited by the hospital’s infection control department and mock Joint Commission surveyors.
The preparatory site visit unearthed potential infection control and patient safety concerns that had not been previously recognized by the sleep centers. “Many of these were small things, like not wiping gel bottles down between patients, cleaning room fans between patients, and using an enzymatic cleaner that required being near an eyewash station,” says Marietta B. Bibbs, BA, RPSGT, CCSH, manager, neurodiagnostics and sleep disorders at Morton Plant Mease Healthcare. “But the mock surveyors had a major concern with reusing PAP interfaces or anything that directly touches the patient’s skin (including respiratory effort belts). We had to come up with a viable solution to address these issues.”
Though the cost of purchasing disposable supplies had not been included in the forecast for operating costs during regular planned budgeting, presumably a frustration for anyone held accountable for meeting forecasted numbers, ultimately department directors, administrators, and team members decided that disposables made the most sense. “We also had to remember that during a Joint Commission survey, we cannot consider cost as the underlying reason for a finding,” Bibbs says.
So the sleep centers now employ one-time-use PAP masks and interfaces, PAP tubing, respiratory effort belts, nasal/oral sensors, and nasal cannulas. “We are still utilizing reusable electrodes but considering moving to disposables,” Bibbs adds.
Switching to disposables meant the sleep labs had to rewrite infection control, cleaning, and portions of the PAP titration policies. “Some areas of the infection control policy also required approval from the infection control committee, especially in the areas where we were not switching to disposables (such as electrodes and PAP humidifier tanks),” Bibbs says. “After the policy was rewritten, we had a special mandatory meeting for all sleep center staff to review the proposed changes and to address any concerns they had. Once we were confident with the policy, we sent it for approval to the infection control committee as well as the medical director.” Following approval, the centers purchased the needed products, supplies, and materials, and the sleep centers continue to have occasional reviews related to patient safety and infection control in team meetings.
When she considers the time that team members would spend cleaning, disinfecting, and putting away reusables each shift, Bibbs finds that the cost of switching to disposables is about the same as the previous reusables. “There is less overtime related to cleaning, and the time that the staff spends in the sleep center is productive time related to the procedure itself rather than related to cleaning and disinfecting,” she says.
But she also concedes that the biggest realized cost is related to the number of PAP masks that are now tried on one patient and discarded. “Prior to switching to disposable interfaces, we offered the patient the opportunity to try on three interfaces during the education and desensitization process. We had to discontinue this practice.” To reduce costs, team members voted on three interfaces that would remain available in the sleep center (based on which had historically been successful the most often), instead of the larger stock it had previously kept on hand.
Dignity Health Mercy Gilbert Medical Center, Arizona
Located in the Phoenix suburb of Gilbert, Ariz, Dignity Health Mercy Gilbert Medical Center’s Sleep Center is in the process of expanding to 6 beds (up from 4). It has always given CPAP masks to patients, as opposed to disinfecting and reusing them, but recently switched another item to one-time-use: its CPAP tubing.
This switch was spurred by a pending Joint Commission survey, though Patrick Lahnan, RST, RPSGT, manager at Dignity Health Mercy Gilbert Medical Center’s Sleep Center, emphasizes that the underlying reason must always be patient safety. “Along with the ever-evolving nature of health care, Dignity Health is constantly finding ways to provide the very best patient care. The Joint Commission is focusing on infection control with an emphasis on following the manufacturers’ guidelines for cleaning and disinfection. Patient safety is the driving motivation,” Lahnan says.
To decide what to switch, Lahnan spent months evaluating each supply, device, and piece of equipment to ensure manufacturer cleaning and disinfection guidelines could realistically be followed. “I looked at disposable versus reusable equipment while considering cost, protocols, staff training, etc. I then based my decision in conjunction with our hospital’s infection prevention department for each piece of equipment individually,” he says.
Lahnan thinks single-use CPAP tubing and CPAP masks “will be more cost-effective long-term,” adding, “these new changes are also beneficial to our patients because they now leave their sleep study with some equipment they can use at home.”
His advice to other sleep labs is as follows: “I recommend doing a thorough search of all options on the market for reusable and disposable equipment to determine what is best for your specific situation. I will do the same on an annual basis due to the fast-changing technology and hopefully lowering price points.”
Texas Children’s Hospital, Texas
The Children’s Sleep Center at Texas Children’s Hospital has 14 beds across 3 hospital-based sleep centers. Wes Moulden, BS, RPSGT, RST, is the sleep program manager across the system. “While we do see some children for common issues such as large tonsils and snoring, many of our patients have serious conditions: from premature infants in the NICU to older children with trisomy 21, neuromuscular diseases, tracheostomies, and other complex medical issues,” Moulden says.
Because of the patient population, including a significant number of immunocompromised children, the centers have historically opted for many categories of disposables. Recently, the Children’s Sleep Center changed to disposable EEG electrodes, inspired by colleagues in the EEG and epilepsy monitoring units. Other disposable products they use include effort belts, oximeter probes, thermistors, electrodes, and CPAP tubing and humidifier chambers.
Moulden outlines the steps involved for a switch. “Firstly, you need to figure out your supply chain….Where previously you might have only kept enough sensors for the amount of beds to typically run each night, now you have to calculate how much of each disposable supply you need on hand to last until your next order, which will also be based on the rate at which you utilize the supply,” he says. He recommends enrolling in a Lean Six Sigma training course to ease this process. (Six Sigma is a methodology used to improve business processes by utilizing statistical analysis rather than guesswork; its methodology is characterized by defining, measuring, analyzing, improving, and controlling.)
Moulden continues, “Next, when developing your policies and procedures, you have to go line by line…and ensure you update anything regarding this equipment—especially infection control-wise. I strongly recommend involving the infection control department if you are in a hospital setting.” This could take anywhere from a week in the private setting to a month or two in a hospital setting, he predicts, adding, “You’ll really want to involve at least one strong night technologist in this process to ensure all aspects get reviewed.
“Finally, for go-live you will need to do some training. Most disposables function very similarly to the reusable versions, and this makes that easier. With disposable electrodes, there’s really no hassle in the switch from the technologist standpoint as the functionality is the same. On the other hand, disposable RIP belt material and thermistors create an extra connection (depending on the brand). As we all know, any time there is artifact to troubleshoot, each connection has to be tested. I strongly suggest a robust education covering all the connection points from the patient all the way back to the recording station.” The Texas Children’s Sleep Center has also identified preceptors who are trained to educate new hires.
For additional advice, sleep labs can reach out to their accrediting organization and to manufacturers and distributors of sleep supplies.
Sree Roy is editor of Sleep Review.