|Bryan LGH pediatric patient Izabell Denman with parents Cody and Alexa Denman.
Tonight, as many as 50 Nebraskan premies are sleeping in the comfort of their own cribs, rather than hospital beds. Despite the risk of being startled by monitor alarms throughout the night, concerned parents are resting easier, too. These parents and babies are beneficiaries of infant apnea (IA) classes held at the Bryan Lincoln General Hospital (Bryan LGH) Medical Center.
Akhtar Niazi, MD, has been the IA program director since 1990. “The program has been very acceptable to local primary care physicians,” says Niazi, a neonatologist, explaining how it relieves nonspecialist providers from day-to-day involvement in the medical management of these children.
The pediatricians, periodically apprised of their patients’ progress, can rely on the IA program to care for the newborns. The IA nursing staff call the parents daily during the initial homecoming, and ongoing trouble-shooting and an after-hours hotline are available through the program.
IA manager Deb Bailey, RN, has been a pediatric pulmonary nurse for 25 years and has 14 years of sleep experience. She commends Bryan for its cutting-edge IA program.
“There has been a marked decrease in the incidence of SIDS,” she says, in part due to Niazi’s innovations. His conservative philosophy mandated embedding extra safeguards into the SIDS program, including tighter physician-directed patient supervision and protocols for parental involvement.
The IA program’s parent training empowers these caregivers by teaching them what to do when their babies stop breathing, how to differentiate a false alarm from one indicating true distress, and how to effectively perform infant CPR. Once they know how to check respiration, heart rate, and other signs, as well as how to perform emergency live-saving techniques, they can take their newborns home with a greater sense of ease.
These infants can be weaned from intensive care much earlier than expected with better outcomes, so health care cost savings are significant. Carefully tracked use of the monitor often shaves 2 to 3 months, even as much as 6 months, off treatment time.
Every 2 weeks, the data from the children’s abdominal monitors is downloaded to the IA database at Bryan LGH, and each child’s progress is clinically evaluated. “I encourage parents to keep an events log, which can be compared with documented compliance charting,” Niazi says. The monitors are less reliable than direct observation, and, while indisputably valuable for data collection, their greatest worth may lie in the reassurance they grant the families.
NINE SLEEP DOCTORS
Tim Lieske, MD, medical director of the Sleep Center for 19 years, hails from a small town 100 miles from Lincoln. He marvels at the growth he has witnessed in the area but is pleased that Lincoln maintains a rural feel. However, the peaceful setting does not mean that Nebraskans are immune from the problems of sleep disordered breathing and insomnia. They keep the Sleep Center as busy as its more urban counterparts. “Sleep apnea and hypertension are common here, and in treating them, we will continue to grow. It won’t be long until I will ask if we can have another pod,” Lieske says.
Awareness of the extent and severity of sleep disordered breathing and concurrent cardiac risks began to emerge in the late 1970s. Marty Klein, PhD, professor of psychology at local Nebraska Wesleyan University, was experimenting with biofeedback and behavior management in his university laboratory. He ran rudimentary sleep studies and tested psychological therapies for resolving sleep complaints.
Unexpectedly confronted with clients who had severe apneas and arrhythmias, Klein would ultimately rethink his laboratory’s freestanding status. When approached about his concerns, Lincoln General Hospital administration integrated Klein’s clinic into their pulmonary department, and they saw their first patient in 1982.
Thus began the Sleep Center’s medical team approach, an approach that benefits their patients who enjoy easy access to a full spectrum of diagnostic and treatment services. Physicians of all specialties benefit from this close collaboration, which, Lieske believes, is the smartest way to work up regimens that can effectively address complex sleep-related disorders.
The Sleep Center’s nine physicians, all pulmonary specialists, serve as gatekeepers, eliminating patients who would not benefit from an overnight sleep study, directing them to more meaningful procedures. This fiscally conservative approach is not only good medicine, it keeps insurers happy. Best of all, overnight studies encounter little resistance from patients because they know these studies are ordered only when it is essential.
Bailey describes the past quarter of a century as one of growth and prosperity for both the Bryan LGH Medical Center and its Department of Sleep Medicine. Bryan LGH was formed by the 1997 merger of Bryan Memorial Hospital and Lincoln General Hospital. The community, with its many shift and transportation workers, had already been schooled in the importance of a good night’s sleep, and the public’s awareness of this need meant busy schedules for the expanded Sleep Center.
Within 8 years, Bryan LGH Medical Center had outgrown the facility built for it at the time of the merger and began a major renovation. The Sleep Medicine Department was again a key player in the building design planning. Clinician input was sought during the construction process, and many improvements can be attributed to this open forum. The mutual goal to provide an environment most conducive to sleep for the patients also would address staff’s concerns.
As a result, the 11-bed Sleep Center is both patient-friendly and has many features that specialists specifically requested. For example, technologists appreciate the practicality of a centrally located and shared workstation and control room. Based on clinicians’ recommendations, lights and televisions were wired so they can be controlled from either inside or outside the patient’s room. A small thing, but critical to a clean study, since entering the patient’s room to turn off lights can potentially cause an arousal.
The new center, completed in 2005, occupies one fourth of the sixth floor in the expanded medical center. Every patient room has amenities, such as personal showers and flat-screen TVs.
Most of the patients are adults and adolescents; however, children also are seen. These pediatric patients are typically at least 6 years old, although occasionally toddlers as young as 2 are admitted. Because of the spacious quarters, parents may retire to their own on-premises bedroom after their child has fallen asleep.
The Bryan LGH Sleep Center trains its own PSG candidates on-site and does not actively recruit out of state. Hiring locally helps assure camaraderie, commitment, and consistency; however, its newest employee, a RPSGT who started in August 2006, relocated from Iowa.
The Sleep Center support staff of 22 includes 18 polysomnologists, many of whom have a respiratory therapy background. In addition, four nurses on staff are trained to run sleep studies. Three techs are designated as traveling and rotate 3 nights per week among 10 off-site clinics. Four of the technologists rarely run studies, as they are fully occupied scoring studies online, working from home. Management believes that this practice makes for cleaner reads, as the scorer does not have to deal with control room distractions or the need to assist with the procedures.
Before the last medical center renovation, nonemergency patients had to wait as long as 3 months for a sleep study. Now, with the expanded facility and large staff, most studies can be accommodated within 2 weeks, and urgent cases, such as imminent heartfailure, can be seen immediately.
The staff is enthusiastic about a recently instituted work schedule, which consists of three consecutive 12-hour shifts. Previously, four 10-hour shifts were the norm, and a 10-hour schedule could be difficult, even dangerous. “Ten can easily turn into 12. It’s sometimes hard to get out of there,” Bailey says.
A full roster can make it easier for a supervisor to grant time-off requests. Bailey has found that by keeping the laboratory well staffed, she usually is able to accommodate individual employees’ changing needs. Careful attention to scheduling, while respecting the personal needs of the technologists, has resulted in the retention of experienced staff.
Staff transitions are facilitated by rigorous recruitment of potential talent and then training them to Bryan LGH’s standards. Currently, no formal polysomnography coursework is available in Nebraska, although Bryan LGH has had preliminary discussions with the Allied Sciences College in Lincoln about developing a PSG curriculum.
“It takes up to a year for a tech to feel completely comfortable,” Bailey says. The complexity of polysomnography is acknowledged by the Sleep Center, and their patient:technologist ratios are often lower than accreditation standards require. For example, never are more than two adults assigned to a single tech, and medically complex cases are typically staffed one on one. Children under 8 always are monitored one on one. In some cases, two technologists will work with a single child, or an adult with multiple medical problems.
A DREAM EMPLOYER
The Sleep Center actively implements the Medical Center’s comprehensive Alertness Awareness program, generally acknowledged as valuable by the entire Bryan LGH Medical Center community.
Leigh Heithoff, RPSGT, BS, the Sleep Center’s clinical specialist, has been with the Sleep Medicine Department (originally at Lincoln) since 1981. She became intrigued with sleep while she was still a college student, her curiosity piqued by an undergraduate class offered on sleep and dreaming.
Under the auspices of the Bryan LGH Sleep Center, Heithoff is in charge of the Alertness Awareness program. She presents a densely packed 45-minute PowerPoint presentation on sleep to every Bryan LGH new hire. Stages, architecture, and circadian rhythms are explained, and good sleep habits are advocated. The Alertness Awareness program was inspired by workplace fatigue programs developed by Mark R. Rosekind, PhD. Rosekind is a former NASA and Stanford sleep researcher and currently is an independent sleep consultant.
Heithoff also represents the Sleep Center when she fields Medical Center staff inquiries about how to improve sleep. “You should watch caffeine and keep a consistent wake-up time,” she advises, pointing out two effective but often violated sleep hygiene principles.
Pivotal to the Alertness Awareness program is the enforcement of a strict policy regarding employees who fall asleep on the job. Falling asleep at work results in a mandatory visit to the Sleep Center. The lack of employee accidents attests to the value of the Medical Center’s “no drowsy driving” policy. Whenever an employee or their supervisor suspects that sleep onset is imminent, arrangements are made for a nap, or even a taxi ride home at shift end.
In addition to the training to recognize drowsiness, the Medical Center equips shift worker areas with vigilance-enhancing lighting, and prohibits shifts longer than 12 hours. Bryan LGH has been recognized by the National Sleep Foundation for this significant contribution to workplace safety.
SLEEPLESS IN LINCOLN
|Akhtar Niazi, MD, (left) and Kathy Berndt, RN, BSN, (right) help Izabell Denman’s parents Alexa and Cody Denman.
The Sleep Center also is known for its public health education efforts. It sponsors popular bimonthly sleep apnea support groups, which are attended by as many as 80 persons with SDB. A novel way that the Sleep Center gets the word out on sleep is through its chemical dependency outreach. Heithoff, who heads up the outreach, explains that “Disrupted sleep is often a precursor to a relapse.” This outreach, which helps rehabilitate underserved populations by educating social service and mental health providers, shows a commitment to the community, and sends a powerful message about the value of sleep.
“We’ve always felt that our mission was more than conducting sleep studies. When I started in sleep, many doctors called it hocus-pocus,” says Richard Bagby, RPSGT, BS. Bagby, who has been with the Bryan LGH Sleep Department since 1985, is interested in tracking the comorbidity of periodic leg movement and obstructive sleep apnea, which frequently present together. Bagby shares his passion for sleep medicine by speaking at the sleep apnea support group.
Lieske has long dreamed of expanding services for insomniacs, and he is gearing up for a fight against this many-faceted condition. Since determining the cause of chronic insomnia is very involved, and minimally requires a vigorous team approach and a highly motivated patient, progress can be expected to be incremental.
Patients suffering from various insomnias—often with type A personalities and sometimes battling psychiatric disorders, such as depression—are advised by Lieske to look at the bright side as much as possible. “Our patients need to acknowledge, ‘I’m still functioning,’ and look at appropriate goal setting, which includes watching out for self-defeating behaviors and attitudes,” Lieske explains.
The Bryan LGH Sleep Center already has implemented a robust infant apnea program, a booming sleep study laboratory, and an award-winning employee alertness safety program and educational outreach efforts. The staff anticipate further expansion as they continue to investigate the factors that are producing more and more sleep-deprived Americans.
Joni Allen is a contributing writer for Sleep Review. For further information, contact [email protected].