Spartanburg Regional Healthcare System finds that HSAT for hospitalized patients is sometimes necessary. Use of portable monitoring can lower hospital readmissions, shorten length of stay, and qualify the patient for durable medical equipment as needed.
The advancement of the role that sleep-breathing disorders play in health-related complaints is tremendous. Growing patient diversity has created challenges of providing care to stabilize current health issues and the prevention of further problems in a rapidly expanding testing population.
Though in-lab testing remains the best practice for assessment of sleep disorders, unfortunately an estimated 85% of clinically significant and treatable obstructive sleep apnea (OSA) patients have never been diagnosed. Comorbidities such as coronary artery disease, obesity, congestive heart failure (CHF), hypertension, and stroke are frequently seen in the OSA patient population.
A study sponsored by the American Heart Association found that “patients with stroke have an increased incidence of obstructive sleep apnea.” “Hypoxia and hemodynamic responses to OSA may have predisposed these patients to stroke.”1 The presence of OSA syndrome in stroke patients may lead to poor outcomes and “should be screened at the moment it is clinically suspected.”2 These findings have greatly increased sleep testing requests.
Various studies have estimated 40% to 70% of CHF patients suffer from sleep apnea. CHF is one of the most common causes of admissions to hospitals in the United States, especially among those over age 65.
Sleep testing is further challenged by regulatory directives for quantitative data for durable medical equipment and treatment options. Hospital-based centers such as Spartanburg Regional Healthcare System (SRHS) where I work must consider appropriate length of stay for our patients and readmission directives mandated by the Centers for Medicare and Medicaid Services (CMS) for chronic illnesses such as chronic obstructive pulmonary disease (COPD), CHF, and diabetes. Portable monitoring and home sleep apnea testing (HSAT) are certainly not new, but have become more developed and technically effective. To be useful, HSAT must be utilized appropriately to be effective and correctly diagnostic.
SRHS consists of Spartanburg Medical Center, a 540-bed research and teaching hospital; acute care hospitals Pelham Medical Center and Union Medical Center; Spartanburg Hospital for Restorative Care; and Ellen Sagar Nursing Center. SRHS provides care to a six-county area of the upstate of South Carolina and western North Carolina. The vast majority of the patients served in SRHS’s sleep centers are tested as outpatients in a 12-bed sleep center located off-site near Spartanburg Medical Center. SRHS’s higher acuity and special needs patients are tested in our two-bed medical center facility. This includes people with limited ambulation, bariatric needs, psychiatric or developmental challenges, as well as high-risk cardiac or pulmonary patients. This assignment approach provides the greatest safety and qualitative study for both patient and staff. Testing on-site may incur higher labor expenses.
There is also the issue of providing testing for our inpatients. We work hard to avoid inpatient testing because these patients are ill and need ongoing clinical care. Medication changes and acute issues affect the length and quality of their sleep, limiting the sleep tracings’ ability to represent an accurate assessment of their sleep complaints. However, there are cases when inpatient testing is necessary.
Delay in testing for these inpatients may impact length of stay, hospital discharge, and qualifications for necessary home medical equipment. Our medical center is often also booked with appointments several weeks out, limiting availability for an in-lab sleep study.
Our team addressed this roadblock by working with our system’s respiratory care department. Staff first determined that the most frequent symptoms generating inpatient orders were for sleep-breathing disorders: COPD, CHF, stroke, witnessed apnea (especially after a procedure and medication), and snoring.
The study also found that the breathing complaints were all too often from formerly diagnosed OSA patients who had been noncompliant with therapy and whose condition had deteriorated. These patients needed reassessment of their level of sleep-disordered breathing and therapy needs. Stroke patients were frequently cared for in our Spartanburg Hospital for Restorative Care and needed to be qualified for home medical equipment. Cardiac patients were often observed post-catheterization or intervention with apnea, and there was a real concern over sending them home before sleep testing could be done.
To meet this challenge, the respiratory care department has assumed HSAT for inpatients. Sleep staff is only on-site a few nights per week, and this limits the sleep staff’s testing ability. Orders for testing were often sporadic, but there was not a constant level of testing need to justify adding additional sleep staff. The respiratory care team staffs our hospitals 24/7 and leadership felt this service was more readily available to meet this testing need.
As with most new services, there have been a few bumps in the road. Because this test had the potential to be used system-wide, there were many more steps that had to be addressed to begin testing than if HSAT would be confined to the sleep service scope of care. Policies and procedures had to be developed. Quality assurance processes had to be written and approved. Medical staff services, biomed, and administrative requirements had to be addressed, and respiratory and nursing staff needed to be educated in use of the HSAT device. This education was provided to all facilities where HSAT would be utilized. Finally, order entry specification and CPT (Current Procedural Terminology) and ICD-10 coding and charges had to be developed for the system’s electronic medical record software.
Reimbursement for HSAT in the hospital, Spartanburg Hospital for Restorative Care, or SRHS’s nursing center will be minimal at best. With this patient group, the team’s sleep testing goal is to save expenses by shortening length of stay where appropriate. Safer discharge will be achieved by being able to qualify patients for home supplemental oxygen or positive airway pressure (PAP) as needed and per the third party or CMS guidelines for qualification. Nursing home and restorative care patients won’t need to be bundled up and transported to our facility for testing, saving transportation fees and making care more comfortable for the patient.
Shari Angel Newman, RST, RPSGT, CSE
Finally, there is the challenge of hospital readmissions. Our hospital system serves a patient population that unfortunately ranks in the top 10 states in our country in the prevalence of diabetes, hypertension, obesity, CHF, and stroke. Wellness efforts with reevaluation of apnea and subsequent encouragement of PAP and treatment compliance will, hopefully, in the long run keep these chronic illnesses stable, allowing for improved patient health and limiting the need for these hospital readmissions.
Proactive change in provision of testing diversity is necessary today in order to deliver quality care and treatment, and encourage wellness. For our system, HSAT for hospital sleep apnea testing is an added service toward successful sleep care.
Shari Angel Newman, RST, RPSGT, CSE, is clinical manager, regional sleep services at Spartanburg Regional Medical Center, and a member of Sleep Review’s editorial advisory board. Newman gives special thanks to Teresa O’Neal, RRT, director of respiratory care services at Spartanburg Regional Healthcare System, for her assistance with this article.
References
1. Chan W, Coutts SB, Hanly P. Sleep apnea in patients with transient ischemic attack and minor stroke: opportunity for risk reduction of recurrent stroke? Stroke. 2010 Dec;41(12):2973-5.
2. Neau JP, Paquereau J, Meurice JC, Chavagnat JJ, Gil R. Stroke and sleep apnoea: cause or consequence? Sleep Med Rev. 2002 Dec;6(6):457-69.
I would like to touch base with Ms. Newman as our center is interesting in touching base on this topic as well. Is there an email I could reach her at?
We have forwarded your comment and email address to the author. Thanks for your interest.
Our hospital currently has a protocol for screening apnea patients but I am interested in how you get around certain insurance requirements to do qualifying HSATs as inpatient. I would also be very interested in speaking with the author.
We have forwarded your comment and email address to the author. Thanks for your interest.
You cited patients with CHF as one of the patient populations you are targeting with use of HSAT, to aid your hospital in meeting the new CMS targets for reduction in hospital readmissions by qualifying those patients for PAP. How do you do that when CMS regulations PROHIBIT the use HSAT for sleep testing among that category of patients? Specifically, CMS LCD L34535, “Home sleep testing is not covered for persons with comorbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure)”.
Centers for Medicare & Medicaid Services LCD L34535 states, “Home sleep testing is not covered for persons with comorbidities (moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure)”. How does your hospital manage to sidestep this Federal prohibition in using HSAT to diagnose OSA in CHF patients?
We certainly abide by CMS directives regarding moderate to severe CHF and other co-morbidities prohibiting HSAT qualification. Our goal is hopefully to get our patient’s compliant with care before their illnesses advance to a more severe level or to utilize in more appropriate application such as mild COPD, dementia, stroke, etc.
I have been trying to get our hospitals to do this for literally the last 6 years. It is incredibly frustrating, given the incidence of undiagnosed and untreated patients. As for those who are asking re HST in CHF patients, if you are not getting reimbursed anyhow who cares? It may allow you to fast track a patient and a HST in hospital is way better than nothing. I have been around long enough to see many guidelines and CMS rulings change.I commend you for being truly patient centered. NHA MD, FACS, FAASM
I have an HST unit, currently trying to get it in use. On inpatients what CPT & billing Codes are you usig for these studies.