As the country stood still while COVID-19 took over, health care and the way we view preventative care changed forever. Hospitals became inundated with patients requiring acute care services, both for COVID-19 and other routine conditions. Prioritization of patients, acuity, and services became everyday practice here in our country for one of the first times in decades. We sat back and watched as our fellow respiratory colleagues worked day-in and day-out, few getting the respite care needed and many traveling to the underserved areas to try and combat this pandemic. We urged patients to stay home and social distance from others, including health care professionals. If you did not need to seek immediate health care, the message was clear to stay home and avoid any unnecessary exposures if you could. Unfortunately, this led to many patients forgoing preventative care and routine screenings, which otherwise might have made a difference in their health care treatment options, prognosis, and outcomes. Elective procedures were put to a halt, thus causing patients no choice but to postpone such care.1
As the country began to watch the pandemic wax and wane, the opportunities changed for patients, but how did it affect their ability to receive care?
Changes in the Sleep Clinic
For technicians, respiratory therapists, and providers working in sleep medicine, the pandemic hit and this influenced jobs. I remember sitting in my office receiving the call telling me that I would be working from home indefinitely and providing telehealth services to my patients. I had never done telehealth before and knew that it would be difficult trying to manage seeing patients safely and securely from home while my three children also had remote schooling. First, it started as just telephone visits and then upgraded to video visits. I even managed to orient two new employees via Zoom during the pandemic. Making sure the bandwidth was enough to keep the visits going was a challenge in itself, especially with the entire neighborhood trying to achieve the same goal.
As the country began to watch the pandemic wax and wane, the opportunities changed for patients, but how did it affect their ability to receive care?
I enjoyed working from home but missed the direct patient interaction. I missed the opportunities to educate my patients on mask fittings and to have that first interaction face to face with them. For some patients, telehealth made their commute to our clinic easier and improved access to care. For others, technology was a challenge, and visits were lost or missed due to lack of communication. This change allowed us to get by and continue moving forward, but only at a snail’s pace. While visits were still happening, testing was on a priority needs basis.
When COVID-19 began, we placed elective procedures on hold. These procedures included sleep studies, and for many institutions and centers, this meant no business or revenue to continue employing staff. Nationally, we saw staffing cut by 25% and studies cut by 80%.2 Many therapists working in sleep centers went back to critical care areas due to emergency needs and unemployment. Others retired early to ensure continued financial support long-term. At the time of initial closure, no one knew what the impact might be or the length of time we would endure during this crisis.
As the pandemic began to change and offices began to open up, I could once again offer face-to-face visits to my patients again after several months of telehealth exclusively. Naturally, some patients were excited to come back. But, on the other hand, some were upset that they could no longer take advantage of the telehealth option.
It was mixed emotions for both staff and providers, as every day you would walk in, report your temperature and symptoms, and hope you made it through safely without contracting this deadly virus, all to help do the one thing you signed up to do: save lives.
Reimbursement for telehealth was expanded, which allowed me to complete more and more visits as time went on. The fear was that the safety net would be pulled sometime soon, and we would be forced to go back to all in-person visits, leading to patient refusals and fewer visits. I had already encountered more insecurities from patients about the safety of the visit, the safety of the study, and how safe positive airway pressure (PAP) therapy could be if they contracted COVID-19. I had to get creative when ordering diagnostic testing, and home portable testing became more readily available and reimbursed. Options for mail-order testing became the norm in our institution to allow our patients to receive the equipment remotely at home and return it without coming into the clinic. The less contact, the better. After diagnosis, they were mailed an autoPAP and instructed on using it remotely via telehealth from the durable medical equipment company. While this was not ideal, it, again, got us by.
Changes to the Sleep Lab
As we put our outpatient procedures on hold, our sleep lab was put into “skeleton crew” mode, and testing was done only on those patients who truly needed it. Titrations were rarely done, and special permission was needed to obtain a study. Cost in sanitation equipment, disposable equipment, and other additional supplies has also made studies more difficult and costly over the last year.
The American Academy of Sleep Medicine (AASM) joined the Centers for Disease Control and Prevention (CDC) to provide safe guidelines for sleep centers and labs during the pandemic in January 2021.3 Some suggestions were to continue implementing telehealth as much as possible, screening patients upon entry to the clinic and lab for symptoms of COVID-19, and continuing to implement face coverings by both the patient and provider during the visit.3 As patients began returning for evaluation and testing, the sleep labs slowly began to reopen. While the labs opened, patients were hesitant to return, and labs were struggling to find respiratory therapists and technicians to fill to empty positions that were created early in the pandemic. Rules for social distancing limited the number of technicians in a lab due to spacing. Patients sought value in remaining at home, even if this meant delaying diagnosis and treatment. We established protocols that outlined how to schedule a patient, how to check in a patient, attach the electrodes, clean up, and so on. Spontaneous split night studies were no longer allowed to occur due to the nature of the PAP portion being considered an aerosolized procedure. To complete titration studies, patients were required to complete a COVID-19 test and quarantine for up to 72 hours before the procedure to provide safety for those involved. The lack of a negative COVID-19 test meant testing was canceled last minute, and a bed sat empty again another night that could have possibly been filled in years passed easily without restrictions in place. Cancellations and no-shows became more common. Our sleep lab still looked like a ghost town on most nights despite reopening, and staff turnover was significant. It will probably take years for patients to regain trust and comfort levels to resume returning to the hospitals and sleep labs for care.
While the pandemic has not ended, sleep medicine has seen its share of ups and downs. As patients started to receive vaccinations for COVID-19, more and more patients felt comfortable participating in studies outside of the home. I have seen an increase in referrals to sleep medicine due to sleep issues caused by the stress of the pandemic. Changes in sleep patterns due to work from home, financial constraints due to unemployment, and stress due to staff burnout have all affected the ability of people to cope with stress and therefore impacts sleep. Insomnia, fatigue, metabolic disorders, alcohol consumption, and obesity have all been rising during the pandemic. This trend, in turn, can increase the risk for sleep-disordered breathing, diabetes, heart disease, and cardiovascular events. Both the known and unknown long-term effects of COVID-19 have caused me to keep guessing what will happen next when it comes to patients who have known sleep apnea or hypoventilation syndromes concurrently. I see patients every day that show signs of significant cardiovascular compromise, hypoxemia, and memory issues post-COVID-19. Monitoring for potential health risks and other complications leads to increased health care spending, from increased COVID-19 screening prophylactically before procedures and for symptomatic patients, cardiovascular testing, and additional health care referrals.
As new strains of COVID-19 are discovered, and the pandemic continues, sleep labs and sleep centers work to rebuild and provide care to patients across the spectrum. I hope that with the constant state of flux that this pandemic has caused, sleep medicine continues to strive to find creative solutions for provided safe and effective care to patients despite the constraints we are faced with. As long as CMS and other third-party payers continue to provide flexibility in coverage and care, we as providers and sleep labs can continue to find ways to help patients sleep better, one night at a time.
- Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns – United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1250-1257. DOI: http://dx.doi.org/10.15585/mmwr.mm6936a4
- Miller, MA and Cappuccio, FP. A systematic review of COVID-19 and obstructive sleep apnoea.Sleep Medicine Reviews, Feb 2021, 55
- https://aasm.org/covid-19-resources/covid-19-mitigation-strategies-sleep-clinics-labs/(accessed 6/25/2021)
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Jessica Schweller is a sleep nurse practitioner and clinical educator at The Ohio State University. She currently works in the sleep disorders center and is also clinical faculty for the MRT program. She is the outgoing Sleep Section Chair for the AARC.
