Sleep Medicine: A Team Sport

No man is an island entire of itself; every man is a piece of the continent, a part of the main— John Donne

Donne’s classic line applies to modern medicine, and sleep medicine is no exception. The complexity of identifying at risk patients, diagnosing sleep disorders, implementing effective therapy, and working with patients to ensure compliance requires a team of well-trained, empathetic professionals.

In short, sleep medicine should be a team sport. While this is true for every facet of medicine, opportunities for team-based care in the management of patients with sleep disorders remain largely unrealized. We can and should achieve more for our patients and our profession. Building a successful team does not require the infrastructure of a university health system or a major corporate multispecialty center. An effective sleep team can be built by anyone with vision and dedication.

The Problem

At least one-third of the population of the United States suffers from some type of chronic sleep problem including insomnia, excessive daytime sleepiness, sleep-related breathing disorders, and parasomnias. The indirect cost of these sleep disorders is estimated to exceed $40 billion yearly because of lost productivity, over $20 billion yearly related to motor vehicle crashes, and more than $10 billion yearly from work-related accidents.¹ Direct medical costs related to obstructive sleep apnea (OSA) and the impact on long-term health are even more staggering.

Sleep accounts for about one-third of our lives but continues to receive little meaningful attention during medical training. Most physicians are not trained on effective team building. The following overview is meant only to begin the conversation about how to build an effective sleep team.

The Players

Patient

Although it can be easy to forget that patients play a central role in every aspect of care, the patient’s role during the evaluation and subsequent management of identified sleep problems must remain at the fore. Therapeutic interventions are only effective in the compliant patient. Communication and education are central to achieving the desired goal. Knowledge is power.

Sleep Specialists

The sleep specialist must fill a number of different but important roles in any sleep team. The sleep specialist must evaluate, diagnose, and direct the educational and treatment approaches for the patient. It is important to remember that the sleep specialist need not provide each of these important services him- or herself, but must actively be involved in an advisory and supervisory role.

Primary Care

The primary care physician should take a central role coordinating the patient’s overall health management, acting as the medical home. Unfortunately, most of these physicians have little or no formal training on the identification and management of sleep disorders. Therefore, the sleep medicine specialist must collaborate closely with the primary care provider. These professionals can help identify patients who are at risk by simply adding a few sleep screening questions to their routine assessments. Furthermore, primary care providers can provide vital encouragement, feedback, and monitoring to patients suffering from sleep disorders. Sleep specialists in turn may assist primary care providers by ensuring they and their referred patients have the information they need about sleep disorders.

Nurse/Nurse Educator

The nurse and nurse educator are central to the managing care of patients with sleep disorders. In many cases, a message is being taken by a nurse for the sleep specialist, who can often act as a coordinator between medical specialties and durable medical equipment providers. Sleep specialists must ensure that nurses and nurse educators understand which follow-up questions are needed for a particular complaint. In smaller practices, this role may be filled by the sleep specialist alone. While advanced certification in sleep education is beneficial, excellent patient care can be achieved through a rigorous and ongoing educational program provided by the sleep specialist.

Nurse Practitioner/Physician Assistant

Physician extenders can dramatically improve the care of patients with sleep problems. It is extremely important to ensure that the nurse practitioner or physician’s assistant is adequately trained, has adequate supervision, and has ready access to consultation with the sleep specialist.

Consultants

A wide array of subspecialists plays a pivotal role in any sleep care team. Dentists, otolaryngologists, and maxillofacial surgeons can all contribute directly to the management of sleep-related breathing disorders. Cardiologists, pediatricians, gastroenterologists, allergists, pulmonologists, neurologists, psychiatrists, and psychologists can provide extremely important input for the optimal management of various sleep disorders and their associated comorbidities.

Allergy. As with many subspecialists, the allergist may identify patients with sleep-disordered breathing during initial or follow-up evaluations. The allergist also serves a vital role in the management of nasal congestion and sinus symptoms which can limit compliance with central positive airway pressure (CPAP) treatments of sleep-related breathing disorders. It is incumbent upon the sleep specialist to communicate the specific nature of the problem and the importance of the allergist’s management of the associated conditions.

Anesthesiology. During any postoperative period, patients are at increased risk of complications related to sleep apnea. If a patient with a sleep disorder is scheduled for a procedure, the anesthesiologist must be made aware of the sleep disorder. During education of patients newly diagnosed with OSA, they should be advised to always notify any surgeon or anesthesiologist that they have OSA. If a patient does not bring the CPAP system for the procedure, the surgeon or anesthesiologist should contact the sleep specialist for specific directions. Furthermore, the surgeon and anesthesiologist are in an extremely advantageous position in the postoperative care unit to identify patients with a previously undiagnosed sleep-related breathing disorder.

Cardiology. A large percentage of patients visiting a cardiologist are at risk for a sleep-related breathing disorder. The cardiologist should include standard sleep screening questions as a component of a standard cardiac evaluation. Conversely, the sleep specialist should screen for cardiac symptoms, which might arise primarily at sleep onset or at awakening. Polysomnography frequently identifies previously unknown cardiac arrhythmias.

Dentistry. Dental sleep medicine has been increasing over the past several years as the quality and effectiveness of oral appliances has improved (see Dental Sleep Medicine). A good working relationship between the dentist and the sleep specialist is of utmost importance. Close follow-up of the efficacy and tolerability of an oral appliance is vital.

Gastroenterology. Patients with restless leg syndrome (RLS) should be screened for low ferritin and serum iron levels. A gastroenterology referral may be necessary to screen for causes of chronic blood loss through the gastrointestinal tract. In terms of identificating patients with OSA, observing the patient following endoscopic procedures can be beneficial.

Hematology. Patients with RLS secondary to low serum ferritin or iron levels may require treatment with intravenous iron. In some cases, a ferritin level that is low enough to contribute to RLS may not be low enough to contribute to anemia. Therefore, a close collaboration between the sleep specialist and a hematologist is of great importance.

Neurology. The patient population evaluated by a neurologist includes large numbers of patients who suffer from comorbid sleep disorders. Patients who have had stroke or have degenerative neuromuscular disorders are at high risk of sleep-related breathing disorders. Parasomnias such as REM-sleep behavior disorder are much more common in patients with Parkinson’s disease and related degenerative disorders. Neurologists should screen their patients for sleep disorders and make the appropriate referrals. The sleep specialist may need to involve a neurologist if a parasomnia suggests the presence of Parkinson’s disease or if a polysomnogram reveals evidence of a potential seizure disorder.

Psychiatry/Psychology. Many sleep disorders are associated with mood disorders. OSA can contribute to the development of depressive symptoms. Insomnia is often associated with depression, anxiety, posttraumatic stress disorder, and bipolar disorder. A close collaborative relationship between the sleep specialist, psychiatrist, and psychologist can help produce an enhanced outcome for both the sleep disorder and the psychiatric condition.

Pulmonology. Numerous pulmonary disorders, including chronic obstructive pulmonary disease (COPD), asthma, pulmonary fibrosis, and more, can be associated with sleep-related breathing disorders. Furthermore, management of sleep disorders can improve management of pulmonary disorders. Certain pulmonary treatments, however, can worsen insomnia and RLS. Therefore, the pulmonologist should screen for any comorbid sleep disorders, and the sleep specialist should communicate management options and treatment limitations to the pulmonologist.

Sleep Technologist

The sleep technologist must fulfill numerous duties in order to ensure optimal patient care. When the study is being performed, the technologist must be able to put the patient at ease. The sleep specialist must have a good understanding not only of the technical aspects of the procedure but also of the clinical issues surrounding the individual patient. A simple order for a sleep study is not typically sufficient for optimal care. The sleep technologist should have access to the clinical history and any special recommendations or orders from the sleep physician. Furthermore, the sleep technologist is in an extremely advantageous position to observe subtle findings, obtain additional history, and provide detailed patient education regarding the disorder, the treatment options, and any potential complications which might interfere with treatment. An open line of communication and ongoing educational program between the sleep physician and a sleep technologist can enhance these roles.

Administrator

In addition to the typical administrative oversight duties, a collaborative relationship between the hospital or clinic administrator and the sleep specialist can help optimize care by ensuring the availability of necessary equipment, personnel, and software upgrades. This has become even more important with the recent shifts in care paradigms.

Office/Laboratory Secretary

The office and sleep center administrative and secretarial duties are central to the smooth operation of a comprehensive sleep program. Secretarial duties include not only scheduling patient visits, but also daily adjustments of appointments to provide flexibility and maximize efficiency. Specific patient studies often need to be matched with particular sleep technicians for specialty studies requiring special skills or expertise. The replenishment of supplies including masks and the scheduling of educational seminars regarding this equipment is of extreme importance.

Durable Medical Equipment Provider

The durable medical equipment (DME) provider should supply the prescribed equipment, educate the patient regarding the care for and cleaning of the equipment, and monitor the patient for compliance and potential complications. In addition, the DME provider should have an open dialogue with the sleep specialist and a sleep specialist’s staff regarding compliance and any problems or complaints voiced by the patient and be willing to work with all parties to overcome obstacles to effective treatment.

Housekeeping

The importance of the housekeeping staff in the operation of a sleep center should never be underestimated. A dirty or unkempt room can easily send a message that the sleep team does not really care about the patient. It is incumbent on the sleep center administration and the sleep specialist to consider the housekeeping staff as a central component of the care team and to make sure that these individuals are aware of their importance.

Team Meetings

Given the complex nature of sleep medicine and the interactions between numerous medical specialties and types of health care providers, regularly scheduled continuing education and team meetings are extremely important. When possible, sleep specialists, consulting physicians, nursing staff, and technologists should be included in the programs.

Communication

Effective communication is obviously of paramount importance. Even the most expert of individual team members will be undermined by poor communication. It is incumbent on the sleep specialist to foster a collegial program that places a high value on good communication and allows input from each member. Good communication between well-trained individuals enhances care.

Conclusion

Teamwork is vital for optimal management of patients with sleep disorders. The specific design of a team does not need to fit one particular pattern. Simply put, it just needs to be effective. No matter what the design, the key is effective communication between team members and the patient. Building a cohesive team not only improves patient care but also increases efficiency and enhances the work environment.

1. Stoller MK. Economic effects of insomnia. Clin Ther. 1994;16:873-897.

James D. Geyer, MD

Alabama Neurology and Sleep Medicine
Tuscaloosa, AL

Paul R. Carney, MD

Department of Neurology
UNC Neuroscience Center
University of North Carolina at Chapel Hill
Chapel Hill, NC

Monica M. Henderson, RN, RPSGT

Alabama Neurology and Sleep Medicine
Tuscaloosa, AL