COVID-19 mitigation strategies for sleep clinics and sleep centers – REOPENING

Updated April 27, 2020

The American Academy of Sleep Medicine is issuing the following updated guidance to help sleep medicine clinicians assess their sleep clinic and sleep center/laboratory operations in response to the spread of the novel coronavirus (COVID-19). This guidance is based on the mitigation strategies recommended by the Centers for Disease Control and Prevention (CDC). Please refer to CDC documents for more comprehensive information.

Situation Summary

While the United States is still in the acceleration phase of the pandemic, and all U.S. states are reporting community spread of COVID-19, different parts of the country are seeing different levels of COVID-19 activity. A nationwide policy of physical distancing, supported by executive orders at the state level, has helped slow the spread of the virus. Now the nation is focused on when and how to relax current restrictions while maintaining strategies to contain the virus and avoid triggering another major surge of cases.

Federal & State Policies

The White House has posted its multi-phased Guidelines for Opening Up America Again, and state governors are releasing similar plans to gradually reopen. The Centers for Medicare & Medicaid Services (CMS) also has posted recommendations for reopening facilities to provide non-emergent, non-COVID-19 health care. We advise stakeholders to review this guidance.

Values

  • Clinical judgment: While evidence-based decision-making is the ideal standard, such evidence is only slowly emerging in this rapidly-evolving public health emergency. Therefore, clinicians must rely on their expertise; consensus documents, if available; and clinical judgment when evidence is lacking.
  • Health & safety: Decision-making must promote and protect the health and safety of both patients and staff, with particular consideration for those who are at higher risk for severe illness.
  • Public health: Decisions also must take into consideration the public health needs of the local community.
  • Caution: When in doubt, err on the side of caution.

Goals

  • Support efforts to gradually and safely reintroduce health care services
  • Implement best practices for infection prevention and control
  • Minimize patient, staff and provider exposure to the virus
  • Maintain access to care and continuity of care
  • Promote public health and safety

General Considerations

COVID-19 status

Note: Serological tests [i.e., antibody tests] are not diagnostic tests. The determination of immune status based on serological tests should be done based on available guidance.

  • Status unknown
    • Absent symptoms and no known/suspected contact with a person who has COVID-19 for at least 14 days
    • No COVID-19 test
  • Presumed negative
  • Self-quarantined
    • Staying home and self-monitoring for 14 days after recently having close contact with a person with COVID-19, or recently traveling from somewhere outside the U.S. or on a cruise ship or river boat
  • Presumed positive
    • Symptomatic (e.g., fever, cough, shortness of breath) and/or positive or pending COVID-19 test
  • Presumed recovered
    • No fever for at least 72 hours without the use of fever-reducing medications, other symptoms have improved, and at least 7 days since symptoms first appeared; OR
    • No fever without the use of fever-reducing medications, other symptoms have improved, and two negative tests in a row (at least 24 hours apart)

Screening

  • Eliminate penalties for patient cancellations and missed appointments related to respiratory illness.
  • Screening of patients: All patients must be screened for potential symptoms of COVID-19 prior to their in-person appointment and again at the time of the appointment before entering the facility.
    • Pre-screening prior to appointment: Use phone calls, patient portals, or online self-assessment tools.
      • Review COVID-19 symptoms such as fever, cough, or shortness of breath.
      • Review COVID-19 status as described above.
      • Reschedule patients with symptoms or positive or pending COVID-19 tests.
    • Screening at time of appointment
      • Check temperature and screen patients again for COVID-19 symptoms and testing status upon their arrival at the facility.
      • Reschedule patients with symptoms or positive or pending COVID-19 tests.
      • Refer for diagnostic testing or clinical care as appropriate.
  • Screening of staff: Health care personnel and office staff must be routinely screened for COVID-19 symptoms and should take temperature checks twice per day. Send staff home if they are symptomatic. Adopt flexible and/or reduced scheduling to account for staff needing to be off due to illness or quarantine. Offer staff adequate rest breaks if working with reduced level of staffing.
    • Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies. Allow ill personnel to stay home and remind staff that they should not report to work when they are ill.
  • Screening with point-of-contact testing: When adequate COVID-19 diagnostic testing is available, patients should be tested in a reasonable timeframe before care. Health care personnel, cleaning staff, and other staff also should be regularly screened with a diagnostic test when COVID-19 testing is available.

Infection Control

  • Ensure that a designated staff member is responsible for regularly monitoring COVID-19 updates from state and local health departments.
  • Use telemedicine, where available and when appropriate, to limit non-urgent, in-person visits. Utilize telemedicine and/or electronic distribution of documents for pre-procedure counseling, consent and screening, and for post-procedure counseling to the maximum extent possible based on availability.
  • Within the facility, promote physical distancing by minimizing time in waiting areas, spacing chairs at least 6 feet apart, maintaining low patient volumes, and reducing face-to-face contact time as much as possible. Consider having patients wait in their vehicles instead of in waiting areas. Avoid lines at check-in and check-out from the clinic/laboratory. Complete as much instruction as possible ahead of time using telemedicine.
  • Whenever possible, limit access of family members and other non-patient visitors to only those required for providing health care services. For translation services, consider using remote-access services.
  • Place visual alerts such as COVID-19 signs and posters at entrances and in strategic places providing instruction on hand hygiene, respiratory hygiene, and cough etiquette.
  • Ensure supplies are available such as tissues, hand soap, waste receptacles, and alcohol-based hand sanitizer in readily accessible areas.
  • Review with staff all procedures for infection control, including cleaning and inspecting all patient-related equipment. Clean reusable medical equipment according to manufacturer’s instructions and follow CDC recommendations for environmental cleaning and disinfection.
    • According to CDC infection control recommendations, routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate in health care settings, including those patient-care areas in which aerosol generating procedures are performed.
    • Refer to List Non the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2, the virus that causes COVID-19.

Personal Protective Equipment (PPE)

  • Actively monitor and secure PPE supplies.
  • Clinicians and staff should wear surgical face masks at all times during this public health emergency.
  • Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.
  • Ensure appropriate use of PPE by sleep technologists and clinic staff during patient interactions in accordance with state and federal guidelines.
  • Procedures with a higher risk of aerosol transmission, such as positive airway pressure (PAP) titration, should be done with great caution, and staff should utilize appropriate PPE such as N95 respirators, gloves and face shields.
    • Personnel with expected use of N95 respirators will need fit testing prior to use in accordance with OSHA 1910.134.

Sleep Clinic & Sleep Center Strategies

The following recommendations are provided only as an advisory. Please seek additional guidance from state executive orders and reopening plans as well as local public health statements.

The AASM strongly urges all sleep clinicians to continue postponing and rescheduling in-laboratory administration of PAP therapy and polysomnography (PSG), except in emergencies, until at least April 30, 2020. The AASM strongly urges sleep clinicians to continue postponing non-urgent care until a later date, if such a recommendation is made by state officials due to local conditions.

Beginning May 1, 2020, the AASM advises sleep clinicians to implement the following strategies, depending on the local level of COVID-19 community spread as reported by your state department of health and local health department. Sleep clinicians should be prepared to adjust operations as local conditions change, with the expectation that intermittent, short-term restrictions or closures may be needed in response to sudden increases in local community transmission.

Community Transmission:  Substantial

Large-scale community transmission, health care staffing significantly impacted, multiple cases within communal settings

  • If testing for COVID-19 infection is available and feasible, all patients should be tested in a reasonable timeframe before coming into the sleep center, in addition to being screened for symptoms.
  • Postpone and reschedule in-laboratory administration of positive airway pressure (PAP) therapy (i.e., PAP titration studies and split-night studies) except in emergency situations, in which case, review the potential for aerosolization and ensure technologists use appropriate PPE.
    • Exception: PAP administration can take place in an airborne infection isolation room (AIIR) — i.e., a negative pressure room — according to CDC transmission-based precautions.
  • Avoid operating PAP in the clinic setting due to the risk of aerosolization.
  • Postpone and reschedule polysomnography (PSG) for children and adults except in emergencies.

Note: During this public health emergency, Medicare will cover PAP devices based on the clinician’s assessment of the patient without requiring PSG or a home sleep apnea test (HSAT). While there are validated screening and assessment tools, specific criteria to justify the prescription of PAP devices are unavailable. Furthermore, CMS has not clarified what follow-up testing, if any, may be required after this public health emergency is over.

  • Restrict HSAT services according to the following parameters.
  • Postpone and reschedule all non-emergency, in-person appointments; conduct visits via telemedicine.

Note: During this public health emergency, Medicare is expanding coverage for telemedicine services and waiving requirements for face-to-face or in-person encounters.

  • For emergency or unavoidable in-person visits, maintain recommended standards for proper use of PPE and follow the CDC’s transmission-based precautions.
  • Visitors should be prohibited, but if they are necessary for an aspect of patient care, then they should be pre-screened in the same way as patients.
  • If language translation is required, consider using remote-access services rather than in-person services.
  • When sleep medicine services are postponed, maintain communication so that patients’ access to the medical team and continuity of care are preserved, and loss to follow-up is minimized.

HSAT Service Parameters

  • If using reusable devices, the units must be cleaned and sanitized according to CDC disinfection standards and manufacturer’s instructions. As an extra precaution during this public health emergency, it would be best to remove a reusable device from service for at least 72 hours in addition to disinfection before its next use.
  • Consider using single-use, fully disposable devices and/or components.
  • Use an HSAT service model (e.g., mail delivery) that ensures patients do not have to leave their home to receive or return the device.
  • Provide patients with access to instructional brochures, video or telemedicine consultations to ensure proper set-up, as well as safe handling of the package upon arrival.
  • Individuals responsible for cleaning reusable HSAT devices must wear appropriate PPE.

Community Transmission:  Minimal to Moderate

Multiple cases of COVID-19 in the community

  • Postpone and reschedule in-laboratory administration of PAP therapy (unless testing takes place in an AIIR), except in emergencies, and avoid PAP use in the clinic setting.
  • Postpone all PSG in older adults, those who are pregnant, and people of any age who might be at higher risk for severe illness from COVID-19.
  • Consider resuming diagnostic PSG for children and adults who are not at higher risk for severe illness from COVID-19.
  • Resume in-person clinic appointments for children and adults who are not at higher risk for severe illness from COVID-19 if telemedicine visits are unavailable or inadequate.
  • Restrict HSAT services according to the previously described parameters, with the additional option of using curbside pickup/return instead of a delivery service model.
  • Visitors should be limited, but if they are necessary for an aspect of patient care, then they should be pre-screened in the same way as patients.

Community Transmission: None or Minimal

  • Resume in-laboratory administration of PAP therapy and PAP use in the clinic setting.
  • Resume diagnostic PSG for all children and adults for whom testing is indicated.
  • Resume in-person appointments as needed, including clinic visits and PAP setups.
  • Resume normal HSAT protocols. (It is no longer necessary to restrict HSAT services according to the previously described HSAT Service Parameters.)
  • Resume normal visitor policies.
  • Continue to monitor state and local public health communication for warnings of any increase in community transmission.

For questions or to provide feedback on this guidance, please contact the AASM at covid@aasm.org.