Sleep Waves - American Association for Respiratory Care

In today’s competitive sleep market, many sleep centers
are looking for new ways to expand quickly and capture
new markets. Many centers are doing this by using nontraditional
locations such as hotels to expand and market
their sleep centers. Some of the largest and most
innovative sleep clinics are using this model (e.g., the
Cleveland Clinic, Duke University, and Vanderbilt University).
Many sleep centers are starting to follow their
lead.
There are many reasons why sleep
centers choose a hotel model to expand.
In fact, most hospitals are having trouble
finding space in the hospital setting
that is convenient for the patient. According
to Nancy Foldvary-Schaefer, DO,
director of the Cleveland Clinic Sleep
Disorders Center, “It is one very easy, inexpensive
solution to the space crunch
that most academic institutions are experiencing.”
1 Around the country, hospitals and private practices
have partnered with hotels to take advantage of the already
built rooms, daily housekeeping services, and creature
comforts. These arrangements are good for the hotel
also because it guarantees that a certain number of
rooms are booked.
Gary Foreman, administrative
director of ancillary services at
Marymount Hospital in Ohio has been
using the hotel model since 2000. According
to Foreman, “The main reason
we chose to use the hotel model was to
be able to bring sleep testing to the communities
where people live. Patients
often have a negative connotation with
going to the hospital — especially for something like a
sleep issue, which they perceive as not being very serious.”
Foreman also stated that in his experience, “patients
seem to enjoy the hotel design and décor, which
provides a familiar and comfortable setting that helps to
eliminate foreign stimuli that can reduce the ability for a
3 Foreman also mentioned that by
using a hotel model you eliminate the capital costs of
building a center, and you can also reduce costs by avoiding
the need to provide housekeeping,
laundry, and maintenance because all
of these amenities are provided by the
hotel. 2
Hotel sleep centers have other advantages,
such as replacing the sanitary
hospital environment with a more luxurious
setting. Patients can also check
in early and use some of the hotel
amenities, such as watching TV, swimming,
checking e-mail (if they brought
a laptop), and taking advantage of the
continental breakfast offered in some
hotels the following morning. 3
About the Author
Chris Schwanenberger, RRT, is
director of respiratory care and
the sleep center at Lutheran
Hospital in Cleveland, OH.
Sleep quality
The million dollar question is, does
sleeping in a hotel really allow the patient
to sleep better than in a hospital
setting? According to Vanderbilt’s Beth
Malow, MD, most of the patients who go
to a hotel model are more satisfied with their experience.
There is little data to suggest that a hotel environment
eliminates the first-night effect. First-night effect is the
alteration in sleep architecture typically seen on
polysomnography readings the first night, which is
thought to be associated with the unfamiliar environ-
6 AARC Times September 2008
Sleep Waves
Nontraditional Diagnostics
Outside of the Sleep Lab
Across the U.S.,
hospitals are
partnering with
hotels to perform
sleep studies.
patient to sleep.” 2 The concept is called the “firstnight
syndrome.”
Another reason the hotel sleep center is attractive
is the fact that it is quicker to expand facilities
because you do not have to wait for a building to
be built or for something to be remodeled. There is
little harm done to the room except for some small
drilling to accommodate the wires for the cameras
and sleep equipment.

Sleep Waves Nontraditional Settings
ment and the technical equipment. In a report in the Journal
of Clinical Sleep Medicine, it is suggested that the hotel
model does not eliminate the first-night effect and that
patients do not sleep any better in the hotel setting than
in the hospital’s main sleep center. Kimberly N. Hutchinson,
MD, and colleagues from Vanderbilt University Medical
Center in Nashville, TN, conducted a study of 49
patients in their hotel-based laboratory and 44 patients
in a hospital-based laboratory. They predicted that the
changes in sleep architecture consistent with the firstnight
effect would be greater in the hospital than in the
hotel patients. The sleep parameter for the hotel-based
patients did not differ from those of the hospital-based
patients. 4
Disadvantages
There are some disadvantages and challenges when
setting up a sleep center in a hotel, the first of which is
convincing the hotel management that this is a good idea
and there would be little damage to the rooms. Another
obvious challenge would be the possibility of loud guests
and traffic in the hallways. Some large centers may rent
an entire floor or section of the hotel. Vanderbilt uses
seven rooms at one end of Marriott’s fifth floor, and doors
labeled Vanderbilt’s Sleep Disorders Center separates the
sleep center from the rest of the guest rooms. 1 In Foreman’s
labs they rented three rooms — one for the control
room and two patient-sleeping rooms. They did have
some trial and error at one of the hotels that they used;
they had to move from their first location due to the excess
traffic and noise. However, they were moved to a
quieter section of the hotel, and things were fine. 2
Another disadvantage is trying to outfit the room for
all of the equipment. Most labs require some small
drilling for the wires for the cameras and the sleep equipment.
This may take some convincing for the hotel management
but can be accomplished quite easily. Foreman
said, “They had adjoining rooms that seemed to help, and
they actually ran the wires along the baseboards and
under the door, thus eliminating the need for drilling
holes.”
Patient safety concerns
One of the biggest concerns when you think of doing
sleep studies in a hotel is ensuring patients’ safety. Foreman
stated, “One of the first things that they did was to
ensure that they had all of the emergency resuscitation
supplies needed for a sleep lab. They had good communication
with the hotel management, explaining that
they were conducting medical testing in those hotel
rooms and what to expect in case of an emergency and
8 AARC Tımes September 2008
The newest and most
controversial topic in sleep
medicine is home sleep
testing.
the need to call 911. They contacted the local emergency
medical squads and the local fire department to inform
them that they were conducting medical testing in the
hotel and in which specific rooms. They also worked with
the hotel and created policies and procedures together,
and they participated in the hotel’s fire drills and included
the hotel in their own emergency drills.” 2
Another safety mechanism was the fact that each
hotel room outfitted for sleep testing had a camera in it
so the technician could see into the patient’s room to ensure
that they were safe during the test. All of the tests
were also recorded so that when the technician entered
the room, what happened in the room was recorded to
ensure safety for the staff and the patient. 2

Another factor when using the hotel sleep center is
making sure that the appropriate sleep patients are seen
in the location best suited for them based on the patient’s
history and co-morbidities. At Foreman’s lab they
developed a good screening mechanism where the physician
and the sleep technicians would review all of the patient’s
history and physical to determine if they were
appropriate for the hotel sleep lab. If the physicians had
any concern about the patients, they were set up in the
hospital’s main sleep center located at the hospital. 2
Home testing
The newest and most controversial topic in sleep
medicine is home sleep testing. The approved Centers for
Medicare and Medicaid Services (CMS) decision memo
that allows coverage for home sleep studies was released
this spring (see www.cms.hhs.gov/mcd/viewdecision
memo.asp?from2=viewdecisionmemo.asp&id=204&).
The National Coverage Determination and Local Coverage
Determination rules are not out yet. Some of the
highlights of the memo include a new 12-week continuous
positive airway pressure (CPAP) trial period for beneficiaries
diagnosed with obstructive sleep apnea (OSA)
whose OSA improved as a result of CPAP during this 12week
period. Another change is that polysomnography is
no longer considered the “gold standard” for OSA. A clinical
evaluation and a Type II, Type III, and Type IV home
device (must have three channels) may now qualify
Medicare patients for CPAP. Limits to both the apneaplus-hypopnea
index and the respiratory disturbance
index have been redefined.
The CMS decision memo leaves a lot of unanswered
questions about how to effectively implement the new
policy. It is unclear whether CMS or individual Local Coverage
Determinations will define the following rule for
“Physician Qualified” to interpret home sleep studies. The
definition of “clinical evaluation” remains undefined. The
definition of the benefit or improvement of the 12-week
CPAP trial period is also very vague. It is uncertain how
this decision will affect many sleep centers, but it appears
home testing is indeed here to stay and will have a
big effect. 5
Options to expand
Hotel sleep centers appear to be a cost-effective way
to expand and market sleep centers. Hotel sleep centers
can be built quickly and strategically placed within the
communities that you wish to serve, and this can be accomplished
with careful planning and cooperation with
the hotel partner. This should increase your patients’
Sleep Waves Nontraditional Settings
satisfaction while maintaining a safe environment for
patients and staff.
Home sleep studies will be an interesting topic over
the next few years, and it is important for respiratory
therapists and sleep technicians to be involved in sleep
testing in the home. ■
REFERENCES
1. Advance For Sleep web site. Checking in: hotel-based sleep centers
may be future of testing. Available at: http://sleep-medicine.
advanceweb.com/Editorial/content/Printfriendly.aspx?CC=69532
Accessed June 3, 2008
2. Foreman G. Administrative director respiratory care and ancillary
services, Marymount Hospital. Interview, June 2008.
3. Fredericksburg.com web site. Sleep tests move to comfy quarters.
Available at: http://fredericksburg.com/News/FLS/2007/122007/
12092007/319877 Accessed July 17, 2008
4. Clinical Lab Products web site. Hotel-based sleep study does not
eliminate “first-night” effect. Available at: www.clpmag.com/reuters_
article.asp?id=20080425clin006%2Ehtml Accessed July 17, 2008
5. Valenza T. Sleep Review web site. Home sleep testing: present position
and predictions. Available at: www.sleepreviewmag.com/issues/
articles/2008-06_09.asp Accessed July 31, 2008
AARC Tımes September 2008 9