Wednesday, November 21, 2007

Respiratory Therapists Try to Take Over Polysomnography

Sleep Review Magazine reports on the attempt of California respiratory therapists to take control of polysomnography:
Respiratory Care Board of California Increases Efforts to Regulate Sleep Industry
In August, the Respiratory Care Board of California (RCB) voted unanimously to pass a motion allowing for the issuance of citations and fines for the unlicensed practice of respiratory care associated with polysomnography. Not only are investigations stemming from this motion under way, but also the RCB has now drafted new licensure legislation.
According to the Respiratory Care Board of California's
Fall 2007 newsletter (launches PDF), "Citations may be issued to both unlicensed personnel and employers of unlicensed personnel illegally practicing respiratory care, with fine amounts up to $15,000. The issuance of these citations and fines is separate from, and in addition to, citations issued to employers by the Department of Health Care Services for failure to use properly licensed personnel."
This move heated up debate among many sleep professionals who feel requiring licensure of RPSGTs is doing little more than widening a divide between the sleep and the respiratory care professions.
Signed into law in 1983, the
Respiratory Care Practice Act tasks the RCB with overseeing the licensure and regulation of respiratory professionals.
"In 2002 we added a code,
Section 3767, which authorized us to cite and fine for the unlicensed practice of respiratory therapy," said Stephanie Nunez, executive officer for the Respiratory Care Board of California (Sacramento). Section 3767 became effective January 1, 2003. "We've been working on this since 2001 and have reached out to the community through surveys and roundtable meetings. Unfortunately, because these individuals are not licensed or regulated, we were very limited in how we were able to contact them." Nunez added that in 2004, there weren't many techs who were credentialed, a fact that has changed in recent years.
While, to date, there have not been any citations or fines issued to either sleep techs or their employers, there has been an ongoing effort from the RCB to inform the community about the new requirement.
"We sent a [online] survey out to more than 400 people, as well as a notice, in 2004," Nunez added. A hard copy of the survey was also distributed to about 150 people. "We received only 29 responses." This type of minimal involvement is a point of frustration for Nunez.
Polysomnographic Technologist Act
In addition to gathering information from the industry on, among other things, how licensing should be instituted, the RCB has put forth its suggested solution, the Polysomnographic Technologist Act. The proposed legislation—which is
available on the organization's site (launches PDF)—is sitting idle, waiting for backing by a public official who could push it into law.
According to an AASMAdvocacy e-mail to AAST members, the proposal would require a sleep technologist to fulfill one of the following criteria to obtain licensure: - Possession of a current license to practice respiratory care in California.- Completion of an accredited respiratory care program as prescribed by the board and has an associated degree.- Completion of an accredited electroneurodiagnostics program as prescribed by the board and has an associated degree.- Completion of a polysomnography educational program prescribed by the board and has an associated degree.- Completion of 18 months or 3,000 hours of full-time paid work experience as an applicant sleep technologist, including 1,000 hours in polysomnography-related respiratory care services as prescribed by the board and satisfactorily performed as verified by a physician or surgeon.
The e-mail also stated, "AAST and AASM are formulating a number of strategies to counter this measure, one of which includes introducing our own bill, but no decision has been made at this time. Though we have not made a decision, we will still be working with our attorneys on our own bill so we are prepared for the upcoming legislative session."
The tone of the e-mail conveys concern—a feeling that Nunez has also recognized among techs. "The feedback we are getting is that [those in the sleep field] are adamantly against any type of regulation, but the fact is that respiratory care has to be performed by a licensed person," Nunez said. "So, we are seeking a resolution to this, and we've tried to stress that we want the techs to get involved, we want them to help us fix this problem."
Those techs are also feeling frustration. In many cases, they view the RCB as "playing favorites" and as trying to eliminate or ignore sleep professionals with additional legislation. Such accusations are unfounded, according to Nunez.
"We recognize that respiratory therapists need additional training in this area and that RPSGTs are probably the best qualified," she said. "Our recommendation is to establish a license category within our board, and it isn't excluding anyone: it recognizes the BRPT exam, it recognizes experience, and it recognizes all the people who are in the practice right now. It is not a turf war. It is a consumer protection effort."
Driving the goal of licensing is the ability to screen and monitor those in the profession. Among other requirements, licensure would mandate that techs pass a criminal background check. Not all hospitals—and very few independent facilities—perform such checks, according to Nunez, and even those who do are not privy to the privileged information the government can access.
"Licensure also addresses employees who are incompetent or who did something unethical. In those cases, the employer, most times, will terminate the tech and that person goes on to work somewhere else, with no record of it," said Nunez. "Granted, someone can do an employment check, but not everyone does—and employers are also leery of giving out that type of information, for fear of being sued."
Accusations of sexual assault by a respiratory therapist this summer focused the spotlight on the importance of regulating the profession, said Nunez.
"I think what's happening right now is the good [techs] are taking offense, because they feel they're being accused and criticized for not being good enough—and that is absolutely not true," she said. "It is the other people that we are worried about. It is about creating a level playing ground and ensuring that everyone has competency testing, such as the BRPT [Board of Registered Polysomnographic Technologists] exam or the NBRC [National Board for Respiratory Care] exam, if that comes about. We are not putting one above the other—we would recognize both."

Essentially, what the Respiratory Care Board of California (RCB) is doing is stating that the performance of sleep studies (polysomnography, cpap/bipap titrations) is respiratory care, and that any sleep center technician who is not a licensed respiratory therapist will be fined, along with their employer (the sleep center).
Rumor has it that in Mississippi respiratory therapists are planning a similar power play, and will try to get state legislation passed in 2008 to require a respiratory therapist to be present whenever cpap/bipap is titrated.
I personally strongly disagree with the RCB in its assertion that polysomnography is respiratory care. Polysomnogaphy was originally developed by psychiatrists, not pulmonologists. The RPSGT credential is the standardard in polysomnography, not the RRT credential.


Terminal Weaner said...

Medicine was originally practiced by shamen and witches. I guess it's to the detrement of the shamen and witches that they neglected to create credentialing boards and secure a niche. Sleep studies are Psychiatry as much as plumbing is astronomy.

oldsleeper said...

The answer is separate state sleep licensure boards.

Many are working towards this end. The AASM has a legal presence in CA and NY and is reaching out to any state that is interested. For the 1st time the AAST is supporting and have pledged support in the formation of state sleep societies (a big duh and about time). We are a group of dedicated sleep therapists working together and pooling our resources and knowledge base - visit us at

sleepy spud said...

This has been brewing in California for many years. As has been the case in other states, notably NJ, it isn't until the respiratory care board starts issuing cease and desist orders or threatening citations that the sleep community awakens and responds by moving towards self-regulation.

I must disagree with Ms. Nunez's statement that the CA sleep community is adamantly opposed to any form of regulation. I think what they are adamantly opposed to is having regulation imposed upon them by an existing board. I don't know when the article quoting her was written because in a conference call earlier this month she stated that the CA RCB has 5 citations pending against individuals or their employers for the unlicensed practice of respiratory care by sleep technologists.

The current MS respiratory care practice act provides an exemption for RPSGTs. So unless they are planning to remove that, RPSGTs will be able to practice. They could and probably will target non-credentialed folks.

Terminal Weaner said...

Look... the way in which the NBRC and CoARC have handled themselves and continue to handle themselves (self serving and money grubbing) lends itself to the Sleep Techs wanting to move away and start their own little club. Here;s the problem: We are already a small community of therapists (RPSGT's and RRT's) so why make ourselves even more splintered by splitting off? Dammit, this is what is wrong with the AARC and what has been RIGHT with nursing for all these years... we can't get our s#!t together and they can... we continue to argue and bitch about why we can't get what we want when we don't get together to lobby properly... we don't deserve anything but what we get until we stop acting like we are all so specialized and different and GET IT TOGETHER... christ, we might as well be in the same bargaining group as the houskeeping staff at this rate.

info said...

We are already a small community of therapists (RPSGT's and RRT's) so why make ourselves even more splintered by splitting off?

What are you referring to? You make non-sensical statements: "Sleep studies are Psychiatry as much as plumbing is astronomy." and oblique references, but where do you stand on this issue.

Who do you feel we are "splintering off" from? NBRC? They DO NOT control sleep medicine. And the last time I checked the history of sleep medicine, it DID start in Psychiatry, so I have no idea what they hell you mean by that statement. Respiratory feels that since THEY view one of the SLEEP THERAPIES as RESPIRATORY in nature, so therefore they should control ALL of Polysomnography. If you cannot see that false argument, then I see where you stand on this issue.

Michael Rack, MD said...

thanks for your comments.
sleepy spud: earlier in the year there was some talk of the respiratory therapists trying to remove the exemption for RPSGT's for CPAP titrations. I haven't heard anything about this issue recently, I guess we'll see when the new MS state legislature meets in January.
oldsleeper: I'll check out

Terminal Weaner said...

To Info-

Retard, the NBRC does, in fact, control part of the credentialing process of sleep medicine as does CoARC and CAAHEP. He who controls the gold... yadda yadda. As for my "nonsense" statements: it is metaphor... and psychiatry is crap. All polysomnography has become is titrating pressures to keep one's airway patent... if this ISN'T respiratory therapy... I am not sure what is. Fall into line.

Michael Rack, MD said...

"All polysomnography has become is titrating pressures to keep one's airway patent..."
From a physician standpoint, that would make polysomnography an ENT rather than a pulmonary procedure.

Michael Rack, MD said...

The December issue of the Journal of Clinical Sleep Medicine has a news article about this.

sleepy in mt said...

The point is that Polysomnography targets much more than just OSA and cpap/bipap titrations. To say that only someone who is an RT can perform things such as EEG (which is what all the rest of sleep consists of other than OSA) and PSG is ridiculous. I think that the BRPT exam for someone with clinical experience and medical background is more than sufficient for performing pap studies. To say you must be an RT is outrageous and an insult to those who have their RPSGT and aren't
RT's and worked very hard to get it.

Laurie Jackson said...

You may not like it but as a health care professional you are required to be held at a higher standard. For patient safety and accountability Respiratory Therapists are required to be licensed, and to maintain continuing education. Your are also required to limit yourself to your range of therapy. Knowing how does not give you the right to practice specific procedures. Titrating the ventilating pressures that enter a patient is clearly Respiratory Therapy and should by law be conducted by a licensed therapist/physician. So if you want to do this therapy you are required to be licensed. Just as I being a RRT for over 25 years must still obtain accreditation to perform polysomnography or pulmonary function testing. I have to be a specialitist and if Sleep Medicine and Respiratory Therapy crossover each other then you have to be a specialist in both professions. It's only fair. No one gets a free ride.

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