The Neurologist Is In, Ep. 1: Sleep Medicine and Curbside Sleep Studies During COVID-19

In Episode 1, Neurology Learning Network’s Sleep Medicine Section Editor Rachel Marie E. Salas, MD, interviews Nancy Collop, MD, and Charlene Gamaldo, MD, about the impact of COVID-19 on their sleep centers at Emory University and Johns Hopkins University, respectively, from the start of the pandemic until now. They also discuss curbside sleep studies, “COVID-somnia,” how clinicians can improve their own sleep during this time, and tips for referring patients to a sleep center during the pandemic. A full transcript is provided below.

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About the Speakers:

Rachel Salas

Rachel Salas, MD, MEd, is an associate professor of Neurology and Nursing; director of Interprofessional Education and Interprofessional Collaborative Practice; director of the Neurology Clerkship; and 2019-2021 Josiah Macy Jr. Faculty Scholar at Johns Hopkins University in Baltimore, Maryland.

Nancy Collop, MD

Nancy Collop, MD, is a professor of Medicine and Neurology, and director of the Emory Sleep Center at Emory University in Atlanta, Georgia. Dr Collop served as the 2011-2012 president of the American Academy of Sleep Medicine.

Charlene Gamaldo, MD

Charlene Gamaldo, MD, FAASM, FAAN, FANA, is a professor of Neurology, Psychiatry, Anesthesia/Critical Care, Nursing, and Public Health; medical director of the Johns Hopkins Center for Sleep and Wellness; and vice chair of Faculty Development in the Neurology Department at Johns Hopkins University in Baltimore, Maryland. Dr Gamaldo is also a certified strengths coach.



Dr Rachel Salas: Welcome, everyone! I'm Dr Rachel Salas. I'm a sleep neurologist at Johns Hopkins. There, I'm also the Neurology Clerkship Director and the Director for Interprofessional Education and Collaborative Practice. I also work very closely with the 2 guests I have here today.

Today, we're going to be talking about the sleep center, and what and how it's impacted through the pandemic; what we've been doing what we're doing now; and what expectations are as we move forward, especially in light of a new surge. With me today, I have 2 directors from 2 different sleep centers.

First, I have Dr Charlene Gamaldo, who's a medical director at the Johns Hopkins Center for Sleep and Wellness. She's also the Vice Chair of Faculty Development at Johns Hopkins’ Neurology Department, and she also represents the School of Medicine Wellness Advisory Council. She's also a professor in neurology there.

Also with us, I have Dr Nancy Collop, who's a professor of medicine and neurology at Emory University. There, she's the director of the Emory Sleep Center, which is a multidisciplinary program incorporating clinic, testing, treatment, education, and research, all in sleep medicine.

She's the former President of the American Academy of Sleep Medicine and is currently the Editor‑in‑Chief of the Journal of Clinical Sleep Medicine. Welcome, Charlene and Nancy!

Dr Charlene Gamaldo: Hello!

Dr Nancy Collop: Thank you! Pleasure to be here.

Dr Salas: When the pandemic hit back in March, I know that a lot of sleep centers quickly closed down or at least halted production not only of sleep studies but also of clinic. We'll start first with Dr Collop. What was your initial response when the pandemic first hit, when the city started closing down?

Dr Collop: It was pretty awful in the beginning. We couldn't see patients. We couldn't do sleep studies. We were all trying to figure out ways to continue to care for our patients remotely. While we had dabbled a little bit at the Emory Sleep Center in telemedicine, we hadn't really done too much.

It took us a little bit—probably a couple weeks—to truly pivot to be able to do telemedicine and then work out some of the other issues related to the lab and home testing and what have you. It was rough in the beginning for sure, not just in the sleep center, but at Emory as a whole.

A lot needed to be taken care of. The hospital had to pivot, too. They stopped doing elective surgeries and what have you. There was a lot of financial pressure as well. It was pretty rough in the beginning. It took us a while to get back on our feet, for sure.

Dr Salas: Charlene, do you want to give us your experience at Hopkins?

Dr Gamaldo: I remember it well. It was Friday the 13th, and how apropos. It was Friday the 13th when we got a sense of what was going on. I actually remember sitting back and saying, "I think this is going to rock our world." Oh my goodness, it certainly had! A very similar sort of situation as what Nancy had mentioned in Emory.

It was, how do you continue to keep things going for the patients? Strokes don't stop, say, "I'm going to take a break. Time out, and let COVID have a chance to do its thing." That doesn't take a break. Nor does the needs of our patients who, I think even more so, the stress of COVID made some of the triggers for the issues they were having with sleep even more prominent.

That was going on in our world in a bigger picture of, what do you do with the elective procedures, as Nancy mentioned? What does that mean for us in terms of our sleep center as an elective procedure, that sort of thing? Even with some of our other contemporaries in the area, their sleep centers had to close down to be used for COVID beds and COVID units.

Helping to absorb and help them to take care of patients as well, it was rough, but I think there was a lot of silver lining that came from that. It's trial by fire in terms of getting things like televisits and that sort of thing going. I'll turn it over to you, Rachel, in terms of thoughts on how we've grown from it, but I would share Nancy's sentiment.

Dr Salas: I think it will be important to see like—we'll start with you, Nancy. When the pandemic first started, what changes did you make that are still carrying through that were actually good choices? We'll talk about lessons learned a little later. For right now, what major changes did you make in the sleep center that are still continuing on, especially now that we've already started to go into our second surge here?

Dr Collop: The biggest thing was we flipped pretty quickly to being able to do telemedicine clinic visits. Again, Emory had started the process of working on that. The challenge, as I'm sure most people who listen to this know, is while telemed has been around for a while, we haven't had much buy‑in from the insurers.

It didn't really make a lot of sense for us to flip to telemed before this time, but once the pandemic hit, it made perfect sense. The federal government started to pay for telemed visits, and the private payers also jumped in. That quickly allowed us to do telemed.

There were definitely some major growing pains to getting that set up because we really didn't have the true infrastructure to how to do it, but we've learned a lot from that time. I think we're still learning. There are things for us to continue to improve upon, but right now, we're still doing mostly telemed visits. We're doing some in person but mostly telemed.

The other thing was our sleep laboratory. Because in the sleep lab, PAP devices aerosolize. You can't really safely do PAP titrations if you don't know if the patient has COVID or not because it's going to aerosolize the virus. For about a month and a half, the lab was closed completely.

Over time, we developed protocols to allow our patients and our staff to be safe. We reopened the lab. I can get into some of the specifics of that later. We reopened the lab, but we lost about 6 weeks. We also did a lot of home sleep testing. We do more home sleep tests than we do lab testing at Emory.

We had to figure out how to, again, get the home test devices to the patients because typically, they would either pick them up at the end of their clinic visit, or they would come in, pick them up, and get instructed on it in our clinic. We had to figure out how to get the home testing devices to the patients.

Fortunately, initially, we had already done some trials with a disposable home sleep test device. By doing that, we didn't completely meet the need, but we were able to at least provide some of the home sleep testing out to our patients by using these disposable devices.

Eventually, we again figured out how to do this with our current home sleep testing devices, or what I call our legacy devices, to have patients come in and pick them up. We did the disposable stuff for a while, and that allowed us to continue to provide that testing.

The final thing I would just mention is we have our own—what I would call our CPAP or our PAP company—that's kind of part of Emory. We provide our own PAP machines. We had to figure out again—typically, the patients would come in and get set up with PAP machine with a respiratory therapist. We weren't wanting to do that. The patients obviously weren't interested in doing that either too much. It's hard to do a PAP setup without face net and a mask on, in addition, so we figured out how to do that virtually as well.

Now, many of our PAP setups are done virtually so the patient comes in, picks up the machine takes, it home, and then there's a scheduled telemed visit. Those are some of the things that we did at Emory.

Dr. Salas: That's great. I know we look to what you're doing. For those of you out there, Dr Collop used to work at Johns Hopkins. That's how Charlene and I know her. She's been a tremendous mentor to us. When COVID hit, I know we reached out where I was curious to see what Dr Collop doing over there at Emory.

Charlene, do you want to share what we did at Hopkins in our sleep center when the pandemic hit and some of the things that we continue to do now?

Dr Gamaldo: Yeah, absolutely. I want to echo that whenever we're trying to maneuver and make some decisions, I always say, "OK, what would Nancy do?" or, "Let me call Nancy and see what she's doing down in Atlanta." Definitely, I consulted with Nancy several times.

Even as Nancy knows as a leader within the academy, through JCSM and what have you, some of the recommendations were also to really think about what's going on. Politics is local. It's like what's going on with COVID in terms of positivity locally. We kept a close eye on the positivity rates within our local area.

It was low enough that we were able to keep the lab open but to a significantly reduced capacity. Based on that for, probably, the first 2 months, we did not see high‑risk patients within the lab. That would of course include individuals over the age of 55 and folks with comorbid conditions that we were certainly concerned about based on what we knew at that point about COVID.

So, we did painstakingly would go through each one of the patients that were referred just to make sure it was appropriate. We also see pediatric patients within our center. We did screen and did allow for some of the patients that the referring doctors had referred to in lab and the patients were okay in met our protocol. We would still have them have an in‑lab study.

As Nancy mentioned as well, because of the concerns with the aerosolization with CPAP, we limited that at first and then slowly reintroduced with using a closed‑circuit mask to reduce the aerosolization—also, once we got complete assurance and had the security of a supply of PPE to ensure that our techs would have all of the appropriate protection.

At the beginning, we made sure that it really didn't get beyond 50% capacity. We have a 6‑bed unit. Even the patients, when they did come in, they were greeted outside and they did not sit in the waiting room.

They went straight into the sleep room and were set up there so that there was no ability to have any cross‑contamination with any other patient. That was done, of course, with the appropriate screening and what have you.

Again, everything is situational. Our particular center, similar to Nancy's, I believe too, is a standalone facility, so it wasn't connected to the hospital. For some patients, that made them feel a lot more comfortable about coming to the facility for in lab or even coming for curbside, which I'll segue to next, is that we really, really ramped up, as Nancy mentioned as well, ramped up our ambulatory testing.

We also did both the legacy ambulatory monitors, which has the environmental issue. You're using the same monitor and you're not throwing it away, but we also did the one‑time use too because sometimes you just have to balance the throw-away with the convenience and the sterility issues, better benefit during this time, so we did that as well.

We also had very minimal telemedicine utilization in our clinic. Now, at this point, half of our providers have not stepped foot in the clinic since COVID because that's now completely televisit.

I was supportive of that because it's like, if you don't need to come in, that's one less person sharing, even with masks on, sharing any possibility for infection, so it's great from that standpoint. Then, we also do some circulating of the staff in terms of who can work from home and that sort of thing.

The telemedicine has, even within our institution, went from 40 televisits a month to—it was 4000 within 30 days of COVID. Again, trial by fire. When you're pushed to it, things happen, so that was awesome, too. Those are the ways we've made it work.

Dr Salas: I was one of those—or I am one of those—clinicians at our center that has not stepped foot one time since February right before COVID hit. It's been tremendous. I'm sure the same at Emory. We get patients from all across not just Maryland, for example, but all across the United States and sometimes even outside the country.

With us going telemed now, we're just more accessible to our patients that were coming and having to pay for travel and sometimes hotel stays to just to see us. I was always frustrated that we were not doing telemedicine because I trained at the University of Texas Medical Branch in Galveston. I was doing telemed since I was a first‑year in med school and all throughout, med school and residency.

Definitely, one of the silver linings that has pushed us in the pandemic is to move forward with telemedicine. My opinion is that we should have done this a long time ago.

Nancy, can you tell us a little bit about your curbside? Like are patients getting down out of their car and coming up to your center, or are staff meeting them outside, masked and the patient opens their trunk? What's your curbside method looking like?

Dr Collop: We're on the fourth floor in the building that we're in. On the first floor, there is the check‑in area. There's several staff that worked on there for the whole building. They would, typically pre‑COVID, would check in patients and then send them up with their paperwork, what have you, to their respective clinics.

What happened when the pandemic hit and we pivoted is that we would take the home sleep testing devices down to the first floor. They would have in them instructions and then information about getting it back to us and what have you. Then, there's a screener at the front door that screens for symptoms and does a temp check.

The patient, at this point, just comes into the first floor, picks up the home sleep testing device, and walks away with it. Then, the next day, hopefully, they'll bring it back. Same thing with the PAP machine. We would take PAP machines down in the first floor. Patients can come in, pick them up. Then, I like to set up telemedicine. Video set‑up would occur at some point later.

One thing that we also did was, we did an educational video for our patients on the home sleep testing device. When they would get their information, it would both be on the paper and through our patient portal. In the patient portal would be a link that was on the Emory YouTube channel, so they could go look at the video that we made as far as instructions on how to do the home sleep testing device.

For the most part, our failure rate is pretty low on that. That's kind of the curbside that we've done. As far as the lab, I'll just comment. Like Charlene mentioned, when patients come in for sleep studies, what we did was we stagger them, so they either come in 7:45, 8:00, or 8:15, I believe.

When they get in the parking garage, they call up to the lab. Then the lab person comes down and does the temp check and the screen, and then individually brings them up and takes them right to the room. There's really no contact with any of the other patients. There's no waiting they go from their car, basically to their bedroom.

Dr Salas: That's great! Charlene, do you want to share with everyone what we're doing—what our curbside looks like? Because we're on the second floor, and also probably include our ambulatory EEG that we do for insomnia patients as well, because that also has continued throughout the pandemic.

Dr Gamaldo: Absolutely. We're on the second floor, very similar protocol as what Emory is doing. Although, I'm jealous—Rachel, I think we need a Johns Hopkins YouTube channel like Emory does. Rachel can be a star of the YouTube for Johns Hopkins Center for Sleep and Wellness.

A similar thing where the patient calls when they arrive, they get the screening over the phone before one of our staff members actually even go outside to do the exchange of the device.

Once they do that, again, it's also staggered. They're greeted outside, they're given instructions with regard to the device and how to use it, and then also given the number to call back if there are any questions or that sort of thing. I think that means we need to have a YouTube channel too, so note to self.

The other thing that, as Rachel mentioned, we also do a sleep EEG device. This is something that's part of our standard protocol for patients who are being evaluated for insomnia, especially if we will plan on referring them to work with our behavioral sleep psychologists.

They're looking at this as more of a longitudinal evaluation and treatment, so this is used. The patients really like it. It gives them an objective assessment of their sleep architecture in the context of their home over 2 nights. It allows them to really see what their sleep waves are doing and that sort of thing.

It's very helpful for a baseline and then oftentimes, it's used to navigate how they want to approach with the behavioral sleep psychologists the strategies to improve their sleep. Oftentimes, it's then redone or repeated after completion of their behavioral sleep program.

We continue that as Rachel mentioned during this time. I would say that for the first month when we were trying to figure out the protocol for curbside, that was the small lull, but we continued that.

Actually, that was really important because again, I think the stress and the triggers from COVID only amplified people's concerns about their sleep, even amplified more people wanting access to address insomnia.

In fact, we know from some data that there's been almost a 15% bump in people pursuing sleep medications through their primary care or other doctors, just during this COVID period. A 15% increase. We feel that we're really helping the frontline with addressing sleep, whether it be insomnia, or sleep apnea, or the multitude of other sleep conditions we take care of.

Dr Salas: Yeah, and that's a good little segue, Charlene, because I know I'm sure the 2 of you—because I know I have been questioned about what we're calling “COVID‑somnia” or “corona‑somnia.”

As Charlene mentioned, there's an increase not only in the patients that we were seeing pre‑pandemic with chronic insomnia and whatnot, but I definitely have patients with apnea and restless leg syndrome that maybe didn't have as much insomnia previously and now do.

Definitely see new patients coming, not only because of the stress of loved ones or themselves getting sick or potentially losing of their job but now what we're finding is that COVID definitely has an effect on the nervous system, right?

Some of our colleagues at Hopkins and the neurology department are doing some really interesting work to better understand what kind of effects the virus is having on the neuro system. I've actually already seen a few patients that have been referred that had COVID, recovered, and now after that, now they have insomnia.

Whether or not that's a direct cause from the virus itself and/or it's probably a combo with all the stress and not just the pandemic, the political environment that we're currently in, the social injustice that's happening, and the siloing of people everywhere, we're in a new normal.

We're really in a grieving period as a group—grieving for the loss of the way things used to be. Nancy, what are your thoughts on this whole idea of COVID‑somnia and what are you seeing in your practice with patients in terms of their response to what we're in right now?

Dr Collop: I think it's like anything. It varies a lot from patient to patient. In general, we've looked at this. We’re already seeing more insomnia new patient visits. We haven't really lost a lot of business. Our number of visits is still high.

We still have a long wait time, but the percent of insomnia is a bit higher than it was. As far as my own patients that I've been seeing, again, it's a little hit or miss. Some people don't mind this quarantine thing. Some people think it's great.

Some people, they just don't like to be around other people and they thrive in it. They think it's just great that they don't have to in Atlanta, not unlike Baltimore, but the commutes can be awful here. Some people really are happy that they're working from home and don't mind it at all.

But then, there's just as many, if not more, people that are very stressed, like you said, about people getting the virus that they know or their fear of getting the virus or their work situation or their family situation, all the other stressors out there related to like you said, the political environment, the election, the protests, all this.

These things stress certain people and more than others, and so it's a very stressful time. The longer that this pandemic goes on and the worse that it gets, which right now, there's no end in sight, I think we're going to continue to see these elevated levels of insomnia and stress.

The other thing I'll just comment as somebody that takes care of a lot of sleep apnea patients is, I was trying to figure this out the other day. Some of my patients have embraced this quarantine to get healthier, spend more time with family, do more exercise, be outside more, whereas others have gone the other direction.

They call it not the COVID‑19, but the COVID‑30. They've gained a lot of weight because they're not as active. We know in addition that obesity and being overweight is a big risk factor for a bad outcome from COVID.

That's another area that there's a lot of new information coming out. That's another piece of this pandemic that I think is important to look at as well, is the whole weight gain that happens.

Dr Salas: For sure. I’ve participated in that myself. Charlene, I'm curious to hear, just because everything I know is probably resonating with what Nancy's saying with us, definitely with me. Maybe could you comment along the same lines, but in terms of the circadian rhythm because that's the other big player when it comes to insomnia, and then with daylight savings time, the shift, and the time schedule? Any comments about that?

Dr Gamaldo: Yeah, what stuck out for me is, we see insomnia even before COVID. It's probably a combination of physiologic predisposition and then situational things. COVID is just like, oh my gosh, a perfect collision of that.

I think that A, from a physiologic and biological standpoint if somebody already had the predisposition and let's say, for instance, they got COVID, we know that there's association with COVID in things like loss of smell.

We know things like loss of smell from a neurodegenerative standpoint can be a precursor for things like cognitive issues later. It can be a preliminary finding of that. The neuro nerd in me was like oh my gosh, could this at all impact that?

We know that poor sleep is a precursor of potential cognitive issues later. Can all of these things go together? That keeps me up at night, makes me wonder. That's a question.

Then, the other is from the situational standpoint is as Nancy mentioned, with every positive— and Rachel and I strength‑coach—any strength has a shadow side.

The shadow side of folks being able to work from home, to have the conveniences of home, the shadow side if it's not properly balanced, you're sitting in front of a computer, like I tell myself sometimes I'm going to turn into a full‑on Zoom screen. That's who I am for 8 hours.

If you're doing that for 8 hours and aren't necessarily balancing it, we know screen time affects your circadian rhythmicity. It can affect your ability to get good sleep at night because of the blue light. How are those things potentially very COVID‑specific, playing into all of these issues folks are having with sleep?

Of course, with that too, if we're working from home all the time, you can have CNN or whatever your news outlet of choice is running in the background, potentially bumping up your blood pressure, that sort of thing. Sometimes people are doing that. You have to actually now consult them.

Guess what? Probably need to turn that stuff off. That's what's really interesting about this and from the circadian rhythm issue, too. Rachel, I think circadian rhythm works best with routine. We help to anchor.

That's what we've always done, is we need to help you anchor your behavior to have your circadian rhythm shifted to where you want it to be for your social, occupational needs.

When we're in this situation, we're working from home all the time and all these things, if we don't have a routine that's in line with that, it causes problems. Those are the new elements of us giving precision advice for patients. Takes on a whole new level because we got so many people working from home, dealing with screens, dealing with this kind of stress.

Dr Salas: Yeah, I think those are all great points. I want to take a second just to pause and just think about, since we are sleep specialists, and Charlene, you mentioned what's keeping you up all night—COVID‑somnia is running rampant for you, to say the least, and just worrying about your patients and worrying about what we're doing at the center. What are some tips that we might want to share as sleep specialists?

Think about what you're doing—maybe some changes you made in your own sleep and wellness that maybe you could share with some of the clinicians out there that I'm sure would love to hear, to pick your brain about how to improve their own sleep so that they can be in a better mindset when they're interacting with people that are lonely, that are sick, and that are worried about getting the virus and they're worried about their sleep. Nancy?

Dr Collop: Well, I think it was interesting listening to Charlene talk about circadian rhythms. One thing that I found though is if there are people—typically, what I guess we see mostly are people that have a little delayed sleep phase trying to get up at 6:00 and go to work, in some ways, the pandemic, again, has been helpful to them because again, they don't have that commute.

They may not have to get up early and they can actually function at their best circadian phase. One tip is that some people may stress about that, but it's probably okay. If they're more of a 9:00 to whatever it would be, 6:00 person and that's their best work time, then that's okay.

They don't have to try to get up and be at work at 7:00 obviously if it fits in with their employer. Again, just to echo, keeping a schedule is very important, so keeping a schedule. The other thing that I really emphasize with my patients is being able to exercise.

Like Charlene said, you can sit in front of these computers for days, it seems like. I tell them to put on their calendar from 12:30 to 1:00, I'm going to get up and go walk around the block or go get on my exercise bike or do something to get out of that rut of just sitting all day long. I think that exercise is very important.

One last thing I'll mention is you talk about watching the news or whatever your medium might be, but if people are stressed out and they find that when they get in bed they're worried about things, I'll tell people to make a worry list.

Write down all that stuff that you're worried about before you go to bed and then put it over there and then the next morning, you can get up and start worrying about it again, but don't let it interrupt your ability to go to sleep at night.

Dr Salas: Charlene, how about your tips? What are Dr Gamaldo's tips to share with the listeners?

Dr Gamaldo: Everything that Nancy said is spot on. A few other things that I would add is that—I'll start with the worry list. I've told patients, "Create a worry list. Then after that, create a what‑I'm‑grateful‑for list even if it's 1 or 2 things."

For some patients, that's a way to hopefully transition into sleep. On a positive note, that can be helpful. Again, revisit it in the morning. That's very helpful. Another thing that's very helpful is, in addition to getting out and getting some exercise, I've told patients, "If it's a sunny day, get out and sit on your deck."

People are like, "I'm afraid. I don't want to bump in anybody." Sit out on your stoop, on your deck. Get sun exposure. Get some sunlight. That's important for your circadian rhythm, as we mentioned before. Also, sun is just a natural mood enhancer. That's very important.

When you talk about isolation and that sort of thing for the people that it matters, we know that having that social engagement, putting it on your calendar, calling a friend, doing a Zoom, whatever, social engagement helps you to be a better sleeper. We knew that before. It's even more important now. That's really important.

In terms of routine during the day, I fall into this trap. I try to do it. You got to give yourself a lunch break. Make sure you put in somewhere in the calendar or in your day. You can't have back‑to‑back meetings, 1‑hour long for 7 straight hours. You do have to go to the bathroom. You do have to eat—those sorts of things.

You can't sell yourself short on that because you will eventually pay for it. Your body, like Rachel always says—it'll build up. It'll manifest some other way if you don't pay yourself back that time that you need to reboot. Those are some of the other things I try to pass onto the patients.

Dr Salas: Those are great! Both of what you and Nancy said are great for not only the clinicians to do for themselves and their family, but hopefully, they'll trickle down to the patients.

I'll add to the list. I do the gratitude. I have to say I was pretty good before, but now I'm doing it in the morning. That's been helpful. The other things that I've done is invest in—I'll put the disclaimer out there.

I don't have sleep issues, but I live in the city. I’ve taken the pandemic to start learning more about feng shui. I started a course of feng shui. I'm invested in an environment, not just the sleep environment, which I think this knowledge is going to help me guide my patients.

I've made changes. Those little changes have been fabulous. I want to put a plug out there for feng shui in your bedroom, especially in your workspace. Many of us are definitely working, if not fully but a majority of the time, from home. That workspace is very important.

Great. I hope that some people picked up some nice tips. I know I did. I know we're getting close to the end. I want to end with maybe some feedback from the 2 of you, some recommendations when you think about our audience who are clinicians, mainly neurologists that are out there.

Any tips for them in terms of what's the best way to refer their patients to us? What are things that they can do maybe to investigate sleep upfront or maybe to acknowledge whether sleep is a problem for their patients? We'll end with that.

What are you recommending? Is that different from pre‑pandemic and now? In other words, are you recommending that they order a sleep study? Should they still be referred to us first, and then we determine what the patient's needs are? We'll go ahead and start with Nancy.

Dr Collop: I don't know that it's necessarily different from pre‑pandemic. For any provider that's considering, or at least should be considering, whether their patient has a sleep disorder, there are some very simple things. Most everybody has intake questionnaires. What is your intake questionnaire? Do you have sleep questions on it? If you do, do you look at them?

I guess for a neurology group, anybody that's had a stroke, you should screen for sleep apnea. You're epileptic, you should screen sleep apnea. Parkinson's disease, obviously. They all have sleep disorders, or most of them will have some sleep disorder. You should be talking to them about their sleep issues. The list goes on and on. Are you screening for it?

As far as the sleep apnea piece, I know sleep apnea is not the only sleep disorder, believe me, but it is, by far and away, the most common one that requires testing. If you're referring a patient for a sleep test, you have to put in your note what your concerns are.

You can't just say home sleep test or lab test. We have to know what are your concerns, not just for us, for the patient, but for the insurance companies. They are going to deny it if it's not well‑documented what the concerns are that you're referring a patient for.

Those are some very simple things, the things that are very basic and pretty easy. If you're concerned if they have snoring and hypertension, that's probably enough. There are very simple keywords that you put in there or sleepiness. That's all we need. It's very critical to have that information in the referral.

Dr Salas: Yeah, I think that's important. I will comment—in my book, I feel that any patient who has any neurological disorder or disease—that's a risk factor for a sleep disorder. That's just, at the end of the day, patients with migraine, dementia, all of them, multiple sclerosis. That was a great tip and certainly will help.

A lot of times, outside referrals come in. Like you're saying, there's a sleep study. It gets denied. The patient's care is prolonged. The patient is upset. Connecting with your sleep specialist or a center—hopefully, you have one near you—would be a good thing to do.

Maybe put that on your bucket list for the pandemic. In that way, when we're out of this, you'll have a good rhythm there. Charlene?

Dr Gamaldo: Absolutely. The list is long that we could even add epilepsy patients, all the neuromuscular disorders, what have you. A couple of things points that I wanted to add is a lot of the EMRs are now starting to have built‑in options for some of the more recognized sleep questionnaires.

It's even reaching out and seeing if those are already available that it could be easily incorporated into your intake. The Epworth Sleepiness Scale that most folks are familiar with is another gold mine, especially for OSA. A lot of times, the insurance companies are looking for the Epworth. That can be very helpful to help expedite the process.

We encourage our colleagues to think about how, in an expeditious way, that they can get that information through EMR. The other thing that I wanted for us to take advantage of is the option of the televisit. We have a window into what the patient's environment is like and also what their routine is like.

If you're seeing your patient for epilepsy at 3:00 in the afternoon and they're still in their pajamas lying in bed, that's maybe a good sign of, "Are you sleeping OK? What's going on with your sleep?" You wouldn't typically have a window to that if you're seeing them in clinic.

Even just taking cues from that and using that as just, "How are you sleeping?" If it looks like it's going into a long, then you can say, "OK, we know the right people to refer you to." Because I know sometimes that's the concern, that it opens up Pandora's box, but it's a wonderful opportunity for us to use televisit to our advantage in terms of understanding the “personomics,” as Dr Salas calls it, of the patient and their environment and who they are.

Dr Salas: Great! With that, I'll wrap it up. I want to thank both Dr Collop and Dr Gamaldo for taking time out of their busy schedule, being the directors of pretty prominent sleep centers and truly are leaders in the field. I know both of them have been contacted by other sleep specialists that are wondering what are you’re all doing in your centers.

They have remained leaders throughout this whole pandemic and doing some cool innovative things. I look forward to the changes that we're going to make moving forward so that we could better connect with our patients and help them.

Thank you! I hope that our listeners were able to pick up some tips and see some of what we're doing. Here's 2 examples of sleep centers that are doing some cool things during this pandemic so that we don't stop care. In fact, we continue with care, and even get our new patients that are suffering with a variety of sleep issues—get them the care that they need.

With that, I'll end there. Thank you!

Dr Gamaldo: Thank you!

Dr Collop: Thank you!