Legal Aspects of Sleep Medicine in the 21st Century
2018; Elsevier BV; Volume: 154; Issue: 3 Linguagem: Inglês
10.1016/j.chest.2018.04.033
ISSN1931-3543
AutoresSaiprakash B. Venkateshiah, Romy Hoque, Nancy A. Collop,
Tópico(s)Hospital Admissions and Outcomes
ResumoMultiple manifestations of sleep disorders may interact with the law, making it important to increase awareness of such interactions among clinicians. Patients with excessive sleepiness may have civil (and in some states criminal) liability if they fall asleep while driving and cause a motor vehicle accident. Employers may be held vicariously liable because of the actions of sleepy employees. Hence, awareness of causes of excessive sleepiness, such as sleep deprivation and OSA, is increasing among trucking, railroad, and other safety-sensitive occupations. Interestingly, litigation related to perioperative complications because of OSA is more frequent than nonoperative issues such as a failure to diagnose OSA. Parasomnia-associated sleep-related violence represents a challenge to clinicians because they may be asked to consider parasomnia as a possible contributing, mitigating, or exculpatory factor in criminal proceedings. Clinicians should also familiarize themselves with the legal and regulatory aspects of running an independent sleep laboratory. Sleep telemedicine practice using 21st century technology has opened novel and unique challenges to existing laws. In this review, we cover the most common interactions between sleep disorders and the law, including the challenges of excessive sleepiness and driving, other legal issues involving patients with OSA, and the liabilities associated with parasomnia disorder. We will also cover some practical legal aspects involving independent sleep laboratories and the field of sleep telemedicine. Multiple manifestations of sleep disorders may interact with the law, making it important to increase awareness of such interactions among clinicians. Patients with excessive sleepiness may have civil (and in some states criminal) liability if they fall asleep while driving and cause a motor vehicle accident. Employers may be held vicariously liable because of the actions of sleepy employees. Hence, awareness of causes of excessive sleepiness, such as sleep deprivation and OSA, is increasing among trucking, railroad, and other safety-sensitive occupations. Interestingly, litigation related to perioperative complications because of OSA is more frequent than nonoperative issues such as a failure to diagnose OSA. Parasomnia-associated sleep-related violence represents a challenge to clinicians because they may be asked to consider parasomnia as a possible contributing, mitigating, or exculpatory factor in criminal proceedings. Clinicians should also familiarize themselves with the legal and regulatory aspects of running an independent sleep laboratory. Sleep telemedicine practice using 21st century technology has opened novel and unique challenges to existing laws. In this review, we cover the most common interactions between sleep disorders and the law, including the challenges of excessive sleepiness and driving, other legal issues involving patients with OSA, and the liabilities associated with parasomnia disorder. We will also cover some practical legal aspects involving independent sleep laboratories and the field of sleep telemedicine. Sleep disorders affect a substantial proportion of the population and can manifest in a variety of ways. Sleep disorders often are not obvious to the individual who has the disorder. These complexities result in occasional entanglements with the legal system. In this paper, we cover the most common interactions between sleep disorders and the law, including the challenges of excessive sleepiness and driving, other legal issues involving patients with OSA, and the liabilities associated with parasomnia disorder. We will also cover some practical legal aspects involving independent sleep laboratories and the field of sleep telemedicine. The blameworthiness of an individual for a behavior is addressed by the legal issue of culpability. Anglo-American law discusses two components to crime: actus rea, the criminal act itself, and mens rea, criminal intent, both of which are required for criminal responsibility. The standard common law test of criminal liability is expressed by the Latin phrase actus non facit reum nisi mens sit rea (the act does not make a person guilty unless the mind is also guilty). The guilty mental state must be present at the time of the action for criminal liability. This requires the act to have occurred in a conscious state, but in cases of sleepiness-related accidents, can be extended to include actions that begin in an unconscious state. Driving while drowsy is a decision made by the driver in a conscious state, but an accident may have occurred during sleep. Awareness before and during the sleepiness-related accident is often the central point when determining criminal liability.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 2Krishnan V. Shaman Z. Legal issues encountered when treating the patient with a sleep disorder.Chest. 2011; 139: 200-207Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Recently, the AAA Foundation for Traffic Safety released a research brief suggesting that drowsy driving is involved in up to 9.5% of car crashes.3Owens JM, Dingus TA, Guo F, et al. Prevalence of drowsy-driving crashes: estimates from a large-scale naturalistic driving study. Paper presented at: 97th Annual Meeting of the Transportation Research Board; January 7-11, 2018; Washington, DC.Google Scholar We will review relevant cases to point out how the law has decided in cases of sleepy drivers. The Connecticut Supreme Court in 1925 addressed the driver's legal duty when possessed by sleep or other unconscious episode. In Bushnell v Bushnell, Mr Bushnell dozed off at the wheel and crashed into a tree. Mrs Bushnell, who was a passenger in the car, was injured in the accident and sued her husband for negligence for failing to operate the car in a reasonable manner. Mr Bushnell argued that sleep occurs without warning. Hence, he was to be excused from his duty to maintain control of the car while asleep. The court challenged Mr Bushnell's explanation that he had no advance warning of sleep onset. The court reviewed medical evidence indicating that unlike a sudden blackout, sleep displays routine and recognizable precursor conditions such as fatigue and dulling of the senses. Hence, the court ruled that Mr Bushnell knew, or should have known, that sleep was affecting his driving and that he should have pulled off the road. Because his sleep episode was foreseeable, the court found Mr Bushnell liable for the cost of his wife's injuries.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 4Bushnell v. Bushnell, 103 Conn. 583, 131 A. 432 (1925).Google Scholar, 5Brown D. Legal obligations of persons who have sleep disorders or who treat or hire them.in: Principles and Practice of Sleep Medicine. 6th edition. Elsevier, Philadelphia, PA2016Google Scholar This ruling did point out that an unforeseeable loss of consciousness (eg, sudden unexpected seizure or blackout) would excuse the driver's duty to exercise due care in driving. The sudden blackout defense is a legal protection for drivers who suffer from a sudden and unforeseen onset of sleep, but it may be difficult to establish if the patients have past experience of a tendency to fall asleep while driving. If one knew that he or she suffered from sleep attacks several times a day, it would be negligent for that individual to get behind the wheel of a car even if the sleep attacks were unexpected. This principle was reaffirmed in 2006 in Vermont, State v Valyou. In this instance, the defendant dozed off many times on the way to work but still continued to drive, ultimately colliding with another vehicle after falling asleep.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 5Brown D. Legal obligations of persons who have sleep disorders or who treat or hire them.in: Principles and Practice of Sleep Medicine. 6th edition. Elsevier, Philadelphia, PA2016Google Scholar, 6State v. Valyou, 910 A. 2d 922–924, 2006 VT 105 (2006).Google Scholar Some state laws (New Jersey's Maggie's Law and Arkansas's Arkansas Act 1296) can lead to criminal liability for drowsy driving. Maggie's Law states that a sleep-deprived driver qualifies as a reckless driver who can be convicted of vehicular homicide. This law resulted from a case in which 20-year-old Maggie McDonnell was killed when a driver who admitted to not sleeping for 30 h crossed three lanes of traffic and hit her car head on. The resultant law is an evidentiary rule establishing that proof of driving after 24 h of sleeplessness "shall give rise to an inference that the defendant was driving recklessly" in order to convict a defendant for vehicular homicide. The law also states that falling asleep while driving may infer recklessness without regarding sleeplessness. Proving reckless fatigue under Maggie's Law is difficult under the law's definition of sleeplessness (without sleep for a period in excess of 24 consecutive hours). Any evidence that the driver took a short nap of even a few minutes during the relevant 24-h period can defeat inference of reckless driving caused by sleeplessness. Punishment may include up to 10 years in prison and a $100,000 fine.5Brown D. Legal obligations of persons who have sleep disorders or who treat or hire them.in: Principles and Practice of Sleep Medicine. 6th edition. Elsevier, Philadelphia, PA2016Google Scholar, 7N.J.S.A. § 2C:11-5(a).Google Scholar The Arkansas Act 1296 classifies fatigued driving as an offense under negligent homicide punishable when the driver involved in a fatal accident has been without sleep for 24 consecutive hours or is in the state of sleep after being without sleep for 24 consecutive hours. Punishment may include up to 1 year in prison and/or a $2,500 fine.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 8Arkansas Code § 5-10-105.Google Scholar Clinicians should inform patients with sleep disorders of the risks of driving or participating in safety-sensitive occupations while drowsy, especially when the patients are not following treatment recommendations. Patients with excessive daytime sleepiness should be informed that there may be civil and/or criminal liability if they fall asleep while driving. Such discussion should be appropriately documented within the patient's medical record. In certain states the physician may be required to inform the department of motor vehicles that the patient is continuing to drive despite having excessive sleepiness caused by their sleep disorder, thereby presenting a danger to the public. Each physician should be aware of the public safety disclosure laws of the state in which they practice. Table 19National Conference of State Legislatures (NCSL). State of the states: drowsy driving. http://www.ncsl.org/research/transportation/summaries-of-current-drowsy-driving-laws.aspx. Accessed April 3, 2018.Google Scholar shows a list of states that require doctors to report medical conditions and states that place licensing limits because of sleep disorders.Table 1List of States That Require Doctors to Report Medical Conditions and the States That Place Licensing Limits Because of Sleep DisordersStates Requiring Doctors to Report Medical ConditionsStates Placing Licensing Limits Because of Sleep DisordersCaliforniaCaliforniaConnecticutConnecticutDelawareFloridaGeorgiaIowaMaineMaineNew JerseyMontanaOregonNebraskaPennsylvaniaNew YorkNorth CarolinaNorth DakotaTexasUtahWisconsinBased on the National Conference of State Legislatures9National Conference of State Legislatures (NCSL). State of the states: drowsy driving. http://www.ncsl.org/research/transportation/summaries-of-current-drowsy-driving-laws.aspx. Accessed April 3, 2018.Google Scholar. Open table in a new tab Based on the National Conference of State Legislatures9National Conference of State Legislatures (NCSL). State of the states: drowsy driving. http://www.ncsl.org/research/transportation/summaries-of-current-drowsy-driving-laws.aspx. Accessed April 3, 2018.Google Scholar. An employer may be held vicariously liable for the acts of an employee that are performed as part of the employee's duties as per the legal doctrine of respondeat superior (let the master answer). Hence, companies who employ drivers will be vicariously liable as employers if the driver falls asleep at the wheel and injures a third party in a crash while performing his or her job. The employers may also be held vicariously liable if they failed to screen for disorders that may impact their employees' ability to drive safely during the hiring process and continued employment. One illustration is the case of Dunlap v W.L. Logan Trucking Co. Norman Munnal (employee) fell asleep while driving a tractor-trailer and killed a woman. His employer invoked the sudden blackout doctrine by blaming the accident on Munnal's sudden unconsciousness. Munnal testified that he had a propensity to fall asleep and that he had fallen asleep at the wheel at least once before. Munnal was also diagnosed with OSA after a polysomnogram after the accident. The court found sufficient evidence that Munnal was aware of his excessive sleepiness. This and an expert's testimony documenting that Munnal probably fell asleep rather than suffered from a sudden blackout, concluded with the court finding Munnal negligent for failing to operate the truck in a safe manner and Logan Trucking Company was held vicariously liable because he had been operating the vehicle within the scope of his employment.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 5Brown D. Legal obligations of persons who have sleep disorders or who treat or hire them.in: Principles and Practice of Sleep Medicine. 6th edition. Elsevier, Philadelphia, PA2016Google Scholar, 10Dunlap v. W.L. Logan Trucking Co., 161 Ohio App. 3d 51, 66. (2005).Google Scholar Such cases are not limited to the trucking industry. On February 2, 2018, the National Transportation Safety Board released a report noting severe, untreated sleep apnea was the cause of two train crashes in the prior 2 years. Both of these trains ran into the end of the bumping posts and crashed into the station, killing one and injuring > 200 passengers. The employing rail systems (New Jersey Transit and Long Island Rail Road) either did not follow sleep testing guidelines (New Jersey Transit) or did not have a guideline in place (Long Island Rail Road).11NTSB News ReleaseNearly identical probable causes for 2 commuter rail accidents drive safety recommendations. National Transportation Safety Board Office of Public Affairs, Washington, DC2018Google Scholar Hence, awareness of screening and treatment of common causes of excessive sleepiness, such as sleep deprivation and OSA, are increasing among trucking, railroad, and other safety-sensitive occupations. The prevalence of OSA in commercial motor vehicle drivers is increased compared with the general population. Unfortunately, there is an absence of screening rules for OSA from regulatory authorities for commercial motor vehicle drivers, and there is no regulatory mandate in the United States for comprehensive OSA risk assessment and stratification. The Federal Motor Carrier Safety Administration (FMCSA) defines a commercial motor vehicle as any vehicle used on a highway in interstate commerce when the vehicle has a weight of ≥ 4,536 kg (10,001 lb), or is used to transport more than eight passengers (for compensation) or more than 15 passengers (without compensation), or is used in transporting hazardous material. Current FMCSA requirements depend largely on subjective report, which is less reliable. Medical consensus recommendations are therefore used in the absence of FMCSA standards. In those diagnosed with OSA, consensus-based risk stratification helps to identify commercial motor vehicle drivers who may benefit from OSA treatment and to establish minimum standards for assessing treatment adherence and efficacy. Further complicating the regulatory environment is the lack of regulation of many of the other motor vehicle drivers who drive vehicles for ride-hailing/ride-sharing services or online food delivery platforms. Individuals who work as drivers in the ride-sharing industry are often employed in a primary job, and they work during their time off. This may lead to driving after extended periods of wakefulness or nights, both of which are factors that can increase the risk of drowsy driving accidents. These drivers are mostly employed as independent contractors; therefore, they are not screened for medical problems that can reduce alertness, such as OSA. This combination of lack of regulation coupled with excessive sleepiness because of sleep deprivation/circadian phase misalignment has the potential for causing serious accidents. The American Academy of Sleep Medicine (AASM) has released a position statement recognizing the risk of fatigue and sleepiness in the ride-sharing industry. The AASM calls on the stakeholders (ie, ride-sharing companies, government officials, law enforcement officers, medical professionals) to work together to address this public safety risk.12Berneking M. Rosen I.M. Kirsch D.B. et al.The risk of fatigue and sleepiness in the ridesharing industry: an American Academy of Sleep Medicine Position Statement.J Clin Sleep Med. 2018; 14: 683-685Crossref PubMed Scopus (10) Google Scholar There is a paucity of data regarding liability for malpractice in diagnosis or treatment of sleep disorders. Litigation related to OSA is frequently associated with perioperative complications more than nonoperative issues, such as a failure to diagnose. Otolaryngologists and anesthesiologists were the most frequently named defendants in a legal database of 54 cases. Eighty-seven percent of cases stemmed from patients with OSA who underwent procedures with resultant perioperative adverse events. Common alleged factors included death (48.1%), permanent deficits (42.6%), intraoperative complications (35.2%), requiring additional surgery (25.9%), anoxic brain injury (24.1%), inadequate informed consent (24.1%), inappropriate medication administration (22.2%), and inadequate monitoring (20.4%).1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 13Svider P.F. Pashkova A.A. Folbe A.J. et al.Obstructive sleep apnea: strategies for minimizing liability and enhancing patient safety.Otolaryngol Head Neck Surg. 2013; 149: 947-953Crossref PubMed Scopus (35) Google Scholar A review of three primary legal databases between 1991 and 2010 for cases involving adults with known or suspected OSA who underwent a surgical procedure associated with an adverse perioperative outcome revealed that the most common complications were respiratory arrest in an unmonitored setting and difficulty in airway management. In 24 cases, the immediate adverse outcomes included death (45.6%), anoxic brain injury (45.6%), and upper airways complication (8%). Most of the patients with anoxic brain injury died eventually (overall death rate, 71%). Verdicts favored the plaintiffs in 58% of cases, and the average financial penalty was $2.5 million (range, $650,000-$7,700,000). These data are probably underestimates given that most such cases are settled out of court and are not accounted for in the legal literature.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 14Fouladpour N. Jesudoss R. Bolden N. Shaman Z. Auckley D. Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature.Anesth Analg. 2016; 122: 145-151Crossref PubMed Scopus (61) Google Scholar Parasomnias are undesirable experiences that may occur during either non-rapid eye movement (REM) (ie, confusional arousals, sleepwalking, sleep terrors) or REM sleep (ie, REM behavior disorder). Parasomnia-associated sleep-related violence (SRV) represents a potential medical-legal issue for sleep medicine physicians because they may be called on to consider parasomnia as a possible contributing, mitigating, or exculpatory factor in criminal proceedings. The prevalence of SRV in those with parasomnia is unknown, with SRV directed at others, such as assault, homicide, sexual assault/rape, or motor vehicle-related offenses, as the incidents that come to the attention of the criminal justice system. The most consistent risk factor for SRV is male sex, and in most SRV cases, sleepwalking is the purported defense. Ingravallo et al15Ingravallo F. Poli F. Gilmore E.V. et al.Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports.J Clin Sleep Med. 2014; 10: 927-935PubMed Google Scholar assessed case reports in the medical literature from 1980 to 2012 in which a sleep disorder was the defense during a criminal trial involving purported SRV or sexual behavior during sleep (SBS). In nine cases of SRV and nine cases of SBS assessed in the review, all the defendants were young men and all of the SBS victims were women, as were nearly all of the SRV victims, a concerning finding given the obvious incentive of men who commit violence against women to malinger, seeking parasomnia-related automatism as a legal defense. Nevertheless, the trial outcomes in all the SBS cases, and two-thirds of the SRV cases, were favorable to the defendant. The clinical evaluations of SRV/SBS cases include history with special attention to habitual sleep/wake periods, medications (particularly hypnotics), illicit drug/alcohol use, and personal/family history of parasomnia. Recollection of vivid dream imagery may suggest either sleep terrors or REM-associated nightmares, but it is often very difficult to clinically distinguish between sleep terrors and REM nightmares by history alone. The proximity of the victim to attacker at the onset of the behaviors is a critical historical detail because according to the International Classification of Sleep Disorders, 3rd edition, the sleepwalker does not generally seek out the eventual victim.16American Academy of Sleep Medicine International Classification of Sleep Disorders; Diagnostic and Coding Manual.3rd ed. American Academy of Sleep Medicine, Darien, IL2014Google Scholar More often a person attempting to restrain, redirect, or awaken the sleepwalker during an episode is unintentionally attacked with primitive defensive aggression in the form of punching, kicking, and so forth. If the victim is neither in proximity to the attacker nor provokes the attacker, these circumstances may cast doubt on a diagnosis of parasomnia-associated behavior.17Morrison I. Rumbold J. Riha R. Medicolegal aspects of complex behaviours arising from the sleep period: a review and guide for the practising sleep physician.Sleep Med Rev. 2014; 18: 249-260Crossref PubMed Scopus (23) Google Scholar Electrophysiologic evaluation should include video polysomnography (PSG); however, the obvious limitation is that even if video PSG does not show evidence of parasomnia behavior, a parasomnia at the time of the incident cannot be definitively excluded. Ultimately, conviction or acquittal will be based on the forensic evidence at the scene of the incident and, if available, eyewitness testimony.1Venkateshiah S.B. Hoque R. DelRosso L.M. Collop N.A. Legal and regulatory aspects of sleep disorders.Sleep Med Clin. 2017; 12: 149-160Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In summary, sleep disorders can often lead to situations with legal and regulatory ramifications. These may vary with issues related to driving, surgical procedures, SRV, and employment. Table 2 lists the knowledge and regulatory gaps which may lead to challenging legal circumstances.Table 2Knowledge and Regulatory Gaps Which May Lead to Challenging Legal Circumstances1. Absence of a dose-response relationship between sleepiness and risk of motor vehicle accident2. Lack of guidelines in determining legal culpability in accidents and injuries occurring because of excessive sleepiness3. Absence of uniform physician reporting rules to regulatory authorities of impaired patients who continue to drive4. Disability determination because of excessive sleepiness and impaired work performance5. Consciousness is not an all or none state but a spectrum leading to challenges in ascribing culpability in parasomnia-related sleep-related violence6. Lack of guidelines for preemployment screening and ongoing monitoring during employment of employee impairment because of sleepiness7. Absence of screening rules for OSA from regulatory authorities in commercial trucking industry drivers8. Mismatch because of 20th century regulatory medical practice laws and rapidly evolving portable sleep monitoring technology Open table in a new tab Freestanding laboratories are sleep laboratories that are operated separately from physician practices or hospitals. Some state laws (Florida, New Jersey, and Alabama) may require freestanding sleep laboratories to obtain licensure before operation.18N.J.A.C. 8:43A - Standards for Licensure of Ambulatory Care Facilities, (2014).Google Scholar, 19Alabama Department of Public Health. Division of Licensure and Certification. Administrative Code. Sleep Disorders Facilities. Chapter 420-5-18.Google Scholar, 20Florida Health Care Clinic Act, PART X, § ss. 400.990-400.995 (2014).Google Scholar Of note, diagnostic testing performed as part of a hospital or physician practice is almost always exempt from state health-care facility licensure. Of note, these states require facility licensure even if the entity performs only home or portable sleep tests in the absence of any physical health-care structure visited by patients.21Brown D. Sleep medicine clinical practice and compliance—United States.in: Principles and Practice of Sleep Medicine. 6th edition. Elsevier, Philadelphia, PA2016Google Scholar Physicians who interpret polysomnograms or home sleep tests are often required by government and commercial payers to hold American Board of Sleep Medicine, American Board of Medical Specialties, or certain other credentials as a condition for reimbursement. There is also a Continuing Medical Education (CME) requirement for sleep physicians as part of credentialing/accreditation. AASM-accredited sleep laboratories require sleep physicians to have 10 CME h/y. Oklahoma prohibits physicians who are not board certified from interpreting sleep studies. The Oklahoma Sleep Diagnostic Testing Regulation Act (2009) declares that it is illegal in Oklahoma for a licensed physician to interpret a sleep study unless the physician is board certified in sleep medicine (American Board of Sleep Medicine or American Board of Medical Specialties) or has completed a 1-year Accreditation Council for Graduate Medical Education-accredited sleep medicine fellowship or received a subspecialty certification in sleep medicine issued by the American Osteopathic Association.21Brown D. Sleep medicine clinical practice and compliance—United States.in: Principles and Practice of Sleep Medicine. 6th edition. Elsevier, Philadelphia, PA2016Google Scholar, 22Oklahoma Sleep Diagnostic Testing Regulation Act:, 63 OK Stat § 63-7200.3 (2014) (2014).Google Scholar PSG technicians who perform and score sleep tests have specialized skills and training and may obtain certification through the Board of Registered Polysomnographic Technologists and the American Board of Sleep Medicine (Registered Sleep Technologist). A few state medical boards (Idaho, Tennessee, New York, California, etc) impose licensure requirements on sleep technicians operating in their state.23California Code of Regulations Title 16. Professional and Vocational Regulations Division 13. Medical Board of California Chapter 4.3. PolysomnographyGoogle Scholar, 24New York: Respiratory Therapy, Respiratory Therapy Technician, and Polysomnographic Technologist, section 8505 of New York's Education LawGoogle Scholar, 25Title 63-Professions Of The Healing Arts Chapter 31-Polysomnography 63-31-106-Licensing requirement., Tennessee Code(2010).Google Scholar, 26IDAPA 22.01.11, Rules for Licensure of Respiratory Therapists and Permitting of Polysomnographers in Idaho., IDAPA 22.01.11 (IAC 2009).Google Scholar Sleep laboratories that fail to use licensed sleep technicians face potential state law criminal or civil penalties. Because CPAP titration performed during PSG overlaps the field of respiratory therapy, some state respiratory therapy boards have brought disciplinary actions against some sleep laboratories for the unlicensed practice of respiratory therapy. Of note, states that have adopted PSG technology laws typically exempt licensed PSG technicians from respiratory therapy licensure requirement.21Brown D. Sleep medicine clinical practice and compliance—United States.in:
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