Letters
In Reply It was good to read the comments of Symvoulakis and colleagues about our recent article on how decisions are made.1 To inform and involve patients in medical decisions is a goal that is valued to varying degrees around the world. It also poses major challenges for health care clinicians around the world, perhaps most acutely in primary care. The writers provide a good list of the problems: the wide variety of medical problems seen in primary care, lack of skills or practice in doing shared decision making, and physicians’ concerns that patients will not do something that they think is medically valuable. It will take some adjusting for physicians to feel comfortable when patients do not make the decisions they would recommend. However, as the writers state: “…striving toward a well-informed and actively involved patient…should become a priority for any health care reform to succeed over time.” We could not agree more.
support algorithms to understand which combination of vital signs and other clinical markers can help identify the patients at risk of clinical deterioration and in need of additional intervention. Furthermore, automating vital sign collection could achieve cost savings by decreasing manual labor, as mentioned by Yoder and colleagues.1 There are already Food and Drug Administration– approved, patient-worn devices that can automatically monitor electrocardiogram, heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and other variables. This is not science fiction dreaming about the future but an opportunity we have to improve patient care now if we design, select, and implement technology in smart ways. Wen Dombrowski, MD, MBA Author Affiliation: Connected Health, VNA Health Group, Red Bank, New Jersey.
Floyd J. Fowler Jr, PhD Bethany S. Gerstein, BA Michael J. Barry, MD
Corresponding Author: Wen Dombrowski, MD, MBA, VNA Health Group, 176 Riverside Ave, Red Bank, NJ 07701 ([email protected]). Conflict of Interest Disclosures: None reported.
Author Affiliations: Informed Medical Decisions Foundation, Boston, Massachusetts (Fowler, Gerstein, Barry); Center for Survey Research, University of Massachusetts, Boston (Fowler).
1. Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;173(16):1554-1555.
Corresponding Author: Floyd J. Fowler Jr, PhD, Center for Survey Research, University of Massachusetts, Boston, 100 Morrissey Blvd, Boston, MA 02125 ([email protected]).
2. Inouye SK. No rest for the weary…or the sick. JAMA Intern Med. 2013;173(16):1555-1556.
Conflict of Interest Disclosures: All authors are employed by the Informed Medical Decisions Foundation. Dr Barry reported receiving a salary as president of the Informed Medical Decisions Foundation, a nonprofit private foundation. Funding/Support: Funding for data collection and manuscript preparation for the research reported in our study1 was provided by the Informed Medical Decisions Foundation. Role of the Sponsor: The Informed Medical Decisions Foundation is a nonprofit organization that supports research and creates decision support materials for patients. Health Dialog, a for-profit company, uses materials created by the foundation as part of the support services it provides to patients through health plans, employers, and providers, and it pays royalties to the foundation for the use of those materials. 1. Fowler FJ Jr, Gerstein BS, Barry MJ. How patient centered are medical decisions? results of a national survey. JAMA Intern Med. 2013;173(13):1215-1221.
Acutely Ill Patients Will Likely Benefit From More Monitoring, Not Less To the Editor Applause to Yoder et al1 and Inouye et al2 for drawing attention to the important but infrequently discussed problems of waking up hospitalized patients while they are trying to rest. The article by Yoder et al1 suggests checking vital signs less frequently for low-risk patients. However, US patients who are hospitalized nowadays are admitted for increasingly higheracuity and complex care, as health care clinicians engage in efforts to prevent hospital admissions and pursue outpatient treatment when feasible. In light of these trends toward hospitalizing high-acuity patients and the increasing availability of monitoring technology,3,4 further research should focus on (1) less intrusive patient monitoring such as portable, patient-worn sensors that continuously collect vital sign data in hospital and home telehealth settings, and (2) data analytics and decision jamainternalmedicine.com
3. Yilmaz T, Foster R, Hao Y. Detecting vital signs with wearable wireless sensors. Sensors (Basel). 2010;10(12):10837-10862. 4. Welch J, Moon J, McCombie S. Early detection of the deteriorating patient: the case for a multi-parameter patient-worn monitor. Biomed Instrum Technol. 2012;(suppl):57-64.
In Reply We appreciate Dr Dombrowski's thoughtful reply to our article1 and agree on all accounts to the excellent points she has raised regarding the important balance between patient rest and adequate monitoring. The escalating level of acuity in hospitalized patients certainly does necessitate more vigilant vital sign collection, but this can be accomplished without foregoing patient sleep. We are equally enthusiastic about the many newly developed and developing technologies that support continuous vital sign monitoring. Not only are patient-worn devices currently commercially available, but it is now even possible to continuously monitor vital signs, such as heart rate and respiratory rate, without coming in contact with the patient, using a sensor placed under the patient’s mattress.2 These devices are poised to revolutionize the way we care for patients on the wards, obviating the need for reflexive manual vital sign collection. However, their impact on patient sleep remains to be seen. An increasing stream of vital sign data will likely result in more frequent alarms. To prevent more noise in the already deafening hospital, careful alarm delivery via ward redesign and electronic health record or paging alerts should be considered.3 Since each alarm will presumably prompt a manual verification, low-risk patients may end up being woken even more frequently than the status quo if the triggering thresholds are not sufficiently specific. Given concerns over increasing alarm frequency, the Joint Commission has recently called on hosJAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/27/2015
475
In Reply It was good to read the comments of Symvoulakis and colleagues about our recent article on how decisions are made.1 To inform and involve patients in medical decisions is a goal that is valued to varying degrees around the world. It also poses major challenges for health care clinicians around the world, perhaps most acutely in primary care. The writers provide a good list of the problems: the wide variety of medical problems seen in primary care, lack of skills or practice in doing shared decision making, and physicians’ concerns that patients will not do something that they think is medically valuable. It will take some adjusting for physicians to feel comfortable when patients do not make the decisions they would recommend. However, as the writers state: “…striving toward a well-informed and actively involved patient…should become a priority for any health care reform to succeed over time.” We could not agree more.
support algorithms to understand which combination of vital signs and other clinical markers can help identify the patients at risk of clinical deterioration and in need of additional intervention. Furthermore, automating vital sign collection could achieve cost savings by decreasing manual labor, as mentioned by Yoder and colleagues.1 There are already Food and Drug Administration– approved, patient-worn devices that can automatically monitor electrocardiogram, heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and other variables. This is not science fiction dreaming about the future but an opportunity we have to improve patient care now if we design, select, and implement technology in smart ways. Wen Dombrowski, MD, MBA Author Affiliation: Connected Health, VNA Health Group, Red Bank, New Jersey.
Floyd J. Fowler Jr, PhD Bethany S. Gerstein, BA Michael J. Barry, MD
Corresponding Author: Wen Dombrowski, MD, MBA, VNA Health Group, 176 Riverside Ave, Red Bank, NJ 07701 ([email protected]). Conflict of Interest Disclosures: None reported.
Author Affiliations: Informed Medical Decisions Foundation, Boston, Massachusetts (Fowler, Gerstein, Barry); Center for Survey Research, University of Massachusetts, Boston (Fowler).
1. Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;173(16):1554-1555.
Corresponding Author: Floyd J. Fowler Jr, PhD, Center for Survey Research, University of Massachusetts, Boston, 100 Morrissey Blvd, Boston, MA 02125 ([email protected]).
2. Inouye SK. No rest for the weary…or the sick. JAMA Intern Med. 2013;173(16):1555-1556.
Conflict of Interest Disclosures: All authors are employed by the Informed Medical Decisions Foundation. Dr Barry reported receiving a salary as president of the Informed Medical Decisions Foundation, a nonprofit private foundation. Funding/Support: Funding for data collection and manuscript preparation for the research reported in our study1 was provided by the Informed Medical Decisions Foundation. Role of the Sponsor: The Informed Medical Decisions Foundation is a nonprofit organization that supports research and creates decision support materials for patients. Health Dialog, a for-profit company, uses materials created by the foundation as part of the support services it provides to patients through health plans, employers, and providers, and it pays royalties to the foundation for the use of those materials. 1. Fowler FJ Jr, Gerstein BS, Barry MJ. How patient centered are medical decisions? results of a national survey. JAMA Intern Med. 2013;173(13):1215-1221.
Acutely Ill Patients Will Likely Benefit From More Monitoring, Not Less To the Editor Applause to Yoder et al1 and Inouye et al2 for drawing attention to the important but infrequently discussed problems of waking up hospitalized patients while they are trying to rest. The article by Yoder et al1 suggests checking vital signs less frequently for low-risk patients. However, US patients who are hospitalized nowadays are admitted for increasingly higheracuity and complex care, as health care clinicians engage in efforts to prevent hospital admissions and pursue outpatient treatment when feasible. In light of these trends toward hospitalizing high-acuity patients and the increasing availability of monitoring technology,3,4 further research should focus on (1) less intrusive patient monitoring such as portable, patient-worn sensors that continuously collect vital sign data in hospital and home telehealth settings, and (2) data analytics and decision jamainternalmedicine.com
3. Yilmaz T, Foster R, Hao Y. Detecting vital signs with wearable wireless sensors. Sensors (Basel). 2010;10(12):10837-10862. 4. Welch J, Moon J, McCombie S. Early detection of the deteriorating patient: the case for a multi-parameter patient-worn monitor. Biomed Instrum Technol. 2012;(suppl):57-64.
In Reply We appreciate Dr Dombrowski's thoughtful reply to our article1 and agree on all accounts to the excellent points she has raised regarding the important balance between patient rest and adequate monitoring. The escalating level of acuity in hospitalized patients certainly does necessitate more vigilant vital sign collection, but this can be accomplished without foregoing patient sleep. We are equally enthusiastic about the many newly developed and developing technologies that support continuous vital sign monitoring. Not only are patient-worn devices currently commercially available, but it is now even possible to continuously monitor vital signs, such as heart rate and respiratory rate, without coming in contact with the patient, using a sensor placed under the patient’s mattress.2 These devices are poised to revolutionize the way we care for patients on the wards, obviating the need for reflexive manual vital sign collection. However, their impact on patient sleep remains to be seen. An increasing stream of vital sign data will likely result in more frequent alarms. To prevent more noise in the already deafening hospital, careful alarm delivery via ward redesign and electronic health record or paging alerts should be considered.3 Since each alarm will presumably prompt a manual verification, low-risk patients may end up being woken even more frequently than the status quo if the triggering thresholds are not sufficiently specific. Given concerns over increasing alarm frequency, the Joint Commission has recently called on hosJAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/27/2015
475
