Letters
will invite their patients to read notes. Ideally, the need to make such decisions will lead to honest and open discussion among all concerned, leading to wise choices and solutions.
on the physical built environment. Involving patients in the redesign of hospital acoustic environments may also improve patient experiences and satisfaction with their hospital care.
Jan Walker, RN, MBA Michael W. Kahn, MD Tom Delbanco, MD
Paul Barach, MD, MPH Vineet M. Arora, MD, MAPP
Author Affiliations: Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Walker, Delbanco); Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Kahn). Corresponding Author: Jan Walker, RN, MBA, Beth Israel Deaconess Medical Center, Division of General Medicine and Primary Care, 1309 Beacon St, Second Floor, Boston, MA 02446 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Author Affiliations: College of Medicine, University College Cork, Cork, Ireland (Barach); Department of Medicine, University of Chicago, Chicago, Illinois (Arora). Corresponding Author: Paul Barach, MD, MPH, College of Medicine, University College Cork, Cork, Ireland ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Chopra V, McMahon LF Jr. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12):1199-1200.
1. Delbanco T, Walker J, Darer JD, et al. Open notes: doctors and patients signing on. Ann Intern Med. 2010;153(2):121-125.
2. Busch-Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645.
2. OpenNotes Initiative. OpenNotes website. www.myopennotes.org. Accessed May 28, 2014.
3. Wolf JA, Madaras GS. Charting a Course to Quiet: Addressing the Challenge of Noise in Hospitals. Dallas, TX: Beryl Institute; 2014.
Hospital Alarms and Patient Safety
4. Mahmood A, Chaudhury H, Valente M. Nurses’ perceptions of how physical environment affects medication errors in acute care settings. Appl Nurs Res. 2011;24(4):229-237.
To the Editor Drs Chopra and McMahon1 highlighted several valid points about the need to redesign patient alarms. However, the authors overlooked the most important reason to redesign the hospital acoustic environment of care—to improve patient safety and well-being. Hospital noise routinely exceeds World Health Organization acceptable standards and is more than just an annoyance. 2 This failure to provide patients with quiet rooms affects clinical outcomes through several mechanisms including sleep deprivation, cardiovascular derangements (increased heart rate and blood pressure), poor wound healing, higher incidence of rehospitalization, patient falls, pain, stress, and dissatisfaction.3 Moreover, poor acoustic clinical environments are associated with excessive cognitive load on staff and interference with speech and communication between health care professionals, both of which can increase risk of medical errors and patient harm.4 Improving acoustic environments for hospitalized patients can decrease rehospitalization rates, improve sympathetic arousal, and raise patient satisfaction compared with ordinary hospital environments.5 Reduced noise was the most common item reported by almost 700 hospital executives for improving patient experiences.3 Almost 90% reported the primary driver was for patients to sleep better. Other top reasons included patientreported outcome measures of faster recovery (76%) and improvements in stress and anxiety (67%). We believe that hospitals need a systemwide alarm policy, protocols that define the alarm management strategy for medical equipment, and delineation of how caregivers and nurses should respond to alarm conditions and signals. A human factors approach based around the hospital’s culture should be used that engages architects, designers, acoustical engineers, facility engineering, staff, and clinicians to address alarm fatigue and its implications
5. Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA, Theorell T. Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. Int J Cardiol. 2005;98(2):267-270.
In Reply In response to our recent Viewpoint, Drs Barach and Arora state that we overlooked the most important reason to redesign the hospital acoustic environment of care. Barach and Arora cite several articles supporting the assertion that hospital noise is associated with adverse patient satisfaction and clinical well-being. We do not disagree with Barach and Arora that hospital noise is an important concern. But their message does not deviate from our proposed schema, which is also aimed at improving patient care. First, it is important to remember that not all alarms are auditory in nature. A novel approach that takes into account different sensory modalities through which alerts can be delivered is a key aspect of our proposal. For example, visual, vibratory, or targeted alerts can be delivered through the use of proximity sensors, specialized wristbands, and e-mails for nonurgent tasks. Second, creating an alarm priority will provide a framework to eliminate unnecessary alarms and consequently also reduce noise. Any alarm with a mute function should be revisited because the existence of such an option is an admission of its limited effectiveness. Last, creating alarms that “learn” baselines and use artificial intelligence to isolate deviations from a “normal” state not only improve patient safety by reducing clinician alert fatigue and alarm accuracy but also reduce false alerts and noise. Improving hospital alarms using a technology-based, clinically relevant approach will not only reduce hospital noise but also improve patient safety. Vineet Chopra, MD, MSc Laurence F. McMahon Jr, MD, MPH
jama.com
JAMA August 13, 2014 Volume 312, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/27/2015
651
Letters
Author Affiliations: Department of Internal Medicine, University of Michigan Health System, Ann Arbor. Corresponding Author: Vineet Chopra, MD, MSc, Department of Internal Medicine, University of Michigan Health System, 2800 Plymouth Rd, Bldg 16, Room 430W, Ann Arbor, MI 48109 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being coinventors of technology used to track catheters in hospitalized patients, which is not an alarm.
CORRECTION Incorrect Phrase in Sentence: In the Letter to the Editor entitled “Housing Mobility and Adolescent Mental Health” published in the July 9, 2014, issue of JAMA (2014;312[2]:190. doi:10.1001/jama.2014.6468), an incorrect phrase was substituted for a word in a sentence. In the second paragraph, the last sentence should have read “It would be of interest to know how the Moving to Opportunity voucher and control boys with PTSD differed with respect to the settings, types,3 chronicity, and severity of the precipitating stressors and PTSD symptoms; whether PTSD cases clustered in boys who relocated to high-poverty neighborhoods after voucherfacilitated moves4; and whether any effect modification by age at randomization is detectable.” This article was corrected online.
Incorrect Units, Group Name, and Author Name: In the Special Communication entitled “HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International Antiviral Society–USA Panel” published in the July 23/30, 2014, issue of JAMA (2014;312[4]:390-409. doi:10.1001/jama.2014.7999), units were incorrectly reported. In the second and third paragraphs in “Section B: Prevention Measures Specific to HIV-Infected Individuals,” the units for CD4 cell counts reported as cells/mL should have been reported as cells/μL. Additionally, in the Author Contributions section, the name del Rio incorrectly appeared as “Del Rio.” Last, in the Funding/Support section, “International Antivirus Society–USA” should have read “International Antiviral Society–USA.” This article was corrected online. Updated Information: In the Viewpoint entitled “An HIV Cure: Feasibility, Discovery, and Implementation” published in the July 23/30, 2014, issue of JAMA (2014; 312[4]:335-336. doi:10.1001/jama.2014.4754), important information became available after the Viewpoint went to press. In paragraph 7, sentence 4 onward has been updated to read “First, the infant referred to as the ‘Mississippi Baby,’ who was born to an HIV-infected mother who had received neither prenatal nor perinatal ART, began receiving full antiretroviral treatment at age 30 hours. It was later determined that the infant was infected, and ART was continued through age 18 months,
652
at which point the child was lost to follow-up. At age 23 months the child was again seen in clinic and had no detectable virus in the blood, despite not taking ART for the previous 5 months, and had no HIV-specific antibodies. These results persisted for a total of 27 months without therapy. However, at age 46 months, the child experienced unequivocal viral rebound (consecutive plasma viral load measurements of 16 750 HIV RNA copies/mL and 10 564 copies/mL). Although a permanent cure was not achieved, the infant’s early treatment led to a markedly sustained virologic remission. In light of these new findings, researchers must now work to better understand what enabled the child to remain off treatment for more than 2 years without detectable virus or measurable immunologic response and what might be done to extend the period of sustained HIV remission in the absence of ART.” Additionally, one reference was updated, another added, and the references were renumbered accordingly. This article was corrected online.
Guidelines for Letters Letters discussing a recent JAMA article should be submitted within 4 weeks of the article's publication in print. Letters received after 4 weeks will rarely be considered. Letters should not exceed 400 words of text and 5 references and may have no more than 3 authors. Letters reporting original research should not exceed 600 words of text and 6 references and may have no more than 7 authors. They may include up to 2 tables or figures but online supplementary material is not allowed. All letters should include a word count. Letters must not duplicate other material published or submitted for publication. Letters not meeting these specifications are generally not considered. Letters being considered for publication ordinarily will be sent to the authors of the JAMA article, who will be given the opportunity to reply. Letters will be published at the discretion of the editors and are subject to abridgement and editing. Further instructions can be found at http://jama.com/public /InstructionsForAuthors.aspx. A signed statement for authorship criteria and responsibility, financial disclosure, copyright transfer, and acknowledgment and the ICMJE Form for Disclosure of Potential Conflicts of Interest are required before publication. Letters should be submitted via the JAMA online submission and review system at http: //manuscripts.jama.com. For technical assistance, please contact [email protected]. Section Editor: Jody W. Zylke, MD, Senior Editor.
JAMA August 13, 2014 Volume 312, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/27/2015
jama.com
will invite their patients to read notes. Ideally, the need to make such decisions will lead to honest and open discussion among all concerned, leading to wise choices and solutions.
on the physical built environment. Involving patients in the redesign of hospital acoustic environments may also improve patient experiences and satisfaction with their hospital care.
Jan Walker, RN, MBA Michael W. Kahn, MD Tom Delbanco, MD
Paul Barach, MD, MPH Vineet M. Arora, MD, MAPP
Author Affiliations: Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Walker, Delbanco); Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Kahn). Corresponding Author: Jan Walker, RN, MBA, Beth Israel Deaconess Medical Center, Division of General Medicine and Primary Care, 1309 Beacon St, Second Floor, Boston, MA 02446 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Author Affiliations: College of Medicine, University College Cork, Cork, Ireland (Barach); Department of Medicine, University of Chicago, Chicago, Illinois (Arora). Corresponding Author: Paul Barach, MD, MPH, College of Medicine, University College Cork, Cork, Ireland ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Chopra V, McMahon LF Jr. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12):1199-1200.
1. Delbanco T, Walker J, Darer JD, et al. Open notes: doctors and patients signing on. Ann Intern Med. 2010;153(2):121-125.
2. Busch-Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645.
2. OpenNotes Initiative. OpenNotes website. www.myopennotes.org. Accessed May 28, 2014.
3. Wolf JA, Madaras GS. Charting a Course to Quiet: Addressing the Challenge of Noise in Hospitals. Dallas, TX: Beryl Institute; 2014.
Hospital Alarms and Patient Safety
4. Mahmood A, Chaudhury H, Valente M. Nurses’ perceptions of how physical environment affects medication errors in acute care settings. Appl Nurs Res. 2011;24(4):229-237.
To the Editor Drs Chopra and McMahon1 highlighted several valid points about the need to redesign patient alarms. However, the authors overlooked the most important reason to redesign the hospital acoustic environment of care—to improve patient safety and well-being. Hospital noise routinely exceeds World Health Organization acceptable standards and is more than just an annoyance. 2 This failure to provide patients with quiet rooms affects clinical outcomes through several mechanisms including sleep deprivation, cardiovascular derangements (increased heart rate and blood pressure), poor wound healing, higher incidence of rehospitalization, patient falls, pain, stress, and dissatisfaction.3 Moreover, poor acoustic clinical environments are associated with excessive cognitive load on staff and interference with speech and communication between health care professionals, both of which can increase risk of medical errors and patient harm.4 Improving acoustic environments for hospitalized patients can decrease rehospitalization rates, improve sympathetic arousal, and raise patient satisfaction compared with ordinary hospital environments.5 Reduced noise was the most common item reported by almost 700 hospital executives for improving patient experiences.3 Almost 90% reported the primary driver was for patients to sleep better. Other top reasons included patientreported outcome measures of faster recovery (76%) and improvements in stress and anxiety (67%). We believe that hospitals need a systemwide alarm policy, protocols that define the alarm management strategy for medical equipment, and delineation of how caregivers and nurses should respond to alarm conditions and signals. A human factors approach based around the hospital’s culture should be used that engages architects, designers, acoustical engineers, facility engineering, staff, and clinicians to address alarm fatigue and its implications
5. Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA, Theorell T. Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. Int J Cardiol. 2005;98(2):267-270.
In Reply In response to our recent Viewpoint, Drs Barach and Arora state that we overlooked the most important reason to redesign the hospital acoustic environment of care. Barach and Arora cite several articles supporting the assertion that hospital noise is associated with adverse patient satisfaction and clinical well-being. We do not disagree with Barach and Arora that hospital noise is an important concern. But their message does not deviate from our proposed schema, which is also aimed at improving patient care. First, it is important to remember that not all alarms are auditory in nature. A novel approach that takes into account different sensory modalities through which alerts can be delivered is a key aspect of our proposal. For example, visual, vibratory, or targeted alerts can be delivered through the use of proximity sensors, specialized wristbands, and e-mails for nonurgent tasks. Second, creating an alarm priority will provide a framework to eliminate unnecessary alarms and consequently also reduce noise. Any alarm with a mute function should be revisited because the existence of such an option is an admission of its limited effectiveness. Last, creating alarms that “learn” baselines and use artificial intelligence to isolate deviations from a “normal” state not only improve patient safety by reducing clinician alert fatigue and alarm accuracy but also reduce false alerts and noise. Improving hospital alarms using a technology-based, clinically relevant approach will not only reduce hospital noise but also improve patient safety. Vineet Chopra, MD, MSc Laurence F. McMahon Jr, MD, MPH
jama.com
JAMA August 13, 2014 Volume 312, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/27/2015
651
Letters
Author Affiliations: Department of Internal Medicine, University of Michigan Health System, Ann Arbor. Corresponding Author: Vineet Chopra, MD, MSc, Department of Internal Medicine, University of Michigan Health System, 2800 Plymouth Rd, Bldg 16, Room 430W, Ann Arbor, MI 48109 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being coinventors of technology used to track catheters in hospitalized patients, which is not an alarm.
CORRECTION Incorrect Phrase in Sentence: In the Letter to the Editor entitled “Housing Mobility and Adolescent Mental Health” published in the July 9, 2014, issue of JAMA (2014;312[2]:190. doi:10.1001/jama.2014.6468), an incorrect phrase was substituted for a word in a sentence. In the second paragraph, the last sentence should have read “It would be of interest to know how the Moving to Opportunity voucher and control boys with PTSD differed with respect to the settings, types,3 chronicity, and severity of the precipitating stressors and PTSD symptoms; whether PTSD cases clustered in boys who relocated to high-poverty neighborhoods after voucherfacilitated moves4; and whether any effect modification by age at randomization is detectable.” This article was corrected online.
Incorrect Units, Group Name, and Author Name: In the Special Communication entitled “HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International Antiviral Society–USA Panel” published in the July 23/30, 2014, issue of JAMA (2014;312[4]:390-409. doi:10.1001/jama.2014.7999), units were incorrectly reported. In the second and third paragraphs in “Section B: Prevention Measures Specific to HIV-Infected Individuals,” the units for CD4 cell counts reported as cells/mL should have been reported as cells/μL. Additionally, in the Author Contributions section, the name del Rio incorrectly appeared as “Del Rio.” Last, in the Funding/Support section, “International Antivirus Society–USA” should have read “International Antiviral Society–USA.” This article was corrected online. Updated Information: In the Viewpoint entitled “An HIV Cure: Feasibility, Discovery, and Implementation” published in the July 23/30, 2014, issue of JAMA (2014; 312[4]:335-336. doi:10.1001/jama.2014.4754), important information became available after the Viewpoint went to press. In paragraph 7, sentence 4 onward has been updated to read “First, the infant referred to as the ‘Mississippi Baby,’ who was born to an HIV-infected mother who had received neither prenatal nor perinatal ART, began receiving full antiretroviral treatment at age 30 hours. It was later determined that the infant was infected, and ART was continued through age 18 months,
652
at which point the child was lost to follow-up. At age 23 months the child was again seen in clinic and had no detectable virus in the blood, despite not taking ART for the previous 5 months, and had no HIV-specific antibodies. These results persisted for a total of 27 months without therapy. However, at age 46 months, the child experienced unequivocal viral rebound (consecutive plasma viral load measurements of 16 750 HIV RNA copies/mL and 10 564 copies/mL). Although a permanent cure was not achieved, the infant’s early treatment led to a markedly sustained virologic remission. In light of these new findings, researchers must now work to better understand what enabled the child to remain off treatment for more than 2 years without detectable virus or measurable immunologic response and what might be done to extend the period of sustained HIV remission in the absence of ART.” Additionally, one reference was updated, another added, and the references were renumbered accordingly. This article was corrected online.
Guidelines for Letters Letters discussing a recent JAMA article should be submitted within 4 weeks of the article's publication in print. Letters received after 4 weeks will rarely be considered. Letters should not exceed 400 words of text and 5 references and may have no more than 3 authors. Letters reporting original research should not exceed 600 words of text and 6 references and may have no more than 7 authors. They may include up to 2 tables or figures but online supplementary material is not allowed. All letters should include a word count. Letters must not duplicate other material published or submitted for publication. Letters not meeting these specifications are generally not considered. Letters being considered for publication ordinarily will be sent to the authors of the JAMA article, who will be given the opportunity to reply. Letters will be published at the discretion of the editors and are subject to abridgement and editing. Further instructions can be found at http://jama.com/public /InstructionsForAuthors.aspx. A signed statement for authorship criteria and responsibility, financial disclosure, copyright transfer, and acknowledgment and the ICMJE Form for Disclosure of Potential Conflicts of Interest are required before publication. Letters should be submitted via the JAMA online submission and review system at http: //manuscripts.jama.com. For technical assistance, please contact [email protected]. Section Editor: Jody W. Zylke, MD, Senior Editor.
JAMA August 13, 2014 Volume 312, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/27/2015
jama.com
