Circulation 122,210 • Volume 34, No. 2 • October 2019   Issue PDF

Solving Gaps in Blood Pressure Monitoring


AlertWatchTM’s decision support software has been used as a technical aid to provide an alert to blood pressure measurement gaps. Although used routinely, the potential effectiveness of this alert to reduce blood pressure gaps has not yet been studied. APSF policy is not to print names of some medical software devices because it could be construed as endorsing that product.

MonitorsI read with interest the letter in the Rapid Response column (APSF Newsletter June 2019) concerning questions about gaps in blood pressure monitoring from Dr. Sheron McLean, a faculty member in our department.1 I am familiar with the issue of blood pressure monitoring gaps, since our multi-institutional study assessing the ability to reduce the incidence of these gaps by utilizing either visual alerts, audible and visual alerts, or no alerts.2 The study showed that audible alerts did reduce monitoring gaps but the visual alerts alone did not.2 Subsequently, we found that blood pressure monitoring gaps are a potential patient safety issue since they were associated with an increased incidence of hypotension.3 Based upon this research, we developed, and have been using, a decision support system with visual and audible alerts that can be programmed for customized alerts. This system (AlertWatch™ Ann Arbor, MI), was commercialized and cleared by the Food and Drug Administration (FDA) as a medical software device.

The name of our company was not indicated in Dr. McLean’s letter apparently because it was removed during the editing process “to avoid any appearance of endorsement by APSF.”4 The response from General Electric (GE) published extensive text and multiple screenshots describing how they are trying to approach this problem. This article could be seen as an endorsement for the GE CARESCAPE B-850 monitor. In the spirit of informing anesthesia professionals about methods for enhancing patient safety, I am surprised the Anesthesia Patient Safety Foundation would not reference a system intended to enhance safety, especially in the context of an entire issue on alarm fatigue and patient safety. APSF should publish the editorial policy on content referencing a commercial product to facilitate communication to the anesthesia community yet avoid the possible perception of “endorsing” a specific product, sponsor, or APSF donor.


Kevin Tremper is the Robert B. Sweet Professor and chair of the Department of Anesthesiology, University of Michigan. He is also the founder and equity holder in AlertWatch.


  1. McLean S. Dear Rapid Response: Monitoring gaps. APSF Newsletter. 2019;34:9.
  2. Ehrenfeld JM, Epstein RH, Bader S, et al. Automatic notifications mediated by anesthesia information management systems reduce the frequency of prolonged gaps in blood pressure documentation. Anesth Analg. 2011; 113:356–363.
  3. Kruger GH, Shanks A, Kheterpal S, et al. Influence on non-invasive blood pressure measurement intervals on the occurrence of intraoperative hypotension. J Clin Monit Comput. 2018; 32:699–705.
  4. Personal Communication to Sheron McLean from APSF, email dated February 19, 2019.


Editorial Response:

Dear Dr. Tremper,

We want to thank you for your interest in the APSF and understand the concern you have raised in your recent letter. The letter from Dr. McLean was submitted to our Rapid Response (formerly Dear SIRS) column. The history of that column is to receive comments, often disparaging, about technology used in patient care, and publish those comments with the opportunity for a corporate response from the vendor. The goal of the column is to provide a forum to bring patient safety concerns about technology to light while allowing the design work by the company to be clarified, and also to highlight any user issues that may have contributed to a problem. Not infrequently, the identified safety concern influences the product design process by the companies and results in product improvement and/or helps to educate professionals about the proper use of the device. Over the years, this column has been very impactful in part because we have worked hard to manage the corporate sensitivities. In the editorial process, we are cognizant of the potential impact if the APSF Newsletter is used as a platform to promote or disparage any particular vendor or technology.

In this particular case, we focused on the concept of blood pressure measurement as a potential patient safety concern and thanks to Dr. McLean, the concept is explored nicely in the APSF Newsletter. Not only was her letter critical of the GE design, but given the fact that AlertWatch™ originated in your department, we were concerned that by mentioning the product by name, her letter would be viewed as an endorsement that could be referenced and used to promote the product. Undoubtedly, you can appreciate the editorial challenges to managing the content in a fashion that informs the readers and provides a forum for companies to highlight the design process yet is neutral with regard to any corporate interests.

Ideally, we would publish an editorial policy that clearly indicates the threshold for mentioning a specific company, but ultimately, the editorial process becomes a matter of judgement. Suffice it to say that the editorial policy is driven to provide a forum for bringing patient safety issues to light without specifically endorsing a particular product or vendor.

Thank you again for taking the time to challenge the editorial process and stimulate us to examine the approach.


Steven Greenberg, MD
Editor-in-chief, Anesthesia Patient Safety
Foundation (APSF) Newsletter

Jeffrey Feldman, MD
Chair, APSF Committee on Technology