Authors
Dr
C Mae Wong, BMBS, MRCP(UK), MRCPCH; Rivendell Research Fellow in Neonatology
Dr
Ben J Stenson, MBChB, MD, FRCPCH, FRCPE; Consultant Neonatologist
Dr
Ian A Laing, MA, MD, FRCPE, FRCPCH; Consultant Neonatologist and Associate
Patient Services Director
Institute
Involved in Study
Simpson
Memorial Maternity Pavilion
Author
Responsible for Correspondence and Reprint Requests
Dr
C Mae Wong
Conflict
of Interest
None
Source
of Funding
Dr
Mae Wong is funded by the Rivendell Trust
Abstract
The
timing of birth-related events may influence neonatal outcome and is often
pivotal in medicolegal cases. This prospective observational study determined
the variation in displayed time on timepieces in a regional maternity unit which
could result in inaccuracies of time documentation. The mean (95%CI) difference
between time displayed and true time was +5sec (±2min
4sec) for delivery room clocks and +1m 8s (±7m
12s) for resuscitation room clocks. The maximum discrepancy between delivery
room and resuscitation room clocks was 7m 52s. The abilities of staff to
estimate the duration of time passed was also assessed. The mean (95%CI)
five-minute estimate was 4m 52s (±3m
12s). These disparities could have considerable medicolegal significance, and
should be taken into consideration in risk management studies. Maternity units
should move towards synchronising all timepieces. Meanwhile, statements about
the precise timing of events should be regarded with suspicion.
Key
Words
Time
perception
"I
have found no standard practice amongst doctors and midwives about the timing of
entries… Frequently, I suspect that the timing is not precise. Nevertheless,
after the event lawyers pore over each entry as though it were the Holy Writ and
minutes here and minutes there become important."
1
Introduction
The
timing of birth-related events can be a determinant of outcome and is often
pivotal in medicolegal cases. Complete disruption of umbilical cord flow may
cause irreversible fetal brain damage in 15 minutes and death in 30 minutes.
Prolonged non-reassuring fetal status is also associated with poorer condition
at birth. The American College of Obstetricians and Gynecologists and the
American Academy of Pediatrics recommend a maximum decision-to-incision interval
of 30 minutes for emergency caesarian section.
2
Longer intervals are associated with increased frequency of cord pH < 7.00
and admission to a neonatal unit.
3
We
hypothesised that there is a wide variation in the time displayed on timepieces
in a regional obstetric unit which could result in inaccuracies of time
documentation. We also hypothesised that there is a wide variation in abilities
of staff to estimate the duration of time passed. Time estimation is often used
during periods of increased clinical workload when charting of events is
performed retrospectively. We aimed to determine the range of error in recorded
times and estimates of elapsed time.
Methods
The
study centre is a tertiary regional obstetric and neonatal unit. Individual
hospital clocks are set manually twice a year. The time displayed (Td) to the
second on delivery room and resuscitation room clocks and staff watches was
recorded. Only healthcare professionals likely to be involved in attending
deliveries and resuscitations and documenting these episodes were recruited.
True time (Tt) was recorded using a digital watch (Casio Lithium DW-280)
standardised to the talking clock. The difference between each timepiece and
true time was calculated as Td minus Tt. Mean and 95% confidence intervals of
the differences were calculated (mean
+/- 2SD). Nursing and medical staff
were also asked to estimate time by saying when five minutes
had elapsed during a period of routine work
without making reference to clocks or watches. 95% confidence intervals of the
estimated time (Te) were calculated (mean +/- 2SD).
Results
Displayed
times
Readings
were obtained from 16 delivery room clocks and 4 resuscitation room clocks. The
mean (95%CI) difference between Td and Tt was +5s (+/-2m 4s) for delivery room
clocks and +1m 8s (+/-7m 12s) for resuscitation room clocks. The maximum
discrepancy between delivery room and resuscitation room clocks was 7m 52s.
Time
estimates
There
were 47 time estimates. Only one individual (the
local professor) forgot about the time-estimate study while it was underway and
had to be reassessed. Te
ranged from 1m 46s to 8m 41s. The mean (95%CI) estimate was 4m 52s (±3m
12s).
Discussion
We
have found considerable variation between displayed time used in recording the
timing of birth-related events. Although the mean time displayed was comparable
to the talking clock this only proves that some clocks were as fast as others
were slow. The distribution of the inaccuracies suggests that times of birth
recorded in notes may vary from the true time by around two minutes either way.
Once a baby is transferred to a separate resuscitation room, timings of events
from birth may vary by almost eight minutes. Ideally the resuscitaire timer
should be used but if overlooked, staff may rely on their watches or room
clocks. This
problem is likely to be diminished in units where infants are resuscitated in
the delivery rooms rather than in a separate location.. In obstetric theatres
the anaesthetic room clock suggested a falsely shorter induction-to-delivery
interval and the resuscitation room clock suggested that babies were
resuscitated before their time of birth.
Professional
staff varied by up to six minutes in their ability to estimate a five-minute
interval. They were tested under non-stress circumstances: perception of time
may alter in stressful situations such as resuscitation.
Present
systems allow marked discrepancies in the recording of times and estimation of
time intervals. These disparities could have considerable medico legal
significance. This should be taken into consideration in risk management
studies. Maternity units should move towards synchronising all timepieces.
Meanwhile, statements about the precise timing of events should be regarded with
suspicion.
Segal's
Law
"A
man with a watch knows what time it is. A man with two watches is never
sure."
Acknowledgements
We
thank Paulien van Dijk, ERASMUS Student, for assistance with data collection,
and all staff who kindly gave up some of their time to participate in this
study.
Leslie,
A. Solicitor. Tactics and Strategies for the Defendant. Conference
Compendium on How to Handle Birth Trauma Litigation, 1997.
Intrapartum Care. In: Hauth JC, Merenstein GB, eds. Guidelines for Perinatal Care. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, 1997;112-113.
Chauhan
SP, Roach H, Naef RW, Magann EF, Morrison JC, Martin JNJ. Cesarean section
for suspected fetal distress. Does the decision-incision time make a
difference? J Reprod.Med
1997;42:347-352.