Journal Club Feature

TIME OUT! IS TIMEPIECE VARIABILITY A FACTOR IN CRITICAL CARE?
By Elizabeth A. Ferguson, RN, BSN, Carey Roth Bayer, RN, MAEd, Susan Fronzeo, RN, BSN, Cheryl Tuckerman, RRT, NPS, Larissa Hutchins, RN, BSN, CCRN, Kathryn Roberts, MSN, CRNP, CCRN, Judy Verger, MSN, CRNP, CCRN, Vinay Nadkarni, MD, and Richard Lin, MD. From The Childrens Hospital of Philadelphia (CRB, SF, CT, LH, KR, JV, VN, RL), Philadelphia, Pa, and Childrens Hospital Los Angeles (EF), Los Angeles, Calif.
BACKGROUND Accurate documentation of time is essential in critical care for treatments, interventions, research, and medicolegal and quality improvement activities. OBJECTIVES To assess use of timepieces in critical care and to determine practical methods for improving their accuracy. METHODS Providers were surveyed to identify timepieces used during routine and emergency care. Times displayed on standard unit and personal timepieces were compared with coordinated universal time. Four models of atomic clocks were assessed for drift for 6 weeks and for resynchronization for 1 week. Bedside monitors were manually synchronized to coordinated universal time and were assessed for drift. RESULTS Survey response was 78% (149/190). Nurses (n = 93), physicians (n = 32), and respiratory therapists (n = 24) use wall clocks (50%) and personal timepieces (46%) most frequently during emergencies. The difference from coordinated universal time was a median of -4 minutes (range, -5 minutes to +2 min) for wall clocks, -2.5 minutes (-90 minutes to -1 minute) for monitors, and 0 minutes (-22 minutes to +12 minutes) for personal timepieces. Kruskal-Wallis testing indicated signicant variations for all classes of timepieces (P<.001) and for personal timepieces grouped by discipline (P=.02). Atomic clocks were accurate to 30 seconds of coordinated universal time for 6 weeks when manually set but could not be synchronized by radiofrequency signal. Drift of bedside monitors was 1 minute. CONCLUSIONS Timepieces used in critical care are highly variable and inaccurate. Manually synchronizing timepieces to coordinated universal time improved accuracy for several weeks, but the feasibility of synchronizing all timepieces is undetermined. (American Journal of Critical Care. 2005;14:113-120)
ccurate documentation of time is essential in the dynamic critical care setting. Outcomes depend on precise timing of interventions, especially in emergency situations. In a pediatric critical care setting, multiple timepieces are used by practitioners for documentation: personal timepieces, wall clocks, beepers, monitors, and so on. Use of different timepieces affects the accuracy of time documen-
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
tation on patients records and blurs the reconstruction of events, treatments, and responses. These inaccuracies may have a major effect on interventions, research, and medicolegal and quality improvement activities. Treatments based on small time intervals are the focus of research on resuscitation. As a result, timepiece accuracy becomes an important variable for validity of resuscitation research. Much of the literature on time documentation comes from research in emergency medical services. The timing of emergency treatments can have a major effect on patients outcomes, yet measurements of the interval before emergency treatment is provided are often based on estimates.1 Becker et al1
AMERICAN JOURNAL OF CRITICAL CARE, March 2005, Volume 14, No. 2
found time discrepancies in 39% of the out-of-hospital cardiac arrests studied and revealed documentation that indicated intervention by emergency medical services personnel occurred before any indication for medical assistance was apparent.1

Appendix A

Modied time record survey DATE: ______ 1. Workplace a. PICU b. 4E CSSH (RRU) 2. Role in the PICU/4E CSSH (RRU) a. Nurse b. Physician c. Respiratory therapist d. Nursing tech 3. Timepiece that you most frequently use during routine treatments/interventions. a. Patient's wall clock b. Patient's monitor clock c. Personal wristwatch d. Beeper (pager) e. Other ______________ 4. Timepiece that you most frequently use during emergency/code blue treatments/interventions. a. Patient's wall clock b. Patient's monitor clock c. Personal wristwatch d. Beeper e. other ______________ 5. Would you reset your personal wristwatch to a standard time for the unit? a. Yes b. No c. Possibly 6. As you turn in this survey, please tell me what time your personal wristwatch reads now. Personal wristwatch time ___________ Atomic time ___________

Abbreviations: 4E CSSH (RRU), pediatric respiratory rehabilitation unit; PICU, pediatric intensive care unit.
Outcomes are dependent on precise

timing of interventions.

The task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council has addressed the inconsistencies in international research. In their recommendations for a uniform method of reporting resuscitation studies, they emphasized the importance of time intervals and the need for use of a standardized time.2 Direct observation has been proposed and tested as a means of assessing treatment intervals accurately for research purposes.3 The variation in time displayed on wall clocks and watches calls into question the validity of the precise timing of events in the resuscitation of neonates.4 Similar discrepancies have also been observed among timepieces used in emergency departments and by emergency medical services personnel.5 The validity of research on resuscitation has been questioned because of the inaccuracies in time documentation for interventions linked to very small time intervals.6,7

Methods

Approval from the hospitals institutional review board was obtained before this prospective, descriptive study was done.
Time discrepancies exist in 39% of
out-of-hospital cardiac arrests studied.
130 nurses, 28 respiratory therapists, and 32 physicians who are in the unique position of documenting time associated with patient care.
Instruments Four atomic clock models were tested in the PICU: Seiko Global Radio Wave Alarm QHR007G, Seiko Corporation, Tokyo, Japan; Sharper Image US Atomic Travel Alarm Clock, Sharper Image Corporation, San Francisco, Calif; Oregon Scientic Radio Controlled Projection Clock with HiGlo Backlight RM 313 PA, Oregon Scientic, Portland, Ore; and Exacta Radio Controlled Clock C-842 WWD, Peking, China. Atomic clocks are designed to receive radiofrequency transmissions of time signals several times a day to autoadjust the time. A receiving tower signal blinks during trans-

Subjects and Setting This study was conducted in 2 critical care areas in a large, urban, pediatric tertiary care setting. One area was a 38-bed pediatric intensive care unit (PICU). The second area was a 12-bed pediatric respiratory rehabilitation unit (RRU). These areas were located in 2 separate buildings of the medical campus. All nurses, respiratory therapists, and physicians employed in the PICU and RRU were included as potential respondents. These healthcare professionals included 114
mission and remains steady once the clock has been updated. The time is kept to within 1 s of coordinated universal time (UTC) at the transmitter site. Despite a delay with added distance from the site or as a result of the signal bouncing between Earth and the ionosphere, most clocks in the United States accurately receive the time within 1/1000 of a second.
Procedure Nurses, respiratory therapists, and physicians employed in the PICU and RRU were surveyed by using a modied time record survey tool (Appendix A). This tool is a modication of the one used by Chamberlin and Nadkarni.8 The survey was used to collect information about the timepieces staff preferred to use during routine and emergency documentation. The tool was also used to gather data on the time displayed on personal timepieces compared with UTC. UTC was compared with the time noted from personal and standard unit timepieces. The difference between UTC and the documented time was calculated and recorded to the nearest minute. Variability in central and bedside timepieces such as wall clocks, central monitoring systems, bedside monitors, and computers was assessed and was compared with UTC. Central monitors (Hewlett Packard M2360A, Hewlett Packard 712/60, Hewlett Packard 78560A, Philips Medical Systems, NA, Bothell, Wash) were manually synchronized to UTC and compared over 5 weeks for drift. The difference between UTC and time displayed on the monitors, T, was calculated to the nearest minute. T was calculated as (timepiece time UTC), so a T greater than 0 indicates that the timepiece time is ahead of UTC. All 4 models of atomic clocks were placed on each of 3 code carts located in the PICU and RRU. In order to detect drift of the atomic clocks, they were manually synchronized to UTC and placed in locked, plastic boxes. The time on each clock was noted once a week at the same time every week for 6 consecutive weeks. Drift was defined relative to UTC posted on the Internet (http://nist.time.gov/timezone.cgi?Eastern /d/-5/java). On the seventh week, each atomic clock was manually reset 1 hour ahead to determine its ability to reset to UTC by radio signal after 24 hours, 72 hours, and 1 week.

Table 1 Timepieces used by critical care practitioners during routine and emergency care*
No. (%) of practitioners using during Timepiece Wall Monitor Watch Beeper Other Routine care 36.5 (24) 2 (1) 105.5 (71) 3.5 (2) 1.5 (1) Emergency care 73 (50) 5 (3) 67.5 (46) 0.5 (0) 1 (1)
*Some respondents listed 2 different timepieces for a given care situation. In that case, their response was counted as 0.5 for each timepiece they listed. Some respondents did not indicate a timepiece preference for emergency care; therefore, the total number of responses for routine and emergency care are not equal.
Responses from the survey were categorized by practitioner group and by practice location. If respondents selected 2 responses to a given item in the tool, each response was counted but was given a weight of 12 for purposes of summary and comparison statistics. The responses from the survey were counted, rounding up for noninteger totals, and compared by using 2 analysis. Because the timepiece data were not normally distributed, nonparametric comparisons were used to analyze the results. Kruskal-Wallis testing was used to compare time differences among multiple groups, and Wilcoxon rank-sum testing was used for paired comparisons.

Results

Staff Timepiece Preferences Of 190 potential respondents, 149 completed the survey. The majority of practitioners who responded were nurses: 74 PICU nurses, 19 RRU nurses, 30 PICU physicians, 2 RRU physicians, 19 PICU respiratory therapists, and 5 RRU respiratory therapists. The number of respondents is smaller in the RRU because that unit has fewer staff members overall. Fourteen respondents selected 2 choices for at least 1 of the items on the survey. Three respondents did not complete all items on the survey. Table 1 is a summary of the responses. Most practitioners used either a wristwatch or a wall clock to determine time for documentation of both routine and emergency care. Seventy-one percent of practitioners preferred to use personal timepieces (eg, wristwatches) for routine care. Fifty percent preferred to use wall clocks during emergencies. This shift in timepiece preference was more prominent among the PICU staff than among the RRU staff, and among practitioners other than nurses rather than among nurses. Figures 1 and 2 graphically demonstrate this shift in preference depending on clinical scenario. According to 2 analysis, timepiece preference differed 115

Data Analysis

Microsoft Excel (Microsoft Corporation, Redmond, Wash) was used for data management. Stata, versions 7.0 and 8.0 (StataCorp LP, College Station, Tex) were used for data analysis. Descriptive statistics were calculated, including means, medians, SDs, and ranges.
% of practitioners 0 Wall clock Monitor Watch Beeper Other % Physicians % Nurses % Respiratory therapists
Figure 1 Timepiece preference for emergency care
Figure 2 Timepiece preference for routine care
significantly between nurses and physicians when grouped across practice location. Nurses favored using wristwatches over wall clocks in both situations, but less so for emergency situations (P =.03). Physicians favored wristwatches over wall clocks for routine situations, but reversed their preference for emergencies (P =.003). Respiratory therapists had a preference shift similar to that of physicians, but this difference was not statistically signicant (P =.10). As summarized in Table 2, a majority of practitioners expressed willingness to synchronize their personal timepieces with an external standard, although the response was not unanimous: 64% responded yes, 16% no, and 20% possibly. The prole of responses to this item varied significantly by practice group (overall P =.002), primarily because of the physicians (physician vs nurse P <.001, physician vs respiratory therapist P =.13).
Kruskal-Wallis testing indicated signicant variations in T for all timepieces (P <.001), even when stratied by care area (P <.001) and by discipline (nurse vs physician vs respiratory therapist, P =.016). By rank-sum testing, paired comparisons between the disciplines indicated that T differed signicantly between physicians and respiratory therapists (P =.004). Differences in T between physicians and nurses (P =.05) and between nurses and respiratory therapists (P =.12) were not signicant.
Drift of Time on Bedside Monitors Drift of monitors (n = 51) was 1 minute or less over a 1-week period. When it was conrmed that the clocks on the PICU bedside monitors were synchronized by the central monitoring system, only the central monitoring systems were monitored in the PICU. Thirteen bedside patient monitors that were not centrally synchronized in the RRU and 7 central and clinical event review monitors in the PICU were followed up for an additional 4 weeks to assess for time drift. After 5 weeks, the RRU had 2 monitors (15%) without drift and 11 monitors (85%) that lagged 1 minute. In the PICU, 1 clinical event review monitor (14%) had no measurable drift, 5 central monitors (71%) were slow by 1 minute, and 1 clinical event review monitor (14%) was slow by 2 minutes compared with UTC. Features of Atomic Clocks in Clinical Care Areas None of the 12 atomic clocks were able to resynchronize to the central transmitter signal when placed on the code carts in the clinical care areas. After being manually set, 11 atomic clocks were accurate to within 30 seconds of UTC at the end of the 6-week observation period. One atomic clock was ahead of UTC by

Most practitioners use a wristwatch or wall clock for both routine and emergency care, but physicians had a greater preference than nurses for using a wall clock during emergencies.
Features of Timepieces in Clinical Care Areas Differences from UTC (T) were recorded for timepieces found in the clinical care areas. Timepieces tracked included staff wristwatches and beepers, wall clocks, bedside and central patient monitors, workstation computers, and clocks on videocassette recorders. As seen in Figures 3 and 4 and Table 3, the distribution of T values in both care areas was wide. 116
Differences from UTC, minutes
Table 2 Willingness of practitioners to synchronize personal timepieces*
Would you reset your personal wristwatch to a standard time for the unit? Practitioner Nurse Respiratory therapist Physician Yes 67 (72.0) 13 (54.2) 15 (48.4) No 8 (8.6) 4 (16.7) 12 (38.7) Possibly 18 (19.4) 7 (29.2) 4 (12.9)
-20 -40 -60 -80 C M MD RN RRT VCR W
*Values are No. (%) of practitioners. Because of rounding, percentages may not all total 100. One physician respondent did not reply to this question.
more than 4 hours after the fth week. It was speculated that this clock might have been accidentally jarred and offset. The atomic clocks had a tendency to drift incrementally over the observation period (Figure 5). The clocks tended to drift ahead of UTC by a few seconds per week, with a mean of 7.1 seconds for the 6 weeks. All of the same 12 clocks were able to resynchronize to the central radio-transmitter signal when placed in a window outside of the hospital setting.
Figure 3 Differences between timepieces in the pediatric intensive care unit and coordinated universal time (UTC)
Abbreviations: C, computers; M, monitors; MD, physicians personal timepieces; RN, nurses personal timepieces; RRT, respiratory therapists personal timepieces; VCR, clock on videocassette recorder; W, wall clock.
Significant differences were found between all timepieces and atomic time.

Discussion

In multiple healthcare settings, studies3,6,8-10 have indicated signicant variability in time found on timepieces used. Lerner et al10 found time deviations from UTC when comparing timepieces from 25 emergency dispatch centers. The difference from UTC they observed ranged from -551 to +117 seconds. In a study6 of emergency medical services in a large metropolitan setting, timepieces varied a mean of 1 minute 45 seconds from UTC, with a range of more than 19 minutes. Fifty-ve percent of timepieces in that study6 varied more than 1 minute from UTC. Time deviations from an atomic clock have been reported to range widely from 14 to 70.7 minutes in a pediatric emergency department and intensive care settings.8 Automatically resetting atomic clocks was not practical for those settings and it was recommended that automated synchrony be further evaluated. One-time synchronization of multiple timepieces to UTC reduces the discrepancies among the times displayed by different timepieces, but the effects of a single synchronization are short-lived.9

Staff Preferences for Timepieces Our study is the rst in which staff members preferences for timepieces in the pediatric critical care setting were examined. Timepiece preference varies significantly among pediatric critical care practitioners. Most prefer personal timepieces (eg, wristwatches) for documentation of routine care interventions. Practitioners tended to change their timepiece preference for documentation of emergency care interventions, favoring wall clocks over other timepieces. The change in preference was more prominent among physicians than among other practitioners. Although the shift to wall clocks also occurred among the nurses, most nurses continue to use personal timepieces during emergencies. Thus, accuracy of both personal timepieces and wall clocks is important. Synchronization to Coordinated Universal Time UTC is not currently the reference standard for time at this institution. In fact, no standard time source or reference has been established, yet our results revealed the significant variability in times displayed on the unit and the personal timepieces used in documentation. Staff members do not routinely set their personal timepieces to UTC. Neither the practicality nor the feasibility of doing so was evaluated during this study. Perhaps the precision of timekeeping devices, rather than their accuracy, is what is important. The specic time standard to which practitioners synchronize their timepieces does not matter so long as the same standards are used for both their timepieces and other hospital devices. Although the majority of caregivers indicated that they would be willing to synchronize their timepieces, the responses were mixed (Table 2). 117
0 Differences from UTC, minutes -20 -40 -60 -80 -100 M MD RN RRT W
Table 3 Differences from coordinated universal time in minutes
Timepiece Computer Monitor Physicians watch Nurses watch Respiratory therapists watch All watches Clock on videocassette recorder Wall clock N* 24 Mean -0.087 -9.02 2.07 0.588 -1.10 0.634 -20.1 Median 0 -2.0 -17 Range -2, +1 -90, -1 -3, +12 -8, +11 -22, +6 -22, 12 -83, -1

-5, +2

Figure 4 Differences between timepieces in the respiratory rehabilitation unit and coordinated universal time (UTC)
Abbreviations: M, monitors; MD, physicians personal timepieces; RN, nurses personal timepieces; RRT, respiratory therapists personal timepieces; W, wall clock.
*The N here for providers is less than the number of respondents because some respondents did not enter a timepiece or atomic clock time.

Once the centralized bedside monitoring system was synchronized to UTC, the drift in time that occurred was 1 minute. This nding suggests that routine resynchronization to UTC might be an option with this type of monitoring system. However, the feasibility of synchronizing all critical care equipment that has a time function (eg, debrillators, ventilators, electrocardiographic equipment) is unknown. Information about patients and interventions can often be retrieved from these machines. If the time recorded on those machines is inconsistent with the monitor time, the value of synchronization of monitors to UTC may be questionable. New innovations such as Bluetooth technology that wirelessly link various pieces of equipment may provide a practical mechanism by which local critical care equipment can be synchronized to a standard time. However, this technology does not work over long distances. Other technologies, such as synchronization with radionavigation satellites and ground stations in the worldwide global positioning system, may be more practical for synchronizing timepieces across an entire enterprise. If all time sources in the unit and related to patients care (eg, wall clock, monitor, computer, debrillator, ventilator, electrocardiographic equipment, computerized order entry systems, laboratory systems) were accurate, then documentation of emergency events with accurate timing would be facilitated.
Usefulness of Atomic Clocks in a Hospital Setting When each of the 4 models of atomic clock was reset to an erroneous time, none were able to resynchronize to the central radio transmitter signal while on code carts in 3 different locations. This result suggests that these models of atomic clock are not a suitable option for use within the 2 critical care units where they were studied. Interfering factors may have included the construction activities that were occurring at the time of the study, the plastic lockboxes in which the clocks were housed, and the effects of other technological equipment used in critical care settings. We conrmed that the atomic clocks evaluated could resynchronize outside of the hospital campus.
Limitations and Future Research
This study involved a single center and used a convenience sample and self-report. Although many models of atomic clock are available, we used only 4 commercially available models from different manufacturers. Finally, the study was limited by the assumption of a direct relationship between timepiece accuracy and documentation accuracy. Further research is needed to determine the effect of timepiece variability on documentation of both routine and emergency interventions. Direct observation of documentation may be one method by which to accomplish this. An investigation of synchronization of the timepieces most frequently used (wall clocks and personal timepieces) could provide changes in practice that are relatively easily implemented. The synchronization of wall clocks and other hospital equipment may be facilitated by new technology that can bring the UTC signal into the hospital structure effectively, such as synchronization with global positioning system satellites.

Timepieces used in critical care are
highly variable and inaccurate, but synchronization of all time-keeping equipment is complex.
A 30 Drift, seconds 0 -10 -Week 6
lifestyles. Investigating practitioners willingness to use an accurate alternative timepiece such as a synchronized bedside monitor or synchronized wall clock rather than a personal timepiece would provide helpful information on how to change practice.

Conclusion

A standard, reliable, and easily accessible source of accurate time for assessment and documentation is necessary in critical care. Our data revealed that multiple timepieces with various degrees of accuracy are used in the pediatric critical care setting. The variability in accuracy can adversely affect patients records, potentially affecting immediate patient care, as well as future medicolegal, continuous quality improvement, and resuscitation research activities. Conventional atomic clocks did not receive the automated radiofrequency signal for synchronization in the hospital setting. Synchronization of bedside and central monitors does provide an accurate timepiece in the areas devoted to patient care. Synchronization could be a cost-effective method for improving timepiece accuracy in this setting. Further evaluation of automated and manual synchronization of all types of timepieces will provide valuable information for improving clinical practice.
ACKNOWLEDGMENTS We thank the multidisciplinary staff of the pediatric intensive care and respiratory rehabilitation units at The Childrens Hospital of Philadelphia for their participation and support. Funding for this study was provided by a research grant from Sigma Theta Tau, Xi Chapter.
REFERENCES 1. Becker L, Ostrander M, Barrett J, Kondos G. Outcome of CPR in a large metropolitan area: where are the survivors? Ann Emerg Med. 1991;20:356-361. 2. Cummins R, Chamberlain D, Abrammson N, et al. Recommended guidelines for reporting of data from out-of-hospital cardiac arrest: the Utstein style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation. 1991;84:960-975. 3. Spaite D, Valenzuela T, Meislin H, Criss E, Hinsberg P. Prospective validation of a new model for evaluating emergency medical services systems by in-eld observation of specic time intervals in prehospital care. Ann Emerg Med. 1993;22:638-644. 4. Wong CM, Stenson BJ, Laing IA. As time goes by. Scott Med J. 2002; 47:138-139. 5. Smith M. Tricks of the trade: its about time. regularly synchronizing timepieces to a single source. JEMS. June 1998;23:30. 6. Cordell W, Olinger M, Kozak P, Nyhuis A. Does anybody really know what time it is? Does anybody really care? Ann Emerg Med. 1994;23:1032-1036. 7. Mosesso V Jr. The most neglected tool in EMS: the clock. Ann Emerg Med. 1993;22:1311-1312. 8. Chamberlin S, Nadkarni V. Time is of the essence: feasibility of radiocontrolled atomic clocks to minimize critical intervention documentation variability [abstract]. Crit Care Med. 2001;29:12(suppl):A161. 9. Ornato JP, Doctor ML, Harbour LF, et al. Synchronization of timepieces to the atomic clock in an urban emergency medical services system. Ann Emerg Med. 1998;31:483-487. 10. Lerner E, Billittier A, Adolf J. Ambulance, re, and police dispatch center times compared with the atomic clock. Ann Emerg Med. 1998;32:118.

B 30 Drift, seconds 0 -10 -C 30 Drift, seconds 0 -10 -Week 6 Week 6
Figure 5 Drift of atomic clocks located on (A) cart A in the pediatric intensive care unit, (B) cart B in the pediatric intensive care unit, and (C) a cart in the respiratory rehabilitation unit.
Seiko atomic clock Sharper Image atomic clock Oregon Scientic atomic clock Exacta atomic clock
Assessment of personal timepiece synchronization and drift from UTC could yield valuable information for narrowing the variability of personal timepieces. However, we found that practitioners often set their personal timepieces ahead to compensate for their
JOURNAL CLUB ARTICLE DISCUSSION POINTS
In a journal club, research articles are reviewed and critiqued. General and specic questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice. When critically appraising this issues AJCC journal club article, Time Out! Is Timepiece Variability a Factor in Critical Care?, consider the questions and discussion points listed below.
Study Synopsis: The purpose of this study was to assess the differences that existed in timepiece use patterns among registered nurses, physicians, and respiratory therapists in critical care and to determine methods to improve timepiece accuracy. Staff in 2 critical care units (n = 149) responded to surveys assessing their use of xed and personal timepieces during routine and emergency care. In addition, times displayed on xed and personal timepieces were compared with coordinated universal time (UTC), and 4 models of atomic clocks were used in the unit and assessed for accuracy during a 6-week period. Bedside monitors were synchronized to UTC and assessed for drift. Study respondents ( 93 nurses, 32 physicians, and 24 respiratory therapists) reported their use of wall clocks (51.0%) and personal clocks (46.3%) to occur most frequently during emergencies. Variability was found among the accuracy of time measured by wall clocks, personal clocks, and monitors. The synchronized bedside monitors were found to have a drift of up to 1 minute. Atomic clocks were accurate to 1 minute for 6 weeks when set manually, but they were unable to synchronize by radio frequency signal. The study results show that the timepieces used in critical care are highly variable and inaccurate. A. Description of the Study What was the purpose of the research? What aspects of critical care do inaccuracies in time measurement affect? Why is the problem signicant to critical care nursing? Methods and Design Describe the procedures that were used to assess time variability. What was the rationale for studying the use of atomic clocks in the intensive care unit (ICU)? Results What was the most preferred method for determining time for documentation of routine and emergency care? How did these methods differ? What were the differences among critical care provider groups? What were the study results with respect to the accuracy of different timepieces used in the ICU? Clinical Signicance What are implications of the study for clinical nursing? What types of timepieces are used in your critical care work area, and what aspects of the study have implications for your practice? important to practice. She shared, The multidisciplinary Critical Care Research Committee decided to conduct research studies to provide bedside nurses an opportunity to engage in and develop research in the critical care setting. The time study was chosen for several reasons, including that it was a topic of interest, had a short timeline, the costs were minimal, and the ndings would be relevant to the unit. Ferguson explained that the research team members actively participated in the study. She shared, The coinvestigator team did the data collection based on a weekly rotating schedule that was developed before the start of data collection. We established guidelines and standards for the various data elements. Information on certain timed tasks was not assessed. Ferguson explained, We decided not to ask which timepiece people used when sending labs because this time was automated in our computer system. With respect to the results, Ferguson shared that several ndings were of interest. She related, While the preferred timepiece shifts from the personal timepiece during routine interventions to the wall clock during emergency interventions for the combined group of practitioners, it is interesting to note that the shift to wall clocks is not as signicant for nurses as for respiratory therapists and physicians. Most nurses continue to use their personal timepieces in both routine and emergency situations. Personal timepieces also proved to be the most accurate. These results may indicate that nurses are aware of the inaccuracies of the other timepieces in patient care areas and therefore continue to use the more accurate personal timepiece. Kathryn Roberts, a co-author, added that the inability of the atomic clocks to resynchronize was a surprising nding. Roberts shared, We were surprised and a little disappointed to find that none of the atomic clocks were able to automatically synchronize themselves with the radio frequency signal. This nding requires further investigation, but it most likely reects that the signal reception from the areas we studied is poor. Implications for Practice: The study results show that variability does exist among timepieces used in the ICU setting. This nding has implications for practice not only for documentation purposes, but also for interventions and procedures performed in the ICU. Ferguson added, This study has signicant implications for patient care, research, and medicolegal and quality improvement activities in the critical care setting. It highlights a topic area that will impact documentation accuracy, risk management, medical error assessment, and patient outcomes. One important question that needs to be answered is whether it is more important to improve timepiece accuracy during crucial minutes in a code, or do we first need to establish the nature of the relationship between accurate timepiece and time documentation/outcomes. As the study highlights, additional research is needed to determine the effect of timepiece variability as well as methods to promote accuracy in timepiece use in the ICU, especially as technologies evolve.

Journal Club feature commentary is provided by Ruth Kleinpell.
Information From the Authors: Elizabeth Ferguson, lead author of this journal club article, provided additional information about the study. She explained that the idea for the study was chosen among several that the ICU team had identied as

KIDS PROJECTION CLOCK OWNER
Congratulations on your purchase one of the first auto-setting always-accurate travel alarm clock ! You are one of the first people in America to own the worlds smallest and most accurate alarm clocks. We want you to be very happy with this product,but please remember this is a radio wave device and not an perfect science. There are certain areas of the Eastern United States (see map) where urban interference or signals from United Kingdoms radio control tower may distort or delay the time setting signal. Even thought these areas may have more difficulty receiving a signal, the Kids Projection Clock contains a very accurate quartz movement and will maintain a precise time even if the radio signal is missed on rare occasions.
Up Arrow keys (Figure A.2)
This key is used for manually setting the time, alarm time or calendar functions. Please refer to the Manual Setting instructions in these instructions for further information. NOTE : Pressing once advance the setting by increments of 1: holding the button down for more the three seconds will accelerate the setting to rapid advance mode. key also is used to reactivate the signal reception process WARNING : The should it become disable. Please see the Trouble Shooting section for further information.

MODEL : RM313PA

RADIO CONTROLLED KIDS PROJECTION CLOCK WITH BACKLIGHT

ZONE (Figure A.3)

The Kids Projection Clock is designed to automatically adjust the time signal to the user selected North American time zone - Pacific, Mountain, Central or Eastern. Pressing the ZONE button once advances the time zone setting (see US map figure A.9). Once the desired time zone block is highlighted on the map, the time will automatically adjust accordingly. WARNING : Do not press and hold the ZONE button for more than three seconds. Use the single press method to set the time zone. Holding the button will turn off the automatic time signal reception. Please see the Trouble Shooting section for further information. P l e a s e a l s o d o n t h e s i t a t e t o c a l l 0 - 3 - ( o r e m a i l helpme@ocientific.com)if you have any question about setting up and/or using your new Kids Projection Clock. In the meantime, all of us at Oregon Scientific hope you enjoy this revolutionary advance in time keeping technology.

ON / OFF (Figure A.4)

This button turns the alarm function on and off. Touching the ON/OFF button one time will either turn the alarm on or off. Please refer to the Alarm Setting instructions for further information. NOTE : When setting the alarm time, the alarm is automatically turned on. If the bell icon [ ] is visible, the alarm is on. Touching the ON/OFF button one time will either turn the Alarm function on or off. If you want to stop the daily alarm while leaving the pre-set time for the following days s wake-up, press the ALARM button. Pressing the ON/ OFF button to stop the wake up alarm will deactivate the alarm function.
KIDS PROJECTION CLOCK CONCEPT
The split-second, precise timeliness of your new Kids Projection Clock is achieved through its pre-tuned internal radio receiver that responds to a special 60 kHz frequency time signal generated by the U.S. Atomic Clock, one of the most accurate clocks in the world. This extraordinary timepiece, located outside Boulder, Colorado, is operated by the U.S. Department of Commerces National Institute of Standards and Technology. Your Kids Projection Clock automatically activates its receiver immediately upon battery insertion and then six times every 24 hours and make any necessary adjustments in its time display. It usually takes about 3-7 minutes for the clock to receive the initial Radio Signal and adjust the time, date and day accordingly. NOTE : You may not receive a signal immediately. Due to possible interference, the best reception often occurs between midnight and 4 a.m. The clock not only sets itself to synchronize its digital time and date with the Atomic clocks signals, but it also automatically adjusts for daylight-savings time! Your clock utilizes a small internal antenna that double as the bedside/desktop stand. (Please see the section on Signal Strength for optimal performance of your Kids Projection Clock) The successful reception of the long wave signal depends on the positioning and location of the clock. Insufficient signal strength or external electrical noises may prevent the unit from receiving a complete signal. The main reasons for poor reception are heavily reinforced concrete and steel structures, and close proximity to electrical units such as TVs and PC monitors.

MODE / SET (Figure A.5)

Press the MODE key once to switch between the display of either the Day of the Week or Seconds on the clock. Kids Projection Clock will continue to display the selected function (Day or Seconds) until the MODE button id pressed again. IMPORTANT : Holding the MODE key for more than three seconds turns on the manual mode for setting the time, date, year and language (English/French/ Spanish). Please refer to this section for specific setting instructions.
(( )) / 24hOFF (Figure A.6)
Press the (( )) key once to show the alarm time. The (( )) /24hOFF icon is displayed in the lower left portion of the screen to alert you that the display is showing the alarm time. To return to the month and date display, press the (( )) key once. To set the alarms please refer to the section on setting The Alarm. NOTE: THE Kids Projection Clock will continue to display the selected function (Alarm Time or Date) until the (( )) button is pressed again.
Do not become concerned if your Kids Projection Clock does not receive a signal within the first few minutes. RF appliances or radios are most effective when placed near a window, and you may need to orient the clock or the antenna to receive a stronger signal. Please be patient with the first receptions of the time signal. Once the Kids Projection Clock has received a time signal, updates are accomplished with greater ease. Please refer to the Trouble Shooting section (at the end of this booklet) for more information.
Projection on (Figure A.7)
Project on turns to enable or disable th continuous projection when adapter is in used. Note: this switch can only be used with the power adapter installed. For mo]. mentary projection, use the [

Figure A

The technology underlying the radio-controlled Kids Projection Clock was previously dedicated only to commercial and industrial uses, including aircraft and ship navigation, broadcasting stations, and research facilities. Oregon Scientific was the first company to develop a consumer-level timepiece with alarm that can truly be called the worlds most accurate clock.

DESCRIPTION OF LCD DISPLAY
Please refer to Figure A for a detailed description of Kids Projection Clock LCD display and refer to the appropriate section(s) of the these instructions for more specific information.

TECHNICAL DATA

A A U M 3 1. 5V
Integrated radio receiver for reception of time signal 10kW transmitter WWVB: at 60kHz Operating temperature: 35-120 F Setting time with interference-free reception: 3-7 minutes Automatic signal-reception activation: six times every 24 hours HiGlo backlighting source: Electroluminescence Battery type: 2 AA (not included) Your last signal reception was excellent and time Synchronization with the US Atomic Clock has Taken place. Your last signal reception was insufficient and it is recommended that you reposition the clock. Indicators On the Display Meaning
Signal Strength Indicator (Figure A.8)

Figure B

FEATURES
Automatic setting of clock by radio signal from the US Atomic Clock Time display with Hour, Minutes, Seconds and Date Day of the week displayed in one of three languages (English, French or Spanish) Dramatic blue HiGlo electroluminescent backlight Alarm with eight-minute snooze Crescendo Alarm increases in volume and intensity Signal Reception Strength indicator U.S. Map icon shows user selected time zone Automatic adjustment for Daylight Savings time Projection of time image Low Battery indicator No indicator
The displayed time has been manually set and is not synchronized by the RF signal. Your radio reception is disabled and no signal reception will be initiated unless it is enabled again.
Time Display (Figure A.9)
The top line of the display shows the hours, minutes and seconds (AM /PM) of the clock. Pressing the MODE button once will switch the Seconds display to the Day of the Week. Kids Projection Clock will continue to display the selected function (Day or Seconds) until the MODE button is pressed again.
DESCRIPTION OF FUNCTION KEYS (Figure A)
Snooze/light (Figure A.1)
A light touch on the top of the snooze button activates the unique electroluminescent backlight for 5 seconds. This lite-touch feature also activates the eightminute snooze function.

US MAP (Figure A.10)

This map represents the four optional time-zone setting. The darkened of filled zone block indicates the user selected time zone. NOTE: When The Kids Projection Clock is receiving a signal from the US Atomic Clock; outline of this map will flash.

Figure C

Note: The display backlight and projection function work simultaneously. When ] is pressed both the backlight and projection func[ tion will activate.
Month/ Date (Figure A.11)
The Second line of the display shows the Mouth and the Date. Pressing the (( )) button once will switch the month and date to show the alarm time The Alarm time is displayed in hours and minutes (AM / PM). NOTE: The (( )) Clock will continue to display the selected function (Month /Date or Alarm Time) Until the (( )) button is pressed again.

Setting the Time

1) Press and hold MODE button for at least three seconds. The Hour segment of the clock time will begin flashing 2) While the Hour segment is flashing press the [ ] button to set the desired hour time (Please note the AM/PM designation) 3) When the desired hour timeis reached press the MODE button again. The Minutes segment of the clock time will begin flashing.

TROUBLE SHOOTING

Problem No Display

Remedy

Check battery compartment. Confirm that batteries are of good quality, and are installed correctly
(( )) Alarm Display indicator (Figure A.12)
This (( )) icon indicates the second line of the display is showing Alarm Time.
4) While the Minutes segment is flashing press the [ desired minutes time.

] button to set the

5) When the desired minutes time is reached, briefly press the MODE button five more times to exit the clock time set mode.
] Alarm ON Indicator (Figure A.13)
] icon indicates that the alarm function is activated.

This Bell [

IMPORTANT : As soon as any manual change in the clock time is mode, there is a loss of the signal strength indicator from the display. NOTE : The next sucessful reception of a radio signal will override a manually set clock time showing the clock running manually.
Did not receive A time signal
If the units are new and just out of the box, allow60- 72 hours cycle for the clock to automatically seek a signal between midnight and 4 a.m. May be caused by too much interference. Relocate the clock or the antenna to position near a window. Be certain the antenna cord is fully extended and look for low battery indicator.
] Low Battery Indicator (Figure A.14)
This [ ] icon indicates that it is time to change batteries. Please refer to the Battery Replacement Section of this manual.

Setting the Year

1) Press and hold MODE button for at least three seconds. The Hour segment of the clock time will begin flashing 2) Briefly press the MODE button and the Minutes segment will begin flashing. 3) Briefly press the MODE button once more. The clock time will disappear and be replaced by a flashing year (Ex. 1995). This is the year set mode. 4) While the Year segment is flashing press the [ sired year. ] button to set the de
USING THE PROJECTION CLOCK
Projection Clock with Battery Power Only To activate the projection feature: Press the Snooze button
May be caused by interference. If the problem persists, move the clock or antenna to a new location. The ExactSet is equipped with a high quality clock mechanism, which insures accuracy between signals.

Loss of Signal

The projection light will illuminate for five seconds and then turn off automatically. Note: There is no option for continual display of the red projection beam with battery only power. If the projection light ON switch is in the on position in battery only mode, the projection beam is disabled.
5) When the desired year is reached briefly press the MODE button four more times to exit the year set mode. IMPORTANT : As soon as any manual change in the clock time is mode, there is a loss of the signal strength indicator from the displayshowing the clock running manually. NOTE : The next sucessful reception of a radio signal will override a manually set clock time showing the clock running manually.

Other Problems

Call Oregon Scientific at 800-853-8883 or through the internet at helpme@oscientific.com
Projection Clock with A/C Adapter Power (Figure C)
To activate the projection feature Press the Snooze button
To activate continuous projection beam (available only with A/C power adapter). Slide the projection light ON switch out to the on position

Setting the Month

Press and hold MODE button until the hour segment of the time display flashes. Press MODE button three more times until you see the month digit flash on the display. Press button until the desired month appears on the display

Backlight

To activate the backlight which will illuminate the LCD panel: Press the Snooze button - the backlight will activate for 5 seconds, and turn off automatically
Press Mode button three more times to exit the set mode and resume normal time keeping.
BATTERY INSTALLATION (Figure B)
To activate the unit simply slide the battery compartment door in the direction of the arrow. Insert the batteries strictly according to the polarities shown therein. Replace the battery compartment door. NOTE : Please do not become alarmed if the unit does mot receive signal directly from the box. The unit will receive most dependable and interference free signal automatically between Midnight and 4 a.m. If you have any questions please give us a call at 800-853-8883 or reach us by email to helpme@osiientific.com.

Setting the Date

Press and hold MODE button until the hour segment of the time display flashes Press MODE button four more times until you see the date flash on the display. Press Dbutton until the desired date appears on the display. Press MODE button two more times to exit the set mode and resume normal time keeping IMPORTANT : As soon as any manual setting changes are made, the display will indicate a loss of signal strength (see SIGNAL STRENGTH INDICATOR) to indicate that the clock is now running on manual settings instead of signals received from the Atomic Clock.

SETTING THE ALARM

1) 2) 3) 4) 5) 6) Press and hold the (( )) / 24hOFF button for at least three seconds. The Hour Segment of the alarm time will begin flashing. While the Hour segment is flashing press the [ ] button to set the desired hour time (please note the AM /PM designation). When the desired hour time is reached, press the (( )) / 24hOFF button again. The Minutes segment of the alarm time will begin flashing. While the Minutes segment is flashing press the [ desired minute time. ] button to set the

Setting Language

Press and hold MODE button until the hour segment of the time display flashes. Press MODE button five more times until you see a single letter (E, F or S) appear on the display next to the time. button until the desired language indicator appears on the display (E Press for English, F for French and S for Spanish). Press MODE button one more time to exit the set mode and resume normal time keeping

When the desired minute time is reached press the (( )) / 24hOFF button again to exit the alarm time set mode.
NOTE : As soon as any change in the alarm time is made the alarm icon (( )) will automatically appear indicating that the alarm is activated. IMPORTANT : The Kids ProjtctionClock will continue to display the ALARM time until the (( )) button is pressed once to return to the Month/Date display.
WARRANTY : Oregon Scientific warrants this product to be free of manufacturing defects for 90 day after purchase. This warranty does not cover product subjected to abuse, misuse or accidental damage. Removal or modification of The Kids Projection Clock antenna cable voids this warranty Defective product returns should be directed to the place of retail Purchase. For customer support call 800-853-8883 or reach us Through the Internet at helpme@oscientific.com.
TURNING THE ALARM ON or OFF
To turn the alarm on or off simply press the ON/ OFF key in any mode. When ] the ON /OFF button is pressed once the alarm is activated (the bell icon [ will appear on the display). The alarm is deactivated when the ON/OFF button is ] disappears from the display. pressed once and the bell icon [ When the crescendo alarm sounds, it may be turned off using one of the following methods. 1) If the SNOOZE /LIGHT key is pressed within two minutes the Snooze is activated and the alarm will sound again in 8 minutes. 2) If the (( )) / 24hOFF key is pressed, the alarm will not sound again until the next day. 3) If the ON/ OFF key is pressed, the alarm is deactivated and will not sound again until it is activated IMFORTANT : If none of the above actions are taken, the alarm will automatically snooze once, sound again in 8 minutes, and will not sound again until the next day.
MANUALLY SETTING: TIME,YEAR, MONTH DATE & LANGUAGE
NOTE : It is highly unlikely you should ever have the desire (or need ) to manually set the clock time, year, month or date of The Kids Projection Clock. However, in the event this becomes necessary please review the following.