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Rapid Responses: Rapid Responses published:
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This letter is simply wrong
- R M Lindley (4 January 2008)
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Lateral Thinking Required?
- Claire Dow (4 January 2008)
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Naked below the elbow - get a fob watch
- April S Brown (4 January 2008)
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Doctors shouted Lister down too!
- Andrew J Ashworth (4 January 2008)
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Simple solution
- Philip Morris (4 January 2008)
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Ashworth's egg-timer in the pocket.
- Hilary Butler (5 January 2008)
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How far do we go?
- Vincent Chan (5 January 2008)
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Advice please
- Steven Ford (5 January 2008)
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Pendant watches
- Sarah H Pennington (5 January 2008)
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At the third stroke, it will be time to set a standard.
- Phillip J. Colquitt (6 January 2008)
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Time out please...
- MIchael Moses (7 January 2008)
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An Outsiders View
- Mark G Simpson (7 January 2008)
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Dumbing down of the Medical Profession
- Henry Atkinson (9 January 2008)
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Wrist watches
- DR ANAND DESHPANDE (9 January 2008)
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More than a time piece
- Peter A west (9 January 2008)
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Clinical value of wristwatch
- Kadiyali Srivatsa (10 January 2008)
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Disorientated time, place, person
- Margaret A Loudon (10 January 2008)
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A bit of perspective please!
- Imran Hamid (10 January 2008)
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Re: A bit of perspective please!
- Phillip J Colquitt (11 January 2008)
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Re: Wrist watches
- SIMON F HILL (15 January 2008)
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Bare below the…What do patients want their doctor to be wearing?
- James Henderson, Henry Budd, James Wimhurst (16 March 2008)
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R M Lindley, Specialist Registrar Queens Medical Centre, Nottingham, NG7 2UH
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Henderson and McCracken state that "This study highlights the necessity for doctors to have sight of a second hand when assessing patients, especially in emergency situations where a clock might not be present" I have no objection to the concept that medical staff need to be able to measure seconds accuractely hand in order to measure pulse, respiratory rate etc. This could of course be done with the use of a timer set to 15 or 30 seconds, but such an easy solution has not been thought of by Henderson and McCracken. Instead, they go on to assert that "Fob watches have been found to be impractical for some clinical procedures". They incorrectly cite an article to back this premise. (Nevill M, Ikeda M. Watch out for infection control. Br J Infect Contr 2006;7:12). This article states that ONE (not some) clinical task was difficult with a fob watch - "In Japan intravenous pumps are rarely used, so staff use their watch for calculating intravenous drip rates. They are required to hold their watch up to the drip chamber in order to do this accurately. This was possible with a wrist-watch, but not a fob watch" Nursing staff have used fob watches in this country for years without an adverse event. I have never seen a doctor estimate drip flow rates using a watch held up to a drip stand. The statement made in this letter, and therefore its entire premise, are flawed. Wall mounted, fob and pocket watches are a practical and easy solution to the requirement to be bare below the elbow. Competing interests: None declared |
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Claire Dow, Consultant Acute Medicine / Geriatrics Royal London Hospital, Whitechapel. London E1 1BB
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One of the solutions to the problem of not wearing a wristwatch was suggested by one of our final year medical students. He continued to wear a wristwatch outside of clinical areas, but would take it off his wrist and attach it to one of the belt loops on his trousers when seeing patients, thus was still able to arrive to clinical sessions on time and be bare below the elbows when required to be so. I realise that this may be easier for my male colleagues than female, but having worn a fob watch since water damage to my wrist watch from repeated hand washing, I have not found any of the problems outlined by the authors. As personal practice I wear this at my waist which I find a more convenient site. Competing interests: None declared |
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April S Brown, RGN - former matron at an acute NHS Trust Healthcare Commission
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As a registered nurse for 18 years, I am appalled that doctors are creating a fuss about having to remove their precious watches. In one instance healthcare is being criticised for poor hygeine standards, but does this not include medical staff or are they immune?? Doctors just need to think a little - what have nurses used for almost 150 yrs? A fob watch. Fob watches are available £5.99 from Argos and other good retailers and maybe the BMJ and BMA could put their power to good use and when medics apply for their annual journal subscripton they could receive a free fob watch. Being a good doctor or nurse is not all about whistles, bells and monitors, its about the basics, good hygeine. After all, we are at work for the beneifit of the patients, not to display our jewellery. Get a fob watch! I work for the Healthcare Commission - the views outlined below are mine and do not necessarily reflect the views of the Healthcare Commission. April Brown RGN BSc PhD Student Competing interests: None declared |
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Andrew J Ashworth, GP Davidson's Mains Medical Centre, 5 Quality Street, Edinburgh, EH4 5BP
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Have we returned to the cosy establishment that Lister challenged by introducing handwashing in the first place? In their desperation to maintain the status quo (a watch on their wrists) these authors have fallen into the age old trap of quoting associated, but not directly relevant evidence. The evidence cited is actually about 1.estimating rates without the use of an independent timing source, 2.time management without knowing the current time and 3.some clinical procedures being dependent on wristwatch technology. An egg timer carried in the pocket and placed on the bedside table would easily overcome the first problem (as would countless other more modern innovations). Communal systems of measuring time have long been used to avoid "consistent lateness": from clocks chiming in town squares to the half-hourly bell ringing in ships that ensured sailors were not late on watch (In Edinburgh we even have a cannon go off at 1 o’clock each day!). Finally, any clinical procedure should have its risks and benefits reviewed regularly - the current situation simply reflects a view that side effects may have become higher than previously understood. Perhaps these authors should use the technology of their forebears and carry pocket watches.... like Lister's critics. Competing interests: I own watches and clocks that do not tick. Though I wear a wristwatch, I have a clock in my surgery to avoiding the patient "clocking" that I may be clockwatching. |
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Philip Morris, Senior Partner of an international agency WD19 5RB
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There was an interesting article in the Telegraph today by Laura Clout, in which Dr James Henderson and Dr Sarah McCracken are quoted as stating not wearing a wristwatch will “put patients at risk”. They have totally missed the reason for the ban and are incorrect. A little lateral thinking would provide a simple solution. I base the above comment on thirty-seven years of owning and running a high class jewellery business and personal experience of how filthy the average watch was and how many times it was necessary for my staff and I to wash our hands after examining them. It had nothing to do with value either as very often the filthiest were of the Omega, Rolex, Audemars Piguet and Pateks quality. Many were totally disgusting and the worst attracted a 20% filth surcharge for servicing. Rings are equally disgusting. If for no other reason the skin exudes moisture and oil which transfers to watches and rings, then dust sticks to these articles and forms a paste which is a perfect warm breeding ground. Leather straps are absorbent and are an even greater hazard, just test the inside of a shirt cuff as the end of the day. Doctors can solve the need for a personal timekeeper in the same way that nurses do, purchase a nurses fob watch and pin it on their scrubs, if a nurse can afford one I am sure it will not cause great financial strain to a consultant or even a lowly houseman and it could save a life on two fronts – less cross infection and an accurate check of pulse rates etc. The average watch of a clean and fastidious person is little short of sceptic. I know this first hand, my own three watches are water resistant which means they can be scrubbed with soap and water every three months or so and each one will make the water in the basin dark and scummy I used to put them through an ultrasonic cleaner as I did my glasses which always created a comment on their cleanliness, there is another potential source of infection. This is one instance where the NHS is correct, there is hope for it yet if they can produce the odd piece of wisdom such as this ban on a regular basis and remove some of their stupidities. Yours sincerely, Philip Morris. P.S. I know a senior Consultant who a few years ago had his spotless tie tested, was appalled at the results and now only wears a tie for meetings. Competing interests: None declared |
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Hilary Butler, freelance journalism home, New Zealand, 2121
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Andrew Ashworth makes the suggestion that an egg-timer removed from the pocket, might solve the problem. What are we talking about dirty watches for, when these suit-trouser pockets that specialists put their hands in all the time, and some carry material handkerchiefs in(urgh), are pretty revolting too. Just what might the egg-timer pass on, throughout the ward? All you suit-trouser wearing medics, line up, and pull your pockets inside out. Under the handkerchiefs and disused toothpicks, let's check out the bug quotient in the fluff at the bottom of the pockets. Hilary Butler. Competing interests: None declared |
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Vincent Chan, Registrar in Emegency and Intensive Care Medicine Perth 6000
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Am sure Hospital pagers and mobile phones are next on the list of what not to wear! Competing interests: None declared |
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Steven Ford, GP Haydon & Allen valleys Medical Practice
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Editor I have not possessed a watch for a couple of decades. For simple telling of the time I rely upon wall clocks, computer screens, mobile phone or car clock etc. If there is an absolute requirement for accurate assessment of pulse or respiratory rate then I would ask anyone close at hand if they might oblige me with a view of their timepiece. For me the watch question is not the key issue. Furthermore, I ceased wearing a tie several years ago. However, most people, let alone patients, would not want me to be bare below the elbow because of extensive psoriasis that is refractory to treatment - currently 22.5mg methotrexate weekly. What advice is to be given to clinicians in my position? Steven Ford Competing interests: I am a watch-free psoriatic. |
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Sarah H Pennington, Paediatric SpR Chesterfield Royal Hospital
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Fob watches (the type which attach via a brooch) are highly unlikely to appeal to those of us who do not wear uniforms in the working environment, given the intrinsic damage to many types of material. Many of them also feature hard corners, which since I regularly pick up babies would seem awkward - many of our neonatal nurses have to regularly remove their fob watches for this reason. Wrist watches attached to belts are very much a male solution, and pocket watches both need handling and are useless in the absence of pockets. Might I recommend to my female colleagues pendant watches, specifically those that come without covers. They do not increase the already high odds of female doctor/nurse confusion. They do not need handling. They are no more or less in the way, and generally easier to clean, than the ID badges on lanyards that we are generally compelled to wear. As an additional benefit in paediatrics, they can also make excellent distractors. There may not be sufficient evidence that absence of a wrist watch improves infection control, but this approach removes the argument. Competing interests: None declared |
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Phillip J. Colquitt, Technician/RN Large Public Australian Hospital
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The focus on all hospital timepieces, regardless of physical shape and design, should be accuracy. A standard for time accuracy should be set and applied. Seven years ago we wondered about the effect of the millennium bug, not the pathogen. At around that time, our hospital replaced perfectly good electric wall clocks which were centrally set at 6 am, with a hodge podge of dubious quality battery powered quartz crystal clocks. The used batteries from these are now polluting the next generation's environment. I found a twenty minute variation between the clock in the patient lift, the one by which we start work in the ward, the wards computer clocks, and the one on my wrist. I then set my wrist watch, my personal laptop, and one of the ward's computer clocks in synchrony, using the telephone pips. After two months of twice weekly checking, all three synchronized pieces are within five seconds of each other. The hospital wall clocks and associates, remain in disgrace. Of course staff may like the ward wall clock to be three minutes slow, because they themselves, are often late. When a cardiac arrest occurs, it becomes important to chronologically list the events: who attended, when they arrived in response to the call, what actions were taken. A wall clock which has a mind of it’s own is useless, whereas my trusty digital wristwatch remains within five seconds of the pips. For taking a pulse, or respiration rate, I often use the plethora of ticking digital displays which abound at the bedside, obviating the need for sweeping second hand clocks. There are simply clocks all around me, which are not so much telling time, but simply counting seconds. Within about 15 seconds of taking a patient’s pulse, I can tell if there is obvious variation from the usual. Even without a time piece. I then look further as applies. With regard to nurse's pinned on watches, they are usually inferior quality, and might best be relegated to the nursing museum with the ceramic bedpans and pictures of horse drawn ambulances. Competing interests: None declared |
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MIchael Moses, SpR Plastic Surgery Norfolk and Norwich University Hospital, NR4 7UY
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I am really quite incredulous at the increasingly bizarre responses Mr Henderson’s and Dr McCracken’s clearly tongue-in-cheek letter has provoked. They have, however, made two points that are incontestable: One, that doctors have difficulty estimating pulse and respiratory rate without an external second counter; and two, that there is no evidence linking the wearing of wristwatches with the transmission of a pathogenic organism to a patient from a healthcare worker. The need for medical staff involved in patient care to be able to count seconds is well recognized. Many published dress codes for hospital staff and students (both medical and nursing) including that for Stanford University Medical Center include the wearing of a watch with second hand as a compulsory requirement. I realise that some studies have demonstrated that lab workers wearing watches and other jewelry had a higher incidence of remaining microbes on their hands after washing. The solution is to wear a washable/waterproof watch, or take it off when washing hands. A fob or pocket watch is not an alternative. Since it must be cradled in one’s hand in order to be of any use, it will rapidly become a repository for infectious organisms with which the wearer has been in contact. My own wristwatch is doused in alcohol gel and washed with soap up to ten times a day. However my mobile phone, computer, PDA, pager etc have never been washed, and are undoubtedly colonized. Correspondents who suggest ‘a timer set to 15 or 30 seconds’and ‘egg timers’ have just missed the point. A wall-mounted clock is the simplest way to ensure that a doctor has line of sight to a second hand in a critical situation. Indeed there is a digital clock/timer above each bed in the cardiac resuscitation area in the new emergency department at Columbia Presbyterian Medical Center in New York, the design of which I influenced whilst on my elective over ten years ago. NHS trusts have removed wall-mounted clocks in order to save money. There are bed occupancy rates of greater than 100% and eight beds in ward bays designed for six. This is more significant in terms of transmission of pathogens than wearing a watch. Competing interests: I have made tea for Dr McCracken at the end of a hard day. |
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Mark G Simpson, Accountant Not Relevant
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I am not a medical professional. But my Aunt died in 1992 when she developed septicemia after a heart operation. So I do a personal interest in infection control in hospitals. I am heartened by most of the comments on this from healthcare professionals. The way this has been reported in the media, such as BBC News on-line, makes it look like doctors are resistant to change, and many are "too posh to wash". This is clearly not the case. I'd also like to point out to the Doctors that apparently can't do without a watch that Argos do a Nurses Fob Watch for £24.79, catalogue reference 254/7619. Which apparently includes a "pulseometer". If this is of "inferior quality", I'm sure that Rolex and Tag Heuer would be able to satisfy demand if asked. I do realise these infection control measures do seem onerous. But you are talking about people's lives here. And at least you are not working for a food manufacturer like Heinz. By Law, their standards of hygiene in food production seem to be far higher than that is required in a healthcare setting. Competing interests: None declared |
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Henry Atkinson, SpR Orthopaedics RNOH Stanmore
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Surely this new ban of wristwatches is all just part of the same dumbing-down process being applied to the Medical Profession. MMC, no white coats, no ties, no suits = further loss of professional status. Are we really just civil servants? Why do we not look to countries with low hospital infection rates for guidance, such as Canada, for example. They have not imposed any Draconian rules. Instead, simple measures such as larger spaces between beds, fewer patients per ward, and more individual cubicles/side rooms seems to keep infection under control. Show us the evidence that "bare from the elbows" makes a difference before imposing rules. Competing interests: None declared |
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DR ANAND DESHPANDE, doctor BL5 2QE
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You have not heard it yet. I have been wearing a wrist watch that is very unusual.(Many of the patients have enquired about it with great admiration and one girl said:"I have never seen a watch like that in all my life." This girl was only twelve year old. So, some day she will see another watch like mine.) My wrist watch is made in Japan. The single rectangular dial has two separate watches fixed in it. One can set these two watches to two different time zones. I have the upper watch set to BST and the lower watch set to Indian Standard Time. So, the two watches run independently of each other but are exactly five and a half hour separate with minute by minute accuracy. Only problem is that both these watches have no second hands in them! I wondered why the Japanese missed it. As I am not working in an emergency ward, very rarely I need to count the pulse rate or respiratory rate with great accuracy. My checking of the pulse of the patient is for the rhythm. I am used to guess the pulse rate and heart rate with reasonable accuracy I need. If really I need to count, I tend to make use of the patient's wrist watch. If they are wearing the wrist watch on their right hand (some are non-conformists, like me!) I use their right wrist. If I see their watch on their left wrist, I use their left wrist. But I never tell them why I use their right or the left wrist. It is not difficult to feel the radial pulse for the rate even if the strap of their wrist watch is on the radial artery. That is what is called improvisation in clinical skills. Everything is not in the textbooks! By the way, the two watches in one comes in two different sizes. You guessed it right-- one for him and one for her! But the prices are the same. Competing interests: None declared |
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Peter A west, Senior Research Associate York Health Economics Consortium but currently seconded to a government agency
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Your various correspondents have clearly missed a key point about wristwatch ownership and display. Particularly for men, who tend to conform to social rules that do not encourage a great deal of neck or wrist jewellery, a wristwatch is a very effective way of showing your status and income. Why else would the watchmakers pay large sums to sportsmen to put them on when photographed? Surely the Rolex is just another part of the status game alongside the personalised number plate and the Concorde cufflinks! And before you ask, I have a black strapped watch with alarm (£50) and a brown strapped one without (£25), which is probably one too many. Competing interests: None declared |
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Kadiyali Srivatsa, Gp GU22 0DR
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The author mentions there is no evidence that wristwatches are carriers of infection. Dress code was strictly implemented and rigorously followed in every developing nation during 1980s. Initially in UK, I used to be surprised how relaxed the doctors were when performing minor surgical procedures in hospitals. Aseptic technique is critical when performing minor practical procedures; it is infrequently taught and audited (1). Notably, nurses, medical students and house staff, who are most likely perform these minor surgical procedures. Skin cleaning is often incomplete, and many attendants still palpate with non-sterile gloves the venipuncture site before needle insertion to cannulae or perform phlebotomy. Hand hygiene also includes maintaining hand health, avoiding nail polish, artificial nails or jewellery and keeping nails trimmed and clean. The fingernail area has been associated with a major portion of hand flora as it can harbour micro-organisms (3). If plastic surgeon is questioning the importance of inanimate objects colonization of bacteria, I wonder who should be more worried about CA- MRSA infection threatening our profession. REFERENCE 1. Parada JP, Schwartz DN, Schiff GD, Weiss KB. Effects of type and level of training on variation in physician knowledge in the use and acquisition of blood cultures: a cross sectional survey. BMC Infect Dis. 2005 Sep 15;5:71 2. Romero-Ortuno R; Contaminant blood cultures, 29 October 2005, BMJ 3. Care and Maintenance to Reduce Vascular Access Complications, April 2005, Guidelines Published by Registered Nurses Association, Ontario, Canada 4. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care. Hygiene Task Force. MMWR 2002; 51(No. RR-16) Competing interests: None declared |
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Margaret A Loudon, Staff grade in Cardiology Torbay Hospital, Devon TQ2 7AA
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Many junior doctors have had a disorientating move across the country in search of elusive jobs, lost their sense of person and worth in a myriad of application forms and now can't tell the time. Perhaps trusts could invest in a ready supply of clocks, second hands appreciated, to show their willingness to help out these staff. Competing interests: None declared |
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Imran Hamid, Specialist Trainee, Trauma and Orthopaedic Surgery. Wessex Institute
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This is just yet another example of how the autonomy of medical profession is being slowly and consistently eroded. EWTD 'compliant' rotas, MMC, and a frustration and distrust of all other centralised initiatives is bubbling over into an otherwise irrelevant debate about watches.
The crux of the argument comes down to a complete failing of common sense. As Mr Atkinson points out in his comment, draconian measures that are based on a flimsy evidence base are a waste of time. I would suggest that those who are concerned with doctors watches and long sleeve shirts as an infection risk, should have a look at computer keyboards, door handles, curtains, drug charts, medical notes and virtually every other inanimate object in a hospital and ban them too. The simple concept of washing hands before and after patient contact, and rolling up sleeves and removing watches when necessary, is far more appropriate rather than a blanket ban. And yes, i freely admit, I would rather wear my Omega Seamaster to work rather than a £5.99 piece of junk from Argos. Competing interests: None declared |
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Phillip J Colquitt, Technicain/RN Independent Comment, but works in Public Hospital
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Must agree. Focusing on one thing as "cause" is ridiculous. May I also suggest that it is the patients themselves who would complain if we did everything by the book and refused to let them interrupt us from decontaminating our hands between patients, like many of them do, every day. I didn't cite the relevant literature in my previous response, but I should inform the reader that it has been shown that inaccuracy of hospital timepieces has serious implications[1,2]. My "conflict of interest" is my Ripcurl Oceantide wristwatch, which I rarely take off. Waterproof to 200 metres, fully washable in antimicrobial solutions, with no pins and with removable woven synthetic band. Retails for about 250 AUD or 115 GBP, suggesting affordable. My accuracy test on one sample - plus or minus 2 seconds per month. Displays the moon phase and the tide in several different locations. Lunar phase does affect human behaviour[3]. It also correlates with seizure on retrospective analysis[4]. 1: Kaye W, Mancini ME, Truitt TL.When minutes count--the fallacy of accurate time documentation during in-hospital resuscitation.Resuscitation. 2005 Jun;65(3):285-90. 2: Ferguson EA, Bayer CR, Fronzeo S, Tuckerman C, Hutchins L, Roberts K, Verger J, Nadkarni V, Lin R. Time out! Is timepiece variability a factor in critical care? Am J Crit Care. 2005 Mar;14(2):113-20. 3.Zimecki M.The lunar cycle: effects on human and animal behavior and physiology.Postepy Hig Med Dosw (Online).2006;60:1-7. Review. 4.Polychronopoulos P, Argyriou AA, Sirrou V, Huliara V, Aplada M, Gourzis P,Economou A, Terzis E, Chroni E. Lunar phases and seizure occurrence: just an ancient legend? Neurology. 2006 May 9;66(9):1442-3. Competing interests: As stated in text |
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SIMON F HILL, consultant microbiologist poole hospital NHS Foundation Trust BH15 2JB
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I would hope that those involved in Infection Control and Management in Hospitals apply a large amount of common sense to how the Department of Health's guidelines on Uniforms and Workwear (1) is applied so that all the superfluous or easily countered arguments raised by clinicians can be minimised from the outset.A case in point is about wristwatches--the wording of any local policy should state they should be removed if not essential to the examination.Wrists cannot be so easily cleaned with alcohol whilst wearing a wristwatch and the high risk activities from an infection control point of view,such as examining a patients wound,urinary or intravenous catheter,rarely require a wristwatch to be visible.It is therefore just common sense to remove them whilst engaged in such activities especially if a patient is in isolation because of carriage of specific pathogens such as MRSA or Clostridium difficile. So please no more debates about rings versus wristwatches versus the sound of ticking clocks disturbing patients(2). 1.Jacob G.Department of Health.Guidelines:Uniforms and workwear:an evidence base for developing local policy.2007 2.Henderson J,McCracken S.Clinical value of a wristwatch.BMJ 2007;336:10. Competing interests: None declared |
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James Henderson, SpR Plastic Surgery Norfolk & Norwich University Hospital NHS Trust NR4 7UY, Henry Budd, James Wimhurst
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A “bare below the elbows” dress code for doctors was introduced by the Department of Health in January 2008, ostensibly in response to concerns about hospital-acquired infections (HAIs). A survey of patient opinion about doctors clothing was conducted in our hospital. An anonymous questionnaire was given to 200 consecutive patients attending outpatient clinics. Respondents selected preferred clothing choices for their doctors. Options included white coats, suits and ties as well as alternatives compliant with the new dress code. Patients were asked to consider professionalism, trustworthiness, and approachability as well as cleanliness. One hundred and sixty two questionnaires were returned (81% response rate). Most patients were unaware of the introduction of a dress code, with 73% believing that doctors had adopted a “smart casual” policy. More patients wanted doctors to wear white coats (49%), rather than a jacket (22%), suit (11%) or uniform (10%). No patients wanted to see doctors in surgical scrubs. Despite this, 48% preferred short sleeves, whilst 35% favoured long-sleeved shirts. Ties were desirable to 44% of patients, with 29% preferring doctors not to wear them. Bow ties were only felt appropriate by 2%. 71% approved of wristwatches, although 14% felt them inappropriate for doctors. Most patients (75%) approved of doctors wearing wedding rings. Facial hair was unacceptable to 37% of patients, and facial jewellery to 66%. Although patients are concerned about the risk from HAIs, the majority of respondents preferred their doctor to be dressed in a more traditional way than the dress code currently allows, with white coats being the most- favoured option. Most patients felt that wristwatches were acceptable, although facial jewellery was undesirable, as was facial hair to a significant minority. The new dress code policy does not comply with patients’ expectations and perhaps more public consultation is required to achieve a clothing policy that reduces the risk of HAIs without eroding patients’ confidence in their doctors. Competing interests: None |
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