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Proc Natl Acad Sci U S A. 2019 Oct 15;116(42):20953-20958. doi: 10.1073/pnas.1909557116. Epub 2019 Oct 1.

A large-scale study reveals 24-h operational rhythms in hospital treatment.

Author information

1
Division of Human Genetics, Center for Chronobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229; Marc.Ruben@cchmc.org David.Smith3@cchmc.org.
2
Division of Human Genetics, Center for Chronobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
3
Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
4
Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
5
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229.
6
Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
7
Divisions of Pediatric Otolaryngology and Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229; Marc.Ruben@cchmc.org David.Smith3@cchmc.org.
8
Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, OH 45267.

Abstract

Hospitals operate 24 h a day, and it is assumed that important clinical decisions occur continuously around the clock. However, many aspects of hospital operation occur at specific times of day, including medical team rounding and shift changes. It is unclear whether this impacts patient care, as no studies have addressed this. We analyzed the daily distribution of ∼500,000 doses of 12 separate drugs in 1,546 inpatients at a major children's hospital in the United States from 2010 to 2017. We tracked both order time (when a care provider places an electronic request for a drug) and dosing time (when the patient receives the drug). Order times were time-of-day-dependent, marked by distinct morning-time surges and overnight lulls. Nearly one-third of all 103,847 orders for treatment were placed between 8:00 AM and 12:00 PM. First doses from each order were also rhythmic but shifted by 2 h. These 24-h rhythms in orders and first doses were remarkably consistent across drugs, diagnosis, and hospital units. This rhythm in hospital medicine coincided with medical team rounding time, not necessarily immediate medical need. Lastly, we show that the clinical response to hydralazine, an acute antihypertensive, is dosing time-dependent and greatest at night, when the fewest doses were administered. The prevailing dogma is that hospital treatment is administered as needed regardless of time of day. Our findings challenge this notion and reveal a potential operational barrier to best clinical care.

KEYWORDS:

biological rhythms; circadian medicine; hospital systems operation; shift work

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