A large-scale study reveals 24-h operational rhythms in hospital treatment
A large-scale study reveals 24-h operational rhythms in hospital treatment
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DOI：
10.1073/pnas.1909557116
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发表时间：
2019-10-15
影响因子：
11.1
通讯作者：
Smith, David F.
中科院分区：
文献类型：
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作者：
Ruben, Marc D.;Francey, Lauren J.;Smith, David F.
医院一天24小时运作，假设重要的临床决策不间断地发生。然而，医院运营的许多方面都发生在一天中的特定时间，包括医疗团队的查房和轮班。目前尚不清楚这是否会影响患者护理，因为没有研究涉及这一点。我们分析了2010年至2017年美国一家大型儿童医院1,546名住院患者中12种不同药物的每日分布情况，剂量约为50万剂。我们跟踪了订单时间（当医护人员发出药物的电子请求时）和给药时间（当患者收到药物时）。订单时间依赖于一天中的时间，以明显的早晨高峰和夜间平静为标志。在所有103，847份治疗订单中，近三分之一是在上午8点到下午12点之间下的。每个订单的首次给药也是有节奏的，但偏移2小时。这些24小时节律的订单和第一次剂量是非常一致的药物，诊断和医院单位。医院医疗的这种节奏与医疗团队的查房时间相吻合，而不一定是立即的医疗需求。最后，我们表明，肼苯哒嗪的临床反应，急性抗高血压药，是剂量的时间依赖性和最大的晚上，当最少的剂量管理。流行的教条是，医院治疗是根据需要进行的，而不管一天中的什么时候。我们的研究结果挑战了这一概念，并揭示了最佳临床护理的潜在操作障碍。
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 similar to 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.