Sunday, September 28, 2014

Utter Rubbish: A Call for a Moratorium on the 4 AM Blood Draw

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself.  Therefore all progress depends on the unreasonable man.  - George Bernard Shaw

Depending on the week and the driver, I am often awakened around 4 AM when one of several delivery trucks backs into the driveway of the restaurant beside my house, 15 feet from my bedroom.  Rankled, I have been known to open the window and have words with the driver, who, in my opinion, should park on the street, thus creating a distance between our house and his beeping, rattling, diesel-idling, polluting truck with its slamming ramps and gates and whatnot.  Because he mindlessly prioritizes a minute or so of his time over my and my wife's uninterrupted sleep.  Sometimes, we just get back to sleep before the next truck comes and awakens us again.

In relating this story to my father, he told me that the residents of a Northeast Ohio municipality recently passed a city ordinance banning the picking up of garbage before a certain hour, because of complaints of the noise and disturbance that the rubbish trucks cause at earlier hours.  Immediately drawing the analogy of the 4 AM phlebotomy visit in the hospital, my father wonders why, in the era of customer service, we subject the sick of society to this indignity and injustice while they're in the hospital.  And the answer is that I don't know.  A quick Google search is of little help.

There are two likely and possibly related reasons for the 4 AM blood draw.  First, in days of yore, physicians rounded very early in the hospital and then went to their office or to the operating room.  They wanted the lab results by the time they rounded so they could complete the rounding task and move on to others and not worry what Mrs. Jones' creatinine was all morning.  So, in essence, we have historically been awakening patients at 4 AM for physicians' convenience.

Second, and probably related to the first, is that lab staffing is optimized by the 4AM blood draw, or so I'm told.  The nighttime phlebotomist goes and does all the blood draws before the end of his shift and gets the blood to the automated machines for the day shift to take over at, say, 6AM.  I'm not well appraised yet of the logistics of this, so if you have further references, please comment below.  I will wager that lab staffing and procedures are dictated by physician demands and that this schedule is a spawn of physicians preferences, but that's just a guess.

Aside from the obvious intuition that patients should not be inconvenienced (with a needle poking them no less) at 4 AM so that a surgeon can be convenienced at 6AM, there are other reasons to question the timing of this practice.  First, most hospitals are now staffed by hospitalists who are there the entire day, rather than private physicians trying to rush off to their single shingle after rounds.  Second, the nocebo effects of hospitalizations are coming into clearer focus.  It needs no further explaining that awakening a patient for a painful blood draw at 4 AM is not good for them.  Third, the early morning lab draw leads to other disruptive cascades that affect the patient.  The potassium comes back at 2.9 - now we have to hang a painful potassium infusion, and, in some protocols draw the potassium yet again later.  These "K and Mag" protocols no doubt proliferated because physicians HATE being called at 5AM with the potassium result.  They want its correction to be put on autopilot.  The result is daily labs, daily repetition of potassium levels (to assure that it has been adequately replaced, of course!) and a callous disregard by the physician that all this is going on, because it's on autopilot and s/he needs not pay any mind to it - even though the physician set the autopilot.  Now sleep is disrupted, somebody orders a sleeping pill (Arrest-You-Will [Restoril] or Am-Bein'-Delirious [Ambien])...and so begins the vicious cycle of nocebo effects.

There is no justifiable reason that this practice of routine laboratory testing and phlebotomy in the early hours of the morning should continue.  It flies in the face of every aspect of patient-centered care.  This week I'm going to meet with hospital and lab administrators to see if I can make headway in changing it - starting perhaps by changing the CPOE (computerized physician order entry) system to default AM lab draws to 8 AM with an option to specify another time.  I expect that I will meet significant resistance because the status quo has powerful inertial forces defending it.  I will report back on my progress.  I encourage other physicians to tackle this issue at their own institutions and report back on their progress as well.  Patients and their families can create momentum too - by refusing blood draws before 8 AM and complaining to hospital administrators.


  1. I met with my admin this week. They were highly receptive to this idea. We shall see. We may be starting something!

  2. Glad to hear it! I've spent all my time working in the ED but it's been weighing more and more on me when I go to follow-up on patients we've admitted and see the sheer number of 4 and 5 am blood draws that are performed for non-essential testing. Please share your experiences down the road with how this goes!

  3. This discussion raises the issue of why there is so much blood testing in general. The concept of "daily labs" really has no merit whatsoever. As I've gotten more experienced in my practice (over years if not decades), I order fewer and fewer blood tests because I have learned that they rarely result in a significant change in management for the patient. Blood testing is part of the health care merry go round. It keeps people busy -- from phlebotomists, to lab staff, to nursing staff, to junior medical staff in thier dogged adherence to the Normalization Heuristic. And the staff member ultimately responsible, ie the attending, is generally the least interested, or the least concerned about minor (or even moderate) deviations from the "normal range" -- because experience has taught him that it usually doesn't matter. BTW, in my hospital phlebotomy rounds are done between 0700 - 0800. Also, as an aside, I think surgeons round so early to avoid acutally having to talk to their patients or their family members. Afterall, if someone is asleep then they obviously can't be in too much discomfort.

  4. I am so glad that I had read this article prior to my son's recent hospitalization. When his night nurse informed us that he was scheduled for a 4 a.m. blood draw prior to discharging him that morning, we declined. Instead of being agitated about the prospect of waking up to yet another blood draw (cue 15-20 beat-per-minute increase on his heart monitor--a result of his tachycardia following a nasty GI bug and severe dehydration)--he was able to go to sleep . . . which is what he most needed at that point, anyway, in this mom's opinion. His labs were re-checked at his pediatrician's office after his discharge and were fine. (Only bilirubin had been very slightly off to begin with.) Thank you for helping me be a a more informed parent and advocate for my son!



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