COMMENTARY

Stop the Daily Blood Draws in Hospitalized Patients

Jaya Mallidi, MD, MHS

Disclosures

May 10, 2021

Mrs Johnson* lies passively in her hospital bed, entangled in wires and tubes. Two large tubes protrude from the right chest wall of her slender frame. They are connected in a Y shape to a white container, attached to the wall suction. There is minimal serosanguinous fluid in the chest tubes. It has been that way for 4 days. Her brown skin cannot camouflage the bruises over both wrists from the multiple blood draws and intravenous lines. Her veins are collapsed like the branches of a fallen tree. Her large eyes that were previously filled with joie de vivre are dull and expressionless. Though her chest wall hurts with every breath, she remains stoic.

Jaya Mallidi, MD, MHS

Mrs Johnson has been in and out of the hospital several times for a recurrent pneumothorax. At 37 years of age, she has no other significant medical problems. She now knows the routine: every 4 hours, vital checks; every morning, blood draw. She does not want to be labeled "difficult or rude." She does not want to offend her caregivers by refusing. But she wonders whether these frequent vital checks and daily blood draws add anything to her care.

At 5:45 AM, the ritual starts. She extends her arm passively for a blood pressure check. Then the blood draw. She raises her elbow without even looking at the phlebotomist. She knows the results will be normal as they have been for 4 days running. Nothing about her situation changed. The phlebotomist ties an orange tourniquet over the upper arm and draws her needle. No words between them. A silent understanding that this needs to be done. But does it?

No Benefit and Potential Risks

Among patients admitted to a hospital, on both medical and surgical services, daily blood draw consisting of a complete blood count, electrolytes, and renal function, at a minimum, is common practice. While laboratory tests are an important part of diagnostic evaluation and subsequent care of patients, approximately 28%, either initial or repeat, are unnecessary. Daily phlebotomy is not only painful for the patients but is also potentially harmful, and is independently associated with hospital-acquired anemia leading to prolonged hospital stay. Thoughtless overuse of laboratory tests can result in more testing and potential patient harm. In studies involving interventions to reduce such overuse, reducing the frequency of laboratory testing did not significantly impact clinical outcomes. In addition, unnecessary lab tests add to rising health costs.

The American Board of Internal Medicine advised against routine daily blood work as part of its Choosing Wisely campaign. However, the practice remains prevalent for reasons that go beyond patient care and necessity. Daily labs are ordered with a simple click of a mouse. The default "admission order set" includes a Complete Blood Count (CBC) daily or Basic Metabolic Panel (BMP) daily. Given our busy schedules, little thought goes into this click. Rounding physicians often do not discontinue the order and repeat testing continues despite clinical stability.

In my experience, physicians — including residents and fellows — do a morning "chart review" of vitals and laboratory results before seeing patients in person. Seeing those daily lab values can reassure us that we're not missing anything. The culture of zero tolerance for uncertainty and defensive medicine drives the overordering of tests. Because phlebotomists do the blood draw, physicians neither witness the patient's discomfort nor do they understand the wasteful cost of that single mouse click. Ordering daily blood draws is the epitome of the clicks without care mantra of modern medicine.

Examples of Success

Various interventions to reduce daily blood draws have been studied. These include education and changes to the computerized physician order entry system such as notifications, altering the default order sets, and using inbuilt functions that do not allow a laboratory test to be ordered daily. To bring about a sustained change in culture requires a multilevel collaborative quality initiative project such as the one that the University of San Francisco tested between 2009 and 2012. Education, audit and feedback scorecards, and financial incentives resulted in a cumulative 8% reduction in lab tests ordered, saving $2 million. In 2017, Eaton and colleagues published an implementation blueprint to eliminate repetitive lab testing of hospitalized patients that involves collaboration of senior leadership and frontline clinicians.

Initiatives like these, however, have not been widely enacted. It is high time for physicians to collaborate with administration and laboratory service personnel and champion quality initiative projects for reducing the overuse of laboratory tests at both the institutional and national levels. This is essential, not only for reducing overall healthcare costs, but more importantly for avoiding unwarranted patient discomfort.

That day, Mrs Johnson lost her stoic expression. As the needle pierced her vein, she shrieked out in pain. She looked at the phlebotomist and wailed, "Enough!" In a monotonous voice, the phlebotomist responded, "Sorry. Seems like your vein is thrombosed. But we need to do the daily blood draw that your physician ordered." "Why? This is torture!" Mrs Johnson sobbed, with tears of pain, holding her elbow.

Later that day, her laboratory results were normal for the fifth straight day.

*Some details have been changed to protect the patient's identity.

Jaya Mallidi is an interventional cardiologist in Santa Rosa, California. An ardent patient advocate, she writes opinion pieces using patient stories as context to highlight problems in the practice of modern-day medicine. In addition, she enjoys digital sketching and playing tennis.

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