Ending the 4 AM Blood Draw
Ending the 4 AM blood draw
The majority of routine lab draws on pediatric patients occur between 4:00 and 6:00 AM. This practice disrupts sleep and, if additional labs are desired after rounds, forces the child to undergo an additional lab draw. The goals of our study were to shift the timing of lab draws until later in the morning and to reduce the number of lab draws and common lab testing performed on patients.
A multidisciplinary team consisting of hospitalists, nurses, educators and residents was created to design an intervention to shift the timing of blood draws. This was primarily done through academic detailing, as well as creation of a blood draw team utilizing existing staff at the patient unit level. It was determined on rounds whether or not patients needed to have lab-work done, and this was communicated to the charge nurse on each unit. Over a 20-week period in late 2014 data were collected. This included a 4-week baseline period, 4 weeks in phase 1, 4 weeks in phase 2, a 4-week washout, and a 4-week post washout. PDSA cycles were done as the project progressed. After phase 1 the data were presented to all stakeholders, and changes were made to allow the process to continue.
During the baseline, two intervention, and post-washout phases a total of 405 lab draws were performed on 1458 patient encounters. The timing of lab draws in each phase is shown in Figure 1. Additionally, there was a decrease in the number of lab draws and lab tests in phase 1 and phase 2, however, by the post washout phase, there was a return to baseline (Figure 2). Seven-day readmission rate did not change significantly between 2013 and 2014 (2.7 v 3.6%, p value 0.9). 103 charts were reviewed by 2 hospitalists to ensure there were no delays in care as a result; there was only one case in which discharge was delayed (1%).
Our data show that it is possible to shift the timing of blood draws from early morning to late morning. Additionally, we were able to reduce the number of routine labs drawn on PHM patients without causing harm to patients or delays in care. However, after a 4-week washout phase, the timing of blood draws shifted back to earlier in the morning, stressing the importance of formal guidelines for routine blood draws on pediatric patients. Because of the success of the pilot study, the decision has been made to extend the intervention to more pediatric subspecialties.