LAUSR

To the Editor: We read with great interest the article recently published by the American Journal of Medical Quality by Hall et al on routine morning blood draws collected at a later time. Although hospitalists surveyed perceived the change as beneficial overall, we question whether there was any noted change to throughput in the unit, given the delay of more than 2.5 hours in phlebotomy and result times. In a recent survey of 61 institutions regarding early discharge, 77% of institutional representatives strongly agreed or agreed that early discharge was a priority. Approximately half of the respondents also rated early discharge as more important than improving interpreter use for non–English-speaking patients, and equally as important as reducing 30-day readmissions and improving patient satisfaction. Another study showed that 38% of providers—including nurses, house staff, and attendings—perceived that delays in discharge time were related to waiting for procedures and tests, including laboratory results. In many institutions, mean discharge times, or “discharge before noon” rates, are followed closely. Increasing these rates is critical to reduce overcrowding in the emergency department and improve overall patient satisfaction. Further studies evaluating later phlebotomy times could benefit from including discharge times as balancing measures. We wholeheartedly agree with the importance of patient-centric models for routine blood draws, as only a few have been described in the literature. This effort could reduce nonurgent disruptions to sleep and be received favorably by not only patients but also phlebotomists and nurses who are tasked with waking patients for painful needle sticks. At our institution we are trying to reduce unnecessary routine labs. We recently encountered a patient who questioned our staff on the necessity of the blood draw at 4:30 am. The phlebotomist gave him a routine reply—“The doctor ordered it”—an honest, albeit unsatisfactory, response for the patient. It made sense from the phlebotomist’s perspective; even if they paged the intern to ask if it was truly necessary, they would get the overnight intern who would rather not remove or delay the order that the day team placed. Communication with the patient could be improved if this blood draw occurred while the ordering clinician was present in the hospital, perhaps at a later time in the morning. It also may allow an opportunity for patients and other staff to question and intervene on the recurring automated daily lab orders that are frequently placed in the era of electronic medical records.