Routine morning complete blood counts (CBCs) and metabolic panels have long been part of the daily rhythm of inpatient care. For decades, many hospitalized patients have awakened to a phlebotomist’s knock regardless of whether their clinical condition had changed.

Today, however, hospitalists and health systems are increasingly questioning whether automatic daily laboratory testing provides meaningful value for every patient. Concerns about hospital-acquired anemia, healthcare costs, patient sleep disruption, and unnecessary resource utilization have prompted many organizations to reexamine long-standing ordering practices.

“Every laboratory test should answer a specific clinical question,” said Gail Clifford, MD, an internal medicine hospitalist and medical consultant at Paramount Wellness Retreat in Haddam, Connecticut. “Simply remaining hospitalized is not, by itself, a clinical indication.”

Not Every Hospitalized Patient Needs Daily Labs

Clifford said she encourages clinicians to begin with one simple question before ordering routine laboratory tests.

“Is the result likely to change what we do for this patient today?” she said.

Daily laboratory testing remains appropriate for patients with active bleeding, unstable electrolyte abnormalities, acute kidney injury, substantial diuresis, medications requiring close laboratory monitoring, or rapidly evolving critical illness, Clifford said.

“When a patient is clinically stable, the physical examination is unchanged, and the treatment plan remains the same, there is rarely a good reason to order another CBC and metabolic panel simply because morning has arrived,” she said.

David Goese, MD, assistant professor of hospital medicine at Northwestern University Feinberg School of Medicine and a physician at Northwestern Medicine, Chicago, said the need for daily laboratory monitoring depends largely on both the patient’s diagnosis and the treatment being administered.

Patients hospitalized with heart failure, infections, chronic obstructive pulmonary disease exacerbations, myocardial infarction, postoperative complications, bleeding events, or complications of diabetes often benefit from daily laboratory monitoring because treatment itself can alter kidney function, electrolyte levels, hemoglobin, and white blood cell counts, he said.

“For example, a patient receiving treatment for a heart failure exacerbation benefits from daily lab monitoring to make sure their kidney function is stable and their electrolytes are not abnormal from diuretic treatments for heart failure,” he said. “On the other hand, there are several other conditions which require hospitalization like acute pain, falls, psychiatric conditions, or arthritis, and after an initial evaluation in the hospital and especially if their blood tests initially are normal, there is not much benefit to routinely monitoring labs every day.”

Goese said that when a new medical issue arises in a hospitalized patient, another set of blood tests to diagnose what is going on is beneficial. But for a stable patient with normal lab values and no new issues, the risks may outweigh the benefits of routinely doing daily lab testing.

Their recommendations align with the Society of Hospital Medicine’s Choosing Wisely campaign, which advises clinicians to avoid repetitive CBCs and chemistry testing in clinically stable patients when results are unlikely to change management.

Breaking the Habit of Automatic Morning Labs

Clifford said the laboratory studies most commonly ordered out of habit are also among the easiest to request together. She said that CBCs, basic and comprehensive metabolic panels, magnesium, phosphorus, and coagulation studies are frequently ordered as routine daily tests rather than in response to a specific clinical question.

“Coagulation testing, in particular, is difficult to justify without bleeding concerns, a planned procedure, liver disease, or medication-specific indications,” she said. “Every laboratory test should answer a specific clinical question. Simply remaining hospitalized is not, by itself, a clinical indication.”

Goese agreed that CBCs and metabolic panels remain the most frequently overused laboratory studies but said unnecessary testing extends beyond routine morning blood work. He said that repeat A1c testing despite recent outpatient results, serial inflammatory markers without a clinical indication, and infectious disease tests ordered outside established guideline recommendations are also frequently overutilized.

“Another example is a diabetes test, the hemoglobin A1c level, which estimates someone’s blood sugar over the past 3 months,” Goese said. “If someone has already had an A1c test recently within the past 3 months, there is no reason to repeat it in the hospital, based on guidelines from the American Diabetes Association recommendations on the frequency of A1c testing. Still, A1c tests are frequently ordered in the inpatient setting.”

The Hidden Costs of Routine Testing

Although an individual blood draw may seem insignificant, the cumulative effects of repeated phlebotomy can be substantial. A study published on April 4, 2024, in the American Journal of Clinical Pathology linked unnecessary inpatient laboratory testing with increased healthcare costs, greater laboratory workload, sleep disruption from early morning blood draws, and hospital-acquired anemia, particularly among patients with prolonged hospitalizations.

Clifford said reducing unnecessary testing is not about withholding information but about obtaining information that meaningfully informs clinical decisions.

“It is about ordering laboratory studies deliberately,” she said.

Changing Ordering Habits

Both experts said changing clinician behavior requires more than reminding physicians to order fewer tests.

Clifford said electronic health records (EHRs) should support thoughtful ordering by eliminating automatic recurring laboratory orders, adding stop dates to standing orders, and making previous laboratory trends easier to review.

She said that some hospitals also require clinicians to indicate the reason for a laboratory test before completing the order, creating a brief pause that interrupts habitual ordering.

Goese said clinical decision support tools can reinforce evidence-based practice by alerting clinicians when testing falls outside established guidelines.

He said EHR reminders discouraging inappropriate repeat testing for Clostridioides difficile infection unless clinical criteria are met are one example of how these systems work, as well as disease-specific pathways that help identify patients who can safely undergo less diagnostic testing.

“I find these very helpful to reassure me when I may not need to do as many blood tests or imaging tests,” he said.

A growing body of quality improvement research suggests these strategies can reduce unnecessary laboratory testing without compromising patient safety. A 2023 systematic review published in BMJ Open Quality found that interventions including clinician education, audit-and-feedback programs, EHR decision support, and changes to ordering policies consistently reduced inpatient laboratory utilization across multiple health systems.

In fact, Goese said he is leading a quality improvement initiative at Northwestern aimed at identifying clinically stable patients who may no longer require daily CBCs or metabolic panels while developing clinical decision support tools to encourage more selective ordering.

Overcoming Culture and Fear

Despite growing evidence supporting high-value testing, both experts acknowledged that changing long-standing practice patterns remains challenging. One of the biggest obstacles, Clifford said, is clinician anxiety.

“Providers worry that the one day they choose not to order routine labs may be the day they miss an important change,” she said.

She said that trainees often adopt the habits of their supervising physicians, whether those practices are evidence-based or simply longstanding tradition.

Goese said the EHR itself can unintentionally reinforce routine ordering because recurring daily laboratory orders are easier to place than individual one-time orders. Additionally, he said that with the competing demands that doctors face on their time, it’s easy to equate thoroughness with ordering additional tests.

“It may seem like repeating blood tests every day helps to not miss anything, but for stable patients with no new acute problems, really it is subjecting patients to mild risks like worsening anemia, discomfort from the repeated blood draws, and also increased costs of hospitalization without necessarily improving the diagnostic process,” Goese said.

Both experts said discussing the next day’s laboratory plan during multidisciplinary rounds can help teams determine which tests remain necessary, which can safely be deferred, and what clinical changes would warrant additional testing.

A More Deliberate Approach

Ultimately, experts said reducing unnecessary laboratory testing is less about limiting care than about delivering more thoughtful care.

“It is all about knowing your patients well, taking time to make sure a stable patient has no new symptoms, keeping an eye on things like vital signs every day in the hospital, and continuing to stay up to date with guidelines,” Goese said.

Clifford agreed that repeated clinical assessment, rather than automatic daily blood work, should guide decision-making.

“Patients remain safest through repeated clinical assessment, clearly defined criteria for escalation, and targeted testing when new clinical concerns arise,” she said. “The goal is to avoid blood draws that are unlikely to provide new information or change management.”

No reported disclosures.