“Why do you have to wake me up at 4 AM to take my blood?”

It’s a complaint most hospitalists hear time and again.

But Stanley Chakabva, MD, did more than listen to the complaints. He took action.

With his colleagues at Parkview Physicians Group in Fort Wayne, Indiana, Chakabva launched a study to look at the effects of delaying early morning blood draws by 2 hours.

Doing so improved the sleep quality and duration, said Chakabva, adjunct clinical associate professor of medicine at the Indiana University School of Medicine, Indianapolis.

The findings, published on February 4 in the Journal of Hospital Medicine, were no surprise, he told Medscape Medical News. “We had hypothesized that those would be the findings we would get,” he said.

The delayed draws were still done early — 6 AM — but the difference resulted in better sleep than the 4 AM blood draws. The researchers assigned 128 patients from adult medical units to the early group or the delayed group, with 64 in each group. Primary outcomes of sleep quality and quantity were evaluated using the Richards-Campbell Sleep Questionnaire and self-reported sleep duration.

The 6 AM group had higher sleep quality, with a mean sleep quality score of 63.7 compared with a mean of 53.2 in the 4 AM group. The 6 AM group reported an average of 7 hours of sleep while the 4 AM group averaged 5.9 hours (P = .02).

“These improvements highlight the importance of considering sleep-friendly operational changes in hospital workflows,” the researchers concluded. They also call for more research.

Ill Effects of Sleep Disruption

Debates about the best timing for hospital blood draws stretch back for years, but accumulating research is highlighting how dangerous sleep disruptions are in hospitalized patients. Frequent clinical interventions, such as testing, can result in many adverse outcomes, such as cognitive deficits, depression, impaired immune function, and elevated morning pressure, Chakabva wrote in his study, citing other research.

Sleep deprivation is one of many perturbations that can adversely affect health up to a month after patients are discharged, according to Harlan M. Krumholz, MD, director of the Yale New Haven Hospital Center for Outcomes and Research in New Haven, Connecticut. He termed the condition “Posthospital Syndrome” more than a decade ago. Patients have increased risks for many conditions during this 30-day window, many of which have little in common with the initial diagnosis, he said.

Logistics of Blood Draw Scheduling

Logistics — many patients, many tests ordered — plays a role, of course, in scheduling before-dawn blood draws.

“To get all the blood draws that are needed, they do need to be pushed back more and more,” said William A. Stevens, MD, a hospitalist at Providence Medical Group Southwest, Seattle, describing a typical scenario echoed by other hospitalists.

The other component is whether the phlebotomist staff is sufficient and their working hours would accommodate pushing later draws, he said.

“Changing lab times for clinicians is notoriously difficult due to the desire to have labs in the morning for rounds and decision making,” agreed Vineet Arora, MD, MAAP, dean for medical education at the Pritzker School of Medicine, University of Chicago, Chicago.

There are practical reasons for the blood draws that patients may see as too frequent.

“They help dictate treatment plans,” Stevens said. It helps a physician decide if they need a consultant. It informs the decision about discharge.

While the research suggests pushing blood draws later helps sleep, he noted that even with the most solid research, a change in practice and widespread adoption often takes 8-10 years.

Status Quo

With all the discussion about the adverse effects of early morning blood draw, Yale researchers looked at the timing of more than 5 million blood draws from more than 79,000 patients hospitalized at two Yale New Haven Hospitals from 2016 to 2019.

“We found that even though the 4-5 AM [draws were] decreasing, overall the 4-7 were increasing,” said Cesar Caraballo-Cordovez, MD, a resident at Yale New Haven Hospital, Connecticut, and the study's lead author. There was some progress in the super-early draws, he said.

Of the total samples, 38.9% were drawn between 4 and 6:59 AM, they found:

• 8.9% between 4 and 4:50 AM
• 16.5% from 5 to 5:50 AM
• 13.5% from 6 to 6:59 AM

They also found 12.2% were drawn between midnight and 3:59 AM. Outside the early morning window, 20.7% were drawn between 7 AM and 11:59 AM.

The researchers conclude that the proportion of early morning draws “was persistently high over 3 years, representing nearly 4 in 19 daily blood draws at the end of the study period.”

Over the years, other researchers have looked at the practicality of evening blood draws and even midnight blood draws.

Neither the Society of Hospital Medicine nor the American Hospital Association give advice or have a position about blood draw timing, according to spokespersons, reasoning that it is a facility-guided decision.

Changing the Status Quo

Some hospitals have made changes, however, and others are researching how to change the timing.

At the University of Chicago, physicians considered how to optimize timing for less acute patients, Arora said.

“For example, if you are only getting labs every 48 hours because someone was stabilizing, you did not need them at 4 AM and you could get them at 6 AM, she said. At her facilities, that helps. “But the default is still very hard to change.”

Individualizing the blood draws can sometimes work, agreed Margaret Fang, MD, MPH, professor of medicine and chief of the Division of Hospital Medicine at University of California San Francisco. For instance, she might order a 9 AM blood draw “for those who I know aren’t leaving that day.”

But too much individualizing makes it difficult on the phlebotomists, she said.

At Yale New Haven Hospital, a program to change the blood draw timing is in the discussion phase.

“We are working on a quality improvement project,” said Caraballo-Cordovez. They are gathering physicians, nurses, phlebotomists, and others to get everyone’s opinion.

“We are trying to get a sense of the problem and what they would think about pushing the blood draws later,” he said. He estimates the program may be launched in the next year or so.

Patient Empowerment Can Help

Expressing concerns about sleep disruption to your physician or other providers can help, hospitalists suggest to patients. “When I get a concern about it, I stop and think, ‘Do I need a repeat [blood draw] or can I push them back?’” Stevens said.

When patients advocate for themselves, “It makes us stop and reevaluate — Do I need them [blood draws] first thing?” Stevens said.

Arora studied a patient empowerment program, I-Sleep, and found it reduced medical care disruption, including blood draws.

Sometime low-tech solutions work, Fang said. At her hospital, if patients express the need for more sleep and a later blood draw, and physicians are OK with it, a hand-written sign is placed on their door — “Don’t wake me up before xxx.” It’s effective, she said.

Chakabva, Caraballo-Cordovez, Stevens, Fang, and Arora reported having no disclosures.

The Parkview study had no funding.