# Abstract

 

## Background There is an increasing amount of blood sample rejection at primary health care facilities (PHCFs), impacting negatively the staff, facility, patient and laboratory costs. 

## Aim The primary objective was to determine the rejection rate and reasons for blood sample rejection at four PHCFs before and after a phlebotomy training programme. The secondary objective was to determine whether phlebotomy training improved knowledge among primary health care providers (HCPs) and to develop a tool for blood sample acceptability. 

## Study setting Two community health centres (CHCs) and two community day centres (CDCs) in Cape Town. 

## Methods A quasi-experimental study design (before and after a phlebotomy training programme). 

## Results The sample rejection rate was 0.79% (*n* = 60) at CHC A, 1.13% (*n* = 45) at CHC B, 1.64% (*n* = 38) at CDC C and 1.36% (*n* = 8) at CDC D pre-training. The rejection rate remained approximately the same post-training (*p* > 0.05). The same phlebotomy questionnaire was administered pre- and post-training to HCPs. The average score increased from 63% (95% CI 6.97‒17.03) to 96% (95% CI 16.91‒20.09) at CHC A (*p =* 0.039), 58% (95% CI 9.09‒14.91) to 93% (95% CI 17.64‒18.76) at CHC B (*p* = 0.006), 60% (95% CI 8.84‒13.13) to 97% (95% CI 16.14‒19.29) at CDC C (*p =* 0.001) and 63% (95% CI 9.81‒13.33) to 97% (95% CI 18.08‒19.07) at CDC D (*p* = 0.001). 

## Conclusion There is no statistically significant improvement in the rejection rate of blood samples (*p* > 0.05) post-training despite knowledge improving in all HCPs (*p* < 0.05). # Results Approximately 6--10 HCPs participated at these different sites. There were 23 study participants ([Table 1](#)) who attended the phlebotomy training session across all the facilities. The age, sex and level of phlebotomy experience of each HCP who attended the training were recorded. There were no exclusion criteria for the above variables of age, sex and level of experience. Most of the HCPs were aged between 30 and 50 years. There was only 1 male participant and 22 females. There were 3 student nurses, 17 nurses and only 3 doctors. The phlebotomy experience across participants varied, with nine participants having less than 5 years' experience, five having 5--10 years' experience and nine having more than 30 years' experience. ::::table-wrap

::: caption
Demographic data of study participants across all four clinics.
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Category Participants *n* (%)

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Rank\
Student nurse 3 (13)
Nurse 17 (74)
Doctor 3 (13)
Sex\
Male 1 (5)
Female 22 (95)
Age\
< 30 years 7 (30)
30--50 years 9 (39)
\> 50 years 5 (22)
Unknown 2 (9)
Phlebotomy experience\
< 5 years 9 (39)
5--10 years 5 (22)
\> 10 years 9 (39):::: [Box 1](#) describes the tool that was developed to facilitate the phlebotomy training, listing all the criteria for laboratory blood sample acceptability. ::: caption ABBAS tool^©^. ::: 1. **REQUEST FORM** 1. Name of facility 2. Diagnosis 3. Name of requesting doctor 4. Date and time of sample collection 5. HCP who took sample 6. Test specified on request form 7. Legible request 8. Patient's details (first name & surname, folder no, age/DOB, sex) 9. Correct sample type for test requested 10. Doctor's signature 11. INR sample -- working contact number of patient or doctor 2. **SAMPLE** 1. Tube not expired (check expiry date on tube)/cracked 2. Correct colour tube 3. Labelled sample (sticker placed lengthwise, NOT covering cap): First name and surname, folder number OR sticker if available 4. Do not pre-label before drawing blood 5. Patient's name on form and sample matching 6. Correct volume of blood (check volume required on tube) 7. Gentle mixing of sample 8--10 times 8. Sample tubes kept at room temperature, NO direct sunlight 9. Samples kept at room temperature, IN FRIDGE if after hours 3. **SAMPLE TRANSPORT** 1. Sealed packet 2. Blood sample/s and request form of index patient in one packet ABBAS tool^©^ compiled by: Drs Abbas, Namane and Mukinda. The total number of blood samples included in the study during May 2014 (pre-training): 7557 from CHC A, 3973 from CHC B, 2321 from CDC C and 589 from CDC D. The total number of blood samples included in the study during July 2014 (post-training): 10 218 from CHC A, 4114 from CHC B, 2279 from CDC C and 630 from CDC D. During the month of May 2014 ([Table 2](#)): 60 of 7557 blood samples (0.79%) were rejected pre-training at CHC A and 79 of 10 218 blood samples (0.77%) post-training (*p* = 0.971). CHC A is the largest of the four facilities. Only 8 of 589 blood samples (1.36%) were rejected pre-training at CDC D and 7 of 630 blood samples (1.11%) post-training (*p* = 0.696). CDC D is the smallest of the four facilities. ::::table-wrap
::: caption
Rejection rate of blood samples before and after the phlebotomy
training.
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Before the phlebotomy training May 2014 After the phlebotomy training July 2014

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CHC/CDC Blood registrations Blood rejections *n* (%) Blood registrations Blood rejections *n* (%) *p*
A 7557 60 (0.79) 10 218 79 (0.77) 0.876
B 3973 45 (1.13) 4114 48 (1.17) 0.886
C 2321 38 (1.64) 2279 37 (1.62) 0.971
D 589 8 (1.36) 630 7 (1.11) 0.696:::: The reasons for blood sample rejection were grouped into four main categories including technique related, knowledge related, request form related and unaccountable preanalytical errors. Technique-related errors include samples that were clotted or haemolysed. Knowledge related errors include errors because of incorrect blood volume or the incorrect blood sample tube used. Request form errors include any error in the completion of the request form such as no patient details indicated, illegible requests, name on sample tube and request form unmatched, no test requested or an unlabelled sample. Unaccountable preanalytical errors include all errors that are not accounted for by the above but that occur in the preanalytical phase of laboratory testing of blood samples. These include samples with missing reasons for rejection, samples older than 3 days, samples that leaked in transit as well as samples that were not received by the laboratory. [Table 3](#) shows a detailed summary of rejection rates and related reasons by facility. At CHC A, many samples were rejected because of clotting, 20 (0.26%) were rejected pre-training and 16 (0.16%) post-training ([Table 3](#)). Request form errors improved post-training from 11 (0.15%) pre-training to 8 (0.08%) post-training. There was an increase in the rejection rate of samples because of unaccountable preanalytical errors, 17 (0.22%) pre-training to 27 (0.26%) post-training ([Figure 1](#)). <figure> <p><img src="" /></p> <figcaption>The rejection rate at CHC A.</figcaption> </figure> ::::table-wrap
::: caption
Rejection rate and reasons for blood sample rejection before and after
the phlebotomy training by facility.
:::

Reasons for rejection Before the phlebotomy training May 2014 *n* (%) After the phlebotomy training July 2014 *n* (%)

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CHC A CHC B CDC C CDC D CHC A CHC B CDC C CDC D\
Technique related 20 (0.26) 8 (0.20) 15 (0.65) 4 (0.68) 20 (0.20) 15 (0.36) 18 (0.79) 2 (0.32)

- Clotted 20 (0.26) 7 (0.18) 15 (0.65) 4 (0.68) 16 (0.16) 14 (0.34) 16 (0.70) 2 (0.32)
- Haemolysed 0 1 (0.01) 0 0 4 (0.04) 1 (0.02) 2 (0.09) 0
  Knowledge related 12 (0.16) 16 (0.40) 5 (0.02) 0 24 (0.23) 9 (0.22) 3 (0.13) 3 (0.48)
- Incorrect blood volume 5 (0.07) 4 (0.10) 2 (0.09) 0 8 (0.08) 3 (0.07) 1 (0.04) 1 (0.16)
- Incorrect sample tube 7 (0.09) 12 (0.30) 3 (0.13) 0 16 (0.16) 6 (0.15) 2 (0.09) 2 (0.32)
  Request form errors 11 (0.15) 11 (0.28) 3 (0.13) 0 8 (0.08) 12 (0.29) 6 (0.26) 0
- Name on form and sample unmatched 3 (0.04) 1 (0.03) 1 (0.04) **-** 4 (0.04) 4 (0.10) 0 **-**
- No patient details 1 (0.01) 0 0 **-** 0 0 0 **-**
- No test requested 1 (0.01) 3 (0.08) 1 (0.04) **-** 2 (0.02) 0 1 (0.04) **-**
- Illegible request 1 (0.01) 0 0 **-** 0 0 0 **-**
- Unlabelled sample 5 (0.07) 3 (0.08) 0 **-** 2 (0.02) 5 (0.12) 3 (0.13) **-**
- No reason stated 0 4 (0.10) 1 (0.04) **-** 0 3 (0.07) 2 (0.09) **-**
  Unaccountable preanalytical errors 17 (0.22) 10 (0.25) 15 (0.65) 4(0.68) 27 (0.26) 12 (0.29) 10 (0.44) 2 (0.32)
- No reason stated 11 (0.15) 0 0 0 18 (0.18) 0 0 1 (0.16)
- Sample leaked 2 (0.03) 0 0 0 1 (0.01) 1 (0.02) 0 0
- No sample received 1(0.01) 2(0.05) 4(0.17) 4(0.68) 5 (0.05) 6 (0.15) 3 (0.13) 1 (0.16)
- Age of sample > 3 days 3 (0.03) 8 (0.20) 11 (0.04) 0 3 (0.03) 5 (0.12) 7 (0.31) 0:::: At CHC B, knowledge related errors reduced from 16 (0.40%) rejected samples pre-training to 9 (0.22%). Twelve samples (0.16%) were rejected because of 'incorrect sample tube'. This was reduced by half (0.15%) post-training. However, all other reasons for blood sample rejection increased post-training ([Figure 2](#)). <figure> <p><img src="" /></p> <figcaption>The rejection rate at CHC B.</figcaption> </figure> At CDC C, many samples were rejected because of clotting pre- and post-training with the rejection rate increasing post-training. Knowledge related errors reduced from five (0.02%) rejected samples pre-training to three (0.13%). Request form errors doubled from three (0.13%) rejected samples pre-training to six (0.26%). Unaccountable preanalytical errors, because of 'age of sample > 3 days' also contributed to many of the blood sample rejections, 11 (0.04%) rejected samples pre-training and 7 (0.31%) post-training ([Figure 3](#)). <figure> <p><img src="" /></p> <figcaption>The rejection rate at CDC C.</figcaption> </figure> CDC D is a smaller 8-hour facility compared to CDC C and only had 4 out of 589 (0.68%) samples rejected because of clotting pre-training, which was reduced to 2 (0.32%). Unaccountable preanalytical errors reduced by half post-training. There were no request form errors pre- or post-training ([Figure 4](#)). <figure> <p><img src="" /></p> <figcaption>The rejection rate at CDC D.</figcaption> </figure> The overall rejection rate, irrespective of facility, showed an increase in the rejection rate post-training, which was not statistically significant ([Table 4](#)). ::::table-wrap
  ::: caption
  Overall rejection rates and related reasons for all facilities combined.
  :::

Before the phlebotomy training May 2014 After the phlebotomy training July 2014 *P*-value and 95% CI

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Related reason for rejection Rejection rate *n* (%) Rejection rate *n* (%) *p* 95% CI
Technique related 47 (0.33) 55 (0.32) 0.38 -8 to 4
Knowledge related 33 (0.23) 39 (0.23) 0.74 -14.39 to 11.39
Request form errors 25 (0.17) 26 (0.15) 0.85 -4.23 to 3.73
Unaccountable preanalytical errors 46 (0.32) 51 (0.30) 0.73 -11.59 to 9.09:::: The pre- and post-training questionnaire scores showed an improvement in phlebotomy knowledge post-training as the average percentage score increased across all clinics. The average score increased from 63% (95% CI 6.97‒17.03) to 96% (95% CI 16.91‒20.09) at CHC A (*p* = 0.039), 58% (95% CI 9.09‒14.91) to 93% (95% CI 17.64‒18.76) at CHC B (*p* = 0.006), 60% (95% CI 8.84‒13.13) to 97% (95% CI 16.14‒19.29) at CDC C (*p* = 0.001) and 63% (95% CI 9.81‒13.33) to 97% (95% CI 18.08 -- 19.07) at CDC D (*p =* 0.001). Participants were asked to grade their level of confidence in phlebotomy on a Likert scale from 1 to 6, with 1 being 'not confident at all' and 6 being 'very confident'. All participants' level of confidence either remained the same or increased post-phlebotomy training ([Figure 5](#)). <figure> <p><img src="" /></p> <figcaption>Level of confidence in phlebotomy across all clinics pre- and post-training using a Likert Scale.</figcaption> </figure> # Ethical consideration This study has been approved by the Health Research Ethics Committee (HREC) of the University of Cape Town (HREC REF: 549/2013) as well as by the Provincial Government of the Western Cape (REF: 2013RP190). The study was conducted according to the Declaration of Helsinki.


Extracted trial result:
Outcome: Phlebotomy questionnaire score: CHC B (continuous)
Intervention: Phlebotomy training programme
Comparator: Control
Intervention group size: 23
Intervention mean: 93
Intervention standard deviation: 1.37
Comparator group size: 23
Comparator mean: 58
Comparator standard deviation: 7.12
Notes: Back calculated SD using CI