醫師輸血知識對輸血決策和指引遵從相關之探討
-以南部某醫學中心為例

研究目的: 適當性輸血不但可以避免發生不良輸血反應，增進病人的安全而且也可以減少血品的過度使用，而醫師對於輸血的認知在輸血決策上扮演了重要的角色。本研究主要目在於探討醫師的輸血知識是否對於輸血決定以及輸血指引遵從性有相關的影響。研究方法: 本研究為橫斷性的研究，以南台灣某醫學中心357位醫師為研究對象，採普查不記名方式進行問卷調查。問卷內容參考文獻整理及教科書自行設計成38個題目包括輸血基本知識題、情境題的輸血決定以及輸血指引遵從態度調查。問卷的專家內容效度CVI值為0.97。總計發出問卷324份，回收問卷227份，回收率為70.1％。統計分析利用SPSS 20.0統計套裝軟體，以描述性、獨立樣本t檢定、單因子變異數分析以及Pearson相關、卡方檢定進行資料分析。研究結果: 醫師的輸血基本知識題答對9至10題者佔60％，低於8題以下佔40％。在剖腹產術後穩定且有出血病人，其紅血球輸血決定的血紅素閾值之平均值是8.7 g/dL，血紅素目標值的平均值是10.0 g/dL，而主治醫師的血紅素目標值決定（10.1 g/dL）高於住院醫師（9.7 g/dL，p值＝0.023）。在沒有出血傾向的ICU病人之血漿輸血決定，回答不需要輸血的醫師佔36％，回答需要輸血醫師佔62％；執行侵入性治療前的預防性血漿輸血，以外科系及住院醫師的INR值決定範圍「1.5-1.9」明顯偏低。創傷病人且沒有出血現象之輸血決定，血紅素閾值平均值是9.1 g/dL，血小板數閾值平均值是6 萬/ul，其中外科系醫師的血小板數閾值明顯較高（p<0.001）。有66.1％醫師決定輸血的方式是以自我的臨床經驗為首要，其中以84.2％的外科系醫師為最顯著（p<0.001）。結論與建議: 本問卷醫師的輸血知識題設計重點在於基本的血品使用知識以及不良輸血反應認知，本研究顯示將近有40％醫師的基本輸血知識仍需加強，然而年資10年以下、總醫師以及內科系醫師的輸血基本知識表現較佳。醫師職稱不同，專業科別不同，對於輸血決策也不同。醫師輸血知識程度高，對於輸血指引遵從態度較佳。由以上結論本研究提出建議，國內醫學各專科學會或醫療機構需定期辦理輸血醫學教育訓練，以提升醫師的用血知識認知。國內衛生主管機關應建立明確的輸血指引方針，透過醫院評鑑以加強監督臨床的輸血實務。

關鍵字

輸血知識；輸血閾值

並列摘要

Objective：Appropriate transfusion does not only prevent untoward transfusion reactions, boost patient safety, but also minimize unnecessary transfusions. Physicians’ knowledge of transfusion plays a vital role in decision-making of transfusion. This study aims to explore if physicians transfusion knowledge is associated with decision-making of transfusion and adherence to transfusion guideline. Materials and Methods：In this cross-sectional study, a total of 357 doctor subjects, who worked in a medical center in southern Taiwan, were selected, based on generally and anonymously questionnaire survey.With literature review and textbook reading, 38 questions were designed by this study, comprising three dimensions: basic transfusion knowledge, scenarios of decision-making and adherence to guideline. Content validity index (CVI) is 0.97.The questionnaires were sent to 324 , responsive 227,and the retrieval rate was 70.1% (227/324). Statistical analyses were performed by SPSS version 20.0, using descriptive statistics, independent t-test, one way ANOVA, Pearson r and Chi-square. Results：Doctors who could score 9 or more of 10 questions on basic transfusion knowledge accounts for 60% of doctors. For patients who is caesarean section postoperatively stable but requires transfusion, average hemoglobin 8.7g/dL is the threshhold to initiate, transfusion and 10.0g/dL is the target value to achieve. The target hemoglobin level to make transfusion decision is higher for attending physicians ( 10.1g/dL) than for residents (9.7g/dL, p value= 0.023). For ICU patients who have no bleeding tendency, 36％ docotors chose not to order plasma transfusion and 62％ docotors chose plasma transfusion. With INR 1.5~1.9 for prophylaxis transfusion prior to invasive procedures, it is surgeons and resident who are most likely to do so. For traumatic patients without bleeding, the average threshhold to initiate transfusion is 9.1g/dL for hemoglobin,and 60,000/ul for platelet. However, a significantly higher platelelt threshhold (75,000/ul, p<0.001) was seen among surgeons. Doctors who make transfusion decision based on clinical experience account for 66.1%, and of these, significant 84.2% are surgeons (p<0.001) Discussion and Suggestion：The dimension on basic transfusion knowledge is to highlight indications for transfusion products and recognition of adverse reactions. This study reveals that regarding basic transfusion knowledge, near 40% of physician are not well equipped, not including junior doctors ( less than 10 years in profession), chief residents and physicians of internal medicine. Decision making varies with ranks and fields of doctors. The higher the basic transfusion knowledge, the better the adherence to guideline. Suggestions are as follows: to boost doctors’ knowledge of blood transfusion, periodic education of blood transfusion must be implemented by medical associations or hospitals. Guideline of transfusion should be renewed periodically by medical associations. Performance on transfusion guideline is critically assessed as benchmarks for hospital accreditation.