醫學中心醫師對使用新鮮冷凍血漿認知、態度之探討

Abstract

本研究主要目的為，瞭解醫學中心醫師對使用新鮮冷凍血漿的認知與態度；探討醫學中心醫師對使用新鮮冷凍血漿的認知、態度之間的關係；探討影響認知及態度的相關因素；瞭解醫學中心輸血委員會運作對醫師使用新鮮冷凍血漿的認知、態度之間的關係。 本研究為一橫斷面（cross-sectional）之研究，針對全台灣18家醫學中心醫師，採用郵寄或分發問卷來進行普查。問卷內容由文獻中整理與訪問醫學中心數科醫師及血庫主管修正而來，並經由專家效度，進行內容審核。問卷分為兩部份，第一部份以醫院為分析單位，共寄出18份問卷，由該院輸血委員會主任委員填寫，回收18份有效問卷，回收率為100％；第二部份以個人為分析單位，共回收860份有效問卷，回收率為11.5％，由結果顯示在信度方面內部一致性相當高。 本研究主要結果如下： 一、對使用新鮮冷凍血漿的認知 約40％醫師對使用血液的知識，可能是不足夠的，年資低的住院醫師的認知程度明顯低於臨床年資較高的總住院醫師及主治醫師，專業科別不同及醫院所在地區不同，認知程度也有不同，如能讓臨床醫師瞭解輸血風險和適應症，可以降低不適當輸血。 二、在對使用新鮮冷凍血漿的態度 (一)處方後稽核措施包括定期抽查各科用血情形、定期公佈用血指標、抽查發現之不適當用血通知醫師等，私立醫院醫師及年齡、臨床年資及最高職稱愈高，態度也愈正面，醫院如定期稽核用血情形，會影響醫師的態度，減少血漿的不適當使用。 (二)處方前提醒措施包括將適應症及及輸血標準輸血風險提供醫師參考、輸血標準置於方便取閱之處、處方前文字警語或電腦提醒…等等，年齡、臨床年資及最高職稱愈高，態度也愈正面，對不同科別有不同的影響程度，對婦產科、急診科影響較大，耳鼻喉科、外科影響不大。 (三)醫院因應健保的措施在血漿這項血品最常被用來替代高價的白蛋白，或醫院政策性的要求減少血漿使用量以降低成本，在專業科別方面，外科系較易受醫院因應健保措施的影響，而在臨床年資、工作職稱較低者及未兼任行政主管者愈容易受影響；假如醫院因應健保的措施對醫療是正面的，後續的影響也是正面的，但如果醫院擬定的措施是負面的，那對醫療的品質而言也將會造成負面的結果。 (四)輸血委員會的影響主要是指醫師認為所屬醫院的輸血委員會究竟有無發揮功能，影響到醫師的態度，在年齡、臨床年資及最高工作職稱愈高者，態度愈正面；在專業科別方面，以婦產科、小兒科、外科等認為較有影響。 (五)病患家屬影響包括「病人狀況不確定，給予輸血會提高家屬認同減少醫療糾紛」、「病情嚴重要求醫師輸血，醫師會配合給予不必要的輸血」在年齡、臨床年資及最高工作職稱愈高者，愈不受影響；在專業科別方面，以急診科和外科較易受病患家屬的影響。 根據以上結果，本研究提出以下建議：(一)醫療機構管理者應擬定與輸血有關的具體住院醫師訓練計畫，定期辦理與輸血有關之在職教育訓練，建立輸血處方前警示或提醒系統，落實輸血委員會功能；(二)相關醫學會加強學術討論會或研討會課程，推動設立輸血醫學專科醫師，擴大辦理醫師層級專業在職訓練；(三)衛生主管機關應加強醫院評鑑內容，辦理醫院間的相關交流活動，獎助或補助偏遠地區醫院推動正確使用血液；(四)後續研究者加深質性研究內容，改善資料收集方式，擴大訪問對象，進一步探討影響醫師使用血液態度的相關因素。

The purpose of this study is primarily to understand the extent of physicians’ knowledge and attitude about Fresh Frozen Plasma (FFP) utilization in medical centers. This is to investigate the physicians’ FFP utilization with the relationship between knowledge and attitude. This is to investigate the related factors between knowledge and attitude, further to understand the executions of the medical center blood transfusion committee affecting the knowledge and attitude of the physicians’ FFP utilization. This study was a cross-sectional study, towards the 18 medical centers nationwide in Taiwan, using mail post questionnaires for investigations. The questionnaire, based on literature research, personal interview with some physicians from different specialties and superior levels at blood banks. The contents are further being verified and qualified through expert’s validity. There are two parts of the questionnaires, one was analyzed at hospital level and had 18 valid samples with response rate of 100%, which are to be filled by the chairman of blood transfusion committee. The second part was analyzed at a individual level and had 860 valid samples with response rate of 11.5%. The results indicate relative high uniformity in terms of credibility.

Major findings from the research include： 1. The knowledge toward FFP utilization: There are approximately 40% of the physicians with insufficient knowledge on blood. Fewer seniority residence physicians have apparent lower knowledge levels in comparison with the higher seniority senior residences or specialists. Due to the different specialties and hospitals in different regions, the level of knowledge differ as well, i.e.: how to get the clinical physicians to understand more on the blood transfusion risks and indications, in order to decrease inappropriate blood transfusions. 2. The attitude toward FFP utilization： a) The audit after prescription includes the below, regular audit on the blood usage status at different specialties, regular publish the blood usage index, random check on the inappropriate usage on physicians with records etc, private hospital physicians and age, clinical experiences, as the higher ranks with more positive attitude. If the hospital conduct audit on a regular basis, which would affect the attitude of the physicians, further to decrease the inappropriate use on blood plasma. b) The reminding before prescription includes providing indications and blood transfusion guideline and risk factors to physicians for references. The blood transfusion guideline should be placed in a place aiding for reading convenience, warning words before prescription and warnings on computers etc, age and clinical experiences, as the more senior physicians with more positive attitudes, which would have different affective levels on different specialties, result in great effects on gynecology and ER, but not great effects on ENT and Surgical appliances. c) The hospitals have accommodated on National Health Insurance (NHI) scheme using the item, FFP to replace high priced Albumin to lower the expenses used. In terms of different specialties, the surgery specialties are more affected by the NHI scheme budget cut. In terms of clinical experiences and lower rank or non-senior administration superiors are more easily affected. If the hospital have positive on NHI budget measures, then the subsequent effects are also positive. If the measures proposed by the hospitals are negative, which then result negatively on medical qualities. d) The main effects on blood transfusion committee are pointed towards if the committee in the hospital has developed their functionalities. The above could also affect the physician attitudes, age, clinical experiences, and the higher ranks with more positive attitudes. In terms of specialties, the blood transfusion board has greater impacts on gynecology, pediatrics, and surgeries. e) The patients’ family effects include “the unstable status of the patients, blood transfusion would increase the recognitions of the family, hence decrease medial disputes”; and “the patients’ family request blood transfusion due to increase severity of the illness, and the physician prescribe unnecessary blood transfusions”. Senior aged physicians or with more clinical experiences would have less effect on the above mentioned factors. In terms of specialties, the physicians on ER or surgeries are more easily affects by the patients’ family. From all the findings above, this study recommended:(1)The hospital should propose concrete training manuals on blood transfusion for residence physicians, conduct occupational education in a regular basis, establish the warning system, to make the blood transfusion committee in real practice.(2)The related association should propose related symposium to reinforce learning discussions or symposium classes, in propagations on establish the blood transfusion specialties physicians, expanding the professional levels on physicians in terms of occupational educations. (3) The health officers should reinforce the contents of hospital audit, conduct the mutual communications within hospitals for related activities, give awards or to support correct usage on blood for hospitals in the outlying regions. (4)The future research could increase the contents of the qualitative studies, improvements on data collections, increasing amount and levels of the people visited, further to investigate on the related factors on effects of the physicians’ attitudes in blood utilization.