In a DPC environment, maintaining stability of quality of medical care and hospital management is an ever-increasing requirement these days. We have carried out a joint research on the evaluation of DPC by means of benchmarking with data in the ZENSHAREN-fixed-point-observation-system. One of our findings is that benchmarking of cost analysis data and clinical indicators make it possible to draw up a standard treatment plan, that is, a standard critical path. Furthermore, the accumulation of this kind of data allows DPC to be evaluated as a system.

At acute hospitals, self-removal and/or accidental removal of tubes are among major adverse events. In addition to causing preventable pain or prolonging hospital stay, self-extubation of tracheal tubes might cause hypoxic encephalopathy and endanger the patient's life. The development of a self-removal risk assessment tool is needed to prevent self-removable of tubes. We conducted a literature survey to identify risk factors for extubation of tracheal tubes.

We identified and reviewed 61 studies regarding extubations of tracheal tubes using PubMed and Ichushi. These included 18 observational studies with controls, 8 cohort studies and 10 case control studies, which were used in this study for their high reliability. Elevated blood urea nitrogen, restless or agitation, weaning and nosocomial infection were identified as risk factors of extubation. No risk assessment tool was verified and approved widely.Risk factor identification using reliable research design and development of risk assessment tool seem necessary to prevent extubation effectively.

Critical paths are useful not only as a tool to improve the quality of medical care but also to reduce the work related burden for physicians and to manage medical costs under the reimbursement system of diagnosis procedure combination (DPC) in Japan. Using the medical record system EGMAIN-GX by Fujitsu, we introduced order-linked critical paths and regimens for cancer chemotherapy. After the introduction and compared to the formerly used paper-path that made using Excel (Microsoft) the time physicians spent on ordering was sufficiently reduced and assumingly the risk of medical errors decreased as well. Comparing the costs to income in DPC from before and after the introduction of the new system, the management of medical costs became easier. The new system definitely reduces the work related burden of physicians and improves the quality of medical treatment.

At the Okayama Medical Center a so-called variance analysis was carried out in order to determine the optimal length of hospital stay using a newly prepared critical pathway based on the Infectious Diseases Society of America (IDSA) / American Thoracic Society (ATS) guideline and the Japanese Respiratory Society (JRS) guideline for community-acquired pneumonia in adults. The treatment schedule of this critical pathway is as follows：administer intravenous β-lactum with oral macrolide as initial treatment for three days, if effective, the treatment is sustained up to the 7th hospital day, otherwise change β-lactum to intravenous quinolone, and the treatment is sustained up to the 10th hospital day.

Over the period from December 2006 to April 2008 eighteen patients were treated using this critical pathway. To simplify the variance, the length of hospital stay beyond 10 days was assumed as negative variance. WBC count and CRP on admission and their decrease rate on the 3rd hospital day were analyzed.

In conclusion, a low decrease rate of WBC count on the 3rd hospital day seemed to be an important factor for a prolonged hospitalization.

A sufficient prevention program against accidental falls is a necessity in hospitals. However, resources are limited due to insufficient numbers of nurses and caregivers, and poor medical funds. In the present study, we investigated the estimated number of foreseeable accidental falls on hospital admission in order to establish an efficient prevention program against falls.

The study included 2,258 patients admitted to the Kameda General Hospital between November 2008 and January 2009. Nurses conducted surveys using our new original checklist of 17 questions to predict a fall on admission. The 17 questions include age, physical functions (3 questions), mental functions (5 questions), compound factors (3 questions) and 5 others. For this checklist we had added some factors reported in previous studies to our original conventional checklist.

Among 2,258 patients, 55 were admitted as a result of a fall. We carried out a multivariate analysis using logistic regression analysis, and were able to extract the following 5 factors to foresee accidental falls: history of fall, trying to move alone without help, poor sitting balance, poor standing balance, and anemia. When applying these prediction factors to the patients, the area under the receiver operating characteristic curve was 0.776. Sensitivity was 0.709, specificity was 0.799.

Using this original checklist as screening tool, inpatient accidental falls could be predicted to some extent. Future studies should concentrate on a more precise and simple prediction tool.

With all the changes in the medical situation, medical care is shifting from the hospital conclusion type to a community conclusion type. In addition, nourishment medical treatment is reviewed by the introduction of Nutrition Support Team (NST), and continuation of a nutrition management becomes a task for the community medical cooperation.

The National Hospital Organization Hamada Medical Center established a community medical cooperation room and a NST. A questionnaire survey using the cooperating medical institutions was conducted to enhance community medical cooperation. The survey highlighted concerns in the nutritive evaluation, and a dissemination of the nutritional therapy was requested by the cooperating institutions. Assessment by the different institutions differed on the issues of nutrition, evaluation of the ability to swallow, meal help, and enteral nutrition. The reasons for these differences lay not only in the quality and services of each institution, but mostly in the difference of patients using these institutions. To handle these issues and meet different needs a report about nutritional management was attached, an inquiry window installed and workshops about nutrition were held. While understanding current needs at the institutions, grasping mutual facts and needs is important for a substantial community medical cooperation.

As medical costs of cancer treatment can be a large burden on cancer patients and treatment fees may spiral to unexpected amounts, the Patient Support Center receives many consultations requests regarding medical costs. Based on the current medical system, most hospitals dealing with cancer patients utilize the Diagnosis Procedure Combination (DPC), which allows a relatively uniform nationwide fee schedule for the same disease or treatment.

In this study, using selected data from past DPC comprehensive fees for specific inpatient treatments, we calculated the approximate average hospitalization costs based on the type of cancer, treatment plans, and duration of hospital stay. Using this database, we constructed a“Cancer Treatment Cost Estimation System”, which allows hospital staff to instantly calculate treatment fees according to the location of a cancer, treatment plans (surgery, radiology, and/or chemotherapy), and duration of hospital stay from any computer within the hospital.

Additionally, by accessing the hospital homepage, these estimates are also accessible from locations outside of the hospital. This system provides useful information for hospital personnel involved in cancer patient care.

The International University of Health and Welfare Mita Hospital realized that its injection ordering system is not organized properly. The prescriptions for anti-cancer chemotherapy injections submitted to the pharmacy department are handwritten, and a considerable number of prescriptions have omitted, wrong, inadequate, or suspicious descriptions prescribing unusual doses. Tasks such as inspecting injection prescription, filing drug administration histories, issuing transfusion labels, etc., all should be carried out by pharmacists.

In this study, referral prescriptions for anti-cancer chemotherapy injections between October 2008 and March 2009 were classified based on content and significance. The prescriptions were classified by contents into seven groups：i) dosage quantity, ii) dosage interval, iii) dosage time, iv) regimen, v) adjunctive therapy, vi) overlapped prescription, and vii) others. The prescriptions were also classified in regard to risk degree into 2 groups of A and B (A>B).

2390 prescriptions for anti-cancer chemotherapy injections were submitted during this study period. Of these, 173 (7.2%) contained suspicious references, while 110 (4.6%) had modifications to the prescription. Classified by content, group i) contained 62 prescriptions, group ii) 13 prescriptions, group iii) 21 prescriptions, group iv) 34 prescriptions, group v) 32 prescriptions, group vi) 6 prescriptions, and group vii) 5 prescriptions. Classified by significance, group A contained 55 prescriptions, and group B 118 prescriptions.

For prescriptions of anti-cancer chemotherapy injections the closest attention must be paid to prevent overdose. This study results confirmed the need for pharmacists to inspect prescriptions and references for suspicious content.

In 2000 the Japanese Ministry of Health, Labour and Welfare introduced the “Healthy Japan 21” policy (motion to national health development in the 21st century), which included a primary and a second prevention policy in regard to lifestyle related diseases. However, the first interim report stated among others an increase in the number of diabetes patients, an increase of obesity in men aged 20 to 60 years, and an increase of lack of vegetable intake. The influence of dietary habits on lifestyle related diseases is enormous. Dietary behavior is also easily affected by the external environment. Food intake habits especially are often unhealthy. For example too much food is consumed at one meal, food is not chewed enough, breakfast not taken at all but then meals eaten late at night. Especially obese people often show an unhealthy life pattern.

This study focuses on night shift nurses, whose occupation often forces dietary habit changes. Dietary habits of night duty nurses were investigated in regard to time of food intake, exercise habits, alcohol intake, as well as age and influences on the physical situation of the nurses. The influences in dietary habits and lifestyle pattern were especially remarkable among nurses in their 20s and their 50s.

To prevent medication errors the Tsukuba Memorial Hospital introduced a new management method for drug administration. A pharmacist was placed directly in a ward and a new management method was studied with the ward nurses. This trial study was effective in decreasing the number of medication errors such as false dosage, overdose, and missing dosage. The new management method reduced medication errors to about one quarter. Answers to a questionnaire survey of the ward nurses included：“time spend on distributing medication decreased and could be used for other tasks” , “consciousness in regard to drug administration increased”, and overall supported the new management method.

The new management methods with the pharmacist in the ward not only improved the safety of drug administration but also promoted nursing efficiency and patient care, and prevented medication errors.