In late years, starting from a receipt computer, changing into an ordering system, and evolving to an electronic medical record, a progress of IT in the medical field has finally reached the times of an electronic critical path that aimed at standardization of medical quality. However, a receipt computer and an ordering system has a strong aspect of computerization in an office work section and therefore there are few systems supporting the needs of medical care staff precisely because an electronic medical record has developed on the extension line. Critical path is a fine result of knowledge that was gathered in a medical scene. As is often the case, though it is managed fantastically at the time of paper-based, as soon as computerized, we have great difficulty for its use.
When an electronic medical record is introduced, it is necessary to tell a system engineer (SE) specifications to systematize, but we feel difficulty in making specifications. On the other hand, SE cannot understand a demand of medical care staff and as a result, dissatisfaction for a system vendor will occur. One solution about such a problem is that medical care staff make software by themselves. We introduce a medical support system which included electronic critical path by File Maker Pro to cause a stir in computerization of medical care world.

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The Niigata Cancer Center Hospital introduced a critical path based management strategy for the prophylactic antibiotic medication of patients who undergo total gastrectomy. First, prophylactic antibiotic medication with flomoxef sodium (FMOX) was limited to only the day of the operation instead of the longer period of the day of the operation plus three consecutive days after surgery. Then the FMOX was exchanged with cefazolin sodium (CEZ), whose use was also limited to only the day of the operation. The present study investigated infection prevention and cost efficiency of FMOX and CEZ for total gastrectomy in 103 cases, employing critical pathway. Two groups were compared: In group A 59 patients received FMOX medication only on the day of the operation. In group B 44 patients received CEZ medication only on the day of operation. In order to verify the validity of the latest critical path, postoperative complications in both groups were investigated, focusing especially on infections. Patients were prescribed a 1g dosage of the relevant antibiotic intravenously once 30 min before the surgery and once afterwards. Although there were significantly more men in group B than in group A, there was no difference between the two groups in regard to age, degree of primary disease, surgical procedures taken, history and duration of the hospital stay after surgery. Postoperative complications in group A and B was 37.3% and 40.9%, respectively, which states no statistical significance. In addition there was no significant difference between the two groups in pancreatitis incidents or infections as well as in the postoperative fever profile over the three days after surgery. The postoperative febrile frequency at day 4 or later (i.e., cases which showed body temperature of 38.0°C or higher) was 49.2% and 38.6% in group A and B, respectively, which also states no statistical significance. There was also no significant difference in the rate of antibiotic remedication and other additional medication. And there was no significant change in laboratory values such as WBC and CRP. The total inpatient cost was lower in group B than in group A. The prophylactic one-day antibiotic medication with CEZ on only the day of surgery is thus considered valid as a critical path for the care of patients who undergo total gastrectomy, and is considered eligible for continuous use hereafter.

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In recent years, patient participation is considered to be essential to secure medical safety. However, patients' role in medical safety and the way to promote patient participation are to be investigated. The purpose of this study is to clarify the role of patients as a detector of adverse events. We distributed a questionnaire to 2, 120 inpatients at3acute care hospitals from November 2004to January 2005. Among 1, 207respondents (56.9%), 128 patients or their family member (10.6%) provided 137cases that “the patient felt unsafe”. The reported cases were classified by an expert panel; 88cases were classified as an “uneasy or dissatisfactory case” not to be relating to safety and 49cases as an “unsafe case” to be relating to safety directly. Among49unsafe cases, the healthcare provider reported only 12cases (24.5%) as an incident or an accident to the hospital reporting system. Although as for 24cases patients informed healthcare providers, only 4cases were recorded in the system. The results of the study suggest that patients can participate in medical safety as a detector of unsafe cases complementing healthcare providers, and that the way to facilitate communication between patients and healthcare providers remains to be investigated to encourage patient participation.

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A critical pathway for the follow-up of postoperative lung cancer patients was introduced among our hospital and the regional healthcare institutes including private outpatient-clinics and a nursing home. This study researches the outcome after one year of implementation. Of53cases between January 2005 and April2006, 28 (52.8%) fitted the criteria for the pathway, were successfully followed-up mainly at twenty-two cooperative institutes and were periodically introduced to our hospital for further check-ups including computed tomograms. Among these, minor variances were observed in only3cases (9.7%). On the other hand, residual cases which were no pathway candidates included patients regularly visiting our hospital for other disorders (40%), faradvanced or early cases (16%), and patients needing adjuvant chemo (radio) therapy (16%). Although our interinstitutional critical pathway for postoperative lung cancer patients still needs some revision, its application is feasible and could be a powerful tool for the functional differentiation at outpatient clinics in Japan.

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In order to examine the usefulness of the critical pathway as a medical standardization relief tool, critical pathway concerning the nursing care of patients who had died during the one year period of April 2005 to March2006was examined. Of the total number of patients who had died during that period, 115patients (60%) were applied to this research. A 1st step was to define a goal of “the ability to satisfactorily prepare for the care of the dying”. Then within the first day, care of the patient was individually set. This was followed by defining a second goal of “aiming by staying calm for a life end with as little pain as possible”. The critical pathway application period for 3 days or less was over 60%, and for8days and more it was still over10%. Some of the outcomes were that the starting point of standardization is the staff's consciousness towards the care, towards the care content and towards the standardization method, and another one was that expenditure of the flat rate system ward as well as early reception and abnormal (unhealthy) grief of a death in a family decreased. Even though overall satisfaction was good in all cases, issues concerning the evaluation of families need to be examined further in the future. In regard to the structure of the critical pathway itself, non application cases, assessment of critical path and examination of those death cases where only records exist and establishment of a care method of the preparation time before the actual care are problematic points and application standards for the critical pathway need to be researched further.

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It has been considered difficult to adopt pathway analysis for acute child diseases because of high variances due to differences in symptoms' improvement between individuals. The Isesaki Citizens Hospital utilizes critical pathway in child pneumonia with fixed outcome since2004, but variances have occurred in all cases. Thus, we conducted a variance analysis to pursue causes, and to draw up ablock critical pathway (hereafter BCP) adopting STEP. STEP consisted of 3 steps, with the criteria of each step-up definitely set on the results of variance analysis: step 1, no fever and no difficulty in respiration; step 2, improvement of total body conditions and test data; step 3, no exacerbation after treatment with antimicrobial drugs. We defined variances to have occurred when a step-up was not achieved within days of the setting.
The introduction of BCP adopting STEP made it possible to restrain the occurrence of variances, and we found that the step-up BCP is useful in acute diseases.

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This study presents the development of a critical pathway for a post-marketing study to explore the availability, security and pharmacokinetics of Doripenem hydrate, a carbapenem antibiotic, administered to patients with pneumonia at a dose of0.25g three times a day. Patients, who met the2criteria for discharge from the hospital, 1.“no fever” and2.“better laboratory data and improvement shown inchest X-ray examinations”, were discharged on the ninth hospital day. Check-ups, observations and drug administration prescribed in the clinical trial protocol to those needed, were adjusted. Subsequently, investigators, nurses and the clinical research coordinator worked together to design this “Plan on Doripenem”.
Since the clinical trials were performed parallel to the medical treatment, other than usual inspections and observations were required. However, by introducing the clinical trials into the critical pathway, both, the trials and the treatment, were implemented without problems. Moreover, patients' localization in the clinical course was simplified and in some cases, treatment was promptly be modified.
The Kumamoto Medical Center has excelled in its medical care including over50% of its inpatients in the critical pathway. Introducing critical pathways into clinical trials enablesthe center to perform high-quality clinical trials and to provide a standardized medical treatment. Additionally, deviations from clinical trial protocols can be avoided and sponsors of clinical trials have direct access to accurate data acquisitions by browsing raw data easily.

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Stroke patients show various neurological symptoms and have variable patterns of recovery. Functional differentiation between acute and recovery stages of strokes could produce systematic and efficient outcomes from the viewpoint of stroke rehabilitation management.
We developed a liaison critical pathway for a regional inter-hospital referral model for a stroke rehabilitation system. For stroke patients, a smooth switch from acute stroke centers to rehabilitation hospitals is desirable to improve their activities of daily living. Some methods are needed to ensure better cooperation between acute stroke centers and rehabilitation hospitals. We also paid attention to the difference between conditions and abilities of stroke patients, and consider that this type of information should be clearly reflected in the medical records. Consequently, the introduction of the liaison critical pathway for stroke rehabilitation has shortened the length of hospital stay.

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This study evaluates Simplified Root Cause Analysis (SRCA) in comparison to Rapid Root Cause Analysis (RRCA).
We first conducted a fact-finding study with RCA team facilitators and RCA training coordinators visiting the sites of incidents and accidents, interviewing the persons involved, and preparing flow charts for the RCA team. The RCA team then drew cause and effect diagrams and identified root causes. Following, five SRCA teams conducted analysis including root causes and contributing factors of the incidents for2hours after which they presented their findings and a plan to improve the involved medical system. This way, compared to the results of RCA and RRCA, new root causes and action plans were developed. Therefore SRCA is a practical analyzing tool for finding correct results in a short time.

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We studied the correspondence of the hospital crisis management to a bacterial water pollution accident at the Kanto Central Hospital of Mutual Aid Association of Public School Teachers. A periodic routine testing of the distillation system taken from the outflow ports17days after an overhaul of a distillation device in the pharmacy revealed bacterial contamination of specimens. Within2hours after notification from the laboratory the hospital's emergency management committee was summoned and headquarter was set up. A list of patients in whom the distilled water was used during the preceding 17days was prepared and a problem “tree” according to the water usage was drawn up with the gathered information and as well as a patient information sheet. The distilled water in question was used for dilution of liquid oral medications in30outpatients and22inpatients. The patients/families were contacted over the phone by physicians and the situation was explained with an official apology according to the prepared position paper in addition to collecting the particular medicine and supplying an alternative one. Comamonas, a non-fermentable bacteria of environment origin, was identified the next day as polluting specimen. After making an appointment, a team of a director or deputy director, a pediatrician/obstetrician and an administrative official visited the patients' homes over the next two days. During each visit inquiries were made into the patient's health and concerns, and a stool culture examination at the hospital's cost was proposed. In all28patients' homes were visited. None of the44patients who had taken medications with the distilled water in question turned out to have any health problems.
Managing a hospital crisis like this one mandates prompt establishment of the emergency management headquarter, intensive information gathering, efficient countermeasures, and an organized response by mobilizing all people concerned.

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In2000, the national healthcare policy of Japan was changed to push for a function-specific reorganization of hospitals, such as acute phase-specific or chronic phase-specific, and to promote at-home-care in order to control healthcare budgets and manpower more efficiently and economically. Among others acute phase hospitals have been required to shorten the average length of stay (LOS). In April2005the National Hospital Organization Okayama Medical Center (OMC), an acute phase general hospital with580beds, expanded its Division of Management for the Regional Medical Liaison (DMRML) by stationing a discharge arranging nurse (DAN), a newly created position, and two medical social workers (MSW) as full-time staff members, whose duties include arrangement and preparation of patients' hospital discharge. A risk-screening checklist (RSC) was developed by the DMRML and applied to adult patients, to be filled out by the nurses in charge at the time of the patient's admission. The team of DAN and MSWs visited every ward (WR) once a week to survey the RSC. They also attended the doctor-nurse conference of each ward to collect information about patients. After a half-year trial, the RSC was revised to evaluate risks more quantitatively and to collect indispensable information for discharge arrangements (DA) completely at admission. In addition, the position of a key-nurse (KN) was established, who is a staff nurse of each ward and in charge of the DA. Since then general meetings of KNs, DAN, and MSWs have been held monthly to discuss any problem at each ward. Through this revised DA system, the fill-out rate of RSC has improved and the average LOS has decreased remarkably. These results suggest that our DA system gives outstanding satisfaction not only to the patients but also to the medical home care staff after discharge.

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Diabetes mellitus is a chronic disease. For a regional cooperation in diagnosis and treatment it is necessary to have information of the clinical data as well as of the life-style background of the patient. We developed a critical pathway for regional cooperation of diabetes mellitus treatment, which would share this kind of information, and applied it to some cases. The top of the format sheet states the control target, action target and drug selections. Inside the time table sheet an evaluation of life-style, the clinical data, content of treatment and instructions are to be filled in. While dietary therapy and exercise are themselves the fundamentals of diabetes mellitus treatment, the patients' actual execution of them is also a goal of the education and instruction. To set and evaluate the clinical outcome of diabetes in the critical pathway includes maintenance of quality of life and reservation of regular life length, information about control of the metabolic state and prevention of complications, as well as life style improvement, action change and a state of mind. These outcomes seem to influence each other. In our study the use of the critical pathway was fairly accepted by patients and the cooperation of the medical staff was satisfactory. For the future we would like to increase the number of applications and to further examine the usefulness of the pathway.

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The management of sterilization of medical equipment is one of the most important factors in the safety management of surgical site disinfection. At our hospital, the sterilization management system ‘T-Racer ^(R)’ produced by the Central UNI Corporation, was introduced in August2004. This system traces all points of sterilization by using barcodes. This system also keeps a record of the use of sterilized medical equipment. During the two years that this system has been used at our hospital, we had 2 recalls. However, through a check of the record of the use of the sterilized medical equipment, we were able to re-sterilize the instruments in a short time. Additionally we developed an order entry system using the WEB-technology. To ensure an accurate data input into the system, the physician has to input the order directly himself. For the future we plan to continue to develop this new concept and improve it further to make it even more useful.

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