“Effects of critical pathways for hip fracture” was reviewed in11articles in 5 developed countries, published from 1993 to 2005. Critical pathway standardizes care and gives patients early ambulation, and reduced complication; consequently, in many cases, it reduces the length of stay (LOS) without degrading patients outcomes. Critical pathway sometimes increases LOS, if the original LOS was short, so that patients can take as much rehabilitation as needed in order to go home and walk independently. About 23 days is considered to be the possible minimum LOS, as long as the patient has regained ambulatory ability. It would be possible to safely reduce LOS to around 23 days in Japan as well, but it would be necessary to improve rehabilitation programs there, especially early ambulation and early walking exercise without limitation of weight-bearing, in order not to negatively affect outcomes at discharge. It is also necessary to observe the effect on patients' long-term outcomes after discharge, including mortality, readmission, ambulatory ability, and residence especially when LOS is reduced in Japan.

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In order to practice efficient medical management by DPC, we examined the current DPC adaptive critical path for lobectomy in lung cancer. From January to December 2005, 57 primary lung cancer patients who were treated using a lobectomy critical path and who were reimbursed by DPC were analyzed. Critical path was set up according to the following schedule: two days for antibiotics administration, three days for drainage, and 21 days of hospital stay taking the DPC group II hospital stay into account. Total direct cost was calculated based on the charge. Cost per patient showed 1, 792, 170 yen in DPC and 1, 668, 698 yen in fee for service (FFS) reimbursement. DPC/FFS ratio was 107.6%. Two patients showed less than100% DPC/FFS ratios. One patient received examination for distant metastasis under general anesthesia and the other was a trans-admission case from the general internal medicine division. DPC/FFS ratio was negatively correlated to hospital stay; longer hospital stay was related to lower DPC/FFS ratio. There were 43 (75.3%) cases who were discharged within DPC group II and they showed significantly higher cost per day compared to those in the DPC group III (80, 255 yen versus70, 824 yen). In order to maintain a high DPC/FFS ratio, the DPC adaptive critical path should be scheduled within group II of hospital stay, and rational use and shift from inpatient to outpatient ward of laboratory examinations seem important.

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Diagnosis Procedure Combination (DPC) was introduced at Hirosaki University School of Medicine Hospital in June, 2003. The impact of DPC in thoracic surgery was investigated based upon the fee for service reimbursement. We retrospectively reviewed 185 cases of thoracic surgery between April 2004 and February 2005, which were reimbursed by DPC. Compared to the former payment system DPC was costlier by 6%. The DPC was high in groups which had coronary bypass surgery, valvular disease operation, aortic arch replacement, congenital heart disease radical operation and lobectomy for lung cancer except in the group that was treated conservatively for an aortic dissection case. In 16 cases DPC was less than with the former payment system. In these cases hospital stay was shorter and in the cases of long hospitalization, complications needed postoperative treatment, a dialysis case needed preoperational treatment of renal insufficiency, and other cases needed before and post operative cardiac catheter tests. Postoperative complications should be prevented, but when they are unavoidable, there is room for improvement by setting a new arm or changing basic charge of DPC.

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For inpatients undergoing chemotherapy the risk to become malnourished because of appetite loss stemming from the side effects of chemotherapy is high. Therefore, a specialdiet improving appetite in these patients should be developed. We served a type of special diet, called “fit diet”, and investigated the effects of this diet. Thirteen chemotherapy patients with poor appetite were divided intotwo groups: a “fit diet” group (F group, receiving “fit diet”, 8 patients), and a control group (C group, receiving “ordinal hospital diet”, 5patients). The “fit diet” was composed of weak smell, smoothly swallowable foods and adjusted to 1500 kcal of energy, 245g of carbohydrate, 50g of protein and 35g of fat per day. Averageintake of energy, blood levels of transthyletine and albumin, total lymphocytes count and cholinesterase were compared between the two groups. Energy intakes before the study period did not differ between the two groups, however, daily energy intake in the F group was 1156±259kcal during the study period, which was significantly higher than that in the C group, 882±279kcal (student's t test). The ratio of energy intake to the expected basal energy expenditure calculated by the Harris-Benedict equation in the F group, was alsohigher than that in the C group, 94% vs 79.7%, respectively. The blood test results did not differ between the groups. According to a questionnaire, “fit diet” was easy to eat and barely caused nausea.
In conclusion, nutrition support for chemotherapy patients using a special diet resulted in improvement of appetite and increase of energy intake.

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A new ordering system was introduced at the Kumamoto Medical Center, and the conventional paper base critical pathway of the educational hospitalization for diabetes mellitus was computerized. Computerized critical pathway anticipated 10-day hospital stay compared to 14-day of the previous paper base pathway. We examined the compliance and variance of the new pathway, as well as the impact on hospitals stay and the proportion of those who achieve the discharge standard. Average length of staywas 12.03±3.41 days; the proportions of those who were discharged within the scheduled hospitals days and who achieved the discharge standard were 58.6% and 100%, respectively. Most of the variances were derivedfrom patient factors. Nutrition guidance and medicine management guidance were offered to 58.82±23.41% and 70.69±36.64% of patients, respectively. As the hospital staff becomes accustomed to the new pathway, it is expected that the compliance will increase as well as the proportion of those who achieve the discharge standard and receive medicine management guidance. As for the nutrition guidance, the impact of revision of reimbursement tariff and poor communication among medical staff seemed to have contributed to the low compliance.
We found that the new computerized critical pathway was useful compared to the paper base pathway although there is room for improvement.

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The Yamanaka-Spa Medical Center' s convalescent ward plays an important role in improving aged patient' s disuse atrophy and helping them to be able to live at home or at senior health care institutions. The management of nursing services is more problematic at the Yamanaka-Spa Medical Center than the treatment of diseases themselves. To resolve these current problems, the Center introduced a “critical pathway to improve contractions” and investigated its usefulness by treating six long-term bedridden patients based on the pathway for one month. As a result, neck contraction and hip joint contraction of all patients improved during this month and all patients became able to sit up at least for one hour. This proves that critical pathways are not only effective in reducing nursing problems at wards for acute stage patients but also at those for chronic stage patients.

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A survey was conducted on 170 outpatients' waiting time and their satisfaction level. Average waiting time which was regarded as permissible by respondents was18minutes for reception, 37minutes for consultation, 23minutes for examination, 10 minutes for calculation of bill, and 68 minutes for hours spend in the hospital. The actual waiting hours for consultation, examination period, and hours spent in the hospital were longer than those of the “permissible” waiting time. The percentage of outpatients who waited for less than the“permissible” waiting time was 45% for waiting for consultation and 38% for hours spent in hospital, respectively. Satisfaction survey revealed that “waiting for consultation” received the least satisfaction level, i.e. average 3points of maximum 5 points. Satisfaction level for out-patient clinic was correlated to satisfaction level of doctor's attention and consultation waiting time. It seems important to investigate “permissible” time and patients' satisfaction level as well as actual waiting time to evaluate the impact of waiting time on patients' satisfaction.

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As the number of diabetic patients is growing, the opportunities for medical staff to use insulin are increasing. Insulin sliding scale is often used in various clinical situations in the hospital. The patterns of insulin sliding scale vary widely depending on the physician and they may be the cause of insulin related incidents. This project team that consisted of physicians, nurses, and pharmacists was formed for the safety management of the insulin treatment in Tohoku University hospital in 2002 using the technique of PDSA cycle. During this project, the insulin sliding scale was standardized at the entire hospital. A questionnaire survey in February, 2005 showed that the standardized sliding scale had been used widely in the hospital and that the work efficiency of the physicians and nurses had improved by the standardization. By continuing this activity decrease of insulin related incidents and safety improvement of insulin therapy are expected.

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Amid rising concerns and criticism related to medical services, it is now strongly required to provide patientcentered, society-oriented services, such as secure medical treatment, appropriate health information for daily life and regional alliances of medical care. With this situation in mind, we need to provide high-quality medical services with a system that guarantees medical personnel' s ability and its quality in acquiring knowledge, technique and in responding. Our nursing division has been accredited to IS09001since 2003. Based on the ISO standard, we adopted the PDCA cycle in nursing education. We grasped nursing needs by the CUDBAS method and set 11categories necessary for nursing practice ability as clinical ladder items. However, it took a lot of time to gather data for evaluation, and it was difficult to ameliorate nursing practice ability. Therefore, we have developed a ladder assessment and an analysis system in cooperation with the Department of Medical Informatics. As a result, we could shorten the total amount of compiling time, and it enabled us to analyze the ladder assessment in real time. The figures of those who had been accredited as ladder I and II were 22.4% and 1.7% respectively, which were lower than expected. Further discussion is necessary about the ladder accreditation criteria, the review of ability checking items, and the improvement of education programs.

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In 2003 the Kyushu Central Hospital showed a positive financial balance for the first time in 25 years. We studied the influences of co-operation of medical institutions in the community on the hospital management from the aspects of relationship between practiced measures, rates of introduction and average hospital stay. Rate of introduction increased from 14.2% in 2000 to 44.7% in 2004. Average hospital stay decreased from 19.6 days in 2000 to 13.8 days in 2004. Establishment of strong partnerships with other medical institutions in the community directly led to the increase of hospital revenue. But the greatest factor of the co-operative management lays in the improvement of the complete medical treatment system of the hospital; diagnosis as well as treatment course.

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The National Nagasaki Medical Center was using about 20 different kinds of disinfectants. To decrease the number of disinfectants and to abolish the strong toxic glutaraldehyde as well as to facilitate their proper use, washer disinfectors were introduced at the Medical Center' s wards and an investigation followed. Sections which had to continue to use glutaraldehyde were instructed to change to ortho-phthalaldehyde which is less toxic. One of the direct results since the wards started using ortho-phthalaldehyde in February 2003 was that the purchase of glutaraldehyde decreased. However, once established customs need effort to be changed. A safe new disinfectant will not be used without understanding of all involved. Therefore, cooperation of pharmacists and link-nurses are of great importance.

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In this paper we report an approach to enhance the efficacy and the compliance of hand-hygiene practices at the NTT Izu Hospital. We planned to take several educational measures in line with recommendations of hand-hygiene with alcohol-based hand rubs issued by Centers for Disease Control and Prevention in 2002. For education and evaluation purposes, we chose lotion with fluorescent materials which was used in handrub actions. The Ecolabo training instrument, which visualizes fluorescent lotion material on hands, was used so that the rubbed hand parts could be evaluated. An investigation of the before-instruction level was done on the 153 nurses of this hospital. And then the education in accordance with our hand-hygiene manuals was introduced. We made map posters which visually showed the not-well-cleaned areas of rub actions. These map posters and the experimental use of the training tools by the nurses themselves effectively promoted the instruction and improved the quality of hand-hygiene.

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Root Cause Analysis (RCA) is a method of learning from both incidents and accidents and it is specifically a method to evaluate points of weakness in a medical system. Because it takes a lot of time to analyze these kind of events, we tried to analyze incidents using Rapid Root Cause Analysis (RRCA). Six RRCA teams were set up to determine root cause and contributing factors for the incidents. After just one hour the RRCA teams presented their findings and suggestions for improvement of their medical systems. There were effective ideas in each team. In conclusion RRCA is an effective analyzing tool for getting valuable results in a short time.

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We studied efficient ways to provide Internet terminal services for inpatients at a university hospital. We placed two terminals at a general surgical ward (91beds) for three months, and conducted questionnaire surveys about this service with 65 users and 27 nursing staff. There were no serious troubles with this service. According to the questionnaire surveys, 38 users thought the service highly valuable for patients. The users expected an increase in the number of terminals and the possible use at the bedside (11, 26 persons, respectively). The result of the nursing staff questionnaire revealed that 12 staff felt “the service was necessary for inpatients”, although 15 staff thought it “not necessary”. Some of them received compliments from users, but others had interruptions of their jobs because of complaints about the service. 23 of the nursing staff thought that the service should be provided in common public space, like a dining hall. In addition a telephone survey was conducted with 14 hospitals in Fukuoka city about their current situations. Four of these hospitals are providing Internet services, though most of the services are in limited places or for limited users. Nowadays there are new systems, which need less installation cost. These ystems would be worthwhile to examine for hospitals.

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