[Objective/Aims] To see any difference in the direct patient care time before and after the introduction of critical paths (CP) to daily practice in a university hospital setting.
[Methods] We analyzed the patient care time of nurses working in the urology ward, where CP were used in approximately 36% of the in-hospital patients. The investigation periods were between April 1998 and July 2000 (the number of CP was 4 or less during this period, i.e. before introducing CP), and between August 2000 and January 2002 (after the introduction of CP; the number of CP was 12). The patient care time was calculated from the database of the Kitasato Nursing System (KNS). Other statistical variables related to hospital business control were analyzed as well.
[Results] The cumulative direct patient care time of the ward was decreased from the mean of 3418 to 3204 minutes per day after the introduction of CP. However, there was no difference in the direct care time per patient before and after the introduction of CP, which were 94.2 and 92.3 minutes per day, respectively. When looking at other factors, the average in-hospital days before and after the introduction of CP were 17.2 and 12.7 days /patient, respectively; the utilization rates of hospital beds were 1.8 and 2.4 cycles/month; the average numbers of patients being admitted, discharged, and in-hospital on one day were 36.3 and 34.7 patients/day; and the rates of in-operation hospital beds were 95.2 and 91.1%.
[Discussion/Conclusion] It is considered that the standardization of treatment and care with the use of CP has facilitated patients to start postoperative self-care much earlier, and also that the time expended on indirect nursing businesses has been decreased greatly after introducing CP. These results suggest that the hospital business management has been improved by the introduction of CP without affecting the direct patient care time as well as the quality of care.

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[Aim] We have used critical path of colonic polypectomy since 1988. The patients had been hospitalized for one day after polypectomy. To shift to day-surgery, the variances of CP and complications of polypectomy were analyzed. [Methods] In the first CP, patients had been hospitalized for one day to observe accidental symptom. After using the CP for 2 years, we analyzed its variances and complications. Then, the CP was modified as day-surgery protocol. The efficacy of day-surgery was analyzed as the differences of the number of polypectomy and number of colonoscopy. [Results] Polypectomy was performed with 260 cases for 2 years and patients were hospitalized for a day. The size of polyps was ranged from 5mm to 30mm, less than five polyps were removed at once. No complication occurred during hospitalization period. One of 260 cases (0.38%) was bled at day 4 after polypectomy. One polyp (10mm) was removed at once in this case. From this res ult, we concluded that one-day hospitalization after polypectomy was not able to avoid complications. Therefo re, we shifted to day-surgery. After introduction of day-surgery, no complication has occurred in 205 cases for a year. The number of polypectomy has shown a year-on-year increase of 46% after transition to day-surgery. [Conclusion] Transition to day-surgery of colonic polypectomy is succeeded with analyze of variances of CP. The day-surgery of colonic polypectomy reduces the burden on the patients, and it increases the number of treatment.

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Five years after the introduction of critical paths to medical practice in Japan, they are extending beyond the hospital setting and now utilized in the connections between hospitals, clinics, and medical supplies information service.
From now on, it is expected to include paths into computerized medical records. It will be necessary to standardize terms and, coding schemes used for paths.
In order to address this need, we extracted paths from the literature and made experimental standardized care categories.
On average, a path was composed of 13.3 care categories.
Care categories, used well in paths are “examination, ” “meal, ” “excretion, ” “cleanness, ” “nutrition, ” “activity and rest, ” “treatment, ” “guidance, ” and“rehabilitation” in order of the frequency of use.
The medical information system development center in japan and academies proceed with the standardization in these parts. Standardization, however, seems to be late for the following types of terms: those that cross some territories, have low relevance to health insurance, or relate to daily life support.
We suggest 10 categories as a tentative plan to standardize critical paths: (1) outcome, (2) examination, (3) nutrition, (4) cleanness, (5) excretion, (6) activity and rest, (7) treatment, (8) guidance, (9) rehabilitation, (10) drugs.

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The length of stay, one of goal of critical paths, is determined by analyzing its long-term outcome. Even in a critical path of short length should be determined by analyzing outcomes of a whole path. These outcomes are decided based on scientific evidences including guidelines.
To classify progress and variances for these outcomes in critical paths, we displayed these factors on a table which all staff members could understand at a glance. On this table we recorded outcomes for every path-day (date counted/or/determined on each critical path) in a vertical axis of the table, and path-days in a horizontal axis. The causes of variances were classified into 4 groups, the patient (including his family), staff members, systems, and social factors. The following observational factors were recorded on this table, 1 Daily activity, 2 Meal, 3 Pain, 4 Urination and Defecation, 5 Cleanliness, 6 Education, 7 Medication, 8 Others. The variances were recorded by these key numbers to make statistics easier.
So far we have applied this table for the 8 critical paths and found that this new method has been useful not only to understand variances and its causes but also to revise critical paths by its results. A definite plan and problems will be discussed.

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A reduction surgery against the stomach disease increased, and critical path (CP) toward the gastric partial resection (PG) and laparoscopic surgery for the early gastric cancer and the submucosal tumor of the stomach became necessary. So, it was analyzed about the various perioperative items targeting 37 patients that CP hadn't been carried out. Result: As for the hospital stay, the postoperative stay and drip infusion periods, median was 16 days (9-25 days), 10 days (8-19 days), and 5 days (3-10 days), respectively, and width of range was seen. But, the first postoperative day, nasogastric tube was removed, removal of urine catheter were the third postoperative day, and a water drinking start the second day, a meal start the third day, removing the stitches the seventh day were about the same as before. CP of the time-task matrix form concerning PG was made, referring to the analysis of clinical items of PG. Several items were set up such as examination, medication, venous infusion, treatment, observation, meal, activity, cleanliness, excretion, safety, education, informed consent, check list, variance, signs of medical stuff as vertical items, and hospitalization days from admission to discharge as horizontal items. A check form by is used for the one for the medical stuff, and it gets a physician's in charge autograph, and starts. It thought of team medical treatment, and physicians in charge, anesthesiologists, nurses, pharmacists, dietitians included co-operation of each section into CP. A patient will admit two days before the surgery and discharge 8th postoperative day, and an antibiotic was made only oneday. A meal started in the third day, and it raised every one meal as raising from the 1/3 rice gruel to all the rice gruel. As a rule, all patients of PG were adapted to this CP, 5 patients were indicated till now. This CP thought to be suitable toward PG without variance of the medical factor.

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A survey in our hospital (252 beds) was conducted to investigate the difference of responses to an incidentreporting system by profession, i.e., doctors, nurses, pharmacists, radiographers, medical technologists, physical therapists, dental technicians, nutritionists, and office workers. 641 incidents were collected for 6 months and the majority of incidents were reported by nurses (55.7%). The number of incidents per staff in each profession was significantly high among pharmacists (10.4/person, p<0.05), while it was lowest among doctors (0.9/person).
Replies to our questionnaire revealed that 78.1% of all staff had the experience of reporting incidents. Doctors, nutritionists and office workers figured relatively low rate of reporting. The most common reasons for reporting was an attitude of self-reflection in nurses, radiographers, physical therapists and dental technicians belonging to the group of employees working face to face with patients. Doctors, nurses and medical technologists mainly reported incidents to simplify their complicated business. The most common factor hindering their report was being busy or uncertainty about whether to submit a case or not, and the latter was outstanding in nutritionists and office workers.
170 nursing staff were divided into 9 groups according to working area to analyze the questionnaire in detail. The number of incidents per staff in each area had significantly positive correlation with the rate of self-reflection and the rate of advice to report given by their colleagues (p<0.05). The degree of recognition of feedback information was positively correlated with the rate of recommendation to report made by their supervisor (p=0.07). An incident-reporting system is a method of knowledge management to externalize tacit knowledge and construct explicit knowledge. The result indicates that we need both a grass-roots movement and a strong leadership to develop this system.

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To build up a close referral relationship between clinics or hospitals and an university hospital, it is very important for doctors at a referred hospital to write back to those referring physicians with elaborate reports concerning referred cases.
Major complaints given to our hospital's Regional Liaison Office matched with the fear felt by the referred physicians themselves. The problem is we don't have systematic follow-up system whether reports for the referred cases were sent to the referring physician, and at present moment it is only the responsibility of individual doctors to write back the reports.

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To provide further “informed consent” a visualized critical path using video-tape was produced. It is called “videopath” and is already being currently used for patients with acute myocardial infarction in our hospital with good reputation. To identify objective effect of this “videopath”, 26 healthy volunteers were separated into 2 groups; one who receives explanation only with oral and the other with the “videopath”, fifteen questions about the disease itself and management process for the patients with acute myocardial infarction were given, and the grade of understanding was measured by the number of correct answers. The mean grade of “videopath” group was significantly (p<0.05) higher. Through this investigation, it has been proved that a “videopath” is a recommendable method to obtain further and higher grade of “informed consent”. Since basic and generalized information and guidance are able to be saved with the “videopath”, it saves time. The saved time can be used for further oral explanation and personal understanding of each patient and the family. In our hospital, more than 10 another items of critical pathways with “videopath” are currently applied.

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On March 1998 in our hospital, subcommittee of critical path was established in the critical committee, in order to improve quality and efficacy of medicine. On June of that year first critical path was introduced to surgical management of cataract. 51 paths had been established by February, 2002, for first four years, about medical examinations, surgical operations, chemotherapy, etc.
But there are not a few problems to be solved in practice. There were some problems turned out around the design of critical path and in the practical use, so we undertook the solution of them.
Critical paths were not unified in form and terms because they were designed by various departments. There were a problem of terms that patient cannot understand, so that the purpose of the informed consent cannot be derived. We established “guidelines to design of critical path”, that enabled the form of critical path to be unified.
Critical paths were designed mainly by nurses, descriptions of therapeutical issues and accounts of medical fee were unsatisfactory. 10 working groups were organized including pharmacist and office clerks for the improvement. And this expanded the contents of our medical services.
But there are next subject that critical paths should be linked to ordering systems. And continuous assessment for critical paths are required through analyses of patients' satisfaction and critical variances.

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Day Surgery Center (DS) in Furukawa City Hospital was opened for public on July 9, 2001. For the purpose of alleviating patients' fears towards surgeries and offering the high quality and equally treated patient care, the hospital has introduced critical path (CP), and also care coordinators have been placed in DS.
Two major features of DS are:
1. Using CP sheets for all diseases
2. Care coordinators are involved in patient care from the time of application for admission to the time of discharging from a hospital.
All the staff as one body had prepared for the establishment of DS such as making CP sheets. We have been supporting patients and their families mentally with our smile and gentle attitudes. It has been one year since its establishment, and we have realized again the importance of the role of CP and the care coordinators in DS from the voice of our patients and other staff of our hospital. We would give every consideration for making better facility and would make effort to appeal the public the advantages of same day surgery.

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The critical path is becoming indispensable for improving the quality of medical serrice in our country, Our hospital has been introduced a hospital-scale critical path since April, the 13th year of Heisei.
Because it was made to make use of CP, it felt the need which cleared and improved problems.
So, questionnaire investigation was done this time, and it became CP it was easier to see by making a staff's opinion reflect and which was easy to use, and the purpose of the CP origin could be reconfirmed.

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This study was designed to reveal consumer's idea about medical information.
Study was made by targeting general population males and females 15 to 65 years old. Extraction method was stratified bi-level extraction by resident registry. Survey method was Questionnaire left for resident by survey staff during home visit. Study 2 was made directly to 409 male and 422 female. Response rate was 27.8%.
This study revealed consumer's idea about which information is most important about medical information, how medical information should be delivered.

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