Under shortening of average length of hospital stay and the environment of introduction of DPC (Diagnosis Procedure Combination) Payment System, introduction of systematic nutrition care management is an urgent issue in order to prevent prolongation of hospital stay due to hospital malnutrition.
For this reason, the Nutrition-path which is a nutrition-related critical path attracts attention. We reviewed the Nutrition-path in this paper as follows; the review about the national questionnaire result about a nutrition path and the following 10 points of a nutrition path.
(1) Including nutrition care management (NCM) in path, (2) Clinical practice guideline relevant to nutrition are referred to at the time of path creation, (3) The combined use with nutrition path and the clinical practice guideline about nutrition, (4) The information disclosure as part of the medical treatment, (5) Set-up of nutrition outcome, (6) Set-up of nutrition variance, (7) Set-up of clinical indicator, (8) The application to risk management, (9) The nutrition path to DPC application, (10) Nutrition electronic path.

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Evidence-based medicine (EBM) has been advocated since 1990' to obtain best outcome in clinical practice based on the results of previous works. Since the purpose of EBM is similar to that of critical paths, the best places to do EBM are the critical paths. The practice of EBM consists of 5 steps, including finding the best evidences and critically appraising the evidence found. It is important to judge the levels of evidence obtained. To judge the levels of evidence, the classification made by Oxford-centre for evidence-based medicine is clear and convenient. EBM can be designated as a medicine based on the highest levels of evidence currently avail able. To be sure, physicians should be aware of the variability of patient's population and respect their sense of values as much as possible. EBM is not a “cookbook” medicine. Physicians should always consider whether or not the evidence obtained can be applied to their patients after analyzing the characteristics of them. Therefore, it is also important to change the orders of critical paths without hesitation, when physicians thought them inappropriate for their patients. In this manuscript, we describe the concept, components and efficacy of EBM based on our experiences.

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The effect of the critical path for patients, who received total abdominal hysterectomy (following ATH) in our department was evaluated by using the Matsushita's criterion. The following points were evaluated; 1. cli nical effects, 2. patients'satisfactory effects, 3. economic effects, for the 162 ATH pathes we used between January 1999 and December 2002. Average hospital stay in 2002 decreased by 4.9 days, total amounts of hospitalization in 2002 increased by 9.7%, rewards of practice per one patient in a day in 2002 increased by 19.7%, compared with those of 1999. Also, in the questionnaire survey for the patients, everyone replied “satisfaction”for the contents and necessity of the path, as well as correspondence of the nurse who explains about the path. It was possible to improve the informed consent and degree of patients'satisfaction by using the path. In addition, the improvement of critical path by collaborating work with physician, nurse, pharmacist and the medical treatment desk work person enabled us to shorten the hospital stay and increase the reward of practice.

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The critical path for the distal gastrectomy, which was shortened prophylactic antibiotic medication from three days after surgery to the operation day alone, is being tried in our hospital. It was compared about the validity of this critical path concerning about postoperative complications (especially, infection). [Patients and method] The A group for 3 days antibiotic medication after surgery was consisted of 109 patients until October from January in 2001, and the B group for one day medication was consisted of 137 patients from October in 2001 to October in 2002. As for the antibiotic, FMOX of 1g was intravenously infused before and after surgery (A group, B group), on the other hand, it was infused two times per day on the operating day and 3 days after surgery (A group). [Result] 1. Though there were more men in the B group than in the A group significantly, there was no difference in the age, stage, surgical procedures, duration of the hospital stay after surgery. The frequency of the past history was higher in the B group significantly. 2. There was no difference about postoperative complications, 21.1% of the A groups and 19.0% of the B groups, respectively. As for infection, there was also no difference between two groups. 3. There was no difference in a change of fever for three days after surgery. The frequency of the febrile cases (more than 37.5 degrees after the 4th postoperative day) was 24.8% in the A group and 31.4% in the B group, and there was no difference for the antibiotic re-medication rate, 10.1% in the A group and 19.7% in the B group, respectively. 4. The B group showed higher leukocyte count and CRP than the A group on the 7th postoperative day due to more often occurrence of postoperative pancreatitis. [Conclusion] Critical path of distal gastrectomy with prophylactic antibiotic one-day medication method was appropriate, and continuous use would be possible.

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We investigated the waiting time at the outpatient's clinic for evaluation of order entry system which developed in March, 2002.
Before the system introduction, an operation flow was reconstructed drastically and the business share was systematized among doctor, nurse, and the clerical worker originally based on the true work.
15, 185 patients who consulted to the outpatient's clinic of the National Nagasaki Medical Center every third week from October, 2002 to April, 2003 were investigated the waiting time (registration time to check out time). The waiting time was decreased gradually every month, the average time was 1: 45 and in only the first visit was 2: 21.
It was most important to re-engineer the working process before information system was developed in the field of medicine.

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We have engaged to reduce the incidence of medication error by reforming a hospital practice manual. However, it has sometimes been ignored to speak out the name, dosage, rout of drugs and the patient's name when dispensing or administering the drugs, although this practice was clearly documented in our manual. To increase the implementation rate of “Speaking out practice”, we made a video that shows how and when to perform “Speaking out practice”. Following the instruction to nurses using this video, the implementation rate was slightly increased. Many nurses recognized the importance of “Speaking out practice”. This may result from an advantage of image device over the manual that can be easily understood. These results suggest that the present video instruction might be useful in training health care workers to prevent medication error.

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Nursing care insurance system, in Japan has been started since April 2000. Our day care rehabilitation section is related to this pay system according to the grade (1 to 5) in nursing the out-patient. Cost price of nursing was calculated by Activity Based Costing (ABC) method and the most profitable grades were studied.
Almost all activities composed of direct nursing, such as recreation, handicraft, physical training for grade 1, 2 and 3, recreation, handicraft, helping of self-support, mental comfort and keeping watching of patient for grade 4 and 5, respectively.
Cost of nursing by enrolled nurse and assistant-nurse were 59 and 21 Japanese-yen per minute, respectively.
In comparison with the fixed fee by this insurance and ABC-based cost, The former was higher than latter, 2915yen in grade 1, 2874 yen in grade 2 and 4598yen in grade 3, respectively. On the contrary, ABC-based cost was higher, 183yen in grade 4 and 1412yen in grade 5.
It is better to have clients of grade 1 to 3, especially 3. Proper arrangement of manpower is also important.

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In April 2001, a regional collaboration system was established to improve collaboration with medical associations. By constructing and managing a database for referred patients, we are now able to promptly respond to inquiries posed by collaborating physicians. By promoting fax reservations for various examinations and tests, the waiting time for patients has been reduced. The results of a follow-up study showed that about 80% of the patients had transferred back to the referring hospital within two months, or in other words, most patients had finished their treatments within this period of time. In 2001, the rate of reverse referral was 75.9%, and it was high for department managers or higher, but there were differences among the departments. While the number of first-time patients has not changed markedly, the number of referred patients has increased, and as a result, the referral rate increased from 27.5 to 34.2%. The hospital bed occupancy rate has decreased slightly each year, but it was still high at 97.0% in 2001. Furthermore, the average hospital stay of 19.0 days in 2000 was shortened to 17.2 days in 2001. Starting in December 2001, the Gifu Prefecture Medical Association began making fax reservations for examinations and tests. Referred patients used to wait 1 to 2 hours, but after implementing this system, the waiting time has been markedly shorter. In the future, the following issues need to be addressed: 1) Improve collaboration by referring patients back to the referring hospital (reverse referral); 2) Promote sharing of expensive medical equipment and simplification of reservations for various tests and examinations; 3) Inform the involved parties to encourage the use of fax reservations for various tests and examinations; 4) Establish a system that can smoothly accept emergency patients; 5) Build a network with other regional medical institutions to avoid the duplication of tests and examinations; 6) Promote reverse referral, make the necessary arrangements when discharging patients, and contact the location where patients are being sent; and 7) Promote home care.

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Digital divide is the problem of producing an information gap between those who can use information technologies, such as a personal computer and the Internet, and those who cannot do. In the United States, this problem was already discussed in the mid-1990s. Also in Japan, the importance is emphasized in the general information field in recent years. The wave of computerization of a medical community rolled in quickly. For the hospital which missed the wave, Digital divide is just a life-and-death problem. However, since the minor scale hospital is put on the severe situation by the influence of medical system reform, it is not easy unlike a large-scale hospital or a public hospital, to invest a large amount and to introduce medical information systems, such as electronic medical record system and HIS-RIS-PACS. However, the wave of computerization of a medical community cannot be bypassed and missing the wave means losing the struggle for existence between hospitals.
In our hospital, the medical operating support system was built in the whole hospital in 2000 using the FileMaker Pro which is commercial database software, and it has contributed to improvement in the quality of medical examination, an improvement of medical efficiency, or improvement in the degree of patient satisfactory. In this paper, we described the advantage of this system and also considered the directivity to which a minor scale hospital should progress in the storm of medical computerization.

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Clinical research coordinators (CRCs) are expected to play important roles in carrying out clinical studies in accordance with the new GCP. However, CRCs are not so well understood in their name and activities. In order to clarify the present situation and activities of CRC, we set a questionaire on the members of medical staffs including doctors, nurses, pharmaceutists, laboratory technologists and administrative officials in Sendai National Hospital.
According to the results, the presence of CRCs were well recognized in 70% and 50% of doctors and nurses, but 30-40% of the staffs did not know even the name of CRC. The activities of CRCs covered included care and examination of the examinee patients (36%), control of the study schedule (25%), data recording (20%), assistance of doctors' obtaining informed concents (5%), completion of clinical report forms (5%), telephone communication with the examinee patients (4%) and others (5%).
The CRCs cover the very wide range of activities and these activities are not performed independently from each other, but comprehensively coordinated by one CRC. In order to better the present situation of CRCs in the clinical studies, the whole staff of the hospital are expected to recognize their role and activities, sharing all kinds of information and making good mutual communication. It should be emphasized that the CRCs make remarkable contribution to improve the reliable relations between patients and medical staffs through careful nursing, safety management and good account to the patients.

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Since the inauguration of public nursing care insurance, physical restraint in long-term care based medical facilities has been banned in principle. However, there is still confusion in clinical practice including the interpretation of physical restraint itself. “Guidance toward no physical restraint” summarized in the Ministry of Health, Labor and Welfare in March 2001 defines specific acts of physical restraint. However, its fundamental conceptualization remains vague. Our hospital, a long-term care based medical facility located in Shizuoka, established its “No Physical Restraint Committee” in April 2001, and completed its original basic guidelines. These guidelines feature a five-rank classification of various physical restraint acts. Restraint at the building and facility level (Level I) may be open to objection, hence these guidelines suggest the possibility of transfer to a lower level even if physical restraint cannot be abolished completely. Moreover, these guidelines address subjects including: the evaluation of risk of falling in the hospital, progress observation, treatment for each patient, and procedures for physical restraint and its periodical revision, as well as improvement in hardware such as living environments and welfare equipment. Recently, the abolition of physical restraint engenders controversy in long-term care facilities. However, because this is considered to be a medical management issue that may also affects acute-phase hospitals in the future, it is inferred to be necessary to discuss immediate action for this issue.

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