[in Japanese]

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The patients with cerebral infarction show variable neurological symptoms and variable pattern of recovery. Critical pathway is the method to facilitate recovery by standardizing the course of therapy and care. Validity of critical pathway for the patient with cerebral infarction has not established yet. We developed critical pathway for the patient with acute mild cerebral infarction and analyzed clinical effect of the pathway. This is historically controlled non-randomized study. The control group includes 37 patients admitted between August and November in 2003, before the introduction of the critical pathway. The critical pathway was used for 35 patients admitted between November 2003 and May 2004. Among these 35 patients, only 1 patient failed to complete the pathway, because he developed pneumonia after admission. So critical pathway group included 34 cases that completed the pathway. Our stroke critical pathway includes the order of the infusion of anti-platelet drug (Ozagrel Na, Cataclot ^®) and free radical scavenger (Edaravone, Radicut ^®) for 2 weeks. The length of stay and infusion was determined by the doctor in charge, depend on the patient condition. There were no significant differences in backgrounds, symptoms, responsible lesions, neurological findings, ADL, complications, accompanying diseases between control and pathway groups. Neurological complications were seen in only control group, not in critical pathway group. There were significant improvements in NIHSS in both groups. This result means the introduction of critical pathway for the management of acute stroke patient does not bring significant clinical improvement. In our literature review, clinical effectiveness of critical pathway for the management of acute stroke patient was not reported in the literature. Critical pathway is most effective for the disease with predictable course. Because control group received effective standard therapy before the introduction of critical pathway, the clinical effect of critical pathway was not significant.

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Nineteen patients over the age of 80 undergoing surgery, ten for gastric cancer and nine for colorectal cancer, were studied to analyze the etiology of postoperative delirium in elderly patients, and to elucidate appropriate preventative nursing care.
Postoperative delirium occurred in 7 out of the 19 (37%). These (“A group”) were evaluated comparatively with the other 12 (“B group”) in order to investigate the background factors. Regarding operative procedure, the incidence rate of delirium was 66% (6/9) in patients with colorectal cancer, and 10% (1/10) in patients with gastric cancer: significantly higher in the former (p=0.0198). However, A and B groups showed no difference in preoperative Hb, vital capacity, blood loss and the postoperative value of serum Na. Further investigation with more cases might be recommended in these points. Regarding the postoperative course of care, the first flatus was 5±1 days in A group, and 4±1 days in B group, the former significantly later than the latter (p=0.0064). The first bowel movement also tended to be later in A group. Preoperative long starvation seemed to be associated with postoperative delirium, since all of the three patients who had colorectal stenosis requiring total parental nutrition underwent delirium. The following two points should also be given sufficient consideration during nursing in addition to the various guidelines on preventative measures for postoperative delirium in patients over the age of 80. 1) In aged patients who suffer from ileus due to colorectal cancer necessitating preoperative fasting and IVH treatment, particular effort should be made with prevention and early detection and treatment. 2) Postoperative recovery of bowel movement is delayed in patients with postoperative delirium, so sufficient nursing assistance with position change and early ambulation should be given.

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There are few reports on the actual behavior of nurses when they are uncertain about medicines or anxious their medicinal knowledge. We investigated whether, in such situations, the actual behavior varied depending on nurses' career. The present investigation was conducted by giving questionnaires mostly about “anxieties about their medicinal knowledge and measures taken” to inpatint clinic nurses in the department of cardiology and cardiovascular surgery. In addition, the inquiries about medicinal knowledge from the nurses to the pharmacists in charge of the ward were recorded, and the content of the inquiries was analyzed. To the question “Do you have any anxiety about your medicinal knowledge?” all nurses had anxieties. Regarding the measures taken at work when they are uncertain about medicines, 72%, 31% and 29% of nurses replied, “Ask peer nurses, ” “Ask physicians” and “Ask pharmacists, ” respectively. The results were examined separately for nurses with less than three years experience and for those with at least three years experience. The answer “Ask peer nurses” was selected by 93% of them with less than three years experience and 62% of them with at least three years experience. On the other hand, as regard to the inquiries from nurses to pharmacists, 21% were about the details of medicines, 21% about medicinal management such as conservative method, 8% about the pharmacology, 8% about the compatibility of mixture, and 6% about the interactions. Thus, since nurses with less experience tend to ask questions to their peer nurses, expert nurses are required to provide appropriate guidance to less-experienced nurses bases on their experience and accurate knowledge. In addition, this result suggests the need for the establishment of an environment where nurses can easily ask questions to other professionals, such as physician and pharmacists.

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Conventional daily nursing care system had failed to undergo an individual and continuous care for patients because of an inconsequently care. Here in we have adopted a fixed and continuous nursing care system since April, 2003, and examined whether we could provide a more excellent nursing care. As a result of the current studies, we could have evidence that the frequency of patients' accidental falls and bedsores were markedly reduced. This improvement was probably due to the reason that the system enabled us to predict those risks. Because the relationship between nursing staffs and patients became intimate and the care needed for patients became very clear, and furthermore because the system gave us precise informations.In addition, in the present study the attempts have been usefully for an understanding of the patient's disorder itself and the planning of the treatment as well, followed by a consistent nursing care in a team.
In conclusion, this new nursing care system will bring great benefits for many patients. Needless to say, the most important status for the attempts is that each nurse realizes their own role and responsibility.

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We report the outcome of NST activity conducted in a small hospital that is specialized in dialysis. Six months after initiation of NST, comparison of total parenteral nutrition (TPN) and enteral nutrition (EN) in terms of number of patients and patient-days showed EN overtaking TPN with the number of EN cases becoming dominant. Annual usage of antibiotics of the third generation or later decreased by half. Usage of cephem, carbapenem, and vancomycin decreased from 574 to 237, 252 to 154, and 298 to 158, respectively. Usage of globulin preparations also deceased from 119 to 41, resulting in a cost reduction of 3.97 million yen/year. Usage of vancomycin suggested a reduction in the occurrence of MRSA. The number of patients with pressure ulcers decreased one year after starting NST, at which time no more than 5% of inpatients suffered from pressure ulcers. No shortening of the average hospital stay was observed after establishment of NST. We did not initiate the critical path. In addition to the outcomes shown above, establishment of NST brought to the hospital a climate of team medicine. A team oriented towards combating pressure ulcers, a swallowing training team, and an infection control team were established, and preparations for establishment of a critical path steering committee are now under way. We believe that the establishment of NST was highly effective in fostering of human resources and innovation of the climate thanks to the small size of the hospital, although the numerical outcome may not have been totally satisfactory.

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Hospital management is usually carried out by a basic management organization and committees. Our hospital has recently reorganized those committees to increase their efficiency. At the beginning we created the Committee Reorganization Project Team which was composed of 12 members. This team performed surveys of the current committee's status and improved in its problems in order to develop a new organization. Under the former organization, there were 26 committees, which were non-systematically named. One person tended to serve as a chairman of multiple committees and their schedule were not well coordinated. They had neither criterion for these establishments nor well defined their individual duties and powers. The project team therefore prepared criteria for establishing new committees. According to the criteria, each committee would compose of hospital members from multiple units, and would have intermediate decision-making authority. All chairpersons were appointed under criteria. Furthermore the TQM committee was organized to oversee the system as whole. All committees are required to submit their goals, actual results, proceedings, etc. The TQM committee checks their activities to adjust each of them. The Departmental Head Committee continues to function as a higher leveled organization which is separated from the committee system. Of the remaining 25 committees, 15 have continued, 4 were combined, 2 were abolished and 12 committees were organized. In this way, the committee system at hospital has been reorganized into 29 committees in 8 departments. As a rule, the regular meetings are held out of business hours. In April 2003, the committees began to function fully under the new system with favorable outcomes. Our present resolution is how committee members should be remunerated for participation.

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Healthcare is in a area of service from the standpoint of marketing. However, medical service has several points that distinguish themselves from other services. The characteristics are as follows; 1) the asymmetry of information is very huge, 2) the outcome of medical service is uncertain, 3) the service is demanded only when consumer needs it.
However, the medical service providers have to take consumer (patient) satisfaction into considerationnowadays. In this paper, how to adapt marketing to medical service is investigated. Then, differentiationstrategy is emphasized.

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