[in Japanese]

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For diabetic patients, the critical path of a four-day educational hospitalization (four-day path) was produced. Since the hospitalization period is too short to control blood glucose, most of the cases leave our hospital before the daily profiles of blood glucose are controlled. In order to verify the effect of a four-day path on the control of diabetes after leaving hospital, case-control study was performed. The value of glycohemoglobin (HbAlc) after leaving hospital was compared with that of the patients of the two-week educational hospitalization path currently used from the former. Ten cases of the four-day hospitalization and ten cases of the two-week hospitalization in the same period were examined. HbAlc of all cases of both groups fell significantly. After thirteen months, the value of the four-day path patients and the two-week path patients were 6.8±0.6%, and 6.9±1.0%, respectively. There was no statistical significant difference of the value of HbAlc between both groups through the observation period of 13 months. Therefore, a four-day path may be an effective tool on the control of blood glucose.

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We constituted critical pathway to relief pain as quickly as possible with lesser adverse effect of opioid for noncurative cancer patients. We made out it with Microsoft Excel, and used on personal computers. In this critical pathway, “good sleeping” was set as first goal and second was “no pain in rest position”. Medications for pain relief are controlled release oxycodone plus NSAIDs and prochlorperazine, stool softener and peristaltic stimulant for adverse effects. The components for everyday assessment include the levels of pain, nausea/ vomiting, constipation, somnolence and hallucination. These outcomes lead the dosage change of opioid and/ or medicinal substitution for next day by calculation using visual basic function due to opioid titration experience. Ten patients were acceptable this critical pathway and all of them achieve the second goal within a week without severe adverse effect except for constipation rarely needed enema and/or removing by finge.

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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 and shorten the length of stay 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 case-controlled study. The control group includes 37 cases admitted between August and November in 2003, before the introduction of the critical path way. The critical pathway was used for 35 cases admitted between November 2003 and May 2004. Among these 35 cases, 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^®, Ono Pharmaceutical Co. Ltd., Osaka, Japan) and free radical scavenger (Edaravone, Radicut ^®, Mitsubishi Pharma Co., Osaka, Japan) for 2 weeks. The length of stay and infusion was determined by the doctor in charge, depending 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. Mean length of stay was 19.9 days for control group, and 15.1 days for critical path group. Critical path group showed statistically significant shortening of mean and variance of the length of stay. Critical path group showed lower hospital charge for rehabilitation and basic hospital stay, and higher charge for infusion. Total hospital charge showed no difference between 2 groups. The introduction of critical pathway had positive economic effect and the revision of critical pathway will bring better effects.

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It may be subjects common in many medical institutions that there is little incident reports submitted from doctors or that cooperation of doctors cannot be easily obtained to activity of a safety control. In this research, in order to explore this cause, a doctor's consciousness to a safety control was investigated and it aimed at clarifying the problem.
Therefore, the questionnaire was carried out for the doctors of the Toho University Hospital. It was guessed that neither transfer of the information from the Safety Control Measure Committee nor guidance of study session holding was transmitted in the doctors with shorter experience years. The defect of communication of information was considered to be one of the causes that the rate of participation to safety control study session is low. Especially, the doctors for the 4-9th year were negative to the report of complications, and their rate of participation to study session was quite low.
It will be desirable to carry out direct communication of information with E-mail since there is a limit especially in the communication of information through the man. Moreover, by holding the study session repeatedly changing the time and a day of the week, it is expected to raise a doctor's consciousness to a safety control by increasing the opportunity of participation.

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One of the most important characteristics of medical service is that the needs of patients induce medical service delivery. The delivery site, such as hospitals, nursing home, and medical doctors can not predict the incidence of the needs, therefore the marketing action has not been considered to be important.
In this report, we investigate the reality and attitude of the hospitals in Japan to marketing action. The result revealed that the management people in Japanese hospitals do not think of marketing now. However, we predict that the marketing action will be necessary for them because of the change of the environment surrounding hospitals.

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There are two important aspects in measures against nosocomial infection: one aspect is to prevent the outbreak of infection, for which thorough standard precaution should be emphasized; the other aspect is to establish a hospital environment that is robust against the emergence of drug-resistant strains, for which proper use of antibacterial agents is essential. Our committee for prevention of nosocomial infection started its initial activity of monitoring of the hospital use of antimicrobials and took subsequent measures including incorporation of an approval system for antibacterial agent use and, upon the use of vancomycin, compulsory determination of the blood concentration. The examination of changes in the drug sensitivity rate has shown a modest improvement in the past three years. This article describes the outcome of our program.

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It has been very difficult to introduce the critical path for the patient of acute myeloid leukemia (AML), because they generally need long term chemotherapy and individualized courses. To introduce the critical path for AML, we made five critical paths for medical staffs to standardize the care for patients and to prevent medical accidents.
In this study we made the critical path which was acceptable for the patients. Six AML patients cooperated to prepare the path. We asked them several questions to make use of their opinions and wishes. And we made 1) the graph expressing the effect of therapy, we called “rabbit stairs” 2) the menu of chemotherapeutics of each day and 3) the pamphlet explaining the therapeutic protocol.
Especially in this path, the AML patients and their family can examine their own bone marrow smears with their doctor, and they can discuss their chemotherapy.

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Outpatient chemotherapy is increasing due to the improved quality of life and the substantial maintenance of side effects. We have created the critical paths for breast cancer chemotherapy which is by far the most common among outpatient chemotherapy. At present, there are seven kinds of breast cancer chemotherapy paths being enforced by the department of surgery. The original purpose of their creation was to prevent medication error, to detect side effects in a timely manner, and to increase clinical efficiency. Though the results achieved by chemotherapy are undoubted, it is particularly important to measure its side effects. We utilize the critical paths in cooperation with pharmacists and nurses to explain to the patient the medical treatment schedule and the possible side effects involved. Our hospital presently is planning to make an outpatient chemotherapy unit in order to unify the various chemotherapy critical paths. We are not only concerned with safety management, but also with using the critical paths to improve the patient, psychological status and to give patients the opportunity to actively participate in the restoraction of their health.

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At the convalescent rehabilitation ward at the acute period hospital, the ideal way of the team approach such as: 1) the way of concerning a patient and a family in case of the switchover from the acute period to being convalescent, 2) the cooperation with the other department staff, 3) the cooperation among the rehabilitation staff, is a primary role. We introduced “the convalescent rehabilitation critical path (plan)” at the same time as establishing a convalescent rehabilitation ward, and then we revised it while using.
We organized a ward critical path examination meeting, because we thought that it was possible to do a rehabilitation team approach in heading for the common purpose to aim at the goal which patient himself set while pursuing the specialty of each numerous type of job.
The each representative revised a critical path regularly, and we repeated the detailed change of about 1year and revised a critical path four times in July, September October, 2003, February, 2004. In the process of revising the critical path, we asked staff members of rehabilitation ward to complete a questionnaire survey, and we used their answers as feedback to improve the pathway. After revising this critical path four times, we learned that there are several important pieces of information necessary for comprehensive rehabilitation servicing to the home support. First, the patient needs to set goals by himself. Similarly, staff members also need to set last goals. Second, staff members need to know the correct progress status of the rehabilitation. Third, staff members need to monitor the directionality of the leaving hospital and the hospital transfer from the convalescent rehabilitation ward. Moreover, in order to embody a team approach, it is important that each person in chage establishes goals and evaluates the situation, and that we confirm patients' ADL status and evaluate about the validity of the last goal during the staff meetings of the patient participatory type, and that we always review the ideal way of the team.

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In the neonatal management except the sick neonate required the hospitalization in neonatal intensive care unit (NICU), adaptation in the environmental change after birth is important. And there is little diversity in the processes, such as observation, intervention, and disposal. Since the outcome is clear like the stability of a respiratory state, or establishment of nursing, it is comparatively easy to introduce critical path in neonatal care. In our hospital, while introducing the critical path in general pediatrics, the conventional neonatal management process is summarized in the neonatal management system using FileMaker Pro, and the system called “neonatal management file” is operating from August 2003.
In this paper, we report the mounting experiment of the neonatal management system and some consideration is added.

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During the 2003/2004 influenza season, we studied the influenza immunization rate number of influenza patients, preventive measures, and post-exposure prophylaxis with oseltamivir, in 198 patients who were admitted to five wards for physically and mentally handicapped patients.
In spite of an influenza immunization rate of 80-100%, 32 of the 40 patients in one ward caught influenza. The reason for the epidemic in the ward was that the first patient was thought to have a common respiratory infection not influenza, since influenza had not spread in our area, consequently, the patient was not immediately isolated from other patients in the same ward.
Influenza did not spread to the rest of the four wards because patients with a fever were immediately isolated from other patients in the same ward. In addition, patient who had been exposed to influenza were administered oseltamivir for post-exposure prophylaxis. The patients administered oseltamivir did not catch influenza and no side effects from the medication were observed. Therefore, it is very important during the influenza season to immediately isolate patients with a fever from other patients in wards for the physically and mentally handicapped. Furthermore, administration of oseltamivir for post-exposure prophylaxis is effective for the prevention of influenza epidemics.

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We describe a system for synchronized video-file viewing and the results of a field experiment with the system. With the recent increase in the number of broadband network users, the commercial prospects for video teleconferencing have greatly improved. Today's broadband network service is best effort and doesn't provide guarantees of bandwidth, so the available bandwidth is constantly changing. Therefore, in the video-teleconferencing system, we give voice communication priority and change the frame rate of the images to suit the available bandwidth. The system has a file-sharing function (e. g. Power Point and Excel). For the system to be useful to sports medicine, the shareable file types will have to include video types (e. g. of operation and rehabilitation). However, the impossibility of maintaining a constant frame rate the real-time sharing of moving pictures difficult. We thus propose a synchronized-viewing system for the collaborative use of moving pictures. In this system, video files to be shared are distributed by FTP before the collaboration, along with the command sequences to control playback, etc., of the files. This allows synchronized play back of the files on a best-effort network.

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Following recent changes among acute phase medical treatments, such as examination and simple treatment, even surgery has been switching over from being “hospitalization-centered” to “outpatient-centered”. As our first efforts, in accordance with this movement, we started with chemotherapy at the Outpatient All-round Treatment Center (referred to the Center hereafter) of our hospital. We discuss here the outline of our Center's program, efficiency of its operation, importance of the presence of full-time pharmacologist (s), preventive measures for adverse effects of the treatments in the Center, merits of day-surgery, and advantages in hospital management. We have found that this system produces a number of advantages not only for the patients and their families but also the hospital workers as well. It would be our pleasure if “outpatient-centered” hospital treatments become practiced more actively, and in turn contribute towards the popularization of the at-homecentered medical treatment system, a stated policy goal of the Ministry of Welfare and Labor.

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Recently, the number of patients coming to ER is increasing in number. Moreover, advanced and precise medical care is required. This causes many problems to doctors and safety management. When our new ER named “ER-Yokkaichi” was opened, the work shift system of doctors has been changed. The detail of our system is reported here.
Previous system: One 1st-year resident and one 2nd-year resident were at work in the ER, backed up by one internist and one surgeon. All four doctors were on duty the next day. All patients were diagnosed by the residents first. The two senior doctors were called when the patients were judged serious. New system: One 1st-year resident, one 2nd-year resident, one emergency doctor (3rd or 4th-year resident), one internist and one surgeon are on duty everyday. The three younger doctors are off duty the next day. All patients are diagnosed by the residents first, and then double-checked by the emergency doctor. The senior doctors are called when the patient needs hospital stay. Our approach is considered to be one of the methods to improve the quality and safety management level of ER.

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