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 practice EBM are believed to be the critical paths. When evaluating the results of clinical trials, we must consider the systematic errors, so called ‘bias’. The most ideal research design to avoid bias is a randomized controlled trial (RCT). In this review, I demonstrate how to search RCT papers using an internet search engine ‘PubMed’ and some results on postoperative care. Incorporating the evidence into critical paths will improve the quality of care.

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We created three types of critical pathways; rehabilitation for the patients with mild, moderate and severe cerebral infarction, and introduced them into clinical practice in March 2004. For evaluation and improvement, we compared several clinical indicators for three groups of patients with cerebral infarction; 33 patients hospitalized in same month of one year before introducing critical pathways (group A), 32 patients just before introducing critical pathways (group B), and 43 patients who was managed with critical pathways (group C) among 86 patients hospitalized after the introducing critical pathways. Also we investigated the state of critical pathways usage and variance. Group C showed significantly better modified Rankin Scale (mRS), Glasgow Outcome Scale (GOS), and Functional Independence Measure (FIM), improvement rate, etc. than group A and B (p<0.05).
There were 13 drop-outs from critical pathways in 43 patients who was managed with critical pathways, and the major reason of drop-out was inappropriate recording. Thirty patients (70%) completed critical pathways, and the major variance of these cases was delay of schedule. It also became clear that the content and the method of critical pathways recording varied among each staffs, and the understanding for critical pathways is poor for rehabilitation and nursing staffs. In the future, further analysis of variance and effect of the critical pathways will be needed to improve its form and use. Also, it is important to standardize the usage of critical pathways by making user manuals, and to educate rehabilitation and nursing staffs. Moreover, it is necessary for every staff to work in closer connection and corporation among other sections.

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In this study, we tried to change the duration of postoperative prophylactic medication of antibiotics from three days to only one day in our critical pathway for total gastrectomy, and the kind of antibiotic from Flomoxf (FMOX) to Cefazolin (CEZ). The propriety of critical pathway was evaluated in terms of postoperative complications, especially infection. [Patients and method] Therewere three groups such as group A, Group B and group C. Group A consisted of 75 patients who received FMOX for four days, from operative day to the third postoperative day after total gastrectomy. Group B consisted of 59 patients who received FMOX in the operative day alone, and group C consisted of 25 patients who received CEZ in the operative day alone. In each group, the antibiotic of 1g was medicated in drip infusion twice on the operative day before and after surgery. Furthermore, group A was added intravenous infusion of 1g FMOX twice a day for three days. [Results] 1. There were no statistical difference about the incidence of post-operative complications and infections among three groups. But the incidence of 52% was highest in the group C. 2. There was little difference about the change of fever pattern for three days after surgery. After 4th day, the number of patients with fever more than 37.5°C was 68% in group B, and there was a significant difference between group A and group B. 3. In the clonological change of WBC and CRP as a laboratory data, there was any difference in WBC between three groups but CRP was higher in the group C. [Conclusion] The prophylactic CEZ oneday medication in the critical path for the total gastrectomy was judged to be clinically acceptable, though the incidence of post-operative complications tended to be slightly high.

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We suppose that few patients successfully treated with percutaneous coronary intervention (PCI) after acute myocardial ischemia (AMI) may drop out from a critical path treatment. We analyzed variances of our 2-week critical path for these patients. We studied consecutive 28 patients successfully treated with PCI after AMI, who were treated according to our 2-week critical path. We divided the patients into 2 groups; group A (n= 18) was the patients who were discharged within 2 weeks, group B (n=10) was the patients who were hospitalized over 2 weeks. We compared clinical and coronary characteristics and serum peak CPK level of the groups. Then, we analyzed variances of group B. Serum peak CPK level was significantly higher (group A: B=1058: 2620IU/ml, p<0.001) and the ratio of residual coronary stenosis and late complication were higher in group B (p<0.05). However, the main reason why hospitalization exceeded 2 weeks was assessing the coronary risk factors and educating the patients. Though the patients who hospitalized exceed the period of 2-week critical path had large infarction size, complicated coronary lesion and many late complications, these were not the main reasons of variances but needed more intensive assessments and education. We propose that the patients with small infarction size can safely treat for less than 2 weeks.

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Previously we made patient satisfaction measure HPSQ-25 as the initial product. Though it had good psychometric proprieties, factor structure analysis suggested reducing the number of the 6 subscales and the 25 items. In this study, we tried to reconstruct the HPSQ-25 and reduce question items to a simple and easy standard. We conducted the self-administered questionnaire survey using HPSQ-25 for 386 inpatients at three medical facilities of Kanto District again and reduced an item using a constant rule.
Results of the reanalysis showed that the four different dimensions in the HPSQ-25 can be concentrated into only one conceptual category “communication aspects between inpatients and staff”, and the 17 items composing the 4 dimensions can be reduced to 6 items. The reconstructed satisfaction questionnaire for inpatients then became to be composed of 13 items and three subscales. The reliability and validity of the new measurement were tested and obtained successful psychometric proprieties.

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The infection control link-nurses act as a link between their own work-place and the infection control team in the hospital. To motivate the infection control link-nurses in our hospital, we had introduced four working groups. After belong to the one of four working groups, the link-nurses worked the part of the infection control work that the infection control team had been done. We have done an awareness survey regarding the role of link-nurse before and one year after the introduction of working group system.
Although only 6 out of 11 link-nurses had the concern for an infection control before becoming the infection control link-nurses, the majority of the link-nurses replied the change of consciousness for the infection control. Regarding the working groups, the link-nurses gave the good evaluation in spite of additional burdens in the work-place. In addition, 10 out of 11 link-nurses replied an additional change of consciousness for infection control after the practical works of infection control by the introduction of working groups. Thus, we confirmed the proof of an insufficient awareness of link-nurses just become a link-nurse in this study.

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In this study, we analyzed the change of pharmacy services and its influential factors including the long-term care insurance system and investigated strategies for maximizing the current role of the pharmacy in the community from 1999 to 2004. Self-administered questionnaires were mailed to all pharmacies in the suburban area. Factor analysis was used to compare the change in pharmacy services and structure of pharmacy function before and after the introduction of the long-term care system.
Three factors were extracted from the survey of pharmacy function after the introduction of the long-term care system: “Filling of prescriptions, ” “Health and welfare-related services, ” and “Supply of goods.” Factor analysis indicated that home visits, participation in activities designed to promote health and proper drug use in the community, and coordinated interaction with home-care professionals are closely related to implementation of an improved system of home-care and welfare-services counseling.
The introduction of long-term care insurance did not have an intrinsic effect on the basic functions of the pharmacy, but it assigned a more central role to health and welfare services as a core pharmacy function. Positive commitment to communication with other professionals and activities to promote health is an effective way for pharmacists to improve health and welfare services in the local community.

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Critical pathway in the surgical ward of Sanin Rosai Hospital was introduced by doctors and nurses at first in 1999 and we use 19 kinds of critical pathways now. It has been developing into the collaboration of the team medical treatment by participation of a pharmacist, a dietitian and other paramedical staffs for these five years. We divide these five years into five groups. The 1st term: The creation and introduction of the critical pathway by doctors and nurses. The 2nd term: Start of the critical pathway committee in Sanin Rosai Hospital inauguration. The 3rd term: The start of team medical treatment with the participation of the other paramedical staffs. The 4th term: Full team medical treatment. The 5th term: Expansion of team medical treatment. We find that team medical treatment is progressed by critical pathway introduction and patient's medical treatment is improved in the quality of care. Also it has become clear that patients understand their own treatment well and actively participate in them from their questionnaire. Although the critical pathway of surgical ward is the source of critical pathway promotion in the whole hospital, there is a big difference among each ward. So we need to consider the promotion of critical pathway in the whole hospital and must start the sharing of the patient information and record among medical staffs and the level up of outcome for further team medical treatment development and arrange the ordering system in the future.

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Critical pathway was introduced in Kagawa Rosai Hospital in 1999. Study meetings for critical pathway of our own hospital or those from other hospitals were held for three years, and 140 critical pathways were made. During the studies for standardization of prevention of pulmonary thromboembolism, and an overturn or a fall of the patient, and of proper use of antibiotics, it seemed to be necessary to have a joint meeting with other committees such as safety keeping or infection control committees. And then monthly joint meetings named critical pathway, or CQI (continuous quality improvement)·critical pathway were held 35 times during following three years from 2002. On the average, 99 members attended the meeting and 8.2 presentations were made in a meeting. 30% of presentation was concerning about critical pathway, another 30% was concerning about other committees, and remaining 40% was about other subjects. Until now, 350 critical pathways have been made, and 14 standards of medical treatment have been made after conference with other committees. Furthermore, presentations about concerned subjects, such as order entry system, hospital accreditation by Japan Council for Quality Health Care, and adding the hospitals collaborate with DPC investigation, were increased at that time, and all of them finished without any trouble.
In conclusion, CQI·critical pathway meeting is useful for improvement of quality and standardization of medical treatment, and for promotion of medical team care.

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Incident reporting system is one of the information gathering method in healthcare risk management. Before 2002, incident reports were gathered by paper from nurses division only. After 2003, reports were gathered through local area network (LAN) from all occupational categories in hospital. The incident reports by paper from July to December in 2002 were compared to the reports through LAN from July to December in 2003. As a result, number of incident reports by paper was 1367 cases and that through LAN was 2177 cases. It has increased by a factor of 1.5. In the incident reports through LAN, the nursing employment accounted for 86% of the content of occupational category. The number of report from doctor, clerical work staff and pharmacist was little. By sharing and analyzing the incident report through LAN, we could respond more quickly to the incident.

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We, Mito General Hospital received certificate of accreditation of International Organization for Standardization (ISO) 9001 of 2000th for improving the quality of the medical treatment in May 11th, 2001. To the process, the patients have been taken the central figure within the guarantee, approach to process, leadership, moreover have been kept improving the quality of the medical treatment by PDCA (Plan, Do, Check, Act) Cycle. We also received the Functional Evaluation Item for supply the insufficient skill of 1509001, and certified Ver4.0 in April 2004. This time, we report the verification item by comparing between 1509001 system and the Functional Evaluation Item.

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The nutrition support team (NST) established on 2001, has been practicing the nutrition care of the patients with nutritional disorder and has enlightened its significance on disease therapy to all staffs. The self-developed application software as NST support tool, built in electrical medical record system, brought remarkable improvement of efficiency and quality level of nutrition control. It also became easy to check operation manuals, critical paths and other information about nutrition control, through the NST web site in the hospital intranet. Furthermore, in cooperation with infection control team, NST achieved various results, such as the decrease in the number of cases of total parenteral nutrition and the increase in that of enteral nutrition, and also the reduction of antibiotics consumption. We have developed special meal for the patient with chronic obstructive pulmonary disease (COPD), which is composed of general staple, lipid-and protein-rich side dish, and between-meal snack. This meal contributed for the improvement of general condition and quality of life of patient.
NST has become to be indispensable in our hospital. However, the fact that the NST are excessively relied on by other staff is big burden of NST member. Therefore, it is necessary to further infiltrate the hospital policy “Mind of sympathy supporting by fine team work”.

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