The liaison critical path created by the Hip Fracture Seamless Care Society in Kumamoto City was prepared and managed on the basis of the necessary criteria for a liaison critical path. It is very useful in improving quality and efficient cooperation of medical liaison treatment. But the liaison critical path doesn't effectively improve the quality and efficiency of the liaison medical treatment, unless it is theoretically backed up.

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In November 2005 the Seamless Care Study Society of Kawaga Prefecture introduced a region wide critical path of cerebral apoplexy in the central and western part of the prefecture. The activities of the Seamless Care Study Society were useful in establishing a human network between multi-occupational medical professionals. Although this region wide critical path is at present employed smoothly, the following new topics are currently under discussion:
1) An additional Seamless Care Study Society was established in Takamatsu City and the East part of the prefecture and since then a region wide critical path of cerebral apoplexy has been in use in the whole prefecture.
2) A home regional wide critical path was drawn up and introduced.
3) In correspondence to amendments to the Medical Service Law and Medical Treatment Fee System, the software of the regional wide critical path of cerebral apoplexy was updated.
4) A secure system, which enables employment of the Internet using K-MIX (Kagawa Internet Medical Exchange), is under construction for easier data analysis and better use of soft mechanism.

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This study assessed the present state of the regional cooperation network in Kumamoto regarding strokes in addition to studying the regional cooperation of the last 13 years. 2 Years later, after sufficient discussions, a liaison critical path for stroke was introduced.
In this critical path system, sheets of the liaison path were passed from the acute stage to a convalescence stage, a maintenance stage and the final stage of home medical care.
Presently 65 hospitals and facilities participate and operate this critical path. The next stage will be to introduce cooperation between the network of rehabilitation doctors and home doctors.

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[in Japanese]

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[in Japanese]

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In January 2006 an electronic health record system was introduced at the Yamagata City Hospital Saiseikan. Simultaneously the automatic ampoule picking system and the bar-code injection enforcement certification system were adopted with the purpose of preventing patients' misunderstanding and errors in injection enforcement.
We analyzed the incident reports on injection enforcement during the eight months just after the system's introduction, comparing them with 197, 121 cases of all injection enforcement certification data over this same period.
The incident rate in the period was 0.049% totally. According to the incident level of our hospital, level 0 was 0.009%, level 1 0.033%, level 2 0.007% and there were no accidents of more than level 3, which are harmful to patients.
During one day, high incident rates were observed at 7:00, 12:00, 17:00 and 22:00, but this did not coincide with the number of injection enforcement.
In a classification of drug efficacy, the incident rate with antineoplastic drug was the highest at 0.668%, and the next highest was with hormonal drugs at 0.093%.
The incident rate increased with the number of mixed drugs. Especially, in the cases of mixing more than 3 drugs, the incident rate was significantly higher than mixing no or with less drugs.
There was no difference though in the incident rate between usual orders and temporary orders.

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In order to explore the role of the Medical Social Worker (MSW) at the hospital, this study compares the assessment in regard of MSWs duty by MSWs, medical staff and office workers and analyzes the MSWs' selfrating.
First, using questionnaires including 22 questions in line with the MSW operational guidelines issued by the Ministry of Health, Labor and Welfare of Japan, 645 people assessed the importance of the MSWs' duty. In addition, by replying to the 42 questions of the MSW professional self-rating system proposed by Minami et al, 94 MSWs evaluated their own performance, both how they should ideally perform and how they actually performed.
There was a large discrepancy between the answers of the MSWs and the office workers regarding patients' life and social support influenced by the MSW's tasks. Concerning the MSW self-rating, the study found a great difference between the ideal and actual performances in the categories “knowledge and theory”, “education and self-training” and “professional skills”.
The category, which ideal score was lowest, was “self-motivation or autonomy”. The results suggest that all the staff working at a hospital should recognize the importance of the MSW's duty on the same level and that education and training for MSWs should be further developed to promote wider autonomy of the MSW.

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Recently numbers of chronic hepatitis C patients, treated with interferon, have been increasing. This fact in mind it becomes more and more important to predict the medical outcome, to decide early on the necessity of continuation or discontinuation of the treatment and to detect complications. In many cases it is impossible to introduce and maintain treatment while observing patients in general medical institutes or clinics alone, a liaison between those and liver diseases specialized institutes is therefore recommended. A questionnaire survey inquiring about problematic issues in regard to chronic hepatitis C diagnosis and treatment showed a demand for cooperation between the Kumamoto Medical Center and related facilities. Thus a liaison critical pathway for a combination therapy of pegylated interferon and ribavirin, which is mostly used in chronic hepatitis C treatment, was drawn up and implemented in April 2008. At the same time both national and local governmental financial support plans for interferon therapy have just been introduced. This study was based on the liaison between designated institutes and practice medical institutes and it now plays an important role in the regional chronic hepatitis C management.

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To introduce a better stroke rehabilitation system, a liaison critical pathway was developed at the Hyogo Brain and Heart Center between the acute stroke center and the stroke rehabilitation department. This was a trial model to strengthen partnerships among the various medical institutions in our community and to introduce a better regional inter-hospital stroke rehabilitation referral system.
Results of a study conducted 1-year after the introduction of the liaison critical pathway shows that the length of hospital stay decreased and activities of daily living for stroke patients improved, compared to before its introduction. During the 1-year trial period, solutions were offered for issues such as differences in evaluations at 2 medical institutions. Attention was also paid to the relationship between the length of hospital stay and stroke patients' activities of daily living.
As a result of this trial, the use of this liaison critical pathway has presently been expanded to various acute stroke centers and stroke rehabilitation hospitals at the Nakaharima disrict in Hyogo Prefecture.

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Hip fracture is one of the most common fractures in elderly people and it tends to increase in the geriatric population. About 80% of the patients, who had a hip fracture treatment at the Kagawa Rosai Hospital in 2005, were further transferred to affiliated medical facilities. Consequently, information sharing between facilities was a necessity.
Therefore in November 2005 the “Seamless Care Study Meeting” was established in order to create a regional alliances critical path. This way patients' information sharing, such as hospitalization days or the progress of rehabilitation by contacting affiliated institutions, became possible.

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Critical paths for total gastrectomy and distal gastrectomy are introduced at our hospital. This study examines which meal contents are suitable from the viewpoint of an early recovery from postoperative low nutrition and patients' satisfaction; additionally the meal content was partially revised.
Between Aug. and Nov. 2006, the clinical data of 29 patients, who used the critical path of total gastrectomy (group T), and 78 patients, who used that of distal gastrectomy (group D), was analyzed and a survey inquiry was carried out. Based on the result this study compares the chronological change of the body mass index (BMI), Albumin (Alb) and hemoglobin (Hb) between a group, which changed its staple food after the 6^th day of a meal intake from rice porridge to regular rice (regular rice group), and a group, which kept its staple food as rice porridge (rice porridge group).
As a result, the proportion of a diet intake of over 50% was 86.2% from both staple food and side dishes in group T, and 85.7% from staple food and 90.9% from side dishes in group D. As for 3 kinds of nutritional supplemental foods, the average intake was 54.8% in group T and 69.5% in group D. The proportion of a request for regular rice was 37.9% in group T and 41.0% in group D. There was no difference in the change of BMI, Alb, and Hb between the regular rice group and the rice porridge group. Most of the patients of group T and group D were able to pass according to the critical path. By changing the staple food to regular rice, the variety of side dishes and cooking ingredients could be improved, contributing to an increase of patients' satisfaction. In conclusion, the meal content of the current critical path is appropriate and a continuation is recommended. In addition, it was also decided to change the dietary plan so that regular rice is used as staple food after the 6^th day of a meal intake.

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In September 2003 an electronic medical record system was introduced at the Toyota Memorial Hospital. At the same time, an ampoule auto-dispensing system was adopted for the delivery of injections from the inventory to the ordering unit. In March of the following year, while making use of the returned drug data (input per ordering unit) and the difference in order data and dispatch data, the hospital started an alibi management of drugs dispatched and a replenishment of drugs. Furthermore, through close coalition with the departments involved, this kind of management was also progressively expanded to cover replenishment, etc. of injections used under the systems of individual departments. This drug inventory management has been useful in preventing incomplete or erroneous input of data pertaining to consumed drugs and reducing the number of steps needed for routine work and confirmation.
In addition daily inventory checks at each hospital unit allowed an IN/OUT control of the injections at each unit and this is expected to prevent illegal use or disappearance of drugs from the inventory of each unit. Inventory control at each unit based on order data alone is also useful as a means of risk control, since it assures that the injections have been performed strictly in accordance with the doctor's instructions given on electronic medical records.
The hospital has recently completed an inter-department system linkage for this kind of inventory management, replacing all manual vouchers related to injections with electronic ones. In doing so, control of injections not only at the individual units but also at the entire hospital was actualized. Since this kind of control allows in ventory checks on a real-time basis, it is applicable also for preparing order data making use of order-related data on electronic medical records and data regarding order implementations, and checks and storage of stocks in preparation for massive disasters, as well as preventing stock shortages.

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For infection control at hospitals single packaged alcohol-soaked cotton sheets are better than bulk packages. However, concerns of higher costs and inconvenience from opening the individually packed cotton sheets are the primary cause for hesitations regarding their introduction.
This study evaluates consumption and costs of alcohol-soaked cotton sheets before and after the adoption of the single packaged product at the National Hospital Organization Kokura Medical Center. Single packaged alcohol-soaked cotton sheets were formally used only for insulin self-injection and the like by diabetes patients. But in June 2006 they were introduced at all hospital wards out of concern for a better infection control. Use of the single packaged product soon increased. By February 2007 more than 70% of the alcohol-soaked cotton sheets throughout the hospital were those single packaged products. The unit price for single package sheets doubled but usage itself decreased and as a result the total cost for alcohol-soaked cotton sheets did not increase. In that sense wasteful usage was avoided after the introduction. In addition, usage was rechecked again in a questionnaire survey 2 years after the first introduction in 2006. The results showed that by then 94% of nurses preferred the single packaged sheets, because they could not only keep the cotton clean and contribute to infection control, but also because their usage felt more convenient in the sense that is it easier portable.
Our study suggests that the adoption of single package alcohol-soaked cotton sheets can improve infection control without extra cost and inconvenience.

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Many fields are working on how to prevent the elderly from falling incidents. It is crucial that physical therapists participate in these kinds of studies. There are many risk factors in regard to falls, such as decline in muscle strength and balance disorder. But, it has recently been reported that older people suffer from “Body Image Disorder”. This study examines the “Body Image” of elderly.
Participants were divided into 2 groups, one was composed of elderly people and the second group was composed of people in their 20th to 30th. The study experiment included two boards. Participants were asked to predict the minimum width at which they could pass between one board and the other, without touching them. This was defined as the “predicted width (PW)”. The researcher then measured the minimum width that participants actually passed and defined that as the “reality width (RW)”. PW was identified as the “body image” of a person and RW as the real body. For this study the researchers calculated the difference between the PW and RW.
The result shows that there was a significant difference between the elder and the younger people in their “body image” ability. It also shows that the “body imaging” capability diminishes, as a person grows older. This loss of one's “ body imaging” is directly connected to not grasping the distance to the surrounding accurately and this is the reason to miss a chair or to fall. Analyzing movements has been the main method for assessing “body image”. It can easily be examined and studied this way and explanations regarding PW and RW as well as instructions to prevent falls and injuries are easily understood. In this sense this kind of assessment serves in educating and assisting in preventing the elderly from falls and serious injuries.

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