A Survey of Palliative Care Ward Nurses’ Awareness, Feelings, Behavioral Intentions and Hands-on Experience in Supporting an Environment in Which End-of-life Cancer Patients Nurture Love with Their Partners

The purpose of this study is to clarify the current state of nursing for the sexuality of patients with cancer at the end-of-life. In December 2018, we asked 313 nurses from 18 palliative care units in Kanagawa Prefecture about their awareness, feelings, and behavioral intentions and hands-on experience for the environment in which patients with cancer nurture love with their partners at the end-of-life. The collection rate of the questionnaire was 52.7% (165 cases). Eighty-two nurses (49.7%) had experience supporting the environment in which patients with cancer nurture love with their partners at the end-of-life. The contents of the support were “Recommend physical contact”, “Listening”, “Recommend hug”, and “Take sufficient time when entering the room, such as waiting for a reply after knocking or calling out”. Meanwhile, at ward conferences, only 11 (6.7%) had talked about the environment in which patients with cancer nurture love with their partners at the end-of-life. It has been suggested that, at present, support for the environment in which patients with cancer nurture love with their partners at the end-of-life is left to individuals and not systematically.

A Retrospective Study to Explore Prognostic Factors of Short Survival in Patients with Malignant Pleural Mesothelioma upon the Time of Admission to Palliative Care Unit

Objective: This study investigated prognostic factors of short survival in patients with malignant pleural mesothelioma (MPM) upon the time of their admission to the Palliative Care Unit (PCU). Method: We conducted a retrospective review of the medical records of 12 patients with MPM, who died at the PCU of our hospital from January 2016 to April 2018. According to the classification of survival period by previous predictor model, these patients were classified into three Groups, Group A: less than 13 days, Group B: between 14 and 55 days, and Group C: more than 56 days. Results: The number of patients was 5 in Group A, 5 in Group B, and 2 in Group C, respectively. Hemoptysis was seen in 40% of patients of Group A only and oxygen inhalation was necessary for all the patients of Group A. Dysphagia and bilateral pleural involvement were seen in 80% of Group A and in 60% of Group B. Pneumonia was seen in 60% of Group A and in 20% of Group B. The above four factors were not seen in Group C. Conclusion: This preliminary study suggests that hemoptysis, dysphagia, bilateral pleural involvement, pneumonia, and oxygen inhalation are possibly prognostic factors of short survival of patients with MPM upon their admission to PCU.

Difficulties and Related Factors of Care for Refractory Cachexia in Palliative Care Units

Purpose: To understand the experiences of and difficulties faced by palliative care unit nurses when caring for refractory cachexia. Method: Palliative care nurses completed anonymous self-report postal questionnaires. Factor and multiple regression analyses were then carried out to interpret results. Results: A total of, 169 valid questionnaire responses were received and analyzed. Six factors were identified relating to the difficulties experienced by nurses when caring for refractory cachexia. [A feeling of helplessness and conflict among patients and families faced with decline and death] was considered the most difficult factor experienced by nurses, and typically other difficulties were considered more prominent when this factor was present. [The approach of assessment and perception of refractory cachexia care] differed according to the nurse’s years of experience, degree of involvement in patient care, and learning opportunities previously encountered. [Nurses tended to cope] more easily with the challenges faced if they had been assigned for >3 years. Conclusion: Six factors were identified as difficulties associated with the care of refractory cachexia. These findings suggest the need for thoughtful dialog with patients and their families and the importance of further educational support for nurses.

Characteristics of Patients with Hematologic Malignancies Admitted to a Palliative Care Unit

Purpose: Patients with hematologic malignancies use palliative care units less frequently than those with solid tumors. The purpose of this study was to clarify the clinical characteristics of patients with hematologic malignancies who had been admitted to a palliative care unit. Methods: The clinical records of patients with cancer who died in our palliative care unit between April 2014 and March 2019 were reviewed retrospectively. We compared the severity of symptoms, the prevalence of symptoms, and the time from the last cancer-directed therapy to death between hematologic and solid tumor patients. Results: We identified 560 cancer patients, 56 (10%) of whom had hematologic malignancies. The overall symptom severity was similar in both groups of patients. Hematologic patients had higher rates of clinically significant fatigue (52% vs. 32%; p=0.004) and fever (45% vs. 21%; p=0.0004) than solid tumor patients. The median interval from the last cancer-directed therapy to death was 69.0 days for patients with hematologic malignancies versus 94.5 days for those with solid tumors (p=0.031). Conclusions: Patients with hematologic malignancies admitted to the palliative care unit have similar symptom severity at the end of life as patients with solid tumors, suggesting similar hospice care needs.

Interconsultas de cuidados paliativos para pacientes con cáncer en un hospital general: Características y oportunidad / Interconsultation on palliative care for patients with cancer in a general hospital. Features and opportunity

Las recomendaciones internacionales apuntan a la integración temprana de cuidados paliativos (CP) en cáncer a través de la atención simultánea y del entrenamiento de los equipos primarios. La Unidad de CP del Hospital General de Agudos E. Tornú realiza interconsultas para pacientes internados en el hospital y brinda capacitación a los equipos tratantes. El perfil de las interconsultas realizadas podría brindar información importante sobre las características de la intervención de CP dentro de la institución. El objetivo de este estudio fue analizar retrospectivamente las interconsultas de primera vez de pacientes con cáncer realizadas a lo largo de 2 años, con foco en la temporalidad, la identificación de problemas por parte del equipo tratante y del equipo de interconsulta de CP, y la prontitud de respuesta y capacidad pronóstica de este último. La población atendida en interconsulta (168 casos) estuvo constituida principalmente por pacientes con enfermedad avanzada, deterioro del estado general, sin posibilidad de tratamiento oncológico y diagnóstico reciente. En aproximadamente 25% de los casos se encontraron indicios de intervención temprana y participación del equipo de CP en la toma de decisiones. Se discute la oportunidad de la intervención de CP y se señalan áreas con necesidad de mejora, como la identificación de síntomas no físicos y el pronóstico, a ser tenidas cuenta en las futuras actividades asistenciales y educativas.

The international recommendations point to the early integration of palliative care (PC) in cancer through simultaneous care and training of primary teams. The PC Unit of the Hospital General de Agudos E. Tornú conducts interconsultations for hospitalized patients in the hospital and provides training to the treatment teams. The profile of the interconsultations carried out could provide important information about the characteristics of the PC intervention within the institution. The objective of this study was to retrospectively analyze the first-time interconsultations of cancer patients carried out over 2 years, focusing on temporality, identification of problems by the treating team and the PC interconsultation team, the promptness of response and the prognostic capacity of the latter. In the period, 168 interconsultations were carried out. Most patients had advanced disease, poor performance status, no possibility of oncological treatment and recent diagnosis. In approximately 25% of the cases, evidence of early intervention and participation of the pc team in decision making was found. The opportunity of PC intervention is discussed and areas needing improvement are indicated, such as the identification of non-physical symptoms and prognosis, to be considered in future care and educational activities.

The Effect of Continuous Subcutaneous Infusion of Chlorpromazine on Refractory Delirium in Advanced Cancer: Retrospective Study

Context: Delirium in cancer is often difficult to control and refractory when haloperidol is invalid which is considered standard therapy. We need second and subsequent-line therapy to reduce hyperactivity and not to over-sedation for refractory delirium. Objectives: To investigate the efficacy and safety of continuous subcutaneous infusion chlorpromazine on delirium refractory to first-line antipsychiatric medications in advanced cancer palliative care setting. Method: The study population consisted of patients who received continuous subcutaneous infusion chlorpromazine for delirium at two certified PCU. Primary endpoint was the proportion of patients who showed improvements in delirium severity by Delirium Rating Scale Revised 98 score of less than 13 or decrease from baseline and maintained the ability to communicate coherently by Communication Capacity Scale Item-4 score of 2 or less. Secondary outcome were the Nursing Delirium Screening Scale subscale score, and injection site reactions evaluated according to the Common Terminology Criteria for Adverse Events. These outcome measures were assessed at baseline, 48 hours and 7 days after the start of the study. Result: Among eighty-four patients, sixty were positive responders (71.4%, 95% CI [61–80]). The mean CCS Item-4 scores significantly decreased from the baseline value of 1.48 (range 0–3) to 1.03 (range 0–3) at post-treatment (p<0.001). Grade 2 or higher injection site reactions were observed in 1 patient (1.2%, 95% CI [0–7]). Conclusion: Our study suggested that continuous subcutaneous infusion chlorpromazine could improve refractory delirium symptoms and patients’ communication capabilities. Although most of the skin disorders observed in association with chlorpromazine were mild, their incidence rates were relatively high, suggesting the need for careful monitoring.

The Usefulness of the 9-item Patient Health Questionnaire (PHQ-9) to Screen Major Depression for Patients on a Palliative Care Unit: A Case That without No Regular Psychiatrist

Background: Mental assessment for patients in a palliative care unit with no regular psychiatrist tends to depend on subjective judgments by other health professionals. We introduced the 9-item Patient Health Questionnaire (PHQ-9) to screen major depression from patients in a palliative care unit and assessed the usefulness of the questionnaire. Methods: The subjects were all patients who were admitted to a palliative care unit. Each patient was asked to answer the PHQ-9 on admission and then was interviewed by a psychiatrist. When PHQ-9 score was of 10 points and above, the case was judged to be positive for depressive disorder. A psychiatrist diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). Results: A total of 83 patients were hospitalized between January 2016 and October 2016. 50 patients completed PHQ-9 and psychiatrist’s interview. Nine cases were positive by PHQ-9 and diagnosed as depressive disorder by a psychiatrist. Seven cases were positive by the PHQ-9 but not diagnosed as depressive disorder. Although 34 cases were judged to be negative by the PHQ-9, 2 cases of them were diagnosed as depressive disorder. The sensitivity and specificity of the PHQ-9 were 81.8% and 82.1% respectively. Conclusion: We found that the PHQ-9 was useful screening test for depression even in palliative care settings.

Analysis of Factors Related to the Terminal Care Attitudes of Nurses in Palliative Care Units

Purpose: This study aimed to clarify the factors contributing to nurses’ attitudes toward terminal care in palliative care units (PCUs). Methods: We conducted a cross-sectional study of nurses in PCUs across Japan using an anonymous self-administered questionnaire, which was mailed to 103 ward managers and 1,671 nurses in PCUs to collect data about nurses’ sociodemographic characteristics. Their attitudes towards terminal care were assessed using the Frommelt Attitudes Toward Care of the Dying Scale Form B (Japanese version). Multiple regression analyses were used to identify the factors associated with attitudes towards terminal care. Results: After excluding missing data, valid responses were obtained from 93 ward managers and 1,112 nurses (response rates of 90.3% and 66.5%, respectively). Based on multivariate analyses, the subdivisions of “positivity of nurses’ attitudes toward terminal care” and “high recognition of the patient- and family-centered care” were associated with working in PCUs voluntarily (β=0.159, β=0.131, p<0.01). The former subdivision was associated with ten personal factors, including “experience as a nurse in a PCU” (β=0.125, p<0.01), “having a certification of End-of-Life Nursing Education Consortium Japan version Core Curriculum” (β=0.065, p<0.05). The latter subdivision was associated with four factors enhancing the PCU environment including “support for creative activities of patients and their families” (β=0.114, p<0.01). Conclusion: This study has suggested that gaining the experience at PCUs with multidisciplinary members on a basic palliative care education, a supportive specialized palliative nursing education, and expanding care system in PCUs are important for the positivity of nurses’ attitudes toward terminal care.

Evaluation of the Successful Insertion Rate of PICC among the Puncture Sites at the Cubital Fossa for Terminally-ill Cancer Patients at the Bedside

<p>Aims: This study aimed to compare the difference in successful insertion rates of peripherally inserted central venous catheters (PICCs) between the different insertion sites at the cubital fossa (basilic, medial cubital and cephalic vein) for terminally-ill cancer patients at the bedside. Methods: Data from eighty-eight terminally-ill cancer inpatients who underwent insertion of PICC from September 2011 to April 2014 were retrospectively analyzed. Successful PICC insertion was defined when the catheter tips were placed in the superior vena cava. Results: PICC insertion was successfully carried out in 72/88 patients (81.8%) in total; 43/50 patients (86.0%) via basilic vein, 23/31 patients (74.2%) via medial cubital vein, and 6/7 patients (85.7%) via cephalic vein. There was no significant statistical difference between the three different approaches in the success rate of PICC insertion (P=0.39). Conclusion: Our findings suggest that the cephalic vein serves as an alternative puncture site of PICC insertion at the cubital fossa for terminally-ill cancer patients under unavoidable clinical circumstances.</p>

A Survey of the Palliative Care Provided by Long-term Care Units Established Together with Palliative Care Units through the Opinions of Staff in Palliative Care Units and Long-term Care Units

<p>Purpose: We investigated the benefits and problem of the palliative care provided by long-term care unit through a survey of staff in palliative care units (PCU) and long-term care units. Methods: Self-reported questionnaires were administered to staff who engaged in PCU and long-term care units. Questions included: awareness of WHO palliative care definition, and, the general idea on palliative care, possibility of cooperation with PCU, advantages / disadvantages, and idea for non-cancer palliative care in long-term care unit. Results: We got responses from 248 medical and nursing-care staff. The percentage of “knowing” the WHO definition was 76.5% in medical staff / 32.3% in care worker, 87.6% in PCU experience / 46.5% in non-experience. Categories of responses are good, advantageous, problematic, difficult requirement, difficulty, etc. The main answers were the difficulty of care, problems of knowledge and technique, and points of problems related to personnel shortage. Medical staff or PCU experienced staff pointed out needs of palliative care and improvement of knowledge and skills. Conclusion: Opinions acknowledging the benefits and necessities for palliative care of long-term care units and a number of problems were revealed.</p>

A Survey of Urinary Catheterization for the End-of-life Cancer Patients in a Palliative Care Unit

<p>Introduction: The urination state of patients in the palliative care unit varies according to their age, performance status, underlying disease, and the presence of delirium. However, there are currently few reports concerning the urination state of these patients. Here, we report the current state of urinary catheterization in our hospital palliative care unit. Methods: A total of 249 consecutive patients hospitalized between January 2012 and December 2013 in our hospital palliative care unit were included. We retrospectively investigated the numbers and causes of urinary catheterization along with the background of the patients (age, underlying disease, and average length of hospital stay). Results: Of the 249 patients, 124 (49.8%) used a urinary catheter. The median period of catheterization was 6 days. Excluding continuation of the previous physician’s orders, the main cause of urinary catheterization was reduced activities of daily living after admission. In 12 cases (9.7%), the catheter was removed because of discomfort of the patients. Conclusion: Approximately half of all patients treated in our palliative care unit received urinary catheterization. As a cause of urinary catheterization, reduced activities of daily living after admission was the most frequent. Since the urination state affects the quality of life in palliative care patients, it is important to consider the appropriate adaptation of urinary catheters.</p>

Evaluating a Palliative Medicine Education Program for Undergraduate Medical Students at a Regional Hospice

<p>Background: There is increasing demand for clinical clerkships in palliative medicine, though conventional medical education has focused only on providing students with sufficient medical knowledge and skills. In Japan, there is no standard program for palliative medicine in undergraduate medical education. Our hospice, in cooperation with a clinical clerkship for palliative medicine launched by Tokyo Medical and Dental University, has developed its own comprehensive bedside learning curriculum. Aim: This study aimed to evaluate the efficacy of the program. Methods: The curriculum involves not only experience in hospice care, ward rounds, and interviews with terminally ill patients, it also provides each medical student with educational sessions moderated by certified hospice nurses and pharmacists. We conducted a self-administered five-point scale questionnaire (with a higher score indicating higher satisfaction) to assess students’ satisfaction and understanding of the program. We also conducted a questionnaire on basic palliative medicine knowledge before and after the program. Results: Twenty students took part in the program. Ratios of scores of 4 or 5 for satisfaction and understanding of the program were 100% and 95%, respectively. Mean rates of correct answers on the pre-program and post-program test were 51% and 85%, respectively; showing a marked increase and emphasizing the educational significance of our curriculum. Students evidently benefit from the experience of bedside learning, and 95% reported having recommended the program to their juniors. Conclusion: These outcomes suggest the program is effective toward developing a standard education program in palliative medicine.</p>

A Survey of the Current Status of the Palliative Care at Long-term Care Units Established Together with Palliative Care Units

<p>Objective: The aim of this study was to investigate the current status of the palliative care provided by long-term care unit that was established together with palliative care unit (PCU). Methods: Self-reported questionnaires were administered to long-term care unit administrators at 24 facilities that was established together with PCU. Questions included: managing the use of narcotic drugs, situation about receiving cancer patients, situation about cooperation with PCU, and difficulty with palliative care. Results: Eighteen (75%) facilities responded to the questionnaire. Fourteen facilities of respondents reported that narcotic drugs were available and usable in long-term care unit, and ten facilities reported that the narcotic drugs could be used in the same way as PCU could. Ten facilities reported that they had doctor(s) knowledgeable about palliative care or prescribing narcotic drugs, and 11 facilities reported that they had nurse(s) experienced about palliative care. Cancer patients were accepted in all 18 long-term care units. Transferring from long-term care unit to PCU due to medical condition changes after hospitalization had been carried out in 17 facilities. Unit administrator’s perceived difficulty lack of staffing, lack of staff expertise and education, and issues surrounding narcotic drug management. Conclusion: These long-term care units were providing palliative care for cancer patients in cooperation with PCU. The survey results indicated the need for solving human resource, educational, and administrative problems.</p>

Animal Assisted Activity in the Palliative Care Unit of a General Hospital

<p>Introduction: Though the animal assisted therapy and the animal assisted activity with animal visiting are widely introduced to general hospitals in Japan, the report of those activities in palliative care units (PCU) of general hospitals are few. Methods: In June 2013 therapy dogs started to visit our PCU with the help of NHO Japan Animal Association. We discussed on the effects and the problems as a part of the palliative care about this activity. Results: Three therapists with 3 therapy dogs came to our hospital twice a month and the total number of 487 patients took part in 73 sessions until September 2016. Those activities made the patients and their families felt better and their communications with staffs were improved. No adverse effects concerning the safety and health were observed in those activities. Discussion: The reliable training and infection control of animals can make easy the introduction of animal therapy to the PCU of a general hospital. Visiting of therapy dogs can provide the healing to not only the patients and their families, but also the staffs in the PCU.</p>

Current Terminal Care for Cancer Patients andSignificance of Palliative Care Units

<p>In order to understand the current status of terminal care for cancer patients and to investigate the significance of palliative care units (PCUs), we reviewed 414 cancer patients who died at our hospital during the 2-year period since October 2013 (PCU: 219 patients, general wards: 195 patients) based on their history of anticancer therapy and use of palliative care. Compared with PCU patients, those in the general wards were older, the diagnosis was delayed, and disease progression was more rapid. It was suggested that these factors had a negative impact on the opportunity to receive standard anticancer therapy and palliative care. Among the patients who received chemotherapy, the median interval from the final treatment to death was 110 days for those in the PCU while it was significantly shorter (55 days) for those in the general wards. Chemotherapy was administered within 1 month before death to 2% of patients in the PCU versus 32% of patients in the general wards, so the rate was much higher among the latter patients. In order to provide appropriate terminal care for cancer patients, the PCU seems to be important. Irrespective of the timing of cancer diagnosis and progression, it is important to increase general social awareness of palliative care and advanced care planning in order to promote the use of palliative care strategies.</p>

A retrospective study of emergency admission to a palliative care unit of cancer patients at home

Purpose：We evaluated that the current state from which a palliative care unit receives emergency admission of cancer patients at home. Methods：We retrospectively investigated the medical records of 393 cancer patients who hospitalized in our unit between January 2013 and December 2014. The patients were shared with a group of two, schedule admission (schedule group) and emergency admission (emergency group), and it was compared with a result on discharge and with a hospitalization period. We investigated admission process, the date and time of admission, and reason for admission in emergency group. Results：The number of patients was 224 of schedule group and 169 of emergency group. The mortality rates were 81% in schedule group and 78% in emergency group (not significant). An emergency group for an average of 24.3 days was shorter for 9 days than schedule groups in a hospitalization period of dead leaving patients (p<0.05). In emergency group, admission process included 128 completed-interviews with the hospitalization, 11 incompleted-interviews before admission and 30 first visits, and 129 patients (76％) admitted within the weekday daytime. Many patients had a complaint of severe pain, appetite loss and oral absorption difficulty, and so much. Conclusions：An emergency group admitted the various processes and the much symptom. There were a lot of cases of early hospital death, but also admitted return at home, and our unit played the role of emergency admission.

The significance of the palliative care unit staffs' participation

Introduction：Although psychosocial support for cancer patients, their family, and those who are bereaved is essential, it is still considered inadequate. Anyone can become a member of the “Gan Cafe” support group, such as those suffering from cancer, those who have survived cancer, family members of cancer patients and those who have lost people to cancer, can get psychosocial support and palliative care support from palliative care unit staff. Case：A 53-year-old male was diagnosed with lung cancer in 2001 and underwent surgery. In 2006 he underwent chemotherapy, as he suffered a relapse. In 2012, while undergoing treatment, he joined the “Gan Cafe” along with his family members. He was able to interact with other members of the group and with the staff of the palliative care unit as a cancer patient, while his wife and children could interact with them as cancer patients family members. Six months later, when being admitted to the palliative care unit, the patient and his family members felt secure as they had become well acquainted with the staff at the “Gan Cafe.” After he had passed away, the wife continued to participate in the “Gan Cafe” as a bereaved family member and the same staff provided her with grief support. Conclusion：Through participation in the “Gan Cafe”, the staff of the palliative care unit was able to provide continuous palliative care with a focus on psychosocial support from the pre-hospital stage to grief support after the patients passed away.

Useful anticoagulation therapy with heparin for Trousseau's syndrome in a terminally ill patient with rectal cancer： A case report

Trousseau syndrome is a clinical condition in which a thrombosis and embolism are caused by hypercoagulation associated with a malignant tumor. Here we report on a patient who developed a cerebral infarction during hospitalization in a palliative care unit due to advanced recurrent rectal cancer and was treated with anticoagulation therapy. A 50—year—old woman who experienced lung metastasis and bone metastases after rectal cancer surgery was hospitalized in a palliative care unit because increasing pain made home care difficult. Although her pain was relieved by drug therapy and irradiation, she developed a partial visual field defect and aphasia in succession when she received medical treatment because of respiratory discomfort due to advanced pulmonary metastases. Multiple cerebral infarctions were observed on a magnetic resonance imaging and blood tests revealed disseminated intravascular coagulation； therefore she was diagnosed with Trousseau syndrome. After the initiation of anticoagulation therapy, the aphasia improved. No adverse events were caused by treatment. All patients in the terminal phase should not be equally judged as not being candidates for anticoagulation therapy. It is necessary to examine each patient’s suitability by considering their prognosis and general condition as well as the significance and safety of the treatment.

A trial of appropriate and fair management of hospitalization to palliative care unit

Compared with the increase of cancer patients, there is insufficiency number of beds at palliative care unit(abbreviated to PCU)and hospice. To utilize them as medical resource efficiently, it is necessary to assess the condition of patients and to decide the order of admission fairly and impartially. The appropriate way of decision is also a prerequisite of the facility criterion of hospice by the Ministry of Health, Labour and Welfare and one of the evaluation items of palliative care by Japan Council for Quality Health Care. Many PCUs and hospices declare that a conference for the hospitalization judgment is held regularly, although few hospitals disclose the process of decision and its criteria of the order of priority. We made a checklist for the judgment of hospice admission in which the needs of hospitalization are converted to the numerical value in terms of patient's willingness, condition, context and prognosis. The checklist was introduced in our PCU in September 2012. In 2013 fiscal year, the conference for the judgment of PCU admission was held almost once a week(51 times)and the total number discussed were 403 cases(7.9 cases per one conference)and those who were actually hospitalized were 187 patients. The imbalance shows the necessity of the fair and impartial decision.

Implementation manual created for carrying out the Animal-Assisted Therapy in the Palliative Care Unit of a general hospital

<b>Introduction：</b>There are various problems in order to perform the Animal-Assisted Therapy（AAT）in the Palliative Care Unit（PCU）of a general hospital, a manual for carrying out is required.<b> Methods：</b>In our hospital PCU, implementation manual has been created by the cooperation of university of research institutes, health center of administrative agency, and the infection control team of our hospital.<b> Results：</b>1st AAT was held in February 2011. Then, at a pace of once a month, AAT was held a total of 35 times until March 2013. During the AAT, therapy dog, handler, doctor, nurses, ward volunteers, health center veterinarian played the role of each as a team. The evaluation meeting held after, in addition to the evaluation and reaction of participants, evaluation of environmental health and compliance with procedure were also performed, implementation report has been submitted to the health center.<b> Discussion：</b>In order to perform the AAT in PCU in general hospital, there are problems such as infection, environment and health. In the practice, by obtaining cooperation experts each, it was possible to create an implementation manual by perspective multicenter multiple sectors. This manual would be helpful to perform the AAT in each facility.