Effectiveness of Clinical Management of COVID-19 Based on Structured Clinical Knowledge and Process Paths.

This study examined the effectiveness of a systematic approach to the clinical management of COVID-19, focusing on nursing turnover. METHODS: Between 2017 and 2019, a clinical process support system based on structured clinical knowledge (Team Compass with the Patient Condition Adaptive Path System; TC-PCAPS) was developed, and implemented in hospitals. In 2020, the COVID-19 clinical management system (COVID-19-CMS) was developed. In this study, the effectiveness of implementing both systems was analyzed. The analysis covered hospitals N, T, and B, where TC-PCAPS implementation started in 2019, 2020, and 2022, respectively. Data for the period from 2018 to 2022 were collected and compared. RESULTS: Hospitals N and T implemented TC-PCAPS in the first year and the COVID-19-CMS in the following year. The nurse turnover rates of these hospitals were lower than those of the prefectures in which they were located. There was a trend towards a gradual reduction in nurse turnover. In contrast, hospital B, which had only just started to introduce these systems, saw a gradual increase in nurse turnover. CONCLUSION: The data collected from these three hospitals suggested that this systematic approach has the potential to reduce nurse turnover, in addition to the previously reported ability of TC-PCAPS to reduce nurse overtime. In Japan, there is a need to respond to future pandemics and reform the work styles of physicians and nurses. The abovementioned systematic approach has great potential for contributing to both of these aims.

Patient Data Sharing and Reduction of Overtime Work of Nurses by Innovation of Nursing Records Using Structured Clinical Knowledge.

Half of nurses' overtime hours are due to records. Nursing records, which are mainly narrative records, cost a large amount of money. However, it has been pointed out that there are problems with their quality and post-use. In this study, we analyzed the value of nursing records for physicians. As a result, we found that the use of standard observation terms in nursing records can create an environment in which patients' conditions can be shared. To create this environment, the physicians of the clinical path committee classified hospitalized patients in terms of disease, treatment, and examination, and created a list of 778 process paths. Physicians, nurses, and researchers collaborated to develop digital contents with high-priority observation items and care actions adapted to patient conditions for each path. We developed a clinical support system equipped with these digital contents. In May 2019, we installed the system in a 900-bed university hospital. Then, in October 2020, we installed the system in a 400-bed general hospital. We used "nurses' overtime hours for recording" and "reduction rate" as indicators of the usefulness of this system. In the 900-bed university hospital, we compared the previous year's results for March, the end of the fiscal year. This overtime hours were 2,944 hours 00 minutes in March 2019 and 2,141 hours 55 minutes in March 2020. 27% reduction was indicated. The respective bed occupancy rates were 90.80 percent and 90.60 percent, with no difference. In the 400-bed general hospital, This overtime hours were compared to the previous year, covering November and December after one month of implementation. 386 hours in November 2019 and 204.5 hours in November 2020. 47% reduction indicated. 366 hours in December 2019 and 214.5 hours in December 2020. A reduction of 41% was shown. These results suggest that the implementation of this system can both improve the quality of team care and reduce overtime.

Factors associated with response to compression-based physical therapy for secondary lower limb lymphedema after gynecologic cancer treatment: a multicenter retrospective study.

BACKGROUND: Lower limb lymphedema (LLL) is one of the most refractory and debilitating complications related to gynecological cancer treatment. We investigated factors associated with response to compression-based physical therapy (CPT) for secondary LLL after gynecologic cancer treatment. METHODS: We performed a multicenter retrospective study using the records of seven medical institutions from 2002 and 2014. Patients who developed LLL after gynecological cancer treatment were included. Limb volumes were calculated from the lengths of the limb circumferences at four points. All participants underwent compression-based physical therapy for LLL. Factors, including MLD, indicative of circumference reductions in LLL were determined. RESULTS: In total, 1,034 LLL met the required criteria of for the study. A multivariate linear regression analysis identified age; body mass index (BMI); endometrial cancer; radiotherapy; and initial limb circumference as significant independent prognostic factors related to improvement in LLL. In analysis of covariance for improvement in LLL adjusted by the initial limb circumference and stratified by BMI and radiotherapy, patients with BMI 28 kg/m2 or higher and receiving radiation rarely responded to CPT. CONCLUSIONS: Improvements in the lower limb circumference correlated with clinical histories and physical characteristics, which may be used as independent prognostic factors for successful CPT for LLL after gynecological cancer treatment.

Nursing Record Innovations Aimed at Harmonizing Structured Clinical Knowledge Among Doctors and Nurses.

Hospitalization expenses account for a high proportion of national medical care expenditure in Japan. In 2015, the total national medical care expenditure in Japan was 42.4 trillion yen, and hospitalization expenses were 15.6 trillion yen (36.8%). Therefore, it is necessary to reduce hospitalization expenses. The labor cost of physicians and nurses accounted for about 1/3rd of all expenditure of general hospitals in 2015. Moreover, the personnel cost of nurses accounted for about 1/5th of all expenditure, indicating that it has a marked impact on hospital management. Nurses spend a lot of time completing descriptive records; however, the quality of such records is poor. It is necessary to improve nurse's records to make them highly accessible and reduce the amount of time nurses spend producing records. The objective of this study was to improve the processes underlying record-keeping by nurses in order to harmonize structured clinical knowledge among doctors and nurses. We created 778 Patient Condition Adaptive Path System (PCAPS) items, covering all of the clinical departments that were registered for the PCAPS content master. The resultant masters will be standardized by sharing them with hospitals that adopt the "Team Compass" application. We were able to summarize all of the information in clinical progress sheets because we could link the information described in electronic medical records with that described in Team Compass. Therefore, it became easy to collect information by linking information about clinical orders. The system also made it possible for foundational nursing plans to be created in collaboration with doctors instead of being developed by nurses alone because it allowed information regarding patients' problems, the clinical process, and observation selection to be shared smoothly with doctors. We implemented Team Compass in May 2019. On the first day, PCAPS-based care pathways were used to treat 580 of 623 inpatients. Approximately 4,000 patients were treated using this system from May to August 2019. No major problems have arisen since the implementation of Team Compass.

Risk factors for late-onset lower limb lymphedema after gynecological cancer treatment: A multi-institutional retrospective study.

INTRODUCTION: Late-onset lower limb lymphedema (LLL) is a significant clinical challenge for physicians dealing with patients that undergo treatment involving the pelvic cavity. We aimed to clarify the prevalence of and risk factors for late-onset LLL after treatment for gynecological cancer. METHODS: We conducted a multicenter retrospective study using records of cases in which LLL diagnosed by physical findings and measurement of limbs girths. Patients with LLL after treatment for uterine cervical, endometrial, and ovarian cancer were sequentially enrolled. We examined the timing of LLL onset and the associations between the time to onset and clinical characteristics, including age, type of cancer, lymphadenectomy sites, and performance of radiotherapy. We also investigated the risk factors for late-onset LLL and their effects on the cumulative incidence of late-onset LLL. RESULTS: In total, 711 patients fulfilled the required criteria. Mean age of was 50.2 years old and median follow-up period was 5.05 years. More than half of them (50.5%) presented with LLL ≥5 years after undergoing treatment for gynecological cancer. A substantial number of patients (29.4%) developed LLL ≥10 years after undergoing treatment for gynecological cancer. Being aged <50 years [(odds ratio (OR): 1.919, P = 0.001), cervical cancer (OR: 1.912, P = 0.001), and radiotherapy (OR: 1.664, P = 0.017) were identified as significant risk factors for late-onset LLL in multivariate logistic regression analysis. CONCLUSIONS: A substantial number of patients present with LLL ≥5 years after receiving treatment for gynecological malignancies. Clinicians are required to identify high-risk patients and inform them of the risk of late-onset LLL.

Reduction of Overwork Time of Nurses by Innovation of Nursing Records Using Structured Clinical Knowledge.

Hospitalization expenses account for a high rate of national medical care expenditure in Japan. The Japanese national medical care expenditure was 42 trillion 364.4 billion yen in 2015, in which hospitalization expenses were 15 trillion 575.2 billion yen (36.8%). Therefore, it is necessary to take measures to reduce hospitalization expenses. The total ratio of the labor cost of physicians and nurses accounted for about 1/3 of all expenditures of general hospitals in 2015. Moreover, the personnel cost of nurses accounted for about 1/5 of all expenditure, showing that the personnel cost of nurses is an element with a large influence on hospital management. The objective of this study was to develop a methodology to reduce the overtime work of nurses accounting for a large rate of personnel expenses by focusing on overtime work, a personnel expense-increasing factor, aiming at hospital cost reduction. First, the cause of overtime work, planning, and recording by nurses were analyzed and an IT application increasing the quality and efficiency of the work was developed. Then, fees for the use and maintenance of the IT system meeting the following conditions were set as a strategy to introduce the system: (1) 50% reduction of the overtime work of nurses and (2) fees 50% or lower than the reduced payment for overtime work. This IT application was introduced to the heads and directors of nursing of 5 hospitals and the strategy was proposed. All heads and directors highly evaluated the system and responded to initiate the process for the introduction. It was suggested that the methodology to reduce the overtime work of nurses proposed by this study is useful and feasible.

Quality Evaluation of Nursing Observation Based on a Survey of Nursing Documents Using NursingNAVI.

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI® contents collaborated with some quality centred hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI®" developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI® contents. It is important to identify the problem of the volatility of the patients' data, conditions and some situation. We developed a survey tool of nursing documents using NursingNAVI® Content for quality evaluation of nursing observation. We recommended some hospitals to use this survey tool. Fifteen hospitals participated the survey using this tool. It is estimated that the volatilizing situation. A hospital which don't participate this survey, knew the result. So the hospital decided to use NursingNAVI® contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.

Information Sharing and the Nursing Practice for the Certified Nurse in Radiation Therapy Nursing.

This study is conducted in order to clarify, however practice and get or sharing information in the Radiation Therapy Nursing of Certified Nurses. We have the group interviews from the four members the Certified Nurses in Radiation Therapy Nursing. It was found that Certified Nurses in Radiation Therapy Nursing felt that don't have the information about the patients who receives radiation therapy. In addition, they thought not able to even determine about whether time required, and not provide the professional nursing care practice. They say that we need the time, place and information. They were determined to be there to be necessary in for exhibiting their abilities. In particular, the most important problems that there aren't systematic information of the patients who receives radiation therapy. It's mean that, not have described the information for Radiation Therapy Nursing, and not obviously structure of nursing process or important assessment's, yet.

Analysis the Nursing Documentation of the Observation Plans and Practices of Breast Cancer Using Nursing NAVI.

We analyzed in nursing observation planning and practices circumstances of a breast cancer patient using the Nursing NAVI® Contents. The result of this analyzed were clearly that the master plan item was satisfying a vital signature, so it could be practiced 100%. But even if the observation item of in-out balance were not records so the implementation rate of the 50%, comparison with the Nursing NAVI® Contents. About the item esteemed as required item, like, the thing with the low observation implementation rate became clear. We found that problem about estrangement of the difference between the planning the observation drafting and the implementation. The implementation item can see a little tendency much, and later, the plan item will be also a problem about the current state to which the necessary item is inferior.

Problem Solving for Volatilizing Situation in Nursing: Developing Thinking Process Supporting System using NursingNAVI® Contents.

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI® contents collaborated with some quality centered hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI®" developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI® contents. A hospital decided to use NursingNAVI® contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.

Development of structured clinical process model of dementia.

As Japan is aging rapidly with more people with dementia, healthcare providers need to develop and share the care delivery model in order to respond to the need of not only the patients' but also of the families' and society's. The authors have developed a disease management and care system of the people with dementia based on the previous model developed by us for other diseases. Through the case reviews of the patients, this model proved to be useful in visually describing the patients' courses. We are going to develop as a next step a model to foresee the patients' progress so that we may be able to make timely interventions. Additionally, we have a plan to use it to improve the Japanese guideline of dementia care.

Developing the structured knowledge model to navigate the nurses' thinking process in their professional judgment and action.

Authors have defined the function of the nursing observation as "monitoring the onset and course of health problems" and that of nursing action as "preventing health problems". We have also identified three foci of the nursing observation and nursing action respectively. The foci of nursing observation are: "signs and symptoms related to the diseases", "complications related to the invasive medical procedures such as surgery" and "adverse effects related to the pharmacotherapy". Those of nursing action are: "nursing care to fulfill the needs arising from the diseases and the medical interventions", "nursing care to prevent the complications", and "nursing care to prevent the adverse effects". Finally, we have categorized hospitalized patients' conditions into "pre-surgery", "post-surgery" and "rehabilitative phase" for the surgical patients and "severe", "moderate" and "mild" for non-surgical ones. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions.

A hospital survey on the utilization of the master file of the standardized nursing practice terminology in Japan.

A common language in nursing facilitates better communication among nurses and other healthcare providers, assuring better nursing care, hence better patient outcomes. As we developed and disseminated the standardized terminology of nursing which provided nurses with a set of terms to describe nursing observations and nursing actions, we run a survey to see how much it was recognized and utilized in actual clinical settings. The result showed that approximately 60% of the respondents were cognizant of our terminology, and again 60% of them were either actually using the terminology or interested in using it in the future. For them, the main purposes of utilizing the terminology were nursing documentation and care planning. Sometimes it was used as an educational tool. This suggests that we should further develop a tool to assist nurses with their documentation and care planning alongside the revision of the terminology itself.

Developing the nursing care plans using the "master file of standardized nursing practice terminology" in Japan.

A common language in nursing facilitates better communication among nurses and healthcare team, assuring better nursing care, hence better patient outcomes. As we developed and disseminated the standardized terminology of nursing which provided nurses with a set of terms to describe nursing observations and nursing actions, we developed a certain number of nursing care plans using the terms in it. The nursing care plans included those for the patients requiring medical (pharmaceutical)/surgical procedures or the patients showing some signs and symptoms. Generally, nurses found that the nursing care plans were useful and flexible enough to allow for the modification according to the needs of each individual patient. In conclusion, the nursing care plans based on the standardized terminology showed its relevance to the clinical settings.

Models for designing long-term care service plans and care programs for older people.

The establishment of a system for providing appropriate long-term care services for older people is a national issue in Japan, and it will likely become a worldwide issue in the years to come. Under Japanese Long-term Care Insurance System, long-term care is provided based on long-term care programs, which were designed by care providers on the basis of long-term care service plans, which were designed by care managers. However, defined methodology for designing long-term care service plans and care programs has not been established yet. In this paper, we propose models for designing long-term care service plans and care programs for older people, both by incorporating the technical issues from previous studies and by redesigning the total methodology according to these studies. Our implementation model consists of "Function," "Knowledge Structure," and "Action Flow." In addition, we developed the concrete knowledgebases based on the Knowledge Structure by visualizing, summarizing, and structuring the inherent knowledge of healthcare/welfare professionals. As the results of the workshop and retrospective verification, the adequacy of the models was suggested, while some further issues were pointed. Our models, knowledgebases, and application make it possible to ensure the quality of long-term care for older people.

Designing Structured Regional Alliance Path Model for Healthcare Coordination Based on PCAPS.

A deficit in medical insurance finance has been observed with an increase in national medical expenses due to rapid aging, and the premium income does not increase. Therefore, efficient functioning of all medical institutions, reinforcement of a coordinated medical care system, and effective practical use of this system are necessary. In this study, a coordinated medical treatment system is considered and a regional alliance path is designed as a tool that facilitates in improving the coordinated medical treatment system step-by-step. It clarifies the future of a patient's condition by providing appropriate management and helps to achieve effective coordination. Further, the regional alliance path helps to prescribe appropriate medical examination and treatment processes that each medical institution should follow by considering the processes followed by local clinics, and further, enables suitable distribution of community medical resources.

A method to improve a job process at a hospital using the "unit process flow chart".

The development of methods to improve the quality of services provided at hospitals has been essential owing to the inadequacy of arrangements for standard procedures and the inadequacy of work instructions based on such procedures. In this paper, we propose a method that involves the following steps: description of the job process, analysis of the causes of incidents, and the planning of improvements for the relevant job process. This method describes a healthcare process using a set of unit process flow charts (UPFCs), which are structured and standardized modules represented in the form of flow charts that elucidate the elements of jobs. Describing a job in this manner allows for an appropriate and in-depth analysis of the causes of incidents that occur during a job process, owing to the fact that the structure and description of the characteristics of relevant unit processes are properly designed. In this paper, we provide a detailed explanation of how this method was developed. Lastly, we apply the method to actual cases at a hospital to illustrate its effectiveness in comparison with the systems that are currently in place.

Structuring clinical nursing knowledge using PCAPS - patient condition adaptive path system.

Quality assurance has become key concerns in healthcare and it is important to standardize the processes for healthcare properly. Though it was needed to describe process of healthcare diagnosis and treatment, it was very difficult by the reason of being service products including complexity and expertise. We challenged to visible, structurize, standardize and IT-systematize of clinical knowledge for healthcare quality management. The patient condition adaptive path system (PCAPS) was developed. PCAPS describes an overall flow of possible clinical pathways that a patient's disease state may trace and detailed medical judgment and treatments for each disease state. It suggests possibility of quality assurance using the standard plan of medical treatment process. PCAPS comprises two major tools: clinical process chart and unit sheet. These describe the total flow of treatment and the concrete medical treatments involved in each step. The PCAPS master is proposed. This is a glossary of the terms that are used in the unit sheet. Each master file has special structure for each work domain. In other words, PCAPS describes the standard process of healthcare using the clinical process chart, unit sheet, and PCAPS master. We apply nursing master file for nursing care action and observation offered by MEDIS-DC in Japan. Through we developed many PCAPS contents, we identified description of structured nursing knowledge. The nursing master file was brushed up by designing PCAPS content using it. It was suggested that PCAPS contents as standard clinical plan designed by medical specialist team included nursing knowledge.