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.

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.

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.

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.

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.

Framework for preventing accidental falls in hospitals - management plan for ADL, medication and medical conditions.

Prevention and reduction of medical accidents is essential. Among medical accidents, accidental falls remain a serious problem. While "assessment score sheets" have already been used in hospitals to prevent accidental falls, satisfactory results have not actually been achieved. In this study, we aim to establish a methodology for preventing accidental falls. We consider that the 'management plan' for each patient includes three factors. A plan of instructions for patients on actions they can take for safety in their ADL (Activities of Daily Living) is essential as a base. Second, a plan to keep up with any short term change in a patient's state is needed, because the state of a hospitalized patient will usually be temporarily affected by medication and changing medical conditions. We develop a model for preventing accidental falls, which enable us to design appropriate management plan for each patient. Then, we develop a prototype system based on the designed model. Finally, we address the result of verification of the model, by applying the prototype system into actual cases in hospitals.

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.

Evaluation of a training program for counselors in contraception and prevention of STIs and a website-based support system.

In Japan, the incidences of pregnancy and sexually transmitted infections (STIs) are increasing among young people. To address these issues, we initiated the following steps: 1) processes supporting contraception and prevention of STIs were created for counseling and construction of an algorithm for that process; 2) a system was developed using a website to support the program for training counselors, and provide practical support during and after the training; and 3) a program for the counselor was developed and is being evaluated. The counseling process was visualized by an algorithm notion method developed by Tsuru et al. Participants registered on the website, enabling them to confirm the lecture contents, record their self studies and submit issues. In order to evaluate this program, a preliminary survey and short tests after the lectures were completed. Participants were nurse-midwives who graduated at a nursing university. 27 participants were expected to complete the program. The answer ratios in the short tests were significantly improved compared to them in the preliminary survey. All participants submitted issues via the website. Further development of the system is planned so that the website can provide practical support by trained counselors and build on the accumulated practical results. Further refinement of the developed algorithm is required so that trained counselors can use it regularly via the website.

Structuring development process of learning knowledge and procedure in healthcare using the unit process flow chart.

Websites are effective in supplying knowledge and learning methods in healthcare and also in improving them. However, either a supplier of the knowledge or a supplier of the learning method based on the knowledge is not able to accumulate what they have learnt through the development. We developed a system to improve development processes of knowledge and of learning method by using the methodology of quality management. In the development, we introduced a concept of Unit Process and used the 'Unit Process Flow Chart' in order to structure a process.

The development of the nursing observation master file.

An observation by the nursing, symptom views by the doctor and result of examinations can be said to be terms expressing a patient status. We collected names of nursing observation items and result notation terms in bottom up from real practice. We performed Structuring and standardization of "an observation item name" and "the result notation" with 8 step method. This master transcribes an observation result in 1 to 1 for an observation name. On this account we put it as another item when result notation is different to the same observation name. Collected terms are 1,653 cases with a set of an observation item name and the result notation.

The development of the nursing action master file.

The nursing action master was developed through collecting terms used by the nurses. The nursing action terms were classified in 2 of the basics and specialty. The nursing action master consists of four hierarchical structures. Serial numbers and ID are set in every hierarchy. It started from 2006 to supply the master and it is revised every year. The number of the publication records is 1,053 basic nursing practice standard terms.

The development of method for continuous improvement of master file of the nursing practice terminology.

Nursing Action Master and Nursing Observation Master were released from 2002 to 2008. Two kinds of format, an Excel format and a CSV format file are prepared for maintaining them. Followings were decided as a basic rule of the maintenance: newly addition, revision, deletion, the numbering of the management and a rule of the coding. The master was developed based on it. We do quality assurance for the masters using these rules.

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.

Structured visualization of expert nursing--An educational program for stoma self-care.

To provide an adequate educational program for patients with a stoma, we have developed an algorithm which was divided into three parts according to the period, i.e., the preoperative period, postoperative period, and rehabilitation period. It was composed of action nodes, thinking nodes, choice branches, assessment item tables, reference tables, and candidate logic tables. Wound Ostomy Continence Nurses (WOCNs) used this algorithm. The results indicated that the algorithm did not omit any important points involved in stoma care, and that it could therefore be successfully applied to patients with a stoma.

Nursing job process analysis from viewpoint of process design by job diagram.

Recently Japan demands more and more quality assurance in clinical practice. Several aspects of issues have been discussed to provide significant suggestions for nursing quality assurance. In the quality management field, Process Design, which is known to contribute to quality assurance, is an important frame. This study attempts to analyze the nursing job process from the viewpoint of process design. As a result, some knowledge on the nursing job process could be comprehended. Process analysis from the viewpoint of Process Design is considered significant in nursing practice and further improvement of its technique and application is a challenge for the future.

Structural visualization of expert nursing: Care to prevent tuberculosis infection for outpatients at their hospital visits.

Tuberculosis infection poses a serious challenge for preventing transmission of contagious diseases at medical treatment facilities in Japan. The authors have therefore developed an algorithm for providing care to prevent tuberculosis infection during the critical period between initial consultation and being admitted to the hospital.

Structural visualization of expert nursing: Dialysis patient education program "PD catheter management".

Structural visualization was implemented on catheter management education for peritoneal dialysis (PD) patients requiring expert nursing. An education program utilizing electronic images was proposed as a method of monitoring the exit site, which is of high importance in PD catheter self-management. Recording images of the exit site and utilizing them as part of the education program encouraged a common understanding of the exit site between nurses and patients, and helped to achieve a better quality of patient education. It is thought that visualization of nursing practice and the thinking processes of expert nurses which have not been expressly stated previously can become a foundation for more advanced nursing care throughout the profession.

Structural visualization of expert nursing: Dialysis patient education program "vascular access management".

Structural visualization was implemented on vascular access management education for dialysis patients requiring expert nursing. As listening to and recording the sound of the Vascular access is important, an education program involving the electronic recording of sounds was proposed. Recording the Vascular access sounds and utilizing them as part of the education program encouraged a common understanding of the sounds between nurses and patients and helped to achieve a better quality of patient education. It is thought that the visualization of nursing practice and the thinking processes of expert nurses which have not been expressly stated previously can become a foundation for more advanced nursing care throughout the profession.

Structural visualization of expert nursing: Expert nursing care for a patient undergoing outpatient radiotherapy.

In the past, almost all patients underwent radiotherapy during the hospital stay. So nurses took care of patients after radiotherapy in the hospital where patients could receive nursing care 24 hours a day. However, recently more and more patients have undergone radiotherapy at clinics as outpatients. This benefits them in enabling them to receive the therapy with improving QOL and maintaining their style of living--on the other hand this requires much self-care ability on their part and patient compliance of outpatient visits depends on their own positive decision-making. Nurses are considered to make decisions or take implementation of various kinds of intervention in the limited time of pre and post proceedings of the therapy when they accommodate patients directly. The process of their intervention has not so far been clarified so that the quality of the care depends on the degree of each individual's capacity or devotion. In addition, with the trend in decreasing hospitalized days, it is predicted that more and more patients will undergo outpatient radiotherapy. So it is significant to clarify the process for quality assurance of nursing.