Exploring the Application of a Multi-Targeted Nursing Group for Enhanced Recovery After Surgery Using the LEER (“Less Pain”, “Early Movement”, “Early Return to a Normal Diet” and “Reassurance”) Model

Figures & data

Table 1 Comparison of the General Characteristics Between Patients in the Traditional Group and the MTGN Group

Baseline Data	The Traditional Group (n=91)	The MTNG Group (n=107)	t/χ^2	P
Gender(Male/Female, case)	49/42	59/48	0.033	0.855
The average age(, year)	58.92±11.28	60.48±9.76	1.043	0.298
BMI(, kg/m^2)	23.22±4.40	22.80±5.01	0.621	0.535
Type of disease[Case(%)]
Primary liver cancer	42(46.54%)	51(47.66%)	0.049	0.832
Pancreatic cancer	29(31.87%)	35(32.71%)	0.016	0.899
Hilar cholangiocarcinoma	8(8.79%)	12(11.21%)	0.318	0.573
Lower common bile duct cancer	12(13.2%)	9(8.41%)	1.183	0.277
Complicated with fundamental diseases[Case(%)]	9(9.89%)	13(12.15%)	0.254	0.614

Notes: 1] t; 2] χ².

Table 2 The Peri-Operative ERAS Strategies in the MTNG Group

Peri-Operative	The MTNG Group
Pre-operation	With the enrollment, the MTNG team would replace the medical record plate with the designated color (pink) medical record plate for the enrolled patient and replace the special bedside sign with white letters on a blue background, which indicated the initiation of the LEER-ERAS workflow. The team members routinely provided the individualized preoperative LEER-ERAS concept education, perioperative related practice introduction and professional guidance, distributed health education brochures, and led the reading of the homemade educational materials of the department. The patients watched the homemade ERAS educational video and perioperative surgical rehabilitation exercises video on the multimedia screens in the wards and public areas of the department. 1. The pain management nursing team: ①The patients were trained to master the basic grading of the VAS through visual, auditory and teaching methods; ②Preoperative pain evaluation and documentation for the patients; ③Patients were given non-steroidal anti-inflammatory drugs (NSAIDs) orally at bedtime for preventive analgesia. 2. The organ function, movement and rehabilitation management nursing team: ① The patients were asked to quit smoking and alcohol, and instructed on proper coughing and expectoration; ②Active training with the breathing trainer; ③The patients were instructed on how to conduct the postoperative “4S (Step1-4)” training (Note: The post-operative “lying”, “sitting”, “standing” and “walking” four-step training, referred to as the 4S training), including torso turning, upper and lower limb movement, thoracic movement, walking training, defecation and urination training, etc. 3. The feeding and nutrition management nursing team: ① The patients were educated about the nutritional pyramid and screened for nutritional risk using the NRS2002, and a low-fat, low-salt, high-quality protein diet was routinely recommended for patients with scores <3 points; ② Patients with a score ≥3 points were considered to be at nutritional risk and the medical team proposed consultation with the nutrition department. Enteral nutrition support was preferred, and an individualized nutrition treatment plan was developed according to the presence of cirrhosis or diabetes mellitus and hypertension; ③ For non-diabetic patients, integrated protein-based enteral nutrition powder (TP) was recommended; For diabetic patients, enteral nutrition emulsion (TPF-D) was recommended; The enteral nutrition was supported preoperatively for ≥7 days with energy supplementation of approximately 400kcal/day. Patients were reassessed for nutritional risk screening using the NRS2002 one week after surgery; ④ No mechanical bowel preparation; The patients fasted for solid food 6h before surgery, no clear liquid food 2h before surgery. 250mL of cool carbohydrate drink was administered orally 2h before surgery for non-diabetic patients, and 250mL of 5% glucose saline was administered orally 2h before surgery for diabetic patients. 4. The psychological management nursing team: ① Pre-operative mood index score was performed, and patients with low mood were nursed for consolation in the ward; ② Patients with moderate to severe mood disorders should fill out the Suicide Risk Assessment Form and consult a psychosomatic medicine specialist to assist during the perioperative treatment; ③ If necessary, the psychosomatic medicine department was asked to instruct the patient to take a short-acting oral sedative and anti-anxiety medication.
Intraoperation	The intraoperative flow referred to the process from the time the patient leaves the ward for the operating room to the time the patient leaves the operating room and returns to the ward. The hepatobiliary medical team nurses in the operating room were included in the MTNG team who continued to assist the anesthesiologists and surgeons with the ERAS intraoperatively. ① In the anesthesia waiting room, anesthesia-related knowledge was introduced to patients, and the supervising physician, traveling nurse and supervising anesthesiologist would check. all the information concerning the patient; ② Assist the physicians by following a combination of multiple analgesic modalities and multiple analgesic drugs throughout the operation; ③ The first pain scoring was conducted immediately after the patient awakening in the PACU. If the score was <4 points, the patient was sent to the ward with a self-controlled intravenous analgesic pump. If the score was ≥4 points, the patient was sent back to the ward with temporary analgesic treatment; ④ Patients without gastrointestinal reconstruction were treated with goal-directed fluid therapy without a postoperative gastric tube, and intraoperative balanced fluid was used to maintain the balance of intake and output; Combined use of a variety of small quilts to cover the exposed skin, together with water beds, thermal blankets, warmers, circulating water suit heating system, blood transfusion and infusion heating and other devices to maintain the central body temperature > 36 °C.
Postoperation	After the patient returned safely to the ward, the MTNG immediately intervened and the medical team issued standard post-operative orders according to the specific procedures in the patient, thus starting the workflow of the post-operative protocol implementation of ERAS in LEER mode. 1. The pain management nursing team: ① The special multimodal analgesia program in our department was routinely conducted: intravenous patient-controlled epidural analgesia (PCEA) pump + ultrasound physical analgesia + intravenous infusion of NSAIDs + bedside infiltration of incisional anesthesia or regional block anesthesia for pain relief if necessary; ② VAS pain scoring was routinely conducted three times(Morning, noon and night) daily. Temporary opioid was administered intramuscularly for pain relief when the VAS score ≥ 4 points; ③ Gradual early switch to oral selective COX-2 inhibitors or NSAIDs for pain relief in patients with well-controlled pain. 2. The organ function, movement and rehabilitation management nursing team: ① “Passive” motor rehabilitation treatment was conducted: airwave pneumatic therapy for both lower extremities, regular drug nebulization expectoration combined with ultrasonic vibration mechanical sputum removal and other respiratory management treatments. Chinese acupuncture rehabilitation physiotherapy was conducted in the rehabilitation medicine department; ② The standardized “4S” rehabilitation training program was adopted, ie postoperative bedside functional exercise, sitting training, standing training and walking training. The training included: coughing and expectoration, urination and defecation, respiratory function training, and trunk strength training of the four extremities. ③ Early postoperative removal of the urinary catheter (within 24 hours); Early removal of the gastric tube (within 24 hours) in cases without gastrointestinal reconstruction; The time of removal in patients with gastrointestinal reconstruction depended on the gastrointestinal decompression and the general condition, but also as early as possible. 3. The feeding and nutrition management nursing team: ① A detailed post-operative nutrition plan was formulated, the volume of EN/PN was daily recorded by the nutrition nurse, bedside instruction on proper food chewing training; ② After awakening from anesthesia, the patient was allowed to drink. On the first postoperative day, the patient was fed through the mouth, with a liquid diet first, and then gradually transition to a semi-liquid diet, soft diet, normal diet according to the own tolerance(food at will); ③ Oral enteral nutrition adjuvant preparation was administered when the transoral feeding was <60% of normal amount; ④ Target-directed rehydration, encouraging oral rehydration with electrolytes and reducing the volume of intravenous rehydration; ⑤ The patients were instructed to chew gum routinely; ⑥ The ultrasonic therapy device was adopted to promote gastrointestinal peristalsis; ⑦ Individualized and standardized application of proton pump inhibitors and broad-spectrum hydrolase inhibitors according to the actual condition in patient; ⑧ For patients with previous bowel difficulties, laxatives could be applied to stimulate the gastrointestinal motility as appropriate. 4. The psychological management nursing team: The patient might be reassessed psychologically after the operation, depending on the situation. For patients who required continued psychological intervention after assessment, in addition to continued bedside psychological counseling, psychopharmacological interventions might continue to be conducted, with the addition of short-acting sedative medications at bedtime.
Discharge	Unified discharge criteria were established: patients were able to move freely, with normal body temperature, with no need for rehydration therapy, eat and drink normally, with good pain control with oral analgesics, good organ function, good bowel movements, good wound healing, and no signs of infection.

Table 3 The Postoperative Recovery Indicators Between the Traditional Group and the MTNG Group

Postoperative Recovery Indicators	Traditional Group (n=91)	MTNG Group (n=107)	t	P
Postoperative VAS (, point)	3.02±1.08	2.50±0.68	4.114	P<0.01
Postoperative ambulation (, d)	3.01±0.72	2.71±1.01	2.367	0.019
Time to postoperative flatulence (, d)	2.34±0.91	1.98±0.63	3.273	0.0012
Postoperative resume to a normal diet (, d)	4.21±1.45	3.62±1.45	2.853	0.004
P-operative extubation of catheter (, d)	4.35±1.66	3.52±1.53	3.658	P<0.01
Postoperative length of hospital stays (, d)	9.81±1.12	8.31±1.72	7.131	P<0.01
Hospitalization expenses (, Yuan)	45,562.24±1768.48	44,702.34±2988.65	2.409	0.017

Table 4 Comparison of Rate of Postoperative Complications, Unplanned Readmission and Implementation of Nursing Measures

Statistic Indicators	Traditional Group (n=91)	MTNG Group (n=107)	t/χ^2	P
Complication[Case (%)]
Pancreatic leakage	13(14.29%)	19(17.75%)	0.437	0.508
Biliary leakage	5(5.49%)	4(3.74%)	0.129	0.719
Hemorrhage	4(4.39%)	6(5.61%)	0.151	0.698
Infection	9(9.89%)	13(12.15%)	0.254	0.614
Delayed gastric emptying	3(3.29%)	4(3.74%)	0.028	0.867
Deep vein thrombosis	5(5.49%)	2(1.87%)	1.895	0.169
Unplanned readmission [Case (%)]	4(4.39%)	2(1.87%)	1.068	0.301
Patients completing all nursing care measures [Case (%)]	70(76.92%)	88(82.24%)	0.863	0.353
Completing the core nursing care measures (, %)	82.31±11.73	91.25±7.62	6.45	<0.05

Notes: 1] t; 2] χ².

Table 5 Comparison of the Patients’ Understanding of the Disease, Compliance, and Satisfaction with Nursing Care

Investigated Indicators	Traditional Group (n=91)	MTNG Group (n=107)	t/χ^2	P
Disease understanding score (, point)	78.66±10.32	86.79±12.62	4.909	<0.05
Compliance to medical treatment scores (, point)	80.01±14.32	85.93±10.44	3.355	<0.05
Satisfaction with nursing care degree [Case (%)]
Very satisfied	40(43.9%)	63(58.88%)	6.327	0.012
Satisfied	41(45.1%)	42(39.25%)	0.680	0.409
Unsatisfied	10(10.9%)	2(0.019%)	7.184	0.007

Notes: 1] t; 2] χ².