Enhanced recovery after surgery-based recovery room nursing improves perioperative safety in gastrointestinal tumor surgery

Abstract

BACKGROUND

Gastrointestinal (GI) tumors are among the most prevalent malignancies, and surgical intervention remains a primary treatment modality. However, the complexity of GI surgery often leads to prolonged recovery and high postoperative complication rates, which threaten patient safety and functional outcomes. Enhanced recovery after surgery (ERAS) principles have been shown to improve perioperative outcomes through evidence-based, multidisciplinary care pathways. Despite its widespread adoption, there is a paucity of research focusing specifically on optimizing ERAS-guided nursing processes in the post-anesthesia care unit (PACU) and evaluating its impact on perioperative safety in patients undergoing GI tumor surgery. This study aimed to investigate whether an ERAS-based PACU nursing protocol could enhance recovery, reduce complications, and improve patient safety in this surgical population.

AIM

To explore the impact of optimizing the recovery room nursing process based on ERAS on the perioperative safety of patients with GI tumors.

METHODS

A total of 260 patients with GI tumors who underwent elective surgeries under general anesthesia in our hospital from August 2023 to August 2025 and were then observed in the recovery unit (PACU) were selected. They were randomly divided into the observation group (the PACU nursing process was optimized based on ERAS) and the control group (the conventional PACU nursing process was adopted) by the random number grouping method, with 130 cases in each group. The time of gastric tube removal, urinary catheter removal, defecation time, hospital stay, time of leaving the room after tube removal, retention time in the recovery room, occurrence of complications, satisfaction and readmission rate were compared between the two groups after entering the room. Compare the occurrence of adverse events in the PACU nursing process between the two groups.

RESULTS

The time of gastric tube removal, urinary catheter removal, defecation time, hospital stay, retention time in the recovery room, total incidence of complications and readmission rate in the observation group were significantly lower than those in the control group, and the satisfaction rate was higher than that in the control group (P < 0.05). The occurrence of adverse events in the PACU nursing process in the observation group was lower than that in the control group (P < 0.05).

CONCLUSION

Optimizing the PACU nursing process based on ERAS can effectively accelerate the recovery process of patients undergoing GI tumor surgery, reduce adverse events, improve nursing satisfaction, and at the same time, lower the incidence of adverse events in the PACU nursing process, providing a more refined management basis for clinical practice.

Key Words: Enhanced recovery after surgery; Recovery room; Nursing; Gastrointestinal tumors; Perioperative period

Core Tip: This study innovatively optimized the post-anesthesia care unit nursing process based on the enhanced recovery after surgery concept. It demonstrates that this structured, evidence-based protocol significantly accelerates patient recovery, reduces complications and adverse events, and improves satisfaction in gastrointestinal tumor surgery, providing a refined management model for this critical perioperative phase.

INTRODUCTION

Gastrointestinal (GI) tumors are one of the most common malignant tumors in China. According to the latest cancer statistics[1], they account for as high as 25% of new cases and 35% of deaths among all malignant neoplasms, imposing a heavy disease burden on society and families. Currently, surgical treatment remains the primary clinical approach. However, due to the complexity of the procedures, significant trauma, and long duration, GI surgery leads to a high incidence of postoperative complications and prolonged recovery, seriously threatening patients' perioperative safety[2,3]. Therefore, finding a nursing model that can optimize the perioperative safety of GI tumor patients is urgent. The enhanced recovery after surgery (ERAS) concept, through a series of evidence-based perioperative optimization measures, covers the entire process from preoperative assessment and prehabilitation, intraoperative minimally invasive techniques and precise anesthesia management, to postoperative pain control, early enteral nutrition, and early mobilization. It aims to reduce patients' physiological and psychological traumatic stress, thereby decreasing complications and accelerating recovery[4,5]. Extensive research[6,7] has confirmed that applying the ERAS pathway in GI surgery can significantly reduce the incidence of postoperative complications and shorten the average hospital stay, indicating that ERAS can safeguard the safety of GI tumor patients. Within this pathway, the post-anesthesia care unit (PACU), as a critical link between the operating room and the general ward, undertakes the important tasks of ensuring patients' smooth recovery from anesthesia, effectively and promptly managing acute postoperative complications, and providing concentrated, professional monitoring and care[8]. However, the traditional PACU nursing model often focuses on the “passive” monitoring of vital signs and the management of emergencies, lacking systematic and structured implementation and evaluation standards, which affects the overall recovery outcomes of patients[9]. Introducing and optimizing the PACU nursing process based on the ERAS concept precisely provides a theoretical framework and practical pathway to address these shortcomings. Nevertheless, current ERAS research mostly focuses on the entire hospitalization period, and studies specifically targeting the optimization of ERAS-oriented nursing processes in the PACU phase and systematically evaluating its impact on the perioperative safety of GI tumor patients remain insufficient. Therefore, this study aims to evaluate the construction of an optimized PACU nursing process based on the ERAS concept and assess the impact of this optimized protocol on the perioperative safety and short-term recovery outcomes of GI tumor patients, intending to provide a more refined management basis for clinical practice.

MATERIALS AND METHODS

General information

A total of 260 patients with GI tumors who were admitted to the PACU after undergoing elective surgery under general anesthesia in our hospital from August 2023 to August 2025 were selected. They were randomly divided into an observation group and a control group using a random number table method, with 130 patients in each group.

Control group: The male-to-female ratio was 55:75; age range was 39-70 years, with a mean age of 52.65 ± 14.76 years; American Society of Anesthesiologists (ASA) physical status classification included 7 patients in grade I, 110 in grade II, and 13 in grade III; anesthesia time ranged from 74 minutes to 235 minutes, with a mean time of 154.22 ± 80.09 minutes; tumor location: 67 cases of gastric cancer, 26 cases of colon cancer, 37 cases of rectal cancer; 91 cases were laparoscopic surgery history; 49 cases were combined hypertension; and 61 cases were complicated with diabetes.

Observation group: The male-to-female ratio was 56:74; age range was 40-70 years, with a mean age of 55.14 ± 14.45 years; ASA physical status classification included 6 patients in grade I, 112 in grade II, and 12 in grade III; anesthesia time ranged from 75 minutes to 239 minutes, with a mean time of 157.02 ± 81.38 minutes; tumor location: 69 cases of gastric cancer, 25 cases of colon cancer, and 36 cases of rectal cancer; 94 cases were laparoscopic surgery history; 51 cases were combined hypertension; and 59 cases were complicated with diabetes.

No significant differences were observed in the general data between the two groups (P > 0.05), indicating comparability.

Inclusion criteria: (1) Pathologically confirmed gastric cancer[10] or colorectal cancer[11] via preoperative GI endoscopic biopsy, with clinical stage T1-3N0M0; (2) Scheduled for elective radical tumor resection surgery; (3) Received general anesthesia combined with intraoperative regional nerve blockade and were transferred to the PACU for observation postoperatively; (4) Karnofsky Performance Status score > 80; (5) No severe dysfunction of major organs or severe malnutrition; and (6) Good patient compliance, ability to cooperate with follow-up, and signed informed consent provided by the patient or their family.

Exclusion criteria: (1) Combined with GI obstruction, active bleeding, perforation, or other conditions requiring emergency surgery; (2) Previous history of radiotherapy or systemic chemotherapy prior to surgery; (3) Previous history of abdominal surgery; (4) Comorbid with mental disorders or impaired cognitive function; (5) Comorbid with uncontrolled severe systemic diseases; or (6) Postoperative plan for direct transfer to the intensive care unit based on intraoperative conditions, rather than returning to the general ward via the PACU. This study was approved by the Ethics Committee of our hospital.

Sample size calculation: The sample size calculation formula for comparing two sets of rates is[12]: n = [P₁ (1 - P₁) + P₂ (1 - P₂)] × [(Z_α/2 + Z_β)/(P₁ - P₂)]², where α = 0.05 (bilateral), β = 0.20 (testing efficiency of 80%), Z_α/2 = 1.96, Z_β = 0.84. According to literature[6,7], it is estimated that the incidence of complications in the control group is P₁ = 30%, while in the observation group it is P₂ = 15%. Substituting the formula, each group requires 118 cases. Considering a 10% dropout rate, the sample size is expanded to 130 cases per group, resulting in a total sample size of 260 cases.

Methods

Control group: Received the conventional PACU nursing protocol. After being transferred to the PACU, the responsible nurse continuously monitored and recorded the patient's heart rate, blood pressure, blood oxygen saturation, and respiration, with recordings taken every 5 minutes. Patients were placed in a supine position without a pillow, with the head turned to one side. Nurses promptly cleared airway secretions and secured venous access and various drainage tubes. Body temperature was measured every 30 minutes, and basic warming measures were applied. Patients were closely monitored for complications such as nausea, vomiting, shivering, and pain, which were managed according to routine physician orders if they occurred. Patients were transferred back to the general ward after their modified Aldrete score reached ≥ 9 points, following a joint assessment by the anesthesiologist and nurse.

Observation group: Building upon the control group, the nursing procedures were optimized based on the ERAS protocol. Team formation: The team composition includes 1 department head, 3 anesthesiologists, 1 head nurse, and 5 anesthesia nurses. Postoperative procedures: After surgery completion, the primary anesthesiologist of the operating room calls to reserve a PACU bed. The primary PACU nurse assigns the bed, while the nursing team prepares the anesthesia machine based on the reservation, sets up the monitor, and prepares the surface warming device. Once the PACU nurse has the bed ready, the primary nurse notifies the primary anesthesiologist. The primary anesthesiologist then manually ventilates the patient using a resuscitation bag and, together with the circulating nurse, escorts the intubated patient to the PACU for monitoring. The primary anesthesiologist may only leave after handing over to the PACU physician and the assigned nursing team regarding the patient's intraoperative vital signs, medications, fluids, intake/output, and other relevant conditions. The circulating nurse hands over to the assigned PACU nurse regarding the patient's various drainage tubes, intravenous access, pre- and post-operative skin condition, blood products and medications brought along, and the patient's personal belongings. Once the patient meets the discharge criteria [Steward score ≥ 4, Visual Analog Scale (VAS) score ≤ 4] and is assessed by the anesthesiologist, the assigned transport nurse escorts the patient back to the ward using transport monitoring equipment and a resuscitation bag. Upon returning to the ward, the nurse hands over to the ward nurse regarding PACU and intraoperative details, including: (1) Verifying the patient's medical record, age, surgical site, and operation time; (2) Checking the functionality of the transport bed to ensure its safety; (3) Inspecting the patency of IV lines, urinary catheters, nasogastric tubes, etc., and checking for any dislodgement; and (4) Carefully completing the surgical patient handover form, including key information such as patient name, surgery type, consciousness, blood pressure, muscle strength, airway, central venous catheter, arterial line, etc. After completing the handover, both nurses sign the handover form for confirmation. The daily morning meeting includes a report on the previous day's handover compliance rate. Incorrect items are communicated to alert relevant personnel. For errors related to the ward, the head nurse communicates directly with the respective ward's head nurse for immediate corrective action. A monthly specialized quality control check is conducted across all surgical wards in the hospital to ensure 100% compliance.

Optimization of anesthesia strategy and emergence phase management: (1) Implement a double-check mechanism: The anesthesiologist marks the nerve block area on the patient's body surface with a red marker based on the surgical incision site. The circulating nurse verifies and confirms the marking before skin disinfection begins. Adhere strictly to the principle: No marking and no procedure; (2) 30 minutes preoperatively in the pre-anesthesia area, the anesthesiologist performs an ultrasound-guided transversus abdominis plane block according to the surgical incision site. Intraoperative remifentanil dosage is maintained at 0.1-0.15 μg/kg/minute. Within 5 minutes of the patient's arrival in the PACU, the PACU nurse completes verification of the patient-controlled analgesia (PCA) pump to ensure correct parameters and proper functioning (formula: Prepared by residents or interns in the operating room according to the anesthesiologist's orders and brought to the recovery room, with secondary verification by the anesthesia nurse). Record the baseline pain score. Thereafter, assess pain intensity every 15 minutes using the VAS scale. When VAS ≥ 4, intravenously administer flurbiprofen axetil 50 mg as rescue analgesia according to physician's orders; (3) The department conducts specialized training on Wednesday afternoons of the first week each month, using a “live demonstration + Power Point presentation” format. Training focuses on PCA pump parameter settings (background infusion 2 mL/hour, bolus dose 2 mL, lockout interval 15 minutes, maximum dose 12 mL), handling common alarms, and key points for observing adverse reactions. Post-training assessment via model operation is required, with a pass mandate for all staff; and (4) PACU nurses strictly implement the “three-check rule for analgesia management”: Verify whether the PCA pump is turned on, confirm the three-way stopcock is open, check patient basic information is complete, and ensure parameters are correctly set.

Improve and standardize systems: (1) Designate the Thursday afternoon of the third week each month as the “tube safety themed day” within the department. The head nurse will organize specialized training sessions using a “theoretical instruction + scenario simulation” model, focusing on tube fixation, monitoring, and emergency response to tube dislodgement; (2) The Department of Nursing will uniformly formulate the “postoperative patient tube handover procedure”: Upon the patient's arrival in the PACU, nurses must complete a tube check within 5 minutes following a top-to-bottom sequence (“nasogastric tube - endotracheal tube - central venous catheter - abdominal drain - urinary catheter”) and reinforce fixation using new devices. Concurrently, color-coded versions of the tube handover flowchart will be posted in conspicuous locations at each PACU bed, clearly defining staff responsibilities and positioning; and (3) The department will conduct daily reporting and monthly assessments of the tube care qualification rate. Those failing to meet the standard must complete retraining within one week.

Implement systematic training for healthcare staff: (1) Senior nurses will provide one-on-one mentoring for new nurses over a three-month period, focusing on equipment operation and troubleshooting; (2) The department will organize “perioperative safety practical training” every two months. Through the review of real cases, the training will reinforce standardized operations in four key phases: Pre-extubation, during transport, during handover, and post-medication. Participants are required to complete full-process operations in simulated scenarios; and (3) The management of typical complications such as hypoxemia will be incorporated into the assessment system. A comprehensive evaluation of healthcare staff's emergency response capabilities will be conducted through theoretical tests, practical operations, and scenario simulations.

Enhance patient care and comfort: (1) Upon the patient's initial awakening in the PACU, nursing staff will inform them of the successful surgery and reassure their family. Actively inquire about discomforts such as chills or pain, and provide detailed explanations regarding procedures like catheter retention; (2) When discontinuing oxygen therapy after 20 minutes of administration, provided vital signs are stable, guide the patient to practice abdominal breathing exercises, performed 5 times hourly; (3) During care, assist the patient into a 30° semi-Fowler's position (with a specialized soft pillow under the head) and moisten the patient's oral cavity every 2 hours using a lemon water spray prepared by the department; (4) Upon the patient's arrival in the PACU, use a forced-air warmer for surface warming. Apply protective restraints to both upper limbs, which should be removed once the patient is awake and able to follow commands; and (5) Ensure curtains are drawn before all nursing procedures, and record pain assessments every 30 minutes.

Observation indicators

Rehabilitation process indicators: The following indicators were observed and compared between the two groups: Time to nasogastric tube removal after PACU admission, time to urinary catheter removal, time to first defecation, length of hospital stay, time from extubation to PACU discharge, and PACU length of stay.

Incidence of complications: The occurrence of complications such as urinary tract infection, anastomotic leakage, and surgical site infection (SSI) was observed in both groups from discharge until 30 days postoperatively.

Diagnosis of urinary tract infection: According to the Clinical Practice Guidelines for Diagnosis and Management of Urinary Tract Infections[13], the diagnosis can be made if any of the following conditions are met: (1) The patient has symptoms such as fever (> 38.0 °C), frequent urination, urgency, and pain during urination, and the bacterial count in the clean midstream urine culture is ≥ 10⁵ CFU/mL; and (2) During the postoperative indwelling catheterization or after extubation, two consecutive (24-hour interval) clean midstream urine cultures showed a bacterial colony count of ≥ 10⁵ CFU/mL.

Diagnosis of anastomotic fistula: Meet any of the following criteria: (1) Postoperative signs of fever, abdominal pain, peritonitis, and the drainage tube leading out intestinal contents or purulent fluid; (2) Abdominal computed tomography scan confirmed the leakage of contrast agent into the abdominal cavity; and (3) Surgery was performed again due to suspected fistula, and the rupture of the anastomotic site was confirmed under direct visualization during the operation.

Diagnosis of SSI: Using the SSI grading and definition criteria of the Centers for Disease Control and Prevention in the United States: Superficial incision SSI[14]: (1) Purulent discharge from the incision; (2) Positive culture of incision secretion; and (3) There is pain, redness, and fever, and the surgeon actively opens the incision.

Deep incision SSI: (1) There is purulent secretion in the deep part of the incision; (2) The incision is cracked or open, accompanied by fever (> 38 °C) or local signs; and (3) Imaging or surgical confirmation of deep abscess.

Organ/cavity SSI: (1) The drainage fluid in the cavity is purulent; (2) Positive fluid or tissue culture in the cavity; and (3) Imaging or surgical confirmation of lacunar abscess. Overall incidence rate = (number of cases with complications/total number of cases) × 100%.

Patient satisfaction and readmission rate: Patient satisfaction was assessed on the day of discharge using a satisfaction questionnaire. This questionnaire covered 20 aspects, including hospital environment, communication of safety precautions, and methods for calling medical staff in emergencies. Each aspect was scored from 0 point to 5 points. Satisfaction levels were defined as very satisfied (total score ≥ 90 points), generally satisfied (total score 60-89 points), and dissatisfied (total score ≤ 59 points). Satisfaction rate = [(number of “very satisfied” patients + number of “generally satisfied” patients)/total number of patients] × 100%.

Incidence of adverse events in the PACU nursing process: Adverse events occurring from the patient's admission to discharge from the PACU were evaluated, including failures to promptly connect the anesthesia machine or monitoring equipment, inadequacies in patient handover, omissions in transferring patient belongings, and non-compliance with standardized care protocols for various catheters and analgesic pumps.

Statistical analysis

Statistical analysis was performed using SPSS version 27.0. Quantitative data that conforms to normal distribution are expressed as mean ± SD, and independent sample t-test is used for inter group comparison; non normally distributed data are represented by median (interquartile range) and Mann Whitney U test is used. Count data is expressed as n (%), and comparison between groups is conducted using the χ² test or Fisher's exact probability method. P < 0.05 indicates a statistically significant difference.

RESULTS

Comparison of clinical indicators between the two groups

The observation group showed significantly shorter times than the control group in the following indicators: (1) Time to nasogastric tube removal: 4.22 ± 1.05 days; (2) Time to urinary catheter removal: 18.20 ± 1.36 hours; (3) Time to first defecation 3.10 ± 0.80 days; (4) Length of hospital stay 9.19 ± 2.13 days; and (5) PACU length of stay: 66.95 ± 15.79 minutes (P < 0.05; Table 1).

Table 1 Comparison of clinical indicators between the two groups (mean ± SD).

Indicator	Control group (n = 130)	Observation group (n = 130)	t value	P value
Time to nasogastric tube removal (day)	6.43 ± 1.24	4.22 ± 1.05	15.803	0.000
Time to urinary catheter removal (hour)	21.44 ± 2.47	18.20 ± 1.36	13.102	0.000
Time to first defecation (day)	3.50 ± 0.45	3.10 ± 0.80	4.969	0.000
Length of hospital stays (day)	12.11 ± 3.29	9.19 ± 2.13	8.495	0.000
Time from extubation to PACU discharge (minute)	55.34 ± 16.59	55.84 ± 15.01	0.255	0.799
PACU length of stay (minute)	90.97 ± 25.97	66.95 ± 15.79	9.011	0.000

PACU: Post-anesthesia care unit.

Comparison of complication rates between the two groups

The total incidence of complications in the observation group (6.15%) was significantly lower than that in the control group (26.15%, P < 0.05; Table 2).

Table 2 Comparison of complication rates between the two groups, n (%).

Indicator	Control group (n = 130)	Observation group (n = 130)	χ2	P value
Urinary tract infection	19 (14.62)	4 (3.08)	-	-
Anastomotic leak	4 (3.08)	0 (0.00)
Surgical site infection	11 (8.46)	4 (3.08)
Total incidence	34 (26.15)	8 (6.15)	19.196	0.000

Comparison of satisfaction and readmission rates between the two groups

The readmission rate in the observation group (0.00%) was lower than that in the control group, while the satisfaction rate (98.46%) was higher than that in the control group (P < 0.05; Table 3).

Table 3 Comparison of satisfaction and readmission rates between the two groups, n (%).

Indicator	Control group (n = 130)	Observation group (n = 130)	χ2	P value
Readmission rate	6 (4.62)	0 (0.00)	4.265	0.039
Very satisfied	110 (84.62)	114 (87.69)	-	-
Generally satisfied	9 (6.92)	14 (10.77)
Dissatisfied	11 (8.46)	2 (6.67)
Satisfaction rate	119 (91.54)	128 (98.46)	6.559	0.010

Incidence of adverse events in the PACU nursing process between the two groups

The observation group had lower rates than the control group (P < 0.05) in the following adverse events: Failure to promptly connect the anesthesia machine/monitoring equipment (6.15%), failure of both parties to jointly review and organize the patient (10.00%), omission of patient-related condition information during handover (3.85%), omission of item handover (6.92%), non-standard catheter care (3.08%), and non-standard analgesic pump handover (4.62%; Table 4).

Table 4 Incidence of adverse events in the post-anesthesia care unit nursing process between the two groups, n (%).

Indicator	Control group (n = 130)	Observation group (n = 130)	χ2	P value
Delayed connection of anesthesia machine/monitor	19 (14.62)	8 (6.15)	5.001	0.025
Failure of both parties to jointly review patient	32 (24.62)	13 (10.00)	9.701	0.002
Omission of patient-related condition info handover	15 (11.54)	5 (3.85)	5.417	0.020
Omission of belongings/item handover	23 (17.69)	9 (6.92)	6.985	0.008
Non-standard catheter care	19 (14.62)	4 (3.08)	10.732	0.001
Non-standard analgesic pump handover	20 (15.38)	6 (4.62)	8.376	0.004

DISCUSSION

Studies have reported that postoperative patients with GI tumors exhibit a high incidence of complications and mortality, which severely threatens their perioperative safety and delays the recovery process[15,16]. These patients primarily undergo anesthesia recovery under monitoring in the PACU. However, traditional nursing models, due to insufficient standardization of procedures, hinder early patient recovery. Therefore, implementing PACU nursing process optimization centered on the ERAS concept is of decisive significance for ensuring the perioperative safety of GI tumor patients.

In the clinical study by Gao et al[17], ERAS-concept-based goal-directed fluid therapy was found to facilitate volume management during radical resection of colorectal tumors, with patients demonstrating favorable postoperative recovery. Hampton et al[18] reported that patients undergoing anterior cruciate ligament reconstruction in the post-ERAS implementation group had significantly shorter PACU stays than those in the pre-ERAS group (62.8 minutes vs 79.4 minutes), along with reduced immediate postoperative analgesic consumption (2.26 mg vs 4.55 mg). These findings indicate that integrating PACU with the ERAS pathway and optimizing its processes is an effective approach to enhancing perioperative safety and recovery quality in GI tumor patients. The results of this study show that the observation group had significantly better outcomes than the control group in terms of postoperative removal of nasogastric and urinary catheters, time to first defecation, length of hospital stay, and PACU retention time. This suggests that optimizing the PACU nursing process centered on the ERAS concept can significantly accelerate the recovery of postoperative GI tumor patients. The analysis attributes this improvement to the optimized handover process, which established a closed-loop procedure of “preoperative reservation-preparation-handover-verification”. By having the primary anesthesiologist reserve PACU beds in advance and nursing staff prepare equipment and warming devices beforehand, a seamless transition of patients from the operating room to the PACU was achieved. During handover, a checklist-based verification covering critical items such as patient condition, medications, tubes, and skin status was implemented, with confirmation and joint signing by both transferring and receiving medical staff, effectively preventing information omissions and handover blind spots. Furthermore, daily morning meetings reporting qualification rates and monthly specialized quality control formed a continuous improvement mechanism, systematically ensuring handover quality and significantly reducing patients' PACU retention time[19].

The study by Fabulas et al[20] demonstrated that suppressed GI function following GI tumor surgery is a risk factor affecting patient recovery. In this study, the observation group implemented a standardized multimodal analgesia protocol, with its core objective being to mitigate surgical stress response through effective pain management. It is known that severe postoperative pain exacerbates neuroendocrine stress, which is closely associated with increased release of proinflammatory cytokines such as tumor necrosis factor-alpha and interleukin-6[21]. Therefore, the optimized analgesic strategy may contribute to a more favorable physiological environment for early recovery of GI function by alleviating systemic inflammatory responses. Simultaneously, the optimized awakening management protocol reduced systemic opioid usage and activated GI μ-receptors, consequently diminishing surgical trauma stress responses and sympathetic nerve tension, while alleviating the inhibitory effects on intestinal motility and secretion[22,23]. This established a favorable neuroendocrine environment for vagus nerve-dominated recovery of GI motility. Therefore, patients in the observation group experienced faster recovery of GI function and achieved earlier first defecation, which also provided a clinical basis for early removal of the nasogastric tube.

From a health economics perspective, this optimized protocol also demonstrates potential value. The significant reduction in hospital length of stay and PACU stay observed in the intervention group indicates an improvement in the turnover efficiency of medical resources, particularly beds and nursing manpower. The decrease in complication rates is directly linked to reduced derivative medical expenses, such as antibiotic use, secondary interventions, additional examinations, and readmissions. Although this study did not conduct a detailed cost analysis, the accelerated recovery process and the reduction in complications together point towards savings in medical resources. Future research could employ cost-effectiveness analysis to further quantify the economic benefits of this protocol, thereby providing more comprehensive evidence for clinical management decision-making.

This study further compared the two groups and found that the observation group demonstrated significantly lower incidence of complications such as anastomotic leakage, reduced readmission rates, and markedly improved patient satisfaction compared to the control group. These results suggest that optimizing the nursing process can enhance perioperative safety and recovery quality in patients undergoing GI tumor surgery. The underlying mechanism may be attributed to the fact that GI tumor surgeries, characterized by prolonged operation time and multiple invasive procedures, carry a high risk of infection for patients[24]. In this study, through standardized management and training of PCA, patients received high-quality analgesia. This enabled and motivated patients to perform effective coughing and deep breathing earlier, and to comply with instructions for early ambulation. Consequently, this fostered a local environment conducive to collagen synthesis and angiogenesis, upregulating the expression of pro-healing factors such as vascular endothelial growth factor and transforming growth factor-beta, improving systemic blood circulation and anastomotic microcirculation, thereby reducing the risk of anastomotic leakage[25]. Simultaneously, the observation group in this study established and standardized protocols and implemented systematic training for healthcare staff. Contents including tube care, handover standards, and analgesia pump management were integrated into a closed-loop management system through flowcharts, checklists, and monthly assessments. This ensured that every healthcare professional could accurately assess extubation indicators and adhere to standardized aseptic techniques. As a result, the indwelling time of urinary catheters was significantly shortened, reducing the opportunity for pathogenic bacteria to migrate upwards along the catheter wall, and consequently lowering the risk of urinary tract and SSIs[26]. In the optimization of nursing processes, patient-centered care is enhanced through comprehensive communication, privacy protection, comfort care, and early functional promotion. Extra attention and explanations are provided to patients experiencing excessively long waiting times. Additionally, during procedures such as urinary catheter drainage and oxygen therapy cessation, patients are granted full informed consent and respect. These measures directly improve patient satisfaction on an emotional and experiential level, while reinforcing their sense of security and trust[27]. Since the observation group exhibited a significantly lower incidence of complications, the risk of readmission due to delayed issues such as infection, anastomotic leakage, and intestinal obstruction was also substantially reduced. This demonstrates that the ERAS-based optimized PACU nursing protocol provides long-term clinical benefits.

This study further found that the incidence of adverse events in the PACU nursing process was lower in the observation group than in the control group, suggesting that the optimization of the PACU nursing process based on the ERAS concept can improve the quality of PACU nursing and patient safety. The reasons for this are as follows: (1) The observation group provided systematic training to medical staff, with a focus on enhancing the standardized operation skills of equipment such as anesthesia machines and monitors; (2) Proficiency was ensured through scenario simulation and assessment, directly reducing the risk of faults such as failure to connect anesthesia machines/monitors in a timely manner; and (3) The structured handover process has been optimized through list-based handover, requiring the sending and receiving medical service providers to verify each other. This systematically reduces problems such as the failure to jointly verify patient and condition information and the omission of item handover caused by the informality of oral handover. The improvement and standardization of the system and process have unified the pipeline handover sequence and care standards through colorful flowcharts. At the same time, the checklists have been integrated into the information platform, enabling issues such as non-standard pipeline care to be discovered and corrected during monthly quality control. In terms of optimizing anesthesia strategies and recovery period management, this project not only established PCA management standards but also provided specialized training for medical staff through Power Point presentations and on-site demonstrations, ensuring the standardization of the entire process from connection and handover to usage. As a result, it significantly reduced the incidents of non-standard handover of analgesic pumps.

CONCLUSION

In summary, the optimized PACU nursing protocol, through structured and standardized management, has accelerated patient recovery, reduced complications, and improved satisfaction, while also decreasing adverse events in the nursing process. The discussion on inflammatory pathway mechanisms in this study is based on reasonable inference drawn from the well-established association between pain, stress, and inflammation, with its specific biochemical pathways requiring direct validation in future research. Furthermore, this protocol demonstrates potential in enhancing the efficiency of medical resource utilization, warranting in-depth health economics evaluation in subsequent studies. However, as this study is a small-sample study, large-scale, multi-center research is needed in the future to further validate its universality. Additionally, in-depth exploration of the impact of this optimized protocol on specific inflammatory factors and long-term survival rates could provide more robust evidence for the refined application of the ERAS concept in key perioperative phases.

ACKNOWLEDGEMENTS

We sincerely thank all patients and their families for participating in this study. We are grateful to the colleagues from the Department of Anesthesiology and Perioperative Medicine and the Department of Gastrointestinal Surgery of Henan Provincial People's Hospital for their support in patient recruitment and nursing implementation.