Impact of bundle care on quality of life and nutrition after transarterial chemoembolization

Abstract

BACKGROUND

The absence of standard postoperative protocols for patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE) may negatively affect health and quality of life (QoL). Bundle care is a multidisciplinary, evidence-based model that offers a structured approach. Yet, its effects on this population remain underexplored. The hypothesis in this study was that the implementation of the bundle care protocol can improve QoL and nutritional status after TACE.

AIM

To examine the effects of a multidisciplinary bundle care protocol on the QoL and nutritional status of post-TACE HCC patients.

METHODS

A tertiary hospital conducted a retrospective study on 80 HCC patients who underwent TACE from June 2023 to January 2025. They were included in the routine care group (control group; n = 40), routine care and bundle care group (intervention group; n = 40). The bundle care protocol included multidisciplinary coordination, dynamic assessments [Patient-Generated Subjective Global Assessment (PG-SGA), Hospital Anxiety and Depression Scale (HADS), Numerical Rating Scale], stepwise analgesia, stratified nutrition support, and intelligent follow-up with WeChat. The nutritional status (PG-SGA), psychological scores (HADS), post-embolization symptoms, and laboratory parameters were outcome measures. Independent t-tests, χ² tests and non-parametric tests were used to analyze data.

RESULTS

Post-intervention, the bundle care group showed significantly lower PG-SGA scores than the control group (1.86 ± 0.89 vs 4.46 ± 2.13, P < 0.001), lower anxiety (HADS- Anxiety: 0.36 ± 0.49 vs 4.25 ± 2.03, P < 0.001) and depression scores (HADS-Depression: 0.00 vs 5.00, P < 0.001). Albumin levels (38.33 ± 4.09 g/L vs 35.60 ± 4.87 g/L, P = 0.008) and body mass index (24.24 ± 2.45 vs 21.67 ± 2.63, P < 0.001) were significantly higher in the bundle care group. Nausea resolution was 97.5% in the bundle care group vs 87.5% in controls (P < 0.05).

CONCLUSION

In patients with HCC after TACE, bundle care can significantly improve nutritional status, psychological status, and symptom control to make a case for further clinical use.

Key Words: Bundle care; Transarterial chemoembolization; Hepatocellular carcinoma; Nutritional status; Quality of life

Core Tip: This study sought to assess a comprehensive bundle care protocol, an evidence-based multidisciplinary model integrating dynamic assessment, stratified nutrition and psychological support, and intelligent follow-up for hepatocellular carcinoma after transarterial chemoembolization (TACE). The bundle care was superior to routine care in improving nutritional statuses (lower Patient-Generated Subjective Global Assessment scores) as well as psychological distress (lower Hospital Anxiety and Depression Scale anxiety and depression scores). It also improved post-embolization syndrome which is a structured approach to facilitate post-TACE recovery.

INTRODUCTION

Transarterial chemoembolization (TACE) is the main locoregional treatment used for unresectable hepatocellular carcinoma (HCC). TACE significantly prolongs survival and controls disease progression by selectively embolizing tumor-feeding arteries with localized delivery of chemotherapy[1]. Despite understanding these regimes short-term complications and long-term adverse effect remains a major issue. The most common post-operative event is post-embolization syndrome (PES) that consists of abdominal pain, nausea/vomiting, and low-grade fever due to ischemic injury, inflammatory cytokines, and cytotoxic drug toxicity[2]. Moreover, 20%-30% of patients have impaired hepatic reserve (Child-Pugh B/C), nutritional derangements (hypoalbuminemia prevalence up to 50%), and psychosocial burdens (25%-40% of patients have anxiety/depression) which all worsen the postoperative frailty that contributes to reduced treatment adherence and QoL[3]. Even with the advancements in TACE techniques, such as drug-eluting bead TACE, management of postoperative symptoms still largely relies on experience-based methods. The lack of standardized protocols based on scientific evidence is a key contributing factor to high readmission rates and increases healthcare costs.

The management of TACE post operative care continues to remain fragmented, primarily focused on symptom alleviation in a reactive manner along with basic patient education[4]. This approach is supported by several important gaps. Nutritional and psychological assessments are poorly utilized; in fact, only 35%-45% of institutions use the Patient-Generated Subjective Global Assessment (PG-SGA) scale for nutrition and fewer than 20% use the Hospital Anxiety and Depression Scale (HADS)[5,6]. As a result, moderate-to-severe malnutrition and mental distress are often overlooked and under-treated. In addition, 30%-40% of patients in this group have inadequate pain management because they are treated with ineffective agents [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs)] and are prescribed opioids with caution[7]. In addition, there is usually no multidisciplinary collaboration framework in place. The participation of nutritionists psychologists and pain specialists is episodic inconsistent and does not provide integrated care. Ultimately, follow-up after discharge relies on patient contact, with an occasional phone call. Less than 10% usage of smart, interactive tools for continuous monitoring has led to fragmented patient data and missed opportunities for timely intervention. Together, these shortcomings demonstrate the pressing need for a standardized, coordinated, and continuous care model, which bundled care aims to offer.

A nursing model relevant to critical care, bundle care, is evidence-based and adapted from existing bundle care and evidence-based practice. The model includes standardized, multidisciplinary interventions, and studies have shown its benefits in critical care, perioperative care, etc.[8]. The value of informatics in the post-TACE care smart intervention mainly reflects in three aspects. First, evidence-based, integration-dynamic assessment by using PG-SGA, HADS, and Numerical Rating Scale (NRS) scales can identify nutritional risks, psychological problems, and symptom severity accurately and timely and recommend corresponding stratified intervention[9]. Second, multidisciplinary collaboration-joint management by interventional, nutrition, psychology, and information department makes resources optimize allocation, such as use of early nutritional support and cognitive behavioral therapy[10]. Third, intelligent extended care-a WeChat based follow up system can upload data of patient real-time symptom, automatic early warning, and personalized intervention recommendation. It also solves the limitations of traditional follow up methods[11]. Recent studies indicate bundle care boosts treatment compliance by 15%-20% and reduces 30 days rehospitalization by about 25% in cancer patients[12]. Yet, in the TACE field, its application evidence is limited to small-sample prospective studies, lacking comprehensive assessment of multiple outcomes like nutrition, psychology, and sleep.

This retrospective study seeks to confirm the impact of bundle care on enhancing QoL and nutritional status in post-TACE patients, providing high-level evidence for clinical application.

MATERIALS AND METHODS

Study subjects

We carried out a retrospective analysis of 80 HCC patients who received TACE treatment at the Department of Interventional Radiology, Affiliated Hospital of Nantong University, between June 2023 and January 2025. Forty patients given routine care were assigned to the control group, and forty receiving bundle care to the experimental group. The Ethics Committee of our hospital approved this study, approval No. 2023-L153.

Inclusion criteria and exclusion criteria

Inclusion criteria: (1) Patients with primary liver cancer after TACE treatment; (2) Liver function Child-Pugh A or B; (3) No mental illness; and (4) Able to complete scales independently or with assistance from data collectors.

Exclusion criteria: (1) Extra-hepatic metastasis occurred; (2) Edema or ascites signs appeared; and (3) Incomplete medical history data.

Data collection and observation indicators

Laboratory indicators: The lab tests comprised hemoglobin, albumin (ALB), neutrophil -to-lymphocyte ratio, platelet-to-lymphocyte ratio, aspartate aminotransferase, alanine aminotransferase (ALT), and total bilirubin.

Disease-related indicators: The disease-related indicators comprised body mass index (BMI), smoking and drinking histories, hepatitis background, Child-Pugh class (A or B), TACE frequency, embolization type, and PES (pain, nausea, vomiting, fever). TACE embolization types were conventional TACE and drug-eluting bead TACE.

PG-SGA: The PG-SGA serves as a trusted method to evaluate the nutritional status of HCC patients. The scale has two parts[13,14]. The first part is completed by patients to evaluate their nutritional status, covering anthropometric measurements, diet, symptoms, and function/activity. The second part is filled out by healthcare workers to evaluate disease status, metabolic stress, and physical examination results[15]. PG-SGA scores divide nutritional status into three categories: Good (PG-SGA A, 0-1 points), suspected or moderate malnutrition (PG-SGA B, 2-8 points), and severe malnutrition (PG-SGA C, ≥ 9 points)[16]. Scores range from 0 to 16, with higher scores reflecting poorer nutritional status.

NRS: The NRS is commonly applied to evaluate pain intensity across cancer and non-cancer patients[17-19]. It uses a scale from 0 to 10 for patients to self-assess their pain. Pain levels are categorized as: 0 (no pain), 1-3 (mild), 4-6 (moderate), and 7-10 (severe), with higher scores indicating worse pain.

HADS: The HADS consists of two parts: HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D). Each subscale’s total score varies from 0 to 21. Scores of 0-7 indicate a normal state, while scores ≥ 8 indicate anxiety or depression[20].

Pittsburgh Sleep Quality Index: The Pittsburgh Sleep Quality Index (PSQI) is commonly applied to evaluate sleep quality in cancer patients[21]. This self-assessment scale looks at sleep over the past month and has 19 items divided into seven parts: Sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep - inducing agents, and daytime dysfunction. Scores range from 0 to 21, with sleep quality categorized as very good (0-5), fairly good (6-10), average (11-15), and poor (16-21).

QoL: QoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30. This scale includes functional scales, symptom scales, and a global health status/QoL scale. Higher scores on the functional and global health scales indicate better functioning and QoL, while higher scores on symptom scales indicate greater symptom burden.

Nursing methods

Control group (conventional health education): Conventional health education, based on traditional nursing, focuses on postoperative symptom management and basic education, with specific content as follows: (1) Postoperative immediate care: (a) Symptom management: Within 24 hours postoperatively, the responsible nurse assesses pain (via NRS score), nausea, vomiting, and fever, and administers symptomatic treatment as per medical advice, such as NSAIDs and antiemetics; and (b) Activity guidance: During bed rest, patients are instructed to keep the punctured limb still for 6 hours, and nurses assist with turning to prevent pressure ulcers; (2) Health education content: (a) Dietary guidance: A high-protein, low-fat, easily digestible diet is recommended, with daily protein intake ≥ 1.2 g/kg. Spicy and irritating foods should be avoided; (b) Adverse reaction education: Patients are orally informed about the possibility and relief methods of PES (fever, abdominal pain), such as physical cooling for fever and promptly reporting worsened pain; and (c) Follow-up plan: A paper follow-up schedule is issued before discharge, requiring patients to return to the hospital for liver function and imaging tests one month postoperatively; and (3) Post discharge follow-up (telephone follow-up): Patients are called within one week of discharge to ask about symptom changes and reminded of follow-up times, but there is no systematic tracking.

Experimental group (conventional health education + bundle care): Bundle care, evidence - based, integrates multi-disciplinary collaboration, standardized processes, and continuous management, with specific strategies as follows: (1) Multidisciplinary team building and division of responsibilities. Team members: The team includes the chief nurse of interventional department (overall supervision), nurses with over 5 years’ experience (nursing implementation), attending physician (medical decisions), and nursing graduate students (communication, coordination, and data recording). Standardized training: Team members receive training on bundle care pathways, including nutrition assessment, psychological intervention skills, and pain management standards; (2) Phase specific nursing pathways. Intensive intervention in the first 24 hours postoperatively. Dynamic symptom monitoring: Pain (NRS), nausea, and vomiting severity are assessed every 4 hours, with stepwise analgesia (paracetamol for mild pain; opioids combined with antiemetics for moderate/severe pain). Early nutritional support: Patients are guided to consume lukewarm liquid diets (e.g., rice soup) 6 hours postoperatively to avoid gastrointestinal irritation. Comprehensive management during hospitalization. Individualized nutrition plan: PG-SGA stratified Intervention: A level (0-1 point): Maintain a balanced diet with 20 g of whey protein powder daily; B level (2-8 points): Collaborate with the nutrition department to formulate a high-energy formula (30-35 kcal/kg/day), using oral enteral nutrition preparations; C level (≥ 9 points): Initiate parenteral nutrition, monitoring electrolytes and liver function. Nutrition education tool: Use illustrated booklets to display high-protein recipes (e.g., steamed fish, tofu), with weekly bedside diet demonstrations. Psychosocial support: Anxiety/depression screening: Daily assessment using HADS scale, with scores ≥ 8 triggering referral to a psychologist for cognitive-behavioral therapy (CBT). Group counseling: Weekly “cancer fighting confidence group” sessions for patients to share experiences and reduce psychological burdens. Sleep intervention: Non-pharmacological measures: Guide patients in pre-sleep foot baths, meditation, and adjust ward lighting/noise. Pharmacological intervention: For PSQI scores ≥ 11, short-term use of low-dose benzodiazepines. Pre-discharge preparation and continuous nursing. individualized discharge plan: Symptom management package: Provide a “nursing kit” with antiemetics (ondansetron), pain record sheets, and emergency contacts. Home nutrition support: Arrange home visits by nutritionists monthly for malnourished (PG-SGA B/C) patients. Intelligent follow-up system: WeChat platform management: Push follow-up reminders and dietary videos via official accounts, with patients uploading daily symptom scores (NRS, nausea level); automatic alert mechanism: The system automatically alerts nurses to follow up on abnormal data (e.g., pain ≥ 4); and (3) Quality monitoring and feedback. Weekly team meetings: Analyze implementation rates of nursing measures and patient compliance data to optimize intervention processes. Patient satisfaction survey: Assess nursing experiences with a Likert scale at discharge, revising any links with satisfaction below 80%.

Assessment time points: Baseline data were collected upon admission. Post-intervention assessments were conducted 1-2 days before discharge (approximately 5-7 days after TACE). Follow-up assessments were performed at 1 month and 3 months after discharge via the WeChat platform and outpatient visits.

Statistical analysis

SPSS 25.0 was used for statistical analysis, with P < 0.05 indicating statistical significance. Continuous variables are presented as mean ± SD or median (interquartile range), and categorical variables as counts and percentages. The χ² test, Fisher’s exact test, independent-sample t-test, or non-parametric test was used to compare differences between or within groups before and after nursing care. Correlation analysis was conducted to assess the correlation between continuous variables and PG-SGA scores before nursing care, using Spearman’s correlation to evaluate the association between continuous variables and PG-SGA scores.

RESULTS

Analysis of baseline and disease-related data before nursing care in two groups of TACE-treated HCC patients

Analysis of pre-nursing data in both groups of HCC patients treated with TACE showed no significant differences in baseline and disease-related data (including PES) (P > 0.05; Tables 1 and 2). Specific indicators including age, gender, BMI, smoking history, liver function classification, and TACE-related details are presented in Tables 1 and 2.

Table 1 Baseline and disease-related data of the two groups before nursing care, n (%).

Variable	Grouping	Subjects of study (n = 80)	Control group (n = 40)	Test group (n = 40)	χ2/Z/t	P value
Age, mean ± SD		60.95 ± 8.22	59.97 ± 8.21	61.93 ± 8.19	0.134	0.863
Sex	Male	67 (83.75)	34 (85.00)	33 (82.50)	0.092	0.762
	Female	13 (16.25)	6 (15.00)	7 (17.50)
BMI, mean ± SD		21.57 ± 2.91	21.68 ± 2.58	21.47 ± 3.26	0.365	0.684
Smoking history	No	26 (32.5)	10 (25.0)	16 (40.0)	2.051	0.152
	Yes	54 (67.5)	30 (75.0)	24 (60.0)
Drinking history	No	27 (33.75)	11(27.50)	16 (40.0)	1.398	0.237
	Yes	53 (66.25)	29 (72.50)	24 (60.0)
CCI grouping	0	69 (86.25)	36 (90.0)	33 (82.5)	4.273	0.118
	1	4 (5.0)	0 (0.0)	4 (10.0)
	2	7 (8.75)	4 (10.0)	3 (7.5)
	≥ 3	0 (0.0)	0 (0.0)	0 (0.0)
Hepatitis history	No	6 (7.5)	1 (2.5)	5 (12.5)	3.394	0.335
	Hepatitis B	66 (82.5)	34 (85.0)	32 (80.0)
	Hepatitis C	6 (7.5)	4 (10.0)	2 (5.0)
	Other	2 (2.5)	1 (2.5)	1 (2.5)
Child-Pugh class	A	70 (87.5)	34 (85.0)	36 (90.0)	0.457	0.499
	B	10 (12.5)	6 (15.0)	4 (10.0)
TACE times	-	2.00 (1.00-4.00)	2.50 (1.00-4.00)	2.00 (1.00-4.75)	0.832	0.423
	1-2	42 (52.5)	20 (50.0)	22 (55.0)	0.223	0.894
	3-5	27 (33.75)	14 (35.0)	13 (32.5)	-	-
	> 5	11 (13.75)	6 (15.0)	5 (12.5)	-	-
TACE embolization type	cTACE	61 (76.25)	29 (72.5)	32 (80.0)	0.621	0.431
	DEB-TACE	19 (23.75)	11 (27.5)	8 (20.0)

BMI: Body mass index; CCI: Charlson comorbidity index; TACE: Transarterial chemoembolization; cTACE: Conventional transarterial chemoembolization; DEB-TACE: Drug-eluting bead transarterial chemoembolization.

Table 2 Comparison of post-embolization syndrome before nursing care between the two groups, n (%).

Variable	Grouping	Subjects of study (n = 80)	Control group (n = 40)	Test group (n = 40)	χ2/Z/t	P value
Pain intensity (NRS)	-	1.50 (1.00-3.00)	2.50 (1.00-3.00)	1.00 (0-2.75)	1.645	0.125
	None (0)	19 (23.75)	7 (17.5)	12 (30.0)	4.336	0.114
	Mild (1-3)	49 (61.25)	24 (60.0)	25 (62.5)
	Moderate (4-6)	12 (15.0)	9 (22.5)	3 (7.5)
	Severe (7-10)	0 (0.0)	0 (0.0)	0 (0.0)
Nausea severity	0	47 (58.75)	24 (60.0)	23 (57.5)	0.065	0.996
	I	6 (7.5)	3 (7.5)	3 (7.5)
	II	23 (28.75)	11 (27.5)	12 (30.0)
	III	4 (5.0)	2 (5.0)	2 (5.0)
Vomiting severity	0	61 (76.25)	34 (85.0)	27 (67.5)	3.403	0.182
	I	9 (11.25)	3 (7.5)	6 (15.0)
	II	10 (12.5)	3 (7.5)	7 (17.5)
	III	0 (0.0)	0 (0.0)	0 (0.0)
Fever occurrence	No	54 (67.5)	30 (75.0)	24 (60.0)	2.051	0.152
	Yes	26 (32.5)	10 (25.0)	16 (40.0)

NRS: Numerical Rating Scale.

Comparison of laboratory indicators before nursing care between the two groups of HCC patients treated with TACE

Analysis of laboratory indicators before nursing care in both groups of HCC patients treated with TACE did not reveal substantial variations in hemoglobin, ALB, neutrophil-to-lymphocyte, platelet-to-lymphocyte, aspartate aminotransferase, ALT, and total bilirubin (P > 0.05; Table 3 and Figure 1).

Figure 1 Comparison of laboratory indicators before nursing care between the control and observation groups. A: Hemoglobin content (g/dL); B: Albumin content (g/L); C: Neutrophil-to-lymphocyte ratio; D: Platelet-to-lymphocyte ratio; E: Aspartate aminotransferase content (U/L); F: Alanine aminotransferase content (U/L); G: Total bilirubin content (g/dL). NS: Not significant (P > 0.05).

Table 3 Comparison of laboratory indicators before nursing care between the two groups, mean ± SD.

Variable	Subjects of study (n = 80)	Control group (n = 40)	Test group (n = 40)	Z/t	P value
Hemoglobin (g/dL)	114.24 ± 20.61	113.7 ± 22.84	114.79 ± 18.59	0.057	0.954
Albumin (g/L)	33.47 ± 3.49	33.74 ± 3.24	33.21 ± 3.76	0.563	0.576
NLR	5.34 ± 2.70	5.57 ± 2.50	5.12 ± 3.92	0.584	0.566
PLR	140.45 (87.80-218.83)	146.55 (94.85-193.83)	126.95 (75.95-260.45)	0.388	0.685
AST (U/L)	51.00 (39.25-94.00)	51.00 (38.50-70.75)	61.00 (40.50-119.75)	0.815	0.422
ALT (U/L)	63.00 (43.25-112.00)	61.00 (43.25-114.25)	65.00 (35.75-103.50)	0.183	0.852
Total bilirubin (g/dL)	18.40 (13.67-26.72)	18.50 (14.83-30.00)	17.70 (12.02-26.72)	1.134	0.301

NLR: Neutrophil-to-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase.

Comparison of pre-nursing emotional and sleep status between the two groups

The HADS and PSQI were used to evaluate the emotional and sleep status of patients in the control and experimental groups before nursing. Results revealed no significant differences in HADS-A, HADS-D, or PSQI scores between the two groups (P > 0.05). Similarly, no significant differences were found in the number of patients with anxiety, depression, or insomnia between the two groups before nursing (P > 0.05; Table 4).

Table 4 Comparison of emotional and sleep status before nursing care between the two groups, n (%).

Variable	Grouping	Subjects of study (n = 80)	Control group (n = 40)	Test group (n = 40)	χ2/Z/t	P value
HADS-A	-	5.79 ± 2.32	6.29 ± 2.21	5.29 ± 2.35	1.628	0.112
	No anxiety (≤ 7)	60 (75.0)	29 (72.5)	31 (77.5)	0.267	0.606
	Anxiety (8-21)	20 (25.0)	11 (27.5)	9 (22.5)
HADS-D	-	6.00 (4.25-8.00)	7.00 (5.00-8.00)	5.00 (3.25-7.75)	1.865	0.063
	No depression (≤ 7)	57 (71.25)	27 (67.5)	30 (75.0)	0.549	0.459
	Depression (8-21)	23 (28.75)	13 (32.5)	10 (25.0)
PSQI	-	6.00 (5.00-7.00)	5.50 (5.00-7.00)	6.00 (5.00-9.75)	0.604	0.514
	Very good (0-5)	37 (46.25)	20 (50.0)	17 (42.5)	4.688	0.196
	Fairly good (6-10)	36 (45.0)	19 (47.5)	17 (42.5)
	Average (11-15)	3 (3.75)	1 (2.5)	2 (5.0)
	Poor (16-21)	4 (5.0)	0 (0.0)	4 (10.0)

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; PSQI: Pittsburgh Sleep Quality Index.

Comparison of pre-nursing nutritional status between the two groups of HCC patients treated with TACE

The PG-SGA scale was utilized to evaluate the nutritional status of HCC patients in both groups before nursing. Results indicated no significant difference in PG-SGA total scores between the control and experimental groups (P > 0.05). Moreover, no significant difference was found in the number of patients across different nutritional status levels between the two groups before nursing (P > 0.05; Table 5).

Table 5 Comparison of nutritional status before nursing care between the two groups, n (%).

Variable	Subjects of study (n = 80)	Control group (n = 40)	Test group (n = 40)	χ2/t	P value
PG-SGA total score, mean ± SD	6.73 ± 3.57	6.96 ± 3.49	6.50 ± 3.70	0.513	0.569
Good nutritional status (PG-SGA-A)	13 (16.25)	6 (15.0)	7 (17.5)	0.245	0.885
Suspected or moderate malnutrition (PG-SGA-B)	39 (48.75)	19 (47.5)	20 (50.0)	-	-
Severe malnutrition (PG-SGA-C)	28 (35.0)	15 (37.5)	13 (32.5)	-	-

PG-SGA: Patient-Generated Subjective Global Assessment.

Analysis of factors influencing nutritional status before nursing care in HCC patients treated with TACE

Data analysis revealed significant correlations between PG-SGA scores and ALT, total bilirubin, pain, nausea, vomiting, anxiety, depression, and sleep quality (P < 0.05) (Table 6).

Table 6 Correlation analysis of nutritional status and indicators before nursing care in hepatocellular carcinoma patients treated with transarterial chemoembolization.

Variable	PG-SGA score
	r value	P value
Hemoglobin (g/dL)	-0.098	0.162
ALB (g/L)	-0.107	0.127
NLR	0.073	0.304
PLR	0.107	0.128
AST (U/L)	0.110	0.116
ALT (U/L)	0.162	0.019
Total bilirubin (g/dL)	0.241	< 0.001
Pain	0.304	< 0.001
Nausea	0.531	< 0.001
Vomiting	0.456	< 0.001
Fever	0.118	0.092
HADS-A score	0.410	< 0.001
HADS-D score	0.358	< 0.001
PSQI score	0.296	< 0.001

ALB: Albumin; NLR: Neutrophil-to-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; PSQI: Pittsburgh Sleep Quality Index; PG-SGA: Patient-Generated Subjective Global Assessment.

Comparison of PG-SGA scores and anxiety, depression status after nursing care between the two groups of HCC patients treated with TACE

Following different nursing interventions for TACE-treated HCC patients, results showed the experimental group’s PG-SGA score was significantly lower than the control group’s (P < 0.05). Additionally, both groups exhibited lower PG-SGA scores post-nursing than pre-nursing (P < 0.05).

Using the HADS for assessment revealed the experimental group had lower HADS-A and HADS-D scores than the control group (P < 0.05). Both groups also had lower scores post-nursing than pre-nursing (P < 0.05). Furthermore, after nursing, the experimental group had a significantly higher number of patients with improved depression and anxiety than the control group (P < 0.05), and the improvement rate in both groups post-nursing was higher than pre-nursing (P < 0.05; Table 7).

Table 7 Comparison of patient-generated subjective global assessment scores and anxiety, depression status after different nursing interventions between the two groups, n (%).

Group/indicator	Post-nursing		χ2/Z/t	P value
	Control group (n = 40)	Test group (n = 40)
PG-SGA score	4.46 ± 2.13a	1.86 ± 0.89b	-4.459	0.000
HADS-A
Score	4.25 ± 2.03a	0.36 ± 0.49b	-6.265	0.000
No anxiety	36 (90.00)a	40 (100.00)b	4.211	0.040
Anxiety	4 (10.00)	0 (0.00)	-	-
HADS-D
Score	5.00 (4.00, 5.00)a	0.00 (0.00, 1.00)b	-6.245	0.000
No depression	34 (85.00)a	39 (97.50)b	3.914	0.048
Depression	6 (15.00)	1 (2.50)	-	-

^aP < 0.05 compared to the control group before nursing.

^bP < 0.05 compared to the same group before nursing.

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; PG-SGA: Patient-generated subjective global assessment.

Comparison of PES after nursing care between the two groups of HCC patients treated with TACE

After different nursing interventions for TACE-treated HCC patients, the PES was compared between the two groups. For NRS scores, both the experimental and control groups had a median score of 0 after nursing, showing no significant difference between them (P > 0.05). Nevertheless, compared to before nursing, both groups experienced a significant decrease in NRS scores (P < 0.05).

After nursing care, while no significant difference in nausea improvement was observed between the two groups (P > 0.05), both groups saw a significant rise in the number of patients with improved nausea compared to pre-nursing (P < 0.05). Similarly, concerning vomiting, although there was no significant difference in the number of patients with improved vomiting between the two groups after nursing (P > 0.05), the experimental group exhibited marked improvement in nausea symptoms post-nursing compared to pre-nursing (P < 0.05; Table 8).

Table 8 Comparison of post-embolization syndrome after different nursing interventions between the two groups, n (%).

Group/indicator	Post-nursing		χ2/Z/t	P value
	Control group (n = 40)	Test group (n = 40)
NRS score	0.00 (0.00-0.00)a	0.00 (0.00-0.00)b	-0.856	0.392
Nausea symptoms			3.550	0.314
0	35 (87.5)a	39 (97.5)b
1	2 (5.0)	1 (2.5)
2	2 (5.0)	0 (0.0)
3	1 (2.5)	0 (0.0)
Vomiting symptoms			1.387	0.709
0	36 (90.0)	38 (95.0)b
1	1 (2.5)	1 (2.5)
2	2 (5.0)	1 (2.5)
3	1 (2.5)	0 (0.0)

^aP < 0.05 compared to the control group before nursing.

^bP < 0.05 compared to the experimental group before nursing.

NRS: Numerical Rating Scale.

Comparison of improvement in laboratory indicators after nursing care between the two groups of HCC patients treated with TACE

In this study, we compared the changes in laboratory indicators of HCC patients in two groups treated with TACE after different nursing interventions. Our results showed that there was no significant difference in hemoglobin levels between the two groups after nursing (P > 0.05). However, the experimental group had significantly higher BMI and ALB levels than the control group after nursing (P < 0.05). Moreover, compared to before nursing, the experimental group also exhibited substantial increases in BMI and ALB levels after nursing (P < 0.05; Table 9, Figure 2).

Figure 2 Comparison of laboratory indicator improvement before and after nursing care between the two groups. A: Body mass index; B: Hemoglobin content (g/dL); C: Albumin content (g/L). ^aP < 0.05 compared between the control and experimental groups after nursing; ^bP < 0.05 compared within the experimental group before and after nursing. NS: Not significant.

Table 9 Comparison of changes in laboratory indicators after different nursing interventions between the two groups, mean ± SD.

Group/indicator	Post-nursing		Z/t	P value
	Control group (n = 40)	Test group (n = 40)
BMI (kg/m2)	21.67 ± 2.63	24.24 ± 2.45a	4.522	0.000
Hemoglobin (g/dL)	121.75 ± 21.49	121.57 ± 17.27	0.034	0.973
Albumin (g/L)	35.60 ± 4.87	38.33 ± 4.09a	2.714	0.008

^aP < 0.05 compared to the experimental group before nursing.

BMI: Body mass index.

DISCUSSION

This retrospective study investigated how bundle care affects the QoL and nutritional status of HCC patients post-TACE. Eighty patients were split into a control group (routine care) and an experimental group (routine care + bundle care). Baseline comparisons (demographics, disease status, laboratory indicators) showed no significant differences between groups (all P > 0.05). Post-nursing analysis revealed significant improvements in the experimental group across multiple indicators. Nutritionally, the PG-SGA score dropped from 6.50 ± 3.70 to 1.86 ± 0.89 (P < 0.001). Mentally, HADS-A and HADS-D scores fell to 0.36 ± 0.49 and 0.00 (P < 0.001). Laboratory indicators also improved, with ALB levels rising from 33.21 ± 3.76 g/L to 38.33 ± 4.09 g/L and BMI increasing from 21.47 ± 3.26 kg/m² to 24.24 ± 2.45 kg/m² (both P < 0.05). Additionally, the experimental group saw higher relief rates for PES symptoms like nausea and vomiting (P < 0.05). These findings suggest that bundle care significantly enhances comprehensive management outcomes for post-TACE patients.

Recent studies on postoperative care after TACE have only focused on one dimension such as nutritional support or pain control with no evidence-based multidisciplinary collaboration[22]. A study found that only 50% of patients with moderate to severe malnutrition get the nutritional support they need. Similarly, less than one in five clinicians have adopted psychological tools such as the HADS[23]. Conversely, the bundle care model presented in this study, which integrates interventional, nutrition, and psychology departments, monitors the subject through PG-SGA, HADS, and NRS assessments while also using an intelligent follow-up system, standardizes and refines multi-dimensional interventions. The current study suggests that the early initiation of nutritional therapy can improve nutritional status in line with a previous study that detected a greater reduction in PG-SGA score (Δ4.64) in the experimental arm as compared to control arm (Δ2.3) due to early enteral/parenteral nutrition[22]. On top of that, the increase in ALB level of the experimental group (Δ5.12 g/L) was greater than that reported in a meta-analysis (average increase of 2.8 g/L post enteral nutrition). This finding emphasizes the necessity of personalized nutrition plans. The anxiety and depression relief rate of experimental in psychological intervention which was 100% normalization of HADS-A and 97.5% HADS-D was much superior to a study’s conventional care group whose anxiety relief was about 60%, this was due to the integration of CBT and group counseling in this bundle care[24]. In terms of PES, the nausea relief rate (97.5%) obtained in our experimental group was similar to that in a randomized controlled trial (RCT; 92%); however, our stepwise analgesia (opioid combinations) likely further reduced moderate/severe pain rates[25]. In addition, the intelligent follow-up system (WeChat platform) improved on the traditional phone follow-up handicap and matched the trend of mobile health interventions from a study. The risk of going back to the hospital fell by 25%[26]. To sum up, the bundle care model from this study is innovative in terms of evidence-based integration, multidisciplinary collaboration and continuous management which provides a more comprehensive care framework for post-TACE patients.

The positive effects of bundle care on patients after TACE are due to the core content of the program. The core content includes: (1) Dynamic assessment and stratified intervention, and the application of scales such as PG-SGA and HADS allows for early assessment and detection of the patient’s nutritional and psychological issues[27]. For example, patients with PG-SGA C who received parenteral nutrition had a significantly increased ALB (P < 0.05), and patients with HADS ≥ 8 had a Δ4.93 reduction in anxiety scores after CBT. This shows the need for precise stratification; (2) Integration of multidisciplinary resources: The early involvement of nutritionists in the design of a high-energy formula and psychologist-led group counseling breaks the traditional nursing barrier, improves the utilization ratio of multidisciplinary resources; and (3) Intelligent and extended care: The WeChat symptom real-time tracking and alert function guarantees continuous post-discharge management and reduces misjudgment due to the blind spot of data gap risks causing complications. The interpretation of findings in the patients in the study showed that pre-nursing nutritional status ALT (r = 0.162, P = 0.019) and total bilirubin (r = 0.241, P < 0.001) were positively correlated with PG-SGA scores. This implies that liver damage might increase the probability of malnutrition. Furthermore, pain (r = 0.304), nausea (r = 0.531), and anxiety/depression (HADS-A, r = 0.410) are significantly associated with deterioration in nutritional status (all P < 0.001). These findings are consistent with a theory of the disease-malnutrition-inflammation of the liver established by researchers. By addressing the symptoms, nutrition and psychology together, bundle care effectively breaks this cycle. Patients' eating ability, as measured by the NRS score to 0 for pain control, led to higher ALB and BMI levels (P < 0.05).

The limitations of this retrospective study include the potential for selection bias and confounding factors, the large number of complex bundle care components which make it difficult to specify the independent intervention impact, and lastly the relatively small number of respondents (n = 80) or short follow-up time. In future research, multicenter RCTs should be organized and the long-term benefits like one year of survival should be verified. Machine learning can be applied to assess care component weights and find the strongest one to optimize for better intervention. The sample should be much larger and Child-Pugh C patients should be included to analyse the suitability of bundle care in different liver function groups. In addition, fusion of biomarkers (i.e., interleukin-6) and patient reported outcomes can improve understanding of bundle care mechanisms. To sum up, the present study has provided some high quality of evidence for post TACE care. Moreover, the multidimensional intervention framework is worth promoting in clinical practice and future research.

CONCLUSION

Evidence from this article implies that the implementation of a bundle care protocol significantly improves nutritional status, psychological status, and control of symptoms in HCC patients following TACE. This integrated care model warrants broader clinical application and further validation in prospective, randomized trials.