Nursing care for patients with liver cirrhosis undergoing surgery for esophageal variceal bleeding in an integrated healthcare system

Abstract

BACKGROUND

Globally, Liver cirrhosis is the 14th leading cause of death and poses a significant threat to human health.

AIM

To investigate the effects of a multidisciplinary collaboration model on postoperative recovery and psychological stress in patients with liver cirrhosis undergoing esophageal variceal bleeding (EVB) surgery within an integrated healthcare system.

METHODS

Between January 2022 and March 2024, a total of 180 patients with cirrhosis and EVB were admitted and randomly assigned to either a control group (standard care) or an observation group (standard care plus the multidisciplinary collaboration model), with 90 patients in each group. Postoperative recovery indicators (time to symptom improvement, time to start eating, time to bowel sound recovery, time to first flatus, and hospital stay), psychological stress responses [self-rating anxiety scale (SAS); self-rating depression scale (SDS)], subjective well-being, and incidence of complications were compared between the two groups.

RESULTS

Compared to the control group, the observation group showed earlier symptom improvement, earlier return to eating, bowel sound recovery, first flatus, and a shorter hospital stay. Pre-intervention SAS and SDS scores were not significantly different between the groups, but post-intervention scores were significantly lower in the observation group. Similarly, there was no significant difference in the subjective well-being scores before the intervention between the two groups. After the intervention, both groups showed improved scores, with the observation group scoring significantly higher than the control group.

CONCLUSION

The observation group also had a lower incidence of complications. Therefore, for patients with liver cirrhosis undergoing EVB surgery, a multidisciplinary collaboration model within an integrated healthcare system can promote early postoperative recovery, reduces psychological stress, improves subjective well-being, and reduces complications and rebleeding.

Key Words: Liver cirrhosis; Esophageal and gastric variceal bleeding; Integrated healthcare system; Multidisciplinary collaboration; Postoperative recovery; Psychological stress

Core Tip: Effective nursing interventions play a crucial role for patients with cirrhosis who undergo esophageal variceal bleeding surgery. These interventions can significantly promote faster postoperative recovery and help reduce psychological stress, ultimately enhancing the overall well-being and quality of life of these patients.

INTRODUCTION

Liver cirrhosis is a chronic and progressive disease characterized by symptoms such as fatigue, reduced appetite, and diarrhea, with high incidence and mortality rates. Globally, it is the 14^th leading cause of death and poses a significant threat to human health[1]. Esophageal variceal bleeding (EVB) is a severe complication of cirrhosis that is indicative of decompensation and high mortality rates. It is estimated that 12%-85% of patients with cirrhosis have esophageal varices, with 41%-80% at risk of gastrointestinal bleeding because of rupture[2,3]. Timely surgical treatment of cirrhosis with EVB is crucial for hemostasis, blood volume restoration, portal pressure reduction, and the prevention of complications and rebleeding[4]. However, the severity of cirrhosis complicated by EVB, accompanied by significant blood loss and increased patient anxiety and fear, can lead to substantial psychological stress, which may affect the stability of the varices and hinder postoperative recovery[5]. Therefore, nursing interventions for patients undergoing surgical treatment for EVB are crucial. The multidisciplinary collaboration model, a leading approach in international medical practice, involves experts from various fields developing personalized intervention plans, thereby improving the quality of care[6]. The integrated healthcare system, a novel medical service model, integrates regional medical resources to build a collaborative service network, facilitates resource sharing and coordinated services, and enhances medical care efficiency. However, the impact of a multidisciplinary collaboration model within an integrated healthcare system on postoperative recovery and psychological stress in patients with cirrhosis undergoing EVB surgery has not yet been reported. In this study, we analyzed 180 patients with liver cirrhosis who underwent EVB surgery at our hospital between January 2022 and March 2024. Therefore, this study examined the effects of a multidisciplinary collaborative model within an integrated healthcare system on postoperative recovery and psychological stress in these patients.

MATERIALS AND METHODS

General data

Diagnostic criteria: Liver cirrhosis complicated by EVB was diagnosed based on endoscopic examination following expert consensus guidelines.

Inclusion criteria: Patients with a confirmed history of liver cirrhosis; presenting with symptoms, such as hematemesis, melena, and reduced hemoglobin levels; met surgical indications and scheduled for surgical treatment; had normal cognitive and communicative abilities; and provided informed consent from the patient or family.

Exclusion criteria: Patients with severe hepatic or renal failure, splenic abnormalities; malignancies; peptic ulcer disease; primary hematologic disorders; coagulation mechanism deficiencies; a history of endoscopic treatment for gastric varices; psychiatric illness or histories; and patients with severe anxiety or depression.

Selection of participants: A total of 180 patients with cirrhosis and EVB admitted to our hospital between January 2022 and March 2024 were selected using a random draw method and divided into control and observation groups, each consisting of 90 patients. The control group comprised 52 males and 38 females, aged 52-76 years, with an average age of 64.00 ± 6.45 years, and a body mass index (BMI) ranging from 17 to 25 kg/m², with an average of 21.00 ± 3.12 kg/m². The Child-Pugh classifications were as follows: A, B, and C, with 20, 44, and 26 cases, respectively. The observation group included 55 males and 35 females, aged 51-76 years, with an average age of 63.50 ± 6.48 years, and a BMI ranging from 18 to 24 kg/m², with an average of 21.00 ± 2.80 kg/m². The Child-Pugh classifications were as follows: A, B, and C, with 22, 43, and 25 cases, respectively. The clinical data of the two groups were comparable (P > 0.05).

Methods

Control group: Standard care was provided, which included routine preoperative assessments, such as complete blood count, coagulation profiles, and electrocardiograms. The patients’ conditions were closely monitored, and basic health education was provided to alleviate negative emotions through verbal counseling. They were informed of the perioperative precautions. The nursing staff strictly adhered to medical orders regarding medication administration and dietary guidance, and reported any abnormalities to the attending physician immediately. The patients were instructed to maintain a healthy lifestyle and undergo regular follow-up checks.

Observation group: In addition to standard care, a multidisciplinary collaboration model was implemented in the context of an integrated healthcare system.

Establishment of a multidisciplinary team: The integrated healthcare system consisted of one central hospital and five branch hospitals. The team comprised a chief physician from the Central Hospital’s Gastroenterology Department with over 15 years of clinical experience, the director of intensive care units, a head nurse, branch hospital ward physicians, clinical pharmacists, deputy head nurses from the endoscopy department, a psychologist, a dietitian, and four nurses formed the nursing team.

Multidisciplinary training: Renowned experts in nursing for liver cirrhosis and EVB surgery, as well as in multidisciplinary collaboration models, were invited to share their knowledge through lectures. A multidisciplinary care manual was distributed to the team members, and a competency assessment was conducted before the commencement of the work. Only qualified individuals were included in the team.

Multidisciplinary consultations: Consultations were held to discuss patient treatment plans. Representatives from various departments expressed their opinions and reached a consensus through discussion.

Intervention methods of the multidisciplinary model: (1) Multidisciplinary ward rounds: Rounds were scheduled based on the availability of multidisciplinary personnel, with clear responsibilities assigned to each department. A WeChat group was established for enhanced communication and timely sharing of patient information. Major rounds were conducted every two days, involving the chief physician, ward physicians, and nurses, who meticulously reviewed all aspects of patient care, incorporated patient feedback, and made necessary adjustments; (2) Health education: During the treatment process, the responsible physician and nurse ensured a smooth handover, detailing the focus of care and potential safety hazards. Two designated nurses provided health education to the patients by distributing brochures and showing videos to inform them about surgery and postoperative precautions, increasing their understanding of the disease and surgery, and promptly answering their questions. The clinical pharmacist worked with the attending physician, developed a medication plan based on medical orders, physical examinations, and clinical data, and instructed the patients to strictly follow medical advice; (3) Psychological intervention: A psychologist assessed the patients' psychological states using the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) and implemented appropriate psychological counseling measures based on the assessment results. Face-to-face communication has been used to alleviate psychological stress in patients with mild anxiety or depression through listening, empathy, and by guiding patients to express their thoughts. In moderate cases, relaxation techniques, such as deep breathing and muscle relaxation, were taught along with playing the preferred music, and medication was administered under the psychologist’s guidance when necessary; (4) Diet guidance: The dietitian educated the patients and their families regarding the potential adverse effects of improper diets and developed individualized dietary plans based on the patient's condition, nutritional indicators, and dietary habits. Patients were advised to start consuming small amounts of warm water within 24 hours post-surgery, progressing to semi-liquid foods such as rice porridge, soft noodles, congee, and vegetable juice if no adverse reactions occurred. As their condition stabilized, a transition to soft foods was made, with strict avoidance of spiky, irritating, and hard foods. Dietary principles emphasized regular, small, frequent meals, and thorough chewing; and (5) Post-discharge follow-up: The multidisciplinary team arranged for a designated nurse to conduct post-discharge follow-ups with patients via telephone and WeChat for three weeks. These follow-ups tracked patients’ conditions, addressed issues, and provided guidance for resolution.

Observational indicators

Postoperative recovery: The postoperative time to symptom improvement, first feeding, bowel sound recovery, first anal flatus, and total hospital stay were recorded for both groups.

Psychological stress response: SAS and SDS were used to assess psychological stress before and after the nursing intervention. Both scales consist of 20 items, scored from 1 to 4, with raw scores calculated by simple addition and then multiplied by 1.25 to obtain standard scores. Scores below 50 indicated no anxiety, whereas scores of 50 or above indicated anxiety. For the SDS, scores below 53 indicate no depression, and scores of 53 or above indicate depressive symptoms, with higher scores indicating greater severity[7].

Subjective well-being: Subjective well-being was assessed using a subjective well-being scale[8] before and after the nursing intervention. The scale consists of four dimensions (objective support, subjective support, self-assessment, and subjective well-being index), with two, two, two, and three items, respectively, each scored from 1 to 4. The total score ranges from 9 to 36, with higher scores indicating greater subjective well-being.

Incidence of complications and rebleeding: Complications included upper gastrointestinal bleeding, electrolyte disorders, and hepatic encephalopathy.

Statistical analysis

Data from this study were processed using SPSS software (version 22.0). Categorical variables were presented as frequencies (n) and percentages (%), and analyzed for independence using the χ² test. Continuous variables were presented as mean ± SD, with independent samples t-test employed to assess mean differences between groups. Statistical significance was set at P < 0.05.

RESULTS

Comparison of postoperative recovery between groups

Compared to the control group, the observation group exhibited earlier symptom improvement, initiation of feeding, bowel sound recovery, and first anal flatus, with a significantly shorter hospital stay (P < 0.05; Table 1).

Table 1 Postoperative recovery in both groups.

Groups	Cases	Time to symptom improvement (day)	Eating time (day)	Bowel sound recovery time (day)	Anal exhaust time (day)	Length of stay (day)
Control	90	2.85 ± 0.80	4.25 ± 0.70	2.30 ± 0.30	2.80 ± 0.40	9.50 ± 1.25
Observation	90	1.80 ± 0.35	2.70 ± 0.65	1.40 ± 0.25	1.45 ± 0.25	6.00 ± 1.05
t		11.408	15.393	21.864	27.151	20.340
P value		< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

Comparison of psychological stress responses between groups

Before intervention, there was no significant difference in SAS and SDS scores between the groups (P > 0.05). After the intervention, the scores in both groups decreased, with the observation group showing significantly lower scores than the control group (P < 0.05). Patients in the observational group experienced a comparatively favorable psychological state, with reduced anxiety and depression levels (Table 2).

Table 2 Psychological stress responses in both groups.

Groups	Cases	SAS (scores)		SDS (scores)
		Before	After	Before	After
Control	90	56.65 ± 4.35	49.85 ± 3.20	59.55 ± 5.10	52.00 ± 3.60
Observation	90	57.00 ± 4.60	45.60 ± 3.35	60.20 ± 5.25	48.50 ± 2.90
t		0.524	8.703	0.842	7.183
P value		0.601	< 0.001	0.401	< 0.001

SAS: Self-rating anxiety scale; SDS: Self-rating depression scale.

Comparison of subjective well-being between groups before intervention

There was no significant difference in the dimensions and total scores of subjective well-being between the two groups (P > 0.05). After the intervention, the scores in both groups increased, with the observation group scoring significantly higher than the control group (P < 0.05). These results highlight the effectiveness of nursing interventions (Table 3).

Table 3 Subjective well-being in both groups.

Groups	Cases	Objective support		Subjective support		Self-evaluation		Subjective happiness index		Total scores
		Before	After	Before	After	Before	After	Before	After	Before	After
Control	90	3.10 ± 1.05	4.55 ± 1.20	3.25 ± 1.05	4.45 ± 1.30	3.95 ± 1.00	5.35 ± 1.00	7.20 ± 1.50	9.50 ± 1.05	17.50 ± 4.30	23.80 ± 5.00
Observation	90	3.25 ± 1.10	6.60 ± 1.25	3.30 ± 1.00	6.15 ± 1.20	3.98 ± 1.05	6.00 ± 1.10	7.00 ± 1.40	10.35 ± 1.10	16.95 ± 4.35	29.10 ± 4.50
t		0.936	11.224	0.327	9.116	0.196	4.148	0.925	5.303	0.853	7.475
P value		0.351	< 0.001	0.744	< 0.001	0.845	< 0.001	0.356	< 0.001	0.395	< 0.001

Comparison of complication rates between groups

The incidence of complications in the observation group was significantly lower than that in the control group (P < 0.05; Table 4).

Table 4 Incidence of complications in both groups, n (%).

Groups	Cases	Upper gastrointestinal bleeding	Electrolyte disturbance	Hepatic encephalopathy	Total incidence
Control	90	9 (10.00)	6 (6.67)	5 (5.56)	20 (22.22)
Observation	90	2 (2.22)	1 (1.11)	1 (1.11)	4 (4.44)
χ2					12.307
P value					< 0.001

DISCUSSION

EVB is a severe complication of liver cirrhosis, resulting from the progression of esophageal and gastric varices. It is characterized by rapid onset, fast disease progression, and high mortality rates. EVB is often a life-threatening condition that requires immediate medical attention[9]. Studies indicate that approximately 40%-95% of patients with liver cirrhosis develop esophageal varices, with approximately 15%-20% experiencing bleeding within 1-3 years of diagnosis[10]. Advances in endoscopic technology have led to an increasing number of patients opting for endoscopic treatment as the first choice. Common methods include endoscopic variceal ligation and injection sclerotherapy, which can directly occlude the varices to achieve hemostasis[11]. Clinical studies revealed that most patients with liver cirrhosis complicated by EVB surgery exhibit psychological stress responses, such as anxiety and depression, which are detrimental to surgical treatment and postoperative recovery[12]. Therefore, strengthening nursing interventions is crucial for patients undergoing surgical treatment for EVB. An integrated healthcare system maximizes the use of medical and health resources by fostering collaboration and resource sharing, improving the quality and efficiency of health services. Implementing a multidisciplinary collaboration model within this framework can enhance the efficiency of medical services and provide better medical services to patients.

Several studies have highlighted that enhanced recovery after surgery (ERAS) protocols, combined with comprehensive nursing care, ensure thorough preoperative education and psychological support, which are known to improve patient outcome. Consistent with these findings, the current study demonstrates that the application of a multidisciplinary collaborative model in EVB surgery facilitates earlier postoperative recovery. Patients in the observation group showed earlier recovery of postoperative symptoms and physical indicators (P < 0.05) compared to the control group, suggesting that the application of the multidisciplinary collaboration model under the integrated healthcare system can promote earlier postoperative recovery in patients. The integrated healthcare system, by efficiently pooling resources from various hospitals, helps improve the quality of medical management. Multidisciplinary collaborative nursing brings together experts from various departments to formulate comprehensive nursing plans tailored to patient needs. Multidisciplinary ward rounds enable a better understanding of patients’ nursing needs and allow targeted adjustments to services based on their opinions and suggestions, thus effectively addressing existing problems. Health education increases patients' awareness of their condition and surgery, enhances self-care ability, and facilitates recovery. Dietary guidance ensures balanced nutrition, maintains body function, strengthens immunity, and promotes early postoperative recovery.

Psychological stress refers to an individual’s physiological or psychological response to stressful events. Subjective well-being represents the overall emotional and cognitive evaluation that people make about their quality of life and is influenced by various factors. Patients with liver cirrhosis complicated with EVB often exhibit significant psychological stress responses and lower levels of subjective well-being[13,14]. Studies suggest that ERAS protocols are feasible and safe for patients with cirrhosis and can reduce postoperative complications and mortality rates. This study emphasized the improvement in psychological stress responses and subjective well-being, demonstrating the potential value of this model in enhancing postoperative recovery and psychological health in patients with cirrhosis. After the nursing interventions, the SAS and SDS scores in the observation group were lower than those in the control group, and the subjective well-being scores were significantly higher than those in the control group (P < 0.05), indicating that the multidisciplinary collaboration model under an integrated healthcare system could reduce psychological stress and improve the subjective well-being of patients. The analysis suggests that an integrated healthcare system can maximize the integration of resources, optimize services, and enhance service efficiency. Multidisciplinary collaboration can enhance diagnosis and treatment, facilitate resource sharing, and enable precise psychological services to patients. Health education enabled patients to have a clear understanding of their condition, eliminating uncertainties, and improving psychological resilience. Psychological counseling tailored to scale assessment results effectively addresses psychological issues, fosters a sense of care and respect, and promotes improved subjective well-being.

Additionally, the incidence of complications in the observation group was significantly lower than that in the control group (P < 0.05), probably because of the implementation of a multidisciplinary collaborative model within an integrated healthcare system that provides multifaceted nursing services to patients, consistent with the findings of previous cohort studies[15]. Patients have a stronger awareness of self-care, better nursing outcomes, and faster recovery, ultimately reducing complication risk.

Therefore, future studies should include long-term follow-up to assess the effects of the multidisciplinary collaborative model on patient outcomes over time, including survival rates, recurrence rates, and quality of life metrics, with the aim of providing more optimal outcomes for the clinical treatment of cirrhosis with EVB.

CONCLUSION

In summary, a multidisciplinary collaboration model within an integrated healthcare system can enhance postoperative recovery, reduce psychological stress, improve subjective well-being, and reduce the incidence of complications in patients undergoing surgery for liver cirrhosis complicated by EVB. This approach is recommended for broader applications in clinical practice.