Fu Zheng Li Qi Tang combined with FOCUS-PDCA model in postoperative rehabilitation of elderly biliary surgery patients

Abstract

BACKGROUND

Elderly patients undergoing biliary surgery face high risks of postoperative complications and delayed recovery due to reduced physiological reserve and frequent comorbidities. Effective rehabilitation strategies are urgently needed. Traditional Chinese medicine, such as Fu Zheng Li Qi Tang, may support recovery through multi-targeted regulation, while the find, organize, clarify, understand, select, plan, do, check and act (FOCUS-PDCA) model offers a systematic approach to optimize nursing quality. We hypothesized that combining Fu Zheng Li Qi Tang with the FOCUS-PDCA model would significantly improve postoperative recovery in elderly biliary surgery patients compared to routine care.

AIM

To evaluate the effect of Fu Zheng Li Qi Tang plus FOCUS-PDCA on postoperative recovery in elderly biliary surgery patients.

METHODS

One hundred and twenty elderly biliary surgery patients (age ≥ 60 years) were randomized into a control group (n = 60) receiving Fu Zheng Li Qi Tang and routine nursing, and an observation group (n = 60) receiving additional FOCUS-PDCA model. Postoperative recovery indicators (time to first flatus, ambulation, hospitalization), Visual Analog Scale pain scores, complications, and nursing satisfaction were compared.

RESULTS

The duration of postoperative bed rest, time to first flatus, and length of hospital stay in the observational group were all shorter than those in the control group (P < 0.0001). The Visual Analog Scale scores of patients in both groups at all time points after the operation were significantly reduced, and the scores of the observation group at all time points were lower than that of the control group (P < 0.0001). Moreover, the total incidence rate of complications in the patients of the observation group was lower, and the satisfaction with the nursing care was higher (P < 0.05).

CONCLUSION

Fu Zheng Li Qi Tang combined with FOCUS-PDCA model accelerates postoperative recovery, relieves pain, reduces complications, and improves nursing satisfaction in elderly biliary surgery patients, demonstrating significant clinical value.

Key Words: Fu Zheng Li Qi Tang; FOCUS-PDCA model; Elderly patients; Biliary surgery; Postoperative recovery

Core Tip: This study determined the application value of the Fu Zheng Li Qi Tang combined with the find, organize, clarify, understand, select, plan, do, check and act (FOCUS-PDCA) model in postoperative recovery for elderly patients undergoing biliary surgery. The integration of traditional Chinese physiological regulation and optimized nursing care in this combination outperformed the use of Fu Zheng Li Qi Tang alone in accelerating recovery, reducing bed rest, time to flatus passage, hospital stay duration, and complications, while also improving satisfaction. This research fills part of the gap in postoperative recovery management for elderly individuals undergoing biliary surgery and has significant clinical application value.

INTRODUCTION

As the aging of the global population continues to accelerate, the proportion of elderly patients necessitating surgical treatment will rise significantly. In the field of general surgery, pancreatectomy, hepatectomy, and cholecystectomy are common types of surgery for elderly patients. Due to the prevalence of multiple coexisting diseases, multiple medications, and diminished and weakened physiological reserves, elderly patients have become a high-risk group for surgical treatment. In addition, elderly patients face the risk of postoperative complications such as infection, delayed recovery of gastrointestinal function, poor pain control, and functional deterioration, which not only prolongs the length of hospitalization, increases the burden of medical care, and results in a serious impairment of the patients’ standard of living[1,2]. Therefore, adequate postoperative care has become increasingly important for elderly patients undergoing surgical treatment. As a medical system with thousands of years of history, Chinese medicine has demonstrated unique value in the field of disease prevention and rehabilitation: Modern studies have shown that Chinese medicine can play a multi-targeted therapeutic role in diseases such as colorectal cancer by modulating multiple keys signaling pathways and influencing biological mechanisms like angiogenesis and immunomodulation[3]. At the same time, it has shown positive effects in improving the health status of patients with sequelae of novel coronavirus pneumonia, especially in the individualized treatment based on traditional Chinese medicine evidence and constitution[4]. In addition, the combination of traditional Chinese medicine and Western medicine may have more significant advantages in stroke rehabilitation compared to Western medicine alone[5]. The above findings suggest that traditional Chinese medicine plays a key role in addressing residual postoperative symptoms and promoting full recovery of patients. The find, organize, clarify, understand, select, plan, do, check and act (FOCUS-PDCA) model is a management model for continuous quality improvement and risk assessment developed by Hospital Corporation of America based on plan-do-check-act (PDCA), which consists of nine steps: Discovery, organizing, clarifying, understanding, selecting, planning, executing, checking, and acting, and the model has been successfully applied in many fields such as nursing, trauma care and surgery, showing good potential for optimizing processes and improving patient outcomes[6-9]. Considering the importance of postoperative rehabilitation in elderly patients and the potential of traditional Chinese medicine and FOCUS-PDCA model in promoting patients’ postoperative rehabilitation, this study combined the application of Fu Zheng Li Qi Tang and FOCUS-PDCA model in the postoperative rehabilitation of elderly biliary surgery patients, aiming at exploring the application value of the combined application model, with the expectation of providing strong support for the patients’ rapid postoperative recovery.

MATERIALS AND METHODS

Baseline information

The 120 elderly biliary surgery patients who attended our hospital was chosen for the study, of which, 63 were male patients and 57 were female patients, aged ≥ 60 years; all patients were clearly diagnosed preoperatively, and elective biliary surgery was performed. Regarding the surgical approach, 60 of the 120 patients underwent bile duct exploration for stone extraction and cholecystectomy, 45 were treated with laparoscopic cholecystectomy, and 15 were treated with choledocho-jejunal Roux-en-Y anastomosis. According to the principles of randomization and voluntariness, these 120 patients were allocated to two groups: The control group and the observation group, with 60 individuals in each; among them, the control group was given Fu Zheng Li Qi Tang and routine nursing program, and the observation group adopted the FOCUS-PDCA model on the basis of the control group. Comparison of the baseline data of patients in the two groups showed that the differences were not statistically significant (P > 0.05) and were well comparable. Specifically, in terms of gender distribution, in the observation group, there were 33 cases of males, and 27 cases of females; in the control group, there were 30 cases of males, and 30 cases of females; in terms of the average age, the observation group was 70.49 ± 8.33 years old, and the control group was 69.25 ± 8.41 years old; and with respect to composition of the surgical modality, within the observational group, there were 28 cases of performing choledochal exploration to remove stones and cholecystectomy 28 cases, laparoscopic cholecystectomy 24 cases, bile duct jejunum Roux-en-Y anastomosis 8 cases, the corresponding surgical modalities in the control group were 32 cases, 21 cases, 7 cases, respectively, with a balanced distribution between the groups. Postoperative recovery such as the time of first flatus and the time to first ambulation as well as the Visual Analog Scale (VAS) scores, complications and nursing satisfaction postoperatively were systematically recorded in both groups, and the rehabilitation conditions of patients in both groups under the reception of different nursing interventions was compared. Prior to initiating the research, each enrolled patient received a comprehensive explanation regarding the study’s objectives, methodologies, possible hazards, and anticipated advantages. All participants then voluntarily appended their signatures to an informed consent document. This retrospective study was approved by the Ethics Committee of the Chongming Branch of Shanghai Tenth People’s Hospital (Approval No. SHSYCM-IEC-1.0/25-YF/05).

Inclusion and exclusion criteria

Inclusion criteria: (1) Meet the indications for biliary surgery and successfully completed the surgery; (2) Not associated with severe organ dysfunction; (3) Age ≥ 60 years; (4) No mental illness and cognitive dysfunction; and (5) Know all the aspects of this research, and sign the written informed consent.

Exclusion criteria: (1) People with advanced malignant tumors; (2) People who are allergic to any ingredient of Fu Zheng Li Qi Tang; (3) People who have mental disorders that prevent them from cooperating with the study; (4) People who have incomplete case data or key information missing; and (5) People who do not cooperate with the rehabilitation and nursing care interventions.

Control group

The prescription of Fu Zheng Li Qi Tang is as follows: Astragalus membranaceus (30 g), Codonopsis pilosula (30 g), Salvia miltiorrhiza (15 g), Taraxacum mongolicum (15 g), Rheum palmatum (12 g), Citrus aurantium (12 g), Polygonum multiflorum (10 g), Leonurus japonicus (6 g). The patients are given the medicine by mouth starting from 4 hours after the operation, and each dose is added with 500 mL of water, and then decocted to extract 150 mL of the juice of the medicine, and then take the medicine frequently with small amount in several times, and then take it in one dose per day, and a treatment cycle consists of five days. Routine nursing program: (1) Vital signs monitoring; (2) Wound care; (3) Dietary guidance; (4) Pain management; and (5) Rehabilitation training guidance. After the operation, closely observe the patient’s temperature, blood pressure, pulse, respiration and other vital signs, regularly change the wound dressing, keep the wound clean and dry to prevent infection; guide the patient’s postoperative diet from fluid, semi-fluid gradually transitioned to general food, avoid spicy stimulation, greasy food. Based on the quantification of patient-reported pain severity, administer appropriate analgesic medication, and instruct patients to ease pain by diverting their attention through methods such as listening to music and chatting; encourage patients to get out of bed as early as possible, and promote the normalization of gastrointestinal function and physical rehabilitation.

Observation group

The FOCUS-PDCA model was implemented in the control group according to the following procedure.

Find: The postoperative rehabilitation process of elderly biliary surgery patients was analyzed to summarize the factors that may affect the rehabilitation, such as postoperative complications (e.g., bile leakage, infection, pain management issues), the degree of knowledge of patients and their families about postoperative rehabilitation, and whether the nursing operation is standardized. Through communication with patients and their families and review of medical records, problems were identified.

Organize: A continuous quality improvement team was formed by the head nurse of the Department of Biliary Surgery, one attending doctor and one deputy director doctor, and three specialist nurses with three or more years of clinical nursing experience. The head nurse is the leader of the team to coordinate the overall quality improvement activities, and the team members work together to collect, organize and analyze the information, and formulate and implement specific programs based on the analysis results. Organize 1 quality improvement meeting every month to summarize the stage results and problems and discuss improvement measures.

Clarify: Clarify the norms and processes of postoperative rehabilitation nursing care for geriatric biliary surgery patients currently carried out, randomly sampling patients for postoperative rehabilitation, summarizing and analyzing the reasons affecting the rehabilitation, such as healthcare personnel failing to put the postoperative precautions and prevention of complications into place, and irregularities in nursing operations, patients and their families' insufficient knowledge of rehabilitation, poor cooperation, etc.

Understand: Summarize and analyze the problems in the postoperative rehabilitation process from three aspects: Nursing, operation, and patients and their families, respectively. Nursing: Nursing staff’s lack of responsibility, lack of professional knowledge, insufficient supervision, failure to reasonably guide patients in rehabilitation training, etc. Operation: Non-standardized nursing operation procedures, immature skills, etc. Patients and their families: Insufficient awareness of the importance of postoperative rehabilitation, lack of self-care skills and knowledge, non-cooperation with rehabilitation training and treatment, etc.

Select: The continuous quality improvement team, led by the team leader, summarized and analyzed the problems in the postoperative rehabilitation process in three aspects: Nursing, operation, and patients and their families, respectively. Under the leadership of the team leader, the Continuous Quality Improvement Team discussed the postoperative rehabilitation improvement plan for the above problems and formulated the final plan. Specifically, the plan includes: For bile leakage risk: Implement standardized bile drainage tube care protocol, establish “Bile Leakage Early Warning Assessment Form” with specific observation indicators (drainage color, volume, character); conduct bedside assessment every 2 hours for first 24 hours postoperatively. For infection prevention: Develop “Elderly Patient Infection Risk Assessment Scale”, implement strict aseptic technique during dressing changes; monitor body temperature every 4 hours; provide oral care 3 times daily; encourage ambulation within 24 hours postoperatively. For pain management: Create “Personalized Pain Management Plan” using multimodal analgesia; combine pharmacological intervention (scheduled non-steroidal anti-inflammatory drugs administration) with non-pharmacological methods (positioning guidance, distraction techniques); assess pain score using VAS every 4 hours and adjust regimen accordingly. For gastrointestinal function recovery: Implement “Gastrointestinal Function Promotion Program” including early ambulation protocol (assist patient to sit on bed edge 6 hours postoperatively, stand beside bed 12 hours postoperatively, walk with assistance 24 hours postoperatively); provide abdominal massage twice daily; administer Fu Zheng Li Qi Tang at specified intervals. Nursing staff should participate in relevant knowledge training and assessment once a month to improve their professionalism; patients and their families should be informed of the knowledge of postoperative rehabilitation and prevention of complications once a month, which can be carried out through short videos and animations to enhance their understanding and acceptance; a rehabilitation nursing assessment sheet should be formulated, and detailed records should be made for each patient’s rehabilitation training and recovery.

Plan: The team members should collect relevant information and organize a meeting to discuss and formulate the final plan. Information and organize meetings for discussion to formulate new standards of postoperative rehabilitation nursing care for elderly biliary surgery patients and announce them in the hospital. The rehabilitation nursing assessment system and training guidelines are revised according to the actual situation and completed in the middle and end of each month respectively. At the beginning of postoperative care, the knowledge of postoperative rehabilitation care and prevention of complications will be taught to the medical and nursing staff of the department once a month; the team leader will randomly inspect the site of postoperative rehabilitation care at unannounced time, 1 time/month.

Do: Nursing intervention according to the above plan and schedule. Increase the number of popularizations of postoperative rehabilitation knowledge and knowledge of complication prevention. In the process of patients' rehabilitation, consult the record sheet and make inquiries to increase supervision and improve the cooperation of patients and their families; closely monitor the physical condition of patients in the postoperative period, and adjust the intervention program according to the law of its dynamic changes; focus on the rehabilitation training of patients, and timely guide and correct irregular movements.

Check: The leader of the team from time to time to check the situation of science popularization of the team members, including whether the patients and their families can accept, whether the knowledge of science is comprehensive, etc. Check whether the patients and their families are standardized and truthfully fill in the rehabilitation care record form; at any time to randomly check the nursing operation of the medical staff is standardized and whether the relevant knowledge assessment scores are up to the standard; regular meetings are held, focusing on analyzing the inadequacies in the work, and based on the actual conditions of the department and the hospital to propose improvement strategies. We hold regular meetings to analyze the shortcomings in our work and propose improvement strategies based on the actual conditions of the department and hospital.

Action: Summarize the improvement of postoperative rehabilitation nursing measures for elderly biliary surgery patients, standardize the record of effective measures during the implementation of the improvement work, and carry them over to the subsequent work; conduct an in-depth analysis of the existing problems and put forward constructive ideas for improvement, and enter into the next cycle of continuous improvement of the quality of care.

Observation indexes

Patients’ postoperative recovery: Observe and record in detail the time to the first postoperative gas emission, postoperative recumbency duration and length of hospital stay between the two comparative cohorts of patients. The shorter the time to the first postoperative venting, the faster the normalization of gastrointestinal function. The shorter the time to first ambulation, the sooner the patient can resume normal activities; the shorter the hospitalization time, the better the overall recovery of the patient.

Patient pain VAS score: Patients in the two groups were evaluated at 6 hours, 12 hours, and 24 hours following surgical intervention, and the score range was 0-10 points, the higher the score, the stronger the pain[10].

Postoperative complications of patients: Statistics on the occurrence of postoperative complications such as infection, bleeding, nausea and vomiting in the two groups of patients[11-13].

Patients’ care quality satisfaction: Patients were evaluated using the hospital’s own nursing satisfaction questionnaire, which included nursing attitude, nursing skills, health promotion, etc., and was divided into four grades, namely, highly satisfied, satisfied neutral, and dissatisfied. Total satisfaction rate was calculated using the formula: (number of highly satisfied cases + number of satisfied cases)/total number of cases × 100%.

Statistical analysis

This study used SPSS version 25.0 software to normalize and analyze the data. Measurement data were expressed as mean ± SD, and independent samples t-test was used for comparison between groups; count data were expressed as n (%), and χ² test was used for comparison between groups. In all statistical analyses, P < 0.05 was used to indicate that the differences were statistically significant.

RESULTS

Evaluation of post-surgical recovery outcomes

As shown in Table 1, the bed-ridden time, first exhaustion time and postoperative hospitalization time of the patients in the observation group were 1.55 ± 0.53 days, 48.25 ± 5.37 hours, and 7.28 ± 1.72 days, respectively, while the bed-ridden time, first exhaustion time and postoperative hospitalization time of the patients in the control group were 2.68 ± 0.65 days, 55.67 ± 6.47 hours, and 11.70 ± 1.91 days, respectively; these data indicate that compared with the control group, the postoperative recovery of patients in the observation group was better (P < 0.0001), suggesting that Fu Zheng Li Qi Tang combined with the FOCUS-PDCA model can accelerate the postoperative recovery process of patients and shorten the critical recovery cycle.

Table 1 Comparative analysis of postoperative recovery in the two groups (mean ± SD).

Groups	n	Time in bed (days)	Time to first flatus (hours)	Postoperative hospitalization (days)
Observation group	60	1.55 ± 0.53	48.25 ± 5.37	7.28 ± 1.72
Control group	60	2.68 ± 0.65	55.67 ± 6.47	11.70 ± 1.91
t		10.43	6.825	13.33
P value		< 0.0001	< 0.0001	< 0.0001

Comparison of postoperative pain Visual Analog Scale scores.

As shown in Table 2, at 6 hours postoperatively, the VAS score in the observation group was 4.12 ± 0.32, while in the control group it was 5.27 ± 0.45; at 12 hours postoperatively, the score in the observation group decreased to 2.15 ± 0.36, while in the control group it was 3.08 ± 0.28; and at 24 hours postoperatively, the score in the observation group further decreased to 1.07 ± 0.25, while in the control group it was 2.12 ± 0.42. The data showed that pain was gradually relieved in both groups over time, but the observation group had lower scores at all times than the control group at all times (P < 0.0001), proving that the combination of Fu Zheng Li Qi Tang and FOCUS-PDCA model had a sustained advantage in controlling postoperative pain in elderly patients with biliary surgical procedures.

Table 2 Comparative analysis of Visual Analog Scale scores (mean ± SD).

Groups	n	6 hours postoperatively (points)	12 hours postoperatively (points)	24 hours postoperatively (points)
Observation group	60	4.12 ± 0.32	2.15 ± 0.36	1.07 ± 0.25
Control group	60	5.27 ± 0.45	3.08 ± 0.28	2.12 ± 0.42
t		16.16	15.88	16.75
P value		< 0.0001	< 0.0001	< 0.0001

Comparison of postoperative complications.

As shown in Table 3, among the patients with postoperative complications in the observation group, there were 2 cases of infection, accounting for 3.33%; 1 case of bile leakage, accounting for 1.67%; 2 cases of hemorrhage, accounting for 3.33%; and 3 cases of nausea and vomiting, accounting for 5.00%; and the total incidence rate of postoperative complications in the observation group was 13.33%; whereas in the control group, there were 6 cases of infection, accounting for 10.00%; there were 2 cases of bile leakage, accounting for 3.33%; there were 5 cases of bleeding, accounting for 8.33%; there were 7 cases of nausea and vomiting, accounting for 11.67%; and the total incidence of postoperative complications in the control group was 33.33%. The number of patients with each complication in the observation group was lower than that in the control group, and the total incidence of postoperative complications in the observation group was lower than that in the control group (P < 0.05). This result suggests that Fu Zheng Li Qi Tang combined with FOCUS-PDCA model significantly reduced the risk of postoperative complications in patients undergoing annual biliary surgery, especially in infection control and gastrointestinal symptom management.

Table 3 Comparative analysis of surgical complications, n (%).

Groups	n	Infection	Bile leakage	Bleeding	Bleeding nausea and vomiting	Total incidence
Observation group	60	2 (3.33)	1 (1.67)	2 (3.33)	3 (5.00)	8 (13.33)
Control group	60	6 (10.00)	2 (3.33)	5 (8.33)	7 (11.67)	20 (33.33)
χ2		6.708
P value		0.010

The Table 4 present the results of the patient care satisfaction survey, 30 patients in the observation group were highly satisfied, accounting for 50.00% of the total number of patients, 20 patients were satisfied, accounting for 33.33% of the total number of patients, 8 patients felt average, accounting for 13.33% of the total number of patients, and there were 2 cases of unsatisfied with the nursing intervention, accounting for 3.33% of the total number of patients. 3.33% of the total number of patients in the observation group, and 83.33% of the total number of patients in the observation group were satisfied with the nursing care; in the control group, 17 patients were highly satisfied, accounting for 28.33% of the total number of patients in the observation group, 23 patients were satisfied, accounting for 38.33% of the total number of patients in the observation group, 15 patients felt fair, accounting for 25.00% of the total number of patients in the observation group, while 5 patients were dissatisfied with the nursing interventions, accounting for 8.33% of the total number of patients in the control group, and the nursing satisfaction of patients in the control group amounted to 66.67%. Thus, it can be seen that the nursing satisfaction of patients in the observation group was significantly higher than that of the control group (P < 0.05), indicating that the combination of Fu Zheng Li Qi Tang and the FOCUS-PDCA model significantly enhanced the recognition of nursing care among elderly biliary surgery patients, and optimized the overall nursing experience of patients.

Table 4 Comparative analysis of patient satisfaction, n (%).

Groups	n	Highly satisfied	Satisfied	Satisfied neutral	Dissatisfied	Total satisfaction
Observation group	60	30 (50.00)	20 (33.33)	8 (13.33)	2 (3.33)	50 (83.33)
Control group	60	17 (28.33)	23 (38.33)	15 (25.00)	5 (8.33)	40 (66.67)
χ2		4.44
P value		0.035

DISCUSSION

For biliary disease management, surgical intervention constitutes a fundamental component, especially for cholangiocarcinoma, which is currently the only treatment that can achieve cure[14]. However, different biliary surgical procedures have their own risk characteristics in clinical application: Bile-intestinal anastomosis may lead to bacterial dysbiosis and metabolic disorders due to the alteration of the physiological flow of bile and the composition of intestinal microflora, which may delay the recovery of the patients[15]; complex surgeries, such as hepatoportal cholangiocarcinoma, are often subject to the limitation of perioperative safety due to the high technical difficulty of the procedures[16]; hepatopancreaticobiliary surgery carries a risk of bile leakage in the postoperative period[17]; meanwhile, after laparoscopic cholecystectomy, any manifestation of deviation from the expected clinical recovery process needs to be alerted to the possibility of biliary tract injury[18]. Elderly patients undergoing biliary surgery are highly susceptible to postoperative complications such as infection and bile leakage. The main reasons for this are twofold: On the one hand, the physiological reserve function of these patients has been significantly reduced, and most of them are combined with a variety of underlying diseases, resulting in a substantial reduction in their tolerance to trauma; on the other hand, the surgery itself is traumatic and will cause some damage to the organism[14]. Therefore, for elderly biliary surgery patients, there is an urgent need for an ideal treatment and nursing program to decrease the risk of postprocedural sequelae, alleviate pain, and expedite the convalescence process, so as to comprehensively improve the postoperative status of patients and facilitate their rehabilitation.

From the perspective of traditional Chinese medicine, biliary surgery is an invasive treatment, and this treatment is very likely to damage the vital energy of elderly patients. Consequently, it is clinically imperative to promote the postprocedural rehabilitation of elderly biliary surgery patients by restoring their normal diet and daily activities as soon as possible after surgery and realizing the support of positive energy to dispel evil. In this study, Fu Zheng Li Qi Tang was applied to the postoperative rehabilitation of elderly patients receiving biliary tract procedures, and the pharmacological effects of the components in its formula were highly compatible with the needs of postoperative rehabilitation, and were able to solve the many problems faced by the patients in the postoperative period. For example, Pericarpium Citri Reticulatae, as a commonly used medicine for alleviating abdominal distension and spleen-stomach disharmony, can effectively improve dyspepsia symptoms by reducing the activation of inflammation-related signaling pathways and regulating the structure and composition of intestinal microorganisms[19]. Taraxacum genus is often used in traditional medicine for clearing away heat, detoxification, promoting blood flow, alleviating blood stagnation, stimulating urine production, and it possesses pharmacological activities such as antimicrobial, antioxidant, anticancer, and antirheumatic activities, which can help to inhibit postoperative infections and attenuate the inflammatory reaction[20]. The main bioactive compounds of Astragalus membranaceus, such as flavonoids, triterpenoid saponins and polysaccharides, have a wide range of effects such as liver protection, immunomodulation, anti-inflammation, antioxidant, etc., which can enhance the immune function of the elderly patients after the operation and promote the recovery of body functions[21]. The main active component of Angelica sinensis, Angelica sinensis polysaccharides, possesses the top ten pharmacological activities, such as antioxidant, immunomodulation, hepatoprotection, anti-inflammation, and blood glucose reduction, etc., and it is also useful in activating blood circulation and promoting menstruation and diuresis. Angelica sinensis polysaccharides has ten pharmacological activities, comprising antioxidant properties, immunomodulatory capabilities, hepatoprotective effects, anti-inflammatory actions, and hypoglycemic effects, and it is effective in activating blood circulation, promoting circulation, lubricating intestines, and relieving pain[22]. Rheum palmatum L. can accelerate the recovery of gastrointestinal function by promoting stagnation and laxation[23]. Corydalis yanhusuo provides a reliable pharmacological basis for postoperative pain relief by virtue through its capacity to enhance hemodynamics and mitigate pain[24]; in addition, Codonopsis pilosula can invigorate the spleen and dispel dampness, and Quercus acutissima Carr. has analgesic, sedative and anti-inflammatory effects, while Pinellia ternata can help improve the digestive function in the postoperative period and enhance the gastrointestinal resistance, and its concomitant analgesic and other effects can also reduce the disturbance of recovery caused by postoperative discomforts, together helping to improve postoperative body function and strengthen gastrointestinal resistance. Together, they can help repair and regulate the postoperative body functions[25-28]. More importantly, beyond the pharmacological effects of individual herbs, the synergistic effect between Fu Zheng Li Qi Tang and the FOCUS-PDCA model represents the core innovation of this study. This synergy operates at three levels: Physiologically, the formula provides multi-targeted regulation to enhance immune function and gastrointestinal motility, creating an optimal internal environment for recovery, while the FOCUS-PDCA model ensures standardized administration and monitoring to maximize herbal efficacy. Managerially, the model dynamically identifies rehabilitation challenges (e.g., bile leakage risk, inadequate pain control) and enables timely intervention, while the formula reduces complication risk by improving the patient’s overall condition. Systemically, the combination creates an integrated “internal herbal regulation + external nursing optimization” approach that establishes a comprehensive system promoting patient recovery.

The FOCUS-PDCA model, as a systematic quality improvement tool, is capable of comprehensively optimizing the postoperative care process for elderly biliary surgical patients through the steps of discovery, organization, clarification, understanding, selection, and planning. In this study, the combination of Fu Zheng Li Qi Tang and FOCUS-PDCA model was used for postoperative rehabilitation of elderly biliary tract surgery patients, and significant results were achieved. The results demonstrated significantly reduced hospitalization duration, postoperative bed rest period, and time to initial exhaustion in the observation group compared to the control group. And postoperative VAS pain scores at 6 hours, 12 hours, and 24 hours were markedly lower in the observation cohort (P < 0.0001), Additionally, the total complication rate of the observation group patients was lower and the nursing satisfaction was higher (P < 0.05). This result is inextricably linked to the FOCUS-PDCA model its inherent advantages in continuous improvement of nursing quality. Through the process of discovery, organization, and clarification, this model is able to systematically identify key issues in the postoperative rehabilitation of elderly biliary surgery patients and continuously optimize the nursing process through targeted training, regular scientific dissemination, and dynamic supervision. This aligns with established literature documenting FOCUS-PDCA’s efficacy in enhancing stoma care proficiency among colorectal ostomy patients and reducing the incidence of deep vein thrombosis in elderly orthopedic patients, both reflecting its characteristics of identifying barriers to recovery through a standardized process, optimizing the nursing care measures with a dynamic adjustment mechanism, and ultimately enhancing the patient’s recovery effect[29,30]. In this study, the synergistic effect of Fu Zheng Li Qi Tang and the FOCUS-PDCA model demonstrated powerful advantages. On the one hand, the unique advantages of traditional Chinese medicine in postoperative conditioning were brought into play to internally regulate patients’ body functions and lay a solid foundation for recovery; on the other hand, the stability of the intervention effect was guaranteed through systematic nursing care to ensure that the various rehabilitation measures could be effectively implemented, and the two together accelerated the postoperative rehabilitation process of elderly patients. Compared to previous studies, this research innovatively integrates traditional Chinese medicine with a modern management model. This integration not only leverages the respective advantages of each approach but creates a “1 + 1 > 2” synergistic effect. This study is the first to demonstrate their combined value specifically in elderly biliary surgery patients: The herbal formula improves the patient’s physiological foundation, enabling more effective implementation of systematic nursing measures, while the refined nursing care ensures stable manifestation of herbal efficacy, with both components mutually reinforcing each other to accelerate recovery.

This study has several limitations: (1) The single-center design with limited sample size may affect the generalizability of results; (2) Lack of long-term follow-up data; and (3) Insufficient exploration of underlying mechanisms. Based on these limitations, we propose the following specific research directions: First, conduct multicenter, large-sample randomized controlled trials to validate the broad applicability of this combined protocol. Second, incorporate objective measures such as microbiome analysis and immune indicator testing to deeply explore the protocol’s effects on gut microbiota, inflammatory factors, and other mechanistic pathways. Third, establish long-term follow-up mechanisms to evaluate the protocol’s effects on patients’ long-term quality of life and complication prevention. Finally, through more refined research designs, parse the respective contributions of the herbal medicine and nursing model components.

CONCLUSION

The Fu Zheng Li Qi Tang combined with FOCUS-PDCA model can accelerate postoperative rehabilitation of elderly biliary tract surgery patients, effectively relieve pain, mitigate complication risks while enhancing caregiver satisfaction, demonstrating notable clinical applicability. Future research should focus on further optimizing this integrated intervention through multicenter collaboration and mechanistic exploration, providing more effective strategies for the rehabilitation management of elderly surgical patients.