Impact of a nursing-led peri-endoscopic management protocol on outcomes in patients with peptic ulcer bleeding undergoing therapeutic endoscopy

Abstract

BACKGROUND

Nursing-led peri-endoscopic management protocols play an important role in reducing the risk of short-term rebleeding in patients with peptic ulcer bleeding and may also contribute to shorter hospital stays.

AIM

To evaluate the impact of a nursing-led peri-endoscopic management protocol on outcomes in peptic ulcer bleeding treated with therapeutic endoscopy.

METHODS

This prospective randomized controlled trial included 130 patients with peptic ulcer bleeding who underwent therapeutic endoscopy at our hospital, between March 2023 and March 2025. Patients were randomly assigned to an observation group (n = 65) or a control group (n = 65). The observation group received a nursing-led peri-endoscopic management protocol, whereas the control group received routine endoscopic nursing care. Outcomes included rebleeding, hospital stay, blood transfusion volume, complications, and patient satisfaction.

RESULTS

Baseline characteristics were comparable between groups (P > 0.05). Rebleeding rates in the observation group were lower than in the control group at both time points: 6.15% (4/65) vs 18.46% (12/65) on day 7 and 9.23% (6/65) vs 24.62% (16/65) on day 30 (all P < 0.05). Mean hospital stay was shorter in the observation group (6.8 ± 2.1 days vs 8.1 ± 2.6 days; P = 0.002). Mean blood transfusion volume was also lower (1.3 ± 0.9 U vs 1.9 ± 1.1 U; P < 0.05). The incidence of endoscopic complications was lower in the observation group (P < 0.05). Patient satisfaction rate was higher in the observation group, 92.31% (60/65) vs 78.46% (51/65) in the control group (P < 0.05).

CONCLUSION

Nursing-led peri-endoscopic management reduces short-term rebleeding in patients with peptic ulcer bleeding after therapeutic endoscopy, shortens hospital stay, decreases blood transfusion requirements, and improves patient experience, indicating substantial clinical value.

Key Words: Nursing-led peri-endoscopic management protocol; Peptic ulcer bleeding; Therapeutic endoscopy; Rebleeding; Clinical outcomes

Core Tip: This protocol integrates dual-risk stratification for bleeding and sedation or airway complications, checklist-based intraoperative coordination, and a time-anchored early warning and follow-up pathway, enabling nurses to transition from routine assistance to proactive, standardized peri-endoscopic management for patients with peptic ulcer bleeding.

INTRODUCTION

Peptic ulcer bleeding is a major cause of non-variceal upper gastrointestinal hemorrhage and remains a leading emergency in gastroenterology. Despite advances in diagnosis and resuscitation, it often presents with rapid onset, substantial blood loss, and a clinically meaningful risk of early deterioration and death[1,2]. Therapeutic endoscopy serves as the first-line hemostatic approach for peptic ulcer bleeding and has improved primary hemostasis rates while reducing the need for surgery[3]. Nevertheless, early rebleeding, hemodynamic instability, and sedation- or aspiration-related adverse events continue to occur after endoscopic therapy, contributing to prolonged hospitalization, increased transfusion requirements, and a greater healthcare burden[4,5].

High-quality peri-endoscopic nursing - covering pre-procedure risk identification, coordination of resuscitation, antithrombotic medication reconciliation, sedation and airway safety, structured postoperative surveillance, and patient education - has been recognized as an important determinant of outcomes and endoscopy unit quality[6]. However, routine nursing pathways often rely on non-standardized assessments and experience-driven communication, which may limit timely risk stratification, early warning, and continuity of care in patients with rapidly changing conditions[7]. Therefore, this trial evaluated whether a nursing-led peri-endoscopic management protocol, built on evidence-based stratification and closed-loop management, could improve short-term clinical outcomes - including rebleeding, length of stay, transfusion requirements, and peri-endoscopic complications - and patient experience in patients with peptic ulcer bleeding treated with therapeutic endoscopy[8].

MATERIALS AND METHODS

Study subjects

A total of 130 patients who underwent therapeutic endoscopy for peptic ulcer bleeding at the our hospital March 2023 and March 2025 were included. The inclusion criteria were as follows: (1) Diagnosis consistent with peptic ulcer bleeding; (2) Endoscopic confirmation of active ulcer bleeding or recent bleeding stigmata requiring therapeutic endoscopic hemostasis; (3) Age 18-80 years; and (4) Provision of informed consent. The exclusion criteria were as follows: (1) Malignant ulcer or suspected tumor-related hemorrhage; (2) Severe coagulation dysfunction that could not be corrected; (3) End-stage organ failure or an expected survival of less than three months; and (4) Cognitive impairment preventing evaluation. Patients were randomly assigned to an observation group or a control group using a random number table, with 65 patients in each group. Baseline characteristics did not differ significantly between the two groups (P > 0.05), indicating comparability.

This study was conducted in accordance with the Helsinki Declaration. The plan has been reviewed and approved by the hospital ethics committee. All patients or their legally authorized representatives provided written informed consent prior to participation in the study. Patient privacy and the confidentiality of clinical data were strictly protected throughout the research process.

Randomization

Eligible patients were randomly assigned to the observation group or control group in a 1:1 ratio using a computer-generated random number table. The randomization sequence was prepared by an independent research assistant who was not involved in patient recruitment, clinical management, or outcome assessment. Allocation concealment was ensured using sequentially numbered, sealed, opaque envelopes that were opened only after patient enrollment. Blinding of nursing staff was not feasible given the nature of the intervention; however, outcome data were collected from medical records by personnel who were unaware of group assignments to minimize potential bias.

Control group

Patients in the control group received routine endoscopic nursing care implemented according to standard departmental procedures. This care included pre-procedure basic assessment and routine education regarding fasting and fluid restriction, assistance with medication administration and establishment of venous access, monitoring of vital signs during the procedure, routine postoperative observation, and dietary guidance.

Observation group

Patients in the observation group received care organized and delivered by specialist nurses in the Endoscopy Center using a nursing-led integrated management protocol. This protocol followed a structured pathway that included risk stratification, standardized resuscitation, sedation and airway safety management, intraoperative hemostasis coordination, early postoperative rebleeding warning, and digital follow-up.

A nursing leadership team was established, consisting of one head nurse, two endoscopy specialist nurses, and several responsible nurses. With the support of gastroenterologists, the team developed a standardized nursing pathway and management checklist for peri-endoscopic hemorrhage. All participating nurses completed protocol training and scenario-based simulation exercises before implementing the program.

During the preoperative phrase, rapid dual-risk stratification was performed within 30 minutes of evaluation. Bleeding risk was assessed by integrating clinical manifestations, vital signs, hemoglobin level, comorbidities, and medical history, with reference to the Glasgow-Blatchford Score and Rockall classification to categorize patients as high-, medium-, or low-risk. Sedation and airway risk were evaluated using the American Society of Anesthesiologists classification, the STOP-Bang questionnaire, and aspiration risk factors such as gastric fullness, vomiting, altered consciousness, obesity, or obstructive sleep apnea. Based on the risk level, a color-coded identification system was applied and displayed at the bedside and on endoscopy record forms. Targeted resuscitation measures were implemented according to risk level. Patients classified as high or medium risk received dual venous access and continuous monitoring of blood pressure and oxygen saturation. Mean arterial pressure and urine output were maintained within target ranges, hemoglobin and coagulation parameters were dynamically reassessed, and intensive proton pump inhibitory therapy was administered and documented. Antithrombotic medication management was initiated by specialist nurses through verification of medication history, after which physicians determined drug discontinuation or bridging strategies and coordinated gastroenterology consultation when necessary. Aspiration prevention measures included evaluation of gastric content risk, positioning patients in the left lateral position, and clearance of oropharyngeal secretions. Patients also performed 5-10 minutes of breathing training before the procedure, and those with significant anxiety received brief mindfulness breathing and targeted explanations of key procedural information.

Intraoperative management focused on coordinated hemostasis and airway safety. An endoscopy specialist nurse served as the intraoperative coordination nurse, while the responsible nurse assisted with materials and supplies. Instruments and medications such as injection needles, hemostatic clips, thermal coagulation equipment, and topical hemostatic agents were prepared in advance according to a standardized checklist. Before key procedural steps including injection therapy, clipping, and thermal coagulation, the specialist nurse confirmed instrument readiness and backup plans with the physician. Positioning and suction strategies were suggested when visualization of the bleeding site was difficult. The ulcer location, size, Forrest classification, hemostatic method, and immediate hemostatic effect were documented in real time during the procedure, and all information was incorporated into a hemostasis coordination record and outcome database for quality control. Sedation and airway safety were managed through coordinated monitoring by the specialist nurse and responsible nurse. In patients considered high risk, sedation was led by an anesthesiologist, while the specialist nurse assisted and continuously monitored airway status. Blood pressure, heart rate, and oxygen saturation were monitored throughout the procedure, while respiratory rate and level of consciousness were closely observed in medium- and high-risk patients. Oxygen therapy was adjusted according to risk level, with routine low-flow oxygen used for standard-risk patients and higher oxygen flow or positional adjustments used for those at greater risk to maintain airway patency. If coughing, changes in respiratory sounds, or a decrease in oxygen saturation occurred, oropharyngeal secretions were immediately suctioned and the physician was asked to pause the procedure for further evaluation. Sedation monitoring records and adverse event registration forms were maintained for quality control.

Postoperative management emphasized early detection of rebleeding and structured recovery guidance. Responsible nurses completed a standardized early warning form for rebleeding at 2 hours, 6 hours, and 24 hours after the procedure. Assessments included trends in vital signs, particularly heart rate and blood pressure, the characteristics and frequency of hematemesis or melena, symptoms of hypoperfusion such as dizziness, diaphoresis, and fatigue, and follow-up hemoglobin measurements order by the physician. A dual-trigger mechanism was used to identify suspected rebleeding events. Clinical triggers included new hematemesis, markedly increased melena, or worsening vital signs, whereas laboratory triggers included a rapid decrease in hemoglobin reaching predefined warning thresholds. When these triggers were identified, the physician on duty was notified immediately, venous access patency was reassessed, blood products were prepared if necessary, and monitoring intensity was increased according to medical orders. Completion of early warning forms was maintained at a rate of at least 95%, and all trigger events, physician notifications, and physician responses were documented for quality improvement purposes. Postoperative recovery also followed a staged diet and activity pathway supervised by responsible nurses and reassessed by specialist nurses in high-risk patients. Dietary progression followed four stages, beginning with fasting and advancing through clear liquids, semi-liquid foods, and soft foods once clinical stability was confirmed. Before each stage advancement, bedside evaluation verified the absence of vomiting, worsening abdominal pain, unstable vital signs, or signs of rebleeding within the previous 24 hours. Detailed dietary instructions, including fluid types and feeding frequency, were provided to reduce the risk of early feeding-related rebleeding. A visual self-management package was implemented by the responsible nurses before discharge, and compliance was checked by specialist nurses. Patients also a received a one-page medication card outlining proton pump inhibitor therapy duration, dosing schedule, and precautions. Education on warning signs of rebleeding was provided, including recurrent hematemesis, a sudden increase in melena volume, marked dizziness, palpitations or fatigue, and decreases in blood pressure or substantial increases in heart rate. Discharge documentation included a signed discharge education form and a questionnaire assessing patient knowledge acquisition.

Observation indicators

Observation indicators included hospital stay, blood transfusion volume, endoscopic complications, and patient satisfaction. Hospital stay was calculated as the number of days from admission to discharge. Blood transfusion volume was defined as the total number of units of suspended red blood cells transfused during hospitalization. Endoscopic complications occurring within 72 hours before or after therapeutic endoscopy, including aspiration, hypotension, and arrhythmia, were recorded, with diagnoses confirmed using electrocardiographic monitoring and medical record documentation when necessary.

Patient satisfaction with perioperative nursing care was assessed using a self-designed questionnaire distributed and collected anonymously by nurses who were not involved in the intervention before discharge. The questionnaire covered seven dimensions: Communication and explanation, technical performance, pain and discomfort management, notification of bleeding risk, timeliness of response, privacy and humanistic care, and discharge guidance and follow-up instructions. It consisted of 10 items, each scored on a five-point Likert scale (1-5 points), yielding a total score ranging from 10 points to 50 points. Satisfaction levels were categorized as very satisfied (≥ 45 points), satisfied (40-44 points), average (30-39 points), and unsatisfied (< 30 points). The satisfaction rate was calculated as follows: Satisfaction rate (%) = [(number of very satisfied cases + number of satisfied cases)/total number of cases] × 100%.

Definition of rebleeding

Rebleeding was defined as recurrent hematemesis and/or melena accompanied by hemodynamic instability (tachycardia or hypotension) and/or a decrease in hemoglobin of ≥ 2 g/dL within 24 hours, requiring repeat endoscopic evaluation, blood transfusion, or escalation of therapy. All suspected rebleeding events were confirmed through clinical assessment in combination with laboratory results and endoscopic findings.

Statistical analysis

Statistical analysis was performed using SPSS version 26.0. Continuous variables were expressed as mean ± SD, and comparisons between groups were conducted using the t-test. Categorical variables were presented as n (%), and comparisons between groups were performed using the χ² test or Fisher’s exact test as appropriate. A P value < 0.05 was considered statistically significant.

RESULTS

General characteristics of patients

Baseline characteristics were comparable between the two groups, with no statistically significant differences observed (Table 1). The mean age was 56.4 ± 12.3 years in the observation group and 57.1 ± 11.8 years in the control group (t = 0.33, P = 0.742). The proportion of male patients was 63.08% in the observation group and 60.00% in the control group (χ² = 0.13, P = 0.718). Ulcer type, Forrest classification, presence of comorbid cardiovascular disease, and prior use of antithrombotic medications were also similar between groups, with no significant differences detected (all P > 0.05).

Table 1 General characteristics of patients, n (%)/mean ± SD.

Group	Observation group	Control group	t/χ2 value	P value
Age (years)	56.4 ± 12.3	57.1 ± 11.8	0.33	0.742
Sex			0.13	0.718
Male	41 (63.08)	39 (60.00)
Female	24 (36.92)	26 (40.00)
Type of ulcer			0.12	0.725
Gastric ulcer	38 (58.46)	36 (55.38)
Duodenal ulcer	27 (41.54)	29 (44.62)
Forrest classification			0.14	0.705
Ia-IIb	44 (67.69)	46 (70.77)
Other	21 (32.31)	19 (29.23)
Cardiovascular disease			0.15	0.702
Yes	19 (29.23)	21 (32.31)
No	46 (70.77)	44 (67.69)
Prior use of antithrombotic medications			0.15	0.699
Yes	16 (24.62)	18 (27.69)
No	49 (75.38)	47 (72.31)

Rebleeding rate after therapeutic endoscopy

The rebleeding rate after therapeutic endoscopy was significantly lower in the observation group at both follow-up time points (Table 2). On day 7, rebleeding occurred in 6.15% (4/65) of patients in the observation group compared with 18.46% (12/65) in the control group (χ² = 4.56, P = 0.033). On day 30, rebleeding occurred in 9.23% (6/65) of patients in the observation group and 24.62% (16/65) of patients in the control group (χ² = 5.47, P = 0.019).

Table 2 Rebleeding rates after therapeutic endoscopy, n (%).

Group	Seven-day rebleeding	30-day rebleeding
Observation group (n = 65)	4 (6.15)	6 (9.23)
Control group (n = 65)	12 (18.46)	16 (24.62)
χ2 value	4.56	5.47
P value	0.033	0.019

Hospital stay and blood transfusion volume

Both length of hospital stay and blood transfusion requirements were lower in the observation group than in the control group (Table 3). The mean duration of hospitalization was 6.8 ± 2.1 days in the observation group compared with 8.1 ± 2.6 days in the control group (t = 3.14, P = 0.002). The mean blood transfusion volume was 1.3 ± 0.9 units in the observation group and 1.9 ± 1.1 units in the control group (t = 3.40, P < 0.001).

Table 3 Hospital stay and blood transfusion volume, mean ± SD.

Group	Inpatient days	Blood transfusion volume (U)
Observation group (n = 65)	6.8 ± 2.1	1.3 ± 0.9
Control group (n = 65)	8.1 ± 2.6	1.9 ± 1.1
T value	3.14	3.40
P value	0.002	< 0.001

Complications and patient satisfaction

Peri-endoscopic complications occurred less frequently in the observation group than in the control group (Table 4). The overall complication rate was 9.23% (6/65) in the observation group compared with 32.31% (21/65) in the control group (χ² = 10.02, P = 0.002). The observation group also had fewer cases of aspiration (1.54% vs 7.69%), hypotension (4.62% vs 13.85%), and arrhythmia (3.08% vs 10.77%). In addition, patient satisfaction was significantly higher in the observation group, with a satisfaction rate of 92.31% (60/65) compared with 78.46% (51/65) in the control group (χ² = 4.99, P = 0.025).

Table 4 Complications and patient satisfaction, n (%).

Group	Complications				Number of satisfied patients
	Aspiration	Hypotension	Arrhythmia	Total incidence
Observation group (n = 65)	1 (1.54)	3 (4.62)	2 (3.08)	6 (9.23)	60 (92.31)
Control group (n = 65)	5 (7.69)	9 (13.85)	7 (10.77)	21 (32.31)	51 (78.46)
χ2 value	-	-	-	10.02	4.99
P value	-	-	-	0.002	0.025

DISCUSSION

Rebleeding represents one of the most important short-term adverse outcomes in patients with peptic ulcer bleeding after endoscopic treatment[9]. In the present study, rebleeding rates in the observation group were significantly lower than those in the control group on both day 7 and day 30. These findings suggest that the nursing-led management pathway was effective not only during the very early high-risk period after endoscopy but also provided a sustained protective effect during the extended post-procedural period, when intensive monitoring is typically reduced. This effect may be closely related to the rapid dual-risk stratification and early warning model implemented in this study[10].

Conventional nursing care often relies on static assessments and experience-based observation. In contrast, the present protocol evaluated bleeding risk and sedation or airway risk simultaneously and displayed the results through a visual risk identification system, allowing nursing resources to be more accurately directed toward patients at higher risk[11]. In addition, the establishment of fixed assessment time points and predefined trigger criteria shifted the recognition of rebleeding from passive observation of overt symptoms to proactive monitoring based on clinical trends and threshold triggers. This approach likely shortened the time required for clinical decision-making and preparation for repeat endoscopy, thereby improving the timeliness of intervention and ultimately reducing the rebleeding rate[12,13].

Several limitations should be acknowledged. First, this was a single-center trial with a moderate sample size, which may limit generalizability to other settings with different case mixes, staffing models, and endoscopy workflows. Second, blinding of nursing staff was not feasible. Although outcome data were extracted by personnel unaware of group allocation, the possibility of performance and detection bias cannot be fully excluded. Third, follow-up focused on outcomes at 7 days and 30 days, and longer-term recurrence, medication adherence, and patient-reported outcomes were not evaluated. Fourth, patient satisfaction was measured using a self-developed questionnaire, and further validation, including assessment of reliability, construct validity, and responsiveness, is needed. Finally, subgroup effects, such as those related to Forrest classification or antithrombotic therapy, and resource-related outcomes including cost-effectiveness were not pre-specified. These aspects should be investigated in future multicenter studies incorporating standardized digital early-warning systems and nursing-sensitive indicators.

In this study, blood transfusion volume in the observation group was lower than that in the control group (P < 0.05), and the length of hospital stay was also shorter (P < 0.05), suggesting that the nursing-led peri-endoscopic management protocol significantly optimized the use of medical resources. This finding closely aligns with the goal-oriented resuscitation care pathway implemented in this study. The structured management checklists strengthened the sequence and timeliness of key clinical actions, including the early establishment of dual venous access, intensive monitoring and recording of vital sign trends, dynamic reassessment of hemoglobin and coagulation parameters, and standardized administration of intensive proton pump inhibitor therapy[14,15]. In patients with peptic ulcer bleeding, early resuscitation, frequent reassessment, and adequate acid suppression contribute to a more stable hemostatic environment and reduce the need for secondary interventions[16,17]. The reduction in blood transfusion volume not only reflects more effective control of bleeding but may also indicate that avoidable delayed hypoperfusion or occult rebleeding was identified and managed earlier, thereby indirectly contributing to the shorter duration of hospitalization[18].

The overall incidence of peri-endoscopy-related complications was lower in the observation group than in the control group (P < 0.05). This finding may be related to the integrated protocol used in the observation group, in which sedation and airway risks were evaluated alongside bleeding risk as central components of the care pathway. Risk classification was performed using the American Society of Anesthesiologists classification, the STOP-Bang score, and aspiration risk factors, and was subsequently matched with a graded airway management strategy. This approach addressed the common tendency in traditional care to prioritize bleeding management while underemphasizing sedation safety, which is particularly important in patients with comorbid conditions, obesity, or suspected obstructive sleep apnea[19]. Preoperative aspiration risk assessment, continuous intraoperative monitoring, and timely suctioning or positional adjustments helped reduce the risk of aspiration and hypoxia. In addition, structured management of sedation-related events may have contributed to reducing physiological stress responses associated with hypotension and arrhythmia, thereby improving overall procedural safety[20].

Furthermore, the observation group implemented a standardized hemostasis coordination checklist during the procedure, with the endoscopy specialist nurse assuming a fixed coordination role. The value of this measure lies not only in improved preparation of instruments and medications but also in the structured prompting of key procedural steps and real-time documentation. Simultaneous recording of the bleeding site, ulcer size, Forrest classification, hemostatic method, and immediate hemostatic outcome established a traceable evidence framework for postoperative risk assessment and follow-up management. This structured approach likely improved adherence to hemostatic strategies and enhanced the efficiency of emergency responses, thereby contributing to the reduction in procedure-related complications[21,22].

The satisfaction rate in the observation group was higher than that in the control group, suggesting that the nursing-led peri-endoscopic management protocol significantly improved patient experience. This finding is consistent with the structured elements incorporated into the protocol, including the staged dietary pathway, one-page medication instruction card, and closed-loop follow-up at one week and one month after discharge. Patients with peptic ulcer bleeding often continue to face challenges after successful hemostasis, such as lifestyle adjustments, medication adherence, and anxiety related to potential rebleeding[23]. The nursing-led management protocol helped reduce patient uncertainty and improve self-management by clearly defining dietary progression criteria, reinforcing recognition of warning signs, providing visual medication guidance, and conducting proactive follow-up during the key risk period after discharge. These measures ultimately translated into higher patient satisfaction and may also contribute to a further reduction in the risk of recurrent bleeding[24,25].

CONCLUSION

In summary, the nursing-led peri-endoscopic management protocol reduced the short-term rebleeding rate, decreased blood transfusion requirements and complication rates, shortened hospital stay, and improved patient satisfaction. These benefits were achieved through the integration of dual-risk stratification, goal-directed resuscitation, graded sedation and airway management, coordinated intraoperative checklists, and a structured early warning and follow-up pathway for rebleeding. However, several limitations should be acknowledged. The study was conducted at a single center with a relatively limited sample size, and the number of some complications was small. In addition, patient satisfaction was assessed using a self-developed questionnaire. Future studies should include multicenter designs and incorporate digital early-warning systems and nursing-sensitive indicators to further evaluate potential benefits across different Forrest classifications and in patients receiving antithrombotic therapy.