Letter to the Editor: Rethinking emergency care pathways for acute intestinal obstruction: From haywire to high performance

Abstract

Acute intestinal obstruction remains one of the most unforgiving surgical emergencies, where delays measured in minutes – not hours – can determine bowel viability, complication rates, and survival. While advances in imaging and operative techniques have improved surgical outcomes, the organizational processes that govern early emergency care often receive far less scrutiny. In this context, Wang et al, published a study in the recent issue of the World Journal of Gastrointestinal Surgery, provide a timely and thought-provoking contribution by demonstrating how a structured multidisciplinary team (MDT)-based emergency nursing pathway can translate system design into measurable clinical benefits. The study also challenges traditional doctor-centric models by highlighting nursing-led team collaboration as a central integrator. It offers an insightful view of how a structured MDT-based emergency care pathway can significantly improve efficiency through clear, predefined roles, interdepartmental communication timelines, and escalation mechanisms. As emergency departments worldwide grapple with overcrowding and workforce strain, structured MDT nursing pathways may offer scalable solutions.

Key Words: Acute intestinal obstruction; Gastrointestinal surgery; Emergency medicine; Multidisciplinary; Multidisciplinary team

Core Tip: The time to coordination before surgery matters as much as the time to surgery itself. Early, structured multidisciplinary team (MDT) activation in acute intestinal obstruction can significantly shorten triage and treatment times, thereby reducing the risk of bowel ischemia and improving postoperative outcomes. Nursing-led team collaboration plays a central role in coordination, ensuring timely information transfer, prompt responses from key departments, and appropriate escalation of care. This thought-provoking study shows that MDT-based models are effective in promoting early collaboration, timely responses, and structured decision-making. Despite ongoing challenges, their potential to optimize outcomes in acute intestinal obstruction should not be underestimated. This editorial presents a compelling case that an MDT-based care pathway may improve efficiency, reduce emergency department backlogs, and enhance surgical outcomes even in resource-limited settings.

TO THE EDITOR

Acute intestinal obstruction remains one of the most time-critical surgical emergencies, accounting for a substantial proportion of acute abdomen admissions worldwide and carrying significant risks of bowel ischemia, perforation, and death when diagnosis or intervention is delayed[1,2]. Despite improvements in access to imaging and acute care, early outcomes remain heavily dependent on system efficiency rather than surgical technique alone[3]. Delays in triage, fragmented interdepartmental communication, and inconsistent nursing workflows continue to undermine optimal care in surgical emergencies[4]. In this context, the study by Wang et al[5], published in the recent issue of the World Journal of Gastrointestinal Surgery, provides timely and pragmatic evidence that a structured multidisciplinary team (MDT)-based emergency nursing pathway can improve both clinical and patient-reported outcomes in acute intestinal obstruction.

STUDY OVERVIEW

Wang et al[5] conducted a retrospective study involving 176 patients with acute intestinal obstruction, comparing conventional emergency care with a structured MDT-based emergency nursing pathway. The pathway emphasized early, coordinated activation of surgery, emergency medicine, radiology, and laboratory services, led by senior nursing leadership through predefined communication protocols and timelines. The study demonstrated significant reductions in triage and emergency treatment times, faster symptom resolution, lower obstruction-related complications within 72 hours, and higher patient quality-of-life scores and nursing satisfaction.

Beyond numerical improvements, the study focuses on process-driven outcomes, reinforcing that early nursing-led pathway coordination can meaningfully influence patient trajectories in emergency surgery[4]. Several limitations, however, should be acknowledged. First, this was a single-center study, and the MDT pathway depended on local operational resources, which may limit generalizability to settings with different staffing and infrastructure. Second, the retrospective design introduces potential selection bias and incomplete documentation, limiting causal inference. Finally, outcomes were largely short-term and process-based, with complications assessed within 72 hours and quality of life measured at discharge.

Breaking traditional dogma: A nursing-led structured MDT pathway for acute intestinal obstruction. Acute intestinal obstruction is inherently multidisciplinary, with outcomes depending on accurate diagnosis and timely radiologic input, supported by coordinated efforts from surgeons, emergency physicians, and nurses[6]. Traditional models of care, characterized by sequential consultations and siloed decision-making, are increasingly misaligned with the demands of modern emergency surgery.

Structured MDT-based care pathways can address these limitations by formalizing roles, responsibilities, and escalation processes. Evidence from other high-risk surgical and medical conditions, including trauma and complex oncologic cases, consistently shows that MDT coordination improves timeliness, enhances surgical outcomes, and increases patient and healthcare satisfaction[7-9]. A recent study by Kudu et al[10] has shown that nursing-led coordination is feasible in life-threatening conditions. In the context of intestinal obstruction, early MDT engagement facilitates rapid differentiation between simple and strangulated obstruction, expedites resuscitation and imaging, and allows early operative planning – factors known to directly influence morbidity and mortality[2,11].

Interestingly, Wang et al[5]. highlight the central role of nurse-led team collaboration in coordinating MDT workflows, underscoring that high-quality emergency surgical care is not solely surgeon-dependent but system-dependent.

CHALLENGES AHEAD

Implementing MDT-based emergency pathways presents practical challenges, despite their numerous advantages. Resource limitations, staffing constraints, and variability in institutional hierarchy may hinder real-time MDT activation. These challenges may be more apparent in low-income and middle-income countries due to widespread human-resource constraints, cultural differences, and slower digital adaptation. Additionally, reliance on digital communication platforms such as WeChat introduces concerns related to data security and variability in responsiveness[12].

Standardization, while necessary for pathway effectiveness, must also allow flexibility for atypical presentations, complex comorbidities, and evolving clinical scenarios. Furthermore, as a single-center retrospective study, the findings by Wang et al[5]. require cautious generalization, highlighting the need for broader validation across diverse healthcare systems.

FUTURE DIRECTIONS

Future research should prioritize a pragmatic, stepped-wedge cluster randomized trial evaluating MDT-based emergency pathways with robust clinical endpoints, including perioperative morbidity and mortality, length of stay, intensive care unit utilization, and cost-effectiveness. Each site can start with usual care; then, at prespecified time points, sites cross over to the MDT pathway in a randomized sequence until all sites adopt it. This adoption ensures control for the learning curve and reduces data contamination. Integration of early warning scores, standardized decision algorithms, and artificial intelligence-assisted triage may further enhance MDT efficiency and real-time situational awareness[13,14]. Broad engagement with clinicians from all disciplines is vital to changing the workflow landscape in the emergency department to ensure success[15].

Embedding MDT communication and crisis-management training within surgical and nursing education curricula would be equally important to ensure preparedness of future generations. Such institutionalization ensures sustainability beyond individual champions and aligns emergency surgical care with contemporary value-based healthcare principles[16]. Global implementation of emergency care pathways remains challenging, especially in low-income and middle-income countries centers, due to various constraints, institutional hierarchy, and cultural norms[17].

CONCLUSION

The study by Wang et al[5] provides compelling evidence that structured MDT-based emergency nursing pathways can significantly improve efficiency, patient experience, and early outcomes in acute intestinal obstruction. It reframes emergency surgical care as an institutional endeavor, in which coordination, communication, and nursing leadership are as critical as surgical skills. As emergency departments worldwide face increasing patient complexity and volume, MDT-driven pathways should be viewed not as optional innovations but as essential components of high-quality care in emergency gastrointestinal surgery.