Effect of whole-process management protocol in preventing device-related intraoperative pressure injuries in patients undergoing gastrointestinal surgery

Abstract

BACKGROUND

Intraoperative device-related pressure injuries are common in gastrointestinal surgery, and conventional nursing has limited preventive efficacy. A comprehensive perioperative strategy is urgently needed.

AIM

To evaluate the efficacy of a whole-process management protocol in preventing device-related pressure injuries during gastrointestinal surgery.

METHODS

This retrospective cohort study included 104 patients undergoing gastrointestinal surgery. The observation group (n = 53) received a whole-process management protocol, while the control group (n = 51) received standard care. The primary outcome was incidence of intraoperative pressure injuries. Secondary outcomes included postoperative complications, recovery indices, inflammatory markers, anxiety, sleep quality, and quality of life. Between-group comparisons were performed using the χ² test, independent t-test, or Mann-Whitney U test, as appropriate. Repeated measures were analyzed using mixed-effects models.

RESULTS

The observation group had significantly lower pressure injury incidence at 1 day postoperatively (5.66% vs 27.45%, P = 0.003) and fewer total complications (50.94% vs 80.39%, P = 0.002). Times to flatus, regular diet, and wound healing were shorter in the observation group (all P < 0.05). Mixed-effects models revealed significant group-by-time interactions favoring the observation group for high-sensitivity C-reactive protein (P = 0.004), anxiety scores (P = 0.008), and all domains of quality of life (P < 0.01).

CONCLUSION

The whole-process management protocol significantly reduces device-related pressure injuries and improves postoperative recovery, inflammation, anxiety, sleep, and quality of life in patients undergoing gastrointestinal surgery.

Key Words: Whole-process management protocol; Gastrointestinal surgery; Device-related pressure injury; Perioperative management; Postoperative complications; Quality of life

Core Tip: This retrospective study evaluated a whole-process management protocol for preventing device-related pressure injuries in gastrointestinal surgery. In 104 patients, the protocol significantly reduced pressure injury incidence at 1 day postoperatively (27.45%-5.66%), lowered complication rates (80.39%-50.94%), and improved quality of life. These findings support proactive, multimodal perioperative prevention.

INTRODUCTION

Intraoperative devicerelated pressure injuries are common complications in patients undergoing gastrointestinal surgery. They primarily result from prolonged localized compression of body tissues by various medical devices, such as catheters and stents, which leads to sustained tissue pressure, ischemia, and hypoxia[1,2]. These clinical manifestations range from skin erythema to varying degrees of deep tissue necrosis, not only increasing patient suffering and prolonging hospital stays but also potentially triggering infections that hinder postoperative recovery[3].

Currently, clinical prevention relies mainly on routine nursing care, including the use of pressure-relieving pads, regular patient repositioning, and local dressing application[4,5]. However, these measures have clear limitations in preventing injuries caused by direct, localized compression from medical devices[1,6]. Their effectiveness depends largely on the subjective experience and vigilance of nursing staff; for prolonged gastrointestinal procedures involving special patient positions, physical decompression alone is often unsatisfactory[7]. Moreover, intraoperative sedation and analgesia may mask early symptoms, leading to delayed intervention.

Therefore, there is an urgent clinical need for a comprehensive, multifaceted perioperative strategy to improve preventive outcomes. The wholeprocess management protocol, as a multimodal, evidencebased pathway[8,9], offers core advantages by optimizing anesthesia, analgesia, fluid management, and early mobilization. This approach reduces surgical stress and improves tissue perfusion, thereby potentially decreasing tissue susceptibility to devicerelated pressure injuries[10].

Based on prior clinical experience and a review of the relevant literature, our research team developed a whole-process management protocol for patients undergoing gastrointestinal surgery. This protocol has been progressively implemented at our hospital since January 2025. Before this date, our hospital primarily relied on standardized routine care to prevent devicerelated pressure injuries. After January 2025, guided by prior clinical experience and evidence-based principles, we adopted the wholeprocess management protocol as the standard intervention. Accordingly, this retrospective study aims to evaluate the effectiveness of this protocol in preventing devicerelated intraoperative pressure injuries during gastrointestinal surgery, and to systematically assess its clinical value in reducing pressure injury incidence, improving postoperative recovery quality, and enhancing overall patient outcomes.

MATERIALS AND METHODS

General information

A retrospective cohort study was conducted on 104 patients who underwent gastrointestinal surgery at Lanzhou University Second Hospital between September 2024 and June 2025. Patients were assigned to two groups based on whether they received the wholeprocess management protocol. The control group (n = 51) received standardized routine care, while the observation group (n = 53) received the wholeprocess management protocol. Specifically, before January 2025, our hospital used standardized routine care for pressure injury prevention in gastrointestinal surgery patients; after January 2025, the wholeprocess management protocol was implemented based on previous clinical experience and evidencebased principles.

Inclusion criteria: (1) Firsttime endoscopic or open gastrointestinal surgery; (2) Adequate verbal expression and communication ability; (3) Age ≥ 18 years; and (4) Provision of informed consent and voluntary participation in the study.

Exclusion criteria: (1) Pre-existing skin breakdown or pressure injury; (2) Concurrent other organ diseases; (3) Palliative surgery for distant metastasis of gastrointestinal tumors; (4) Preoperative antineoplastic chemotherapy; and (5) Gastrointestinal obstruction.

The primary outcome measure of this study was the incidence of intraoperative pressure injuries. Diagnosis and staging of pressure injuries strictly adhered to the International Guidelines for Pressure Injury Prevention, Assessment, Treatment, and Care[11]: (1) Stage 1: Nonblanching erythema with intact skin; (2) Stage 2: Partial loss of epidermis, presenting as a superficial open ulcer or an intact/ruptured serous blister; and (3) Stage 3 and above: Fullthickness skin loss with exposure of subcutaneous fat, muscle, or bone. Any skin changes meeting these criteria were diagnosed as intraoperative pressure injuries (Figure 1). This study was reviewed and approved by the Medical Ethics Committee of Lanzhou University Second Hospital (Approval No. 2026A-440), and all procedures were carried out in accordance with the Declaration of Helsinki.

Figure 1  Flow diagram of patient selection and grouping process.

Intervention methods

The two groups received different perioperative management strategies. To evaluate the effectiveness of the integrated wholeprocess management protocol in preventing devicerelated pressure injuries during surgery, we implemented the following two strategies (Figure 2).

Figure 2  Schematic diagram of grouped interventions.

Control group: Patients received standard care[12]. Preoperatively, they underwent routine preoperative assessment and received standard health education, including pressure injury prevention guidance. Intraoperatively, standard positioning techniques were employed, and basic pressurerelieving pads were used to protect pressure points. Operating room nurses monitored vital signs and maintained nursing records according to established protocols. Postoperatively, patients returned to the ward, where routine monitoring protocols were implemented. Symptoms such as nausea, vomiting, and pain were managed symptomatically as needed.

Observation group (whole-process management protocol): (1) Task force establishment: Led by the head nurse, the team included three operating room specialty nurses and two gastrointestinal surgery nurses. Two gastrointestinal surgeons, and one anesthesiologist were invited to refine the protocol and provide professional guidance; (2) Protocol development: A systematic literature search was conducted using databases with the keywords “pressure injuries”, “gastrointestinal surgery”, “intraoperative pressure ulcers”, “devicerelated pressure injuries”, and “perioperative management”, prioritizing publications from the past decade. The quality of relevant guidelines and consensus statements was assessed using the AGREE II tool[13]. Meta-analyses were evaluated using the JBI Quality Assessment Tool[14], and clinical research reports were assessed using the AHRQ Cross-Sectional Study Evaluation Criteria[15]. High-level evidence was extracted and combined with clinical experience to preliminarily outline the protocol, which was then refined through internal discussions and expert consultations; (3) Preoperative phase: Comprehensive risk assessment was performed using the CORN Intraoperative Acquired Pressure Injury Risk Assessment Scale[16]. Internal consistency in our cohort was acceptable (Cronbach’s α = 0.82). Highrisk patients (CORN score ≥ 12) received prophylactic application of 5 mm silicone foam dressings (Mepilex, Mölnlycke) on the sacral, occipital, and heel areas. Individualized psychological counseling was also provided; (4) Intraoperative phase: (a) Positioning: Patients were placed on a viscoelastic gel operating table pad (Action^® Gel, 3M), with additional gel pads (Trulife, 5 mm thickness) under the elbows, heels, and head; (b) Micro-interventions: With the surgeon’s approval and without compromising the surgical field, pressure points were gently offloaded every 2 hours by repositioning the head or upper limbs for 1-2 minutes. Each offloading maneuver was documented in the pressure injury monitoring record; (c) Temperature management: Forced-air warming blankets (Bair Hugger, 3M) were applied to maintain a core temperature ≥ 36 °C; and (d) Monitoring: A dedicated pressure injury monitoring record was completed every 30 minutes, documenting skin color, temperature, and device contact; (5) Postoperative phase: Early mobilization was encouraged, and pressure areas were reassessed at 1 hour and 1 day after surgery; and (6) Implementation and adherence: Before the intervention, the five participating nurses completed a 2-hour training session covering risk assessment, positioning techniques, microintervention timing, and documentation. A 10-item practical examination (passing score ≥ 85%) was used to certify competency; all nurses passed on the first attempt. No additional staff were hired; the protocol tasks were absorbed by the existing nursing team, requiring approximately 15 extra minutes per patient per operative day. Protocol adherence was monitored by the head nurse using a 12-item checklist, and the adherence rate in the observation group was 94.3% (50/53).

Observation indicators

General information: The following variables were compared between the two groups: Gender, age, body mass index (BMI), surgery type, surgery duration, intraoperative positioning (supine/Lithotomy/Lateral), anesthesia type (combined general-epidural vs general anesthesia alone), intraoperative hypotension [mean arterial pressure (MAP) < 65 mmHg], and warming method (forcedair warming vs routine blanket).

Incidence of pressure injuries: Pressure injury incidence was assessed at the end of surgery, 1 hour postoperatively, and 1 day postoperatively. One day postoperatively was the primary time point for staging[17]. The 1-hour assessment served to distinguish transient reactive hyperemia from persistent nonblanchable erythema. For patients with dark skin, palpation was used to aid detection of stage 1 injuries. Diagnosis and staging adhered to the updated National Pressure Injury Advisory Panel staging system[18]: Stage 1: Intact skin with nonblanchable erythema; stage 2: Partialthickness skin loss with exposed dermis; stage 3: Fullthickness skin loss with visible adipose tissue; stage 4: Fullthickness skin and tissue loss with exposed fascia, muscle, or bone; unstageable: Fullthickness skin and tissue loss obscured by slough or eschar; and deep tissue pressure injury: Intact or nonintact skin with persistent non-blanchable deep red, maroon, or purple discoloration. Only skin changes directly attributable to intraoperative devices (e.g., endotracheal tube, bite block, catheters, monitoring lines) were counted; and pressure injuries resulting from postoperative devices (e.g., bed rails, drainage tubes) were excluded through chart review and bedside assessment.

Incidence of complications: Postoperative complications, including nausea and vomiting, sore throat, abdominal distension, incisional infection, pulmonary infection, and anastomotic fistula, were recorded for both groups.

Postoperative recovery outcomes: The following recovery outcomes were documented for both groups: Time to flatus, time to resumption of a normal diet, wound healing time, time to ambulation, and length of hospital stay.

Quality of life: Patients’ quality of life was evaluated before surgery and at discharge using the World Health Organization Quality of Life-BREF[19]. The two groups were assessed across four domains: Social relationships, psychological well-being, physical health, and environment. Higher scores indicated better quality of life.

Statistical analysis

Continuous variables were first tested for normality using the Shapiro-Wilk test. Normally distributed data were presented as mean ± SD and compared between the two groups using the independent samples t-test. Non-normally distributed data were presented as median (interquartile range) and compared using the Mann-Whitney U test. Categorical variables were compared using the χ² test or Fisher’s exact test. For repeated measures (inflammatory markers at three time points; anxiety, sleep quality, and quality of life at two time points), a linear mixed-effects model was fitted with group, time, and the group-by-time interaction as fixed effects and patient as a random effect. Post-hoc pairwise comparisons were adjusted using the Bonferroni correction. All tests were two-sided, and a P value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY, United States).

RESULTS

Comparison of general patient characteristics between the two patient groups

Comparisons of general characteristics between the two groups, including sex, age, BMI, surgical type, surgical duration, intraoperative positioning (supine, lithotomy, or lateral), anesthesia type (combined general-epidural vs general anesthesia alone), and incidence of intraoperative hypotension (MAP < 65 mmHg), revealed no statistically significant differences (all P > 0.05), indicating that the two groups were comparable at baseline. The control group did not receive forced-air warming as part of routine care, whereas all patients in the observation group received forcedair warming according to the protocol (Table 1).

Table 1 Comparison of general patient characteristics between the two patient groups, n (%) or mean ± SD.

Project	Control group (n = 51)	Observation group (n = 53)	t/χ2	P value
Gender
Male	27 (52.94)	28 (54.90)	0.000	0.991
Female	24 (47.06)	25 (49.02)
Age (year)	45.27 ± 8.31	45.62 ± 8.19	-0.215	0.830
BMI (kg/m2)	22.37 ± 3.25	22.45 ± 3.28	-0.125	0.901
Types of surgery			0.577	0.447
Laparoscopic surgery	30 (58.82)	35 (68.63)
Open surgery	21 (41.18)	18 (35.29)
Surgery time (hour)	7.26 ± 2.31	7.35 ± 2.28	-0.222	0.825
Intraoperative positioning			0.551	0.759
Supine	35 (68.63)	37 (69.81)
Lithotomy	9 (17.65)	11 (20.75)
Lateral	7 (13.73)	5 (9.43)
Anesthesia type			0.116	0.733
GA + EA	39 (76.47)	42 (79.25)
GA	12 (23.53)	11 (20.75)
Intraoperative hypotension			0.124	0.725
Yes	9 (17.65)	8 (15.09)
No	42 (82.35)	45 (84.91)

BMI: Body mass index; GA + EA: Combined general-epidural anesthesia; GA: General anesthesia alone.

Comparison of pressure injury incidence between the two patient groups

When comparing the incidence of pressure injuries between the two groups, the observation group had lower rates immediately after surgery, at 1 hour postoperatively, and at 1 day postoperatively than the control group. A significant difference was observed at 1 day postoperatively (P < 0.05; Table 2). Regarding pressure injury severity at 1 day postoperatively, the majority were stage 1 in both groups (control: 10/14, 71.4%; observation: 3/3, 100%). The control group additionally had three stage 2 injuries (21.4%) and one stage ≥ 3 injury (7.1%), whereas the observation group had no injuries beyond stage 1 (Table 2).

Table 2 Comparison of pressure injury incidence between the two patient groups, n (%).

Time point	Control group (n = 51)	Observation group (n = 53)	χ2	P value
Immediately after surgery	7 (13.73)	2 (3.77)	3.256	0.071
1 hour after surgery	9 (17.65)	3 (5.66)	3.659	0.056
1 day after surgery	14 (27.45)	3 (5.66)	9.025	0.003a
Stage 1	10 (19.61)	3 (5.66)
Stage 2	3 (5.88)	0 (0)
Stage ≥ 3	1 (1.96)	0 (0)

^aP < 0.01.

In the control group, the 14 pressure injuries observed at 1 day postoperatively were associated with the following devices: Endotracheal tube (n = 6), bite block (n = 3), urinary catheter (n = 3), and monitoring lines (n = 2). In the observation group, the 3 pressure injuries at 1 day postoperatively were associated with the endotracheal tube (n = 2) and bite block (n = 1).

Comparison of complication rates between the two patient groups

When comparing the incidence of complications between the two groups, the observation group had a significantly lower overall complication rate (50.94%) than the control group (80.39%; P < 0.05). Additionally, the observation group showed lower rates of nausea and vomiting, sore throat, abdominal distension, incisional infection, pulmonary infection, and anastomotic fistula than the control group (Table 3).

Table 3 Comparison of complication rates between the two patient groups, n (%).

Complication type	Control group (n = 51)	Observation group (n = 53)	χ2	P value
Nausea and vomiting	32 (62.75)	20 (37.74)	-	-
Sore throat	24 (47.06)	6 (11.32)	-	-
Abdominal distension	3 (5.88)	2 (3.77)	-	-
Incision infection	3 (5.88)	2 (3.77)	-	-
Pulmonary infection	3 (5.88)	1 (1.89)	-	-
Anastomotic fistula	2 (3.92)	1 (1.89)	-	-
Total complications	41 (80.39)	27 (50.94)	9.959	0.002a

^aP < 0.01.

Comparison of postoperative recovery between the two patient groups

Comparing postoperative recovery between the two groups, the observation group demonstrated significantly shorter times to gastrointestinal passage, resumption of regular food intake, and wound healing compared to the control group (P < 0.05; Figure 3).

Figure 3 Comparison of postoperative recovery between the two patient groups. ^aP < 0.001 vs the control group; ^bP < 0.01 vs the control group.

Comparison of quality of life between the two patient groups

Preoperatively, no significant differences in quality of life were observed between the two groups (all P > 0.05), indicating baseline comparability. At discharge, both groups showed improvements in the scores for social relationships, psychological well-being, physical health, and environment compared with preoperative levels (all P < 0.05), and the observation group had significantly higher scores than the control group (all P < 0.05; Figure 4).

Figure 4 Comparison of quality of life between the two patient groups. ^aP < 0.001 vs the control group. A: Social relationships; B: Mental health; C: Surrounding environment; D: Physical health.

DISCUSSION

This retrospective analysis evaluated the comprehensive impact of the integrated whole-process management protocol on patients undergoing gastrointestinal surgery. The key findings indicate that the protocol not only effectively prevents devicerelated intraoperative pressure injuries but also improves multiple aspects of postoperative recovery. Compared with patients who received conventional care, those managed with the whole-process management protocol had lower rates of skin injury and complications, faster recovery of gastrointestinal function, and better quality of life. These findings collectively confirm that systematically integrating whole-process management principles into perioperative care can substantially enhance surgical safety and patient recovery through multitargeted interventions.

The whole-process management protocol demonstrated significant efficacy in reducing device-related pressure injuries, likely due to its shift from passive, reactive care to a proactive, multi-layered preventive strategy[20,21]. Unlike conventional care, which relies on basic pressure-relieving devices and periodic monitoring, the protocol integrates risk-stratified preoperative planning, dynamic intraoperative tissue offloading, and physiological support (e.g., temperature management). This combination addresses both the mechanical and physiological contributors to pressure injury, thereby breaking the cycle of sustained tissue ischemia[22,23]. Such a systematic, risk-informed approach provides a more reliable protective framework than routine care alone[24]. While established ERAS protocols emphasize functional recovery, they lack specific guidance for intraoperative device-related pressure injury prevention[25,26]. Our protocol fills this gap by offering a structured, adherence-monitored bundle that can be integrated into ERAS pathways to further enhance patient safety.

The findings of this study further extend the benefits to patients’ overall rehabilitation experience. Patients in the observation group had higher quality of life scores at discharge, reflecting improved recovery outcomes. This result likely stemmed from the synergistic effects of multiple factors[27]. On one hand, enhanced preoperative counseling and individualized psychological support directly empowered patients by promoting greater informed consent and a sense of control, thereby alleviating fear and anxiety about the unknown surgical procedure. On the other hand, the direct physiological benefits of the whole-process management protocol, including reduced surgical trauma, more effective pain management, fewer postoperative complications, and accelerated functional recovery, contributed substantially to the observed improvement in patients’ overall wellbeing, as reflected in their higher quality of life scores at discharge[28]. Together, these findings underscore the patient-centered nature of the whole-process management protocol, whose value lies not only in optimizing biological indicators but also in enhancing the overall patient experience throughout the entire medical process.

Although formal cost-effectiveness analysis was not performed, the observed reduction in total complications (from 80.39% to 50.94%) and shorter hospital stay (implied by faster recovery of flatus and diet) suggest potential healthcare cost savings. Preventing complications reduces hospital costs through multiple mechanisms: Lower demand for diagnostic tests, medications, and prolonged nursing care[29]; shorter length of stay, which decreases bed occupancy costs[30]; and avoidance of costly interventions such as reoperation or intensive care for severe complications. Pressure injury prevention itself has been shown to be cost-effective, with prevention bundles achieving significant cost savings compared with routine care[31]. Beyond cost savings, preventing device-related pressure injuries also improves patient satisfaction. Patients who experience fewer postoperative complications, including pressure injuries, report higher satisfaction with nursing care and overall hospitalization[32]. The absence of pressure injury-related pain, reduced anxiety about wound healing, and faster return to normal activities all contribute to a better patient experience. Thus, the whole-process management protocol offers not only clinical but also economic and patient-centered benefits. Future studies should incorporate formal cost-effectiveness analyses, including quality-adjusted life years and patient-reported satisfaction measures, to fully evaluate the economic impact of implementing this protocol[33,34].

This retrospective, single-center study has inherent limitations that preclude causal inference. First, unmeasured confounding, including temporal improvements in nursing care (e.g., staff learning effects, policy changes) due to the historical control design, as well as selection bias, cannot be ruled out. Thus, the findings should be interpreted as hypothesisgenerating, and prospective multicenter studies are needed. Second, the CORN scale was originally developed for neurosurgical patients; its validity in gastrointestinal surgery has not been formally established, which may have introduced bias in risk stratification. Third, this study did not include a formal health economic analysis. Fourth, inter-rater reliability (e.g., Cohen’s kappa) for skin assessments was not calculated due to the retrospective design, which may have introduced measurement bias. Future research should develop and validate specialized predictive models for gastrointestinal surgery populations, conduct health economic evaluations to quantify resource savings from preventing complications, and include formal reliability testing for skin assessments.

CONCLUSION

In summary, the findings of this study indicate that the whole-process management protocol represents an effective and multifaceted strategy for preventing device-related pressure injuries in patients undergoing gastrointestinal surgery. By establishing a comprehensive system that integrates systematic risk assessment, dynamic intraoperative protection, systemic stress regulation, and humanistic psychological support, this method not only significantly reduces the risk of superficial tissue damage but also comprehensively optimizes the physiological rehabilitation process of patients. Therefore, widespread adoption and refinement of this multimodal, collaborative management pathway in clinical practice hold significant importance for enhancing patient safety and well-being.