Analysis of Influence of Clinical Nursing Pathway Construction and Implementation on Patient Outcomes in Anesthesia Recovery

Summary

This study protocol aims to compare the outcomes of patients received in the anesthesia recovery room who were managed according to a routine nursing approach versus a clinical nursing pathway approach.

Abstract

The application of the clinical nursing pathway in the anesthesia recovery room is of great significance for improving nursing quality and reducing the incidence of complications. However, the influence of the clinical nursing pathway construction scheme and implementation path on patient outcomes in the anesthesia recovery room is not clear. In this study, 200 patients in the surgical anesthesia recovery room, aged 50 to 70 years old and graded as American Society of Anesthesiologists Physical Status Classification System (ASA) II-III, were randomly divided into the control group (n=100) and the interventional group (n=100). The control group received routine nursing measures, while the interventional group received a structured clinical nursing pathway. The Aldrete score and the stay time in the anesthesia recovery room before and after nursing intervention were compared between the two groups. VAS score at transfer out of the anesthesia room, postoperative patient compliance rates, nursing satisfaction, and complication rates were recorded. Before the intervention, there was no significant difference in Aldrete scores between the interventional group and the control group (p = 0.939). After the intervention, the Aldrete score and nursing satisfaction of patients in the interventional group were significantly higher than those in the control group despite comparable compliance rates. Moreover, the stay time in the anesthesia recovery room, pain VAS score at the time of transfer out of the anesthesia room, and the complications rates were found to be lower in the interventional group. The construction of a clinical nursing pathway in an anesthesia recovery room can improve the recovery and pain of patients, shorten the stay time, reduce the incidence of complications, and enhance nursing satisfaction, making it worthy of clinical promotion and application.

Introduction

Post-anesthesia care is defined as the period of recovery from the anesthetic agents' effects, where a thorough monitoring of vital signs is performed along with nursing interventions¹. During this period, mild complications such as nausea and vomiting, moderate complications such as excessive pain, and severe complications such as bleeding and asphyxia can develop². The implementation of routine nursing intervention can promote the postoperative recovery of patients; however, it lacks refinement, standardization, and a personalized approach. Thus, the complexity and variability of patients' conditions and complications discharged from the surgery room to the post-anesthesia recovery room impose high knowledge and skills in the nursing team, which does not always display such qualifications. Moreover, the increased volume of admitted patients and excessive workload may reduce the capacity of nurses to ensure the needed personalized care in the post-anesthesia setting³. More importantly, although consensus guidelines on enhanced recovery after surgery exist, they do not provide standardized protocols, particularly for nursing care according to patients evolution^4,5.

Clinical nursing pathway is a newly emerging concept of post-anesthesia care, which is based on a more enhanced and cost-effective quality of patient management and selection in the anesthesia recovery room^6,7,8. Thus, the clinical nursing pathway changes the traditional flexible nursing into a standardized plan and is committed to improving the quality of clinical nursing and ensuring the efficiency of medical care, while achieving a good cost-benefit ratio⁹. In a practical sense, patients receive a more interdisciplinary, rigorous (based on assessment scores), and selective post-anesthetic resuscitation.

Notably, since maintaining a good balance between patient safety and limited medical resources is one of the key factors in ensuring a cost-effective strategy in the anesthesia recovery room, the clinical nursing pathway has the objective of providing patient-tailored management. Studies have found that distinguishing fast and slow passage paths can promote the rational utilization of medical resources between high-risk and low-risk patients while promoting patients safety¹⁰. Generally speaking, the fast channel path is designed for low-risk patients with a stable state during anesthesia and recovery, while the slow channel path is for high-risk patients who underwent major operations or developed major post-operative complications¹¹. However, there is no consensus regarding the criteria that can be used for patients' classification in the anesthesia recovery room.

Studies have shown that adopting standardized and coordinated nursing measures and clinical care pathways in the anesthesia recovery room can improve patient outcomes¹². However, it remains unclear if these modalities offer a higher efficacy in improving the outcomes of the anesthesia recovery room than routine care. Therefore, we conducted the following interventional study to compare the outcomes of a clinical nursing pathway strategy and routine nursing in patients admitted to the post-anesthesia recovery room. The intervention consisted of fast and slow clinical nursing paths where patients' discharge was based on the assessment tool Aldrete score, with 9 as a cutoff value to select low-risk (≥ 9; candidates for fast discharge) from high-risk (˂ 9; candidates for slow and longer admissions) patients for complications. Other complementary criteria were also considered, notably complications not determined by the classic Aldrete score, pain level, and postoperative nausea and vomiting. The objective of this study is to test whether the developed clinical nursing paths-based intervention can enhance the recovery level and reduce the complications rates after general anesthesia.

Protocol

The research received approval from the ethics board of Affiliated Hospital of Gansu University of Chinese Medicine (approval no. Ethics [2024]011). All participants in the study provided their written informed consent. The study was conducted in accordance with the Declaration of Helsinki. The study subjects were 200 patients with lumbar spinal stenosis treated in the Affiliated Hospital of Gansu University of Chinese Medicine and Gansu Provincial Hospital of Traditional Chinese Medicine from January 2024 to December 2025. All patients underwent intervertebral disc removal, spinal canal decompression, intervertebral bone grafting, and pedicle screw internal fixation, which met the inclusion and exclusion criteria of the study.

Patient selection
The following inclusion criteria were used: Age from 50 to 70 years old with ASA grade II-III¹³, confirmed diagnosis of lumbar spinal stenosis with radiological examination, undergoing planned surgery of intervertebral disc removal, spinal canal decompression, intervertebral bone grafting, and pedicle screw fixation, receiving full general anesthesia with a combination of static and inhalation, being transferred to the anesthesia recovery room with tracheal intubation.

The following exclusion criteria were used: Undergoing emergency surgery, being pregnant, having severe comorbidities (e.g., late-stage chronic renal disease, hepatocellular insufficiency, malignancy, etc., or multiple organ failure, being diagnosed with a mental illness or cognitive impairment, or any condition that alters communication, developing any serious adverse reactions, drug intolerance, or self-withdrawal during the study period.

Grouping method
According to the order of admission, the patients were randomized into a control group and an interventional group using a computer-generated sequence to ensure unbiased group allocation. Patients were randomly included in the control group and the interventional group, until each group reached 100 patients. Patients were recruited strictly in accordance with the predefined inclusion and exclusion criteria. Following this, eligible participants were randomly assigned to either the interventional or control group to ensure the integrity and comparability of the study cohorts.

Intervention method
The control group was given routine nursing management while the interventional group was managed according to the standard clinical nursing path of the anesthesia recovery room (Figure 1). The standard clinical nursing path consisted of three aspects described below.

Preparation for the post-anesthesia recovery: After the patient was transferred to the anesthesia recovery room, the ECG monitor and ventilator were connected, the breathing and parameters were adjusted according to the actual situation of the patient, and the double-lung breathing sound was auscultated. The head of the bed was raised by 5° to 30°, and the neck of the patient was cushioned with a soft pillow. All vital signs were set to be monitored. The anesthesiologist handed over the patient's condition, anesthesia information, patient's personal belongings, doctor's orders, drugs, special items, etc., to the medical staff in the anesthesia recovery room. After the patients were transferred to the anesthesia recovery room, the Aldrete score¹⁴ was performed immediately based on routine resuscitation care, and at the same time, it was determined whether there were complications other than the 5 Aldrete score items. Complications other than the 5 in the Aldrete score were included as additional items of the modified Aldrete score. Nursing measures were taken according to the initial Aldrete score and patient condition.

Recovery process: During the process of post-anesthesia recovery, the nurses in the recovery room rigorously performed tracheal intubation removal according to standard procedures. Additionally, they provided multiple respiratory resuscitation gestures, including sputum aspiration care, tracheal intubation care, drainage tube care, ventilator care, and oxygen atomization inhalation after tracheal intubation removal. Moreover, nurses constantly evaluated the patient's condition, detected any signs of complications, observed wound dressing, drainage tube, venous access, and other placed equipment, executed the doctor's advice, and wrote nursing documents. The Aldrete score was repeatedly measured every 30 min, while complications and other manifestations of the patients were observed.

Patient discharge with fast and slow clinical nursing paths: When the patient's Aldrete score was ≥ 9, and there were no signs of complications, a transfer out of the anesthesia recovery room was made (fast path). At this time, nurses in the anesthesia recovery room should hand over to the nurses in the ward, explain the precautions to the patient's family members, and follow up on the anesthesia recovery situation on the 2^nd day after the transfer. Patients with Aldrete scores of 0-8 points or complications were transferred to the intensive care unit (ICU) for further treatment (slow path).

Patients with complications other than the five items of the Aldrete score were treated according to the type of complications and were given adequate anesthesia and resuscitation care.

Aldrete score and pain score
Aldrete scores contain 5 different items, including activity, respiration, circulation, consciousness, and oxygenation, with each item scored from 0 to 2 according to the degree of physiological recovery. Notably, a higher score indicates a better physiological state and post-anesthetic recovery^14.

The pain degree was evaluated according to the visual analogue scale (VAS) which corresponds to the followings: Score 0: = no pain (feel good, no pain treatment); 1-3 points = mild pain (obvious feeling of pain, need psychological comfort and moderate analgesia); 4-6 points = moderate pain (feel the pain is very obvious); 7-10 points = severe pain (feel the pain is intense, sometimes need to take a combination of drugs analgesia). The higher the score, the more intense the pain.

Secondary outcomes
Recovery room stay time corresponded to the time from transfer to recovery room to transfer out of recovery room. The incidence of complications corresponded to the events occurring in the anesthesia recovery room. Common complications affecting transfer out of the resuscitation room after lumbar surgery were evaluated, including pain, nausea and vomiting, and postoperative delirium. Compliance after anesthesia recovery includes full compliance if the patient was able to fully cooperate with the operation of medical staff, partial compliance if the patient reluctantly cooperates with the operation of medical staff, or with a slight conflict, and non-compliance if the patient does not cooperate with the operation of medical staff, and struggles.

Postoperative nausea and vomiting
Postoperative nausea and vomiting were evaluated according to the VAS: Score 0 = no nausea and vomiting (feel good, no need to deal with), 1-4 points = mild nausea and vomiting (feel nausea and vomiting, no obvious symptoms of nausea and vomiting, need psychological comfort), score 0-4 assigned 0 points; 5 to 6 points = moderate nausea and vomiting (need drug treatment, inform the anesthesiologist to deal with), assign 1 point; 7-10 points = severe nausea and vomiting (requires medical treatment, inform the anesthesiologist, sometimes with a combination of drugs). The higher the score, the more nausea and vomiting.

The postoperative delirium (POD) score was modified according to the Richmond Agitation Sedation Scale (RASS)¹⁵. Score 0 = awake and calm; score 1 = anxious, but not aggressive; score 2 = restlessness (frequent aimless movements, and ventilator resistance), score 3 = very agitated (grabbing or pulling out various drainage or catheter, aggressive); and score 4 = combative showing violent behavior (obvious belligerent violence, posing an immediate danger to staff).

Other complications
Other complications were classified as others according to the severity and whether they affected the transfer out of the resuscitation room. Other complications were assigned 0 points = other complications were not directly or indirectly related to the transfer out of the resuscitation room, such as tooth shaking or loss, slight skin indentation, and blood loss < 50 mL/h; 1 point = there is a certain causal relationship between other complications and metastasis, such as mild skin allergy, obvious pressure sore, bleeding volume 50-100 mL/h, 2 points = There is a direct or inevitable relationship between other complications and the transfer out of the resuscitation room, such as the case of severe allergies, blood loss >100 mL/h.

Statistical analysis
In this study, all the original data were entered into the statistical software, double-checked, and a bilateral test was used. A p = 0.05 was taken as the test level, and p < 0.05 indicated statistical significance. The counting data were described statistically with percentages, and the measurement data were described statistically with mean ± standard deviation. When the two groups were compared, the statistical data was tested by the χ² test. Measurement data were t-tested.

Results

Demographic analysis
In total, there were 200 patients (n=100 in each group), with an age range of 50 to 70 years and an ASA grade ranging from II to III. No significant difference was observed in terms of age, gender, and ASA grade (p > 0.05) as shown in Table 1.

Aldrete score
The nursing interventions were performed on patients who were transferred to the anesthesia recovery room following surgery. Before the interventions, there ...

Discussion

Our study showed the following salient results: post-anesthetic recovery assessed by Aldrete score was superior in patients who underwent the clinical nursing pathway scheme as compared to those receiving routine care; the former group of patients also had a faster discharge from the anesthesia recovery room as compared to matched controls. Moreover, the VAS score and complication rates were lower in the interventional cohort, suggesting both greater subjective and objective post-anesthetic improvements. The clinical nur...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Analgesic (Fentanyl)	Janssen	NDC 50458-008-02
Anesthetic Gas (Sevoflurane)	Baxter	NDC 10019-773-60
Anti-Emetic (Ondansetron)	GSK	NDC 0173-0696-00
Blood Pressure Cuff	Welch Allyn	7162-075
Chlorhexidine Solution	3M	62076-80101
Endotracheal Tube	Medtronic	8691-5149
IV Catheter	BD	381534
IV Infusion Set	Baxter	2N2520
Laryngoscope	Teleflex	01-0028-001
Local Anesthetic (Bupivacaine)	Fresenius Kabi	NDC 63323-497-50
Nasal Oxygen Cannula	Hudson RCI	1801
Needle (Sterile)	BD	305175
Opioid Antagonist (Naloxone)	Hospira	NDC 0409-1773-02
Propofol (Injectable)	Fresenius Kabi	NDC 63323-497-01
Absorbent Gauze	Medline	MDS093544
Aldrete Score Form	Custom Design	N/A
Computer with SPSS 22.0	IBM	Not Specified
ECG Monitor	Philips	IntelliVue MX450
Electronic Randomizer	Research Randomizer	v4.0
Patient Satisfaction Form	Custom Design	N/A
Pedicle Screw System	Medtronic	CD Horizon Solera
Richmond Agitation Scale	Vanderbilt University	v1.3
Soft Pillow	Medline	NONSKU0001