Effect of Multidisciplinary Team-Based Refined Nursing on Outcomes in Elderly Patients with Liver Cirrhosis and Upper Gastrointestinal Bleeding

Summary

Multidisciplinary team-based refined nursing enhanced short-term results and quality of life in elderly liver cirrhosis patients with upper gastrointestinal bleeding, but had no impact on long-term survival or comorbidities.

Abstract

The purpose of this study is to investigate how a multidisciplinary team (MDT)-based refined nursing approach enhances clinical outcomes (including hemostatic efficacy, nutritional improvement, psychological well-being, rebleeding rates, and life quality) in elderly liver cirrhosis (LC) patients complicated with upper gastrointestinal bleeding (UGIB). Using a prospective randomized controlled trial design, 120 elderly LC + UGIB patients (2023-2024) were randomized to receive either routine care (control group, n = 60) or MDT-based refined nursing (intervention group, n = 60). MDT-refined nursing includes 3-phase interventions: acute phase (24-72 h) with half-hourly vital sign monitoring and enteral nutrition initiation within 6 h of hemostasis; recovery phase (3-7 days) incorporating pharmacist-led medication reconciliation and biweekly psychotherapy; and 1-year follow-up with telemedicine support. The main outcome measures were hemostasis time, blood transfusion volume, blood pressure control, self-care ability, nutritional status, psychological well-being, short-term adverse events, 1-year rebleeding incidence, and quality of life. The results of the study showed that the intervention group showed better outcomes in hemostasis, nutrition, psychological status, and quality of life, but survival was unaffected. However, quality-of-life measures favored the intervention group. In conclusion, MDT-based refined nursing optimizes hemostasis efficiency, nutrition, and mental health in elderly LC patients with UGIB while lowering rebleeding risk and enhancing life quality.

Introduction

Liver cirrhosis (LC), a prevalent chronic progressive digestive disorder with a rising global incidence, particularly affects individuals aged over 60 years who constitute nearly 40% of cases^1,2. Upper gastrointestinal bleeding (UGIB) is one of the most serious complications of LC, with an annual incidence of 30%-50%^3,4. Elderly LC patients face heightened risks due to frequent comorbidities such as multiorgan dysfunction, reduced vascular elasticity, and impaired coagulation. Consequently, their mortality rate during initial bleeding episodes reaches 40%-60%, while the rebleeding risk is 2-3 times higher compared to younger patients, leading to significantly poorer prognoses⁵.

The current standard treatment for LC complicated by UGIB primarily involves endoscopic hemostasis and pharmacological treatment⁶. Yet, nursing, as a key link in the treatment chain, has not been fully tapped. Conventional nursing models are dominantly pathology-driven, although it can ensure the safety of the patient's life, it has these limitations: (1) Due to frequent comorbidities (e.g., diabetes, cardiovascular diseases), limited physiological reserves, and significant individual variability, elderly patients require personalized care beyond standardized nursing protocols⁷; (2) Current conventional nursing models often lack interdisciplinary support (e.g., from nutritionists or psychologists), leading to overlooked critical factors such as depression and malnutrition that impact recovery⁸; (3) Delayed nursing measure adjustment and failure to monitor condition changes dynamically lead to a delay in rebleeding prevention⁹. Therefore, optimizing nursing interventions to reduce rebleeding risk in such patients and enhance their long-term quality of life is a crucial clinical focus.

Recently, the research by Ai H. suggests the potential of refined nursing in improving patient outcomes¹⁰. However, its design and interdisciplinary coordination for elderly patients remains undefined, with limited supporting evidence. Given this, we plan to break through the traditional nursing framework to innovatively build a multidisciplinary team (MDT)-based refined nursing model. Leveraging an MDT (gastroenterology, geriatrics, nutrition, psychology) and holistic geriatric assessments, we will formulate personalized, phased interventions for elderly patients characterized by physiological fragility, comorbidity complexity, and psychological fragility, and verify the model's application value in elderly patients with LC and UGIB. The results are expected to provide a new paradigm for the nursing of critically ill elderly patients, fill the gaps in the research of group-specific nursing intervention for the elderly, and provide an evidence-based basis for emergency department formulation of stratified nursing standards and optimization of medical resource allocation, carrying profound clinical value and social significance.

Protocol

Ethical approval was granted by the Bioethics Committee of Beijing Friendship Hospital Affiliated to Capital Medical University (Approval number: 2024-P2-424-02), and all participants provided written informed consent. The reagents and the equipment used are listed in the Table of Materials.

1. Selection of research subjects

The research was carried out as a prospective randomized controlled trial in our hospital's Gastroenterology and Geriatrics Department between January 2023 and February 2024. The study focused on elderly LC patients suffering from UGIB.

2. Inclusion and exclusion criteria

Inclusion Criteria: Age ≥65 years, meeting LC diagnostic criteria¹¹ with hospital confirmation; First-time or recurrent UGIB (hematemesis/melena, hemoglobin drop ≥20g/L or systolic blood pressure (SBP) drop ≥20mmHg, with endoscopic verification of esophagogastric variceal rupture/portal hypertensive gastropathy as the source of bleeding); Stable vital signs, ability to comply with nursing interventions and follow-up; Cognitive capacity to comprehend survey scales. Exclusion Criteria: Non-LC-related bleeding etiology; Severe heart, kidney, brain, or other organ failure; Terminal malignancy with life expectancy <3 months; History of psychiatric disorders or substance dependence impairing cooperation; Pregnancy or lactation.

3. Grouping

A total of 120 subjects were selected after sample size estimation and screening based on inclusion/exclusion criteria. Randomization divided them equally into intervention and control groups (60 each). To ensure blinding, independent research assistants, uninvolved in the intervention, handled group allocation, keeping both participants and investigators unaware of group assignments. Allocation concealment was achieved via sequentially numbered opaque envelopes, with blinded outcome assessment using electronic case report forms. Baseline comparisons indicated no significant differences (P>0.05, Table 1).

4. Intervention methods

The control group received standard nursing care post-admission. During the acute phase (24-72 h after bleeding), interventions included continuous electrocardiograph (ECG) monitoring (hourly vital signs), nil-by-mouth status (transitioning to liquids after bleeding cessation), fluid replacement/blood transfusions, and monitoring of hematemesis/melena volume, hemoglobin, and coagulation. In the recovery phase (3-7 days post-bleeding), patients were advised on low-salt soft diets (avoiding rough/hard foods), with liver function (ALT, AST, bilirubin) and electrolyte monitoring. Additionally, education was carried out to emphasize preventing straining during defecation and avoiding alcohol. A discharge manual was distributed, with a one-week telephone follow-up conducted to evaluate compliance and symptoms (e.g., distension, fatigue).

Patients in the intervention group received refined care through an established MDT approach. The care team included gastroenterology/geriatric nurses, nutritionists, psychotherapists, and attending physicians. Before joining the team, all members were required to complete an intensive training program (7 days) on specialized nursing care for elderly LC patients with UGIB, focusing on three key areas: (1) thorough geriatric evaluation, (2) management of concurrent health conditions, and (3) mental health support strategies. Participation required the successful completion of competency evaluations.

1. Acute phase
   1. Patients received intensive monitoring, including half-hourly vital sign checks and hourly assessments of consciousness and skin temperature. (2) Patients were evaluated for constipation risk, with lactulose solution (Batch No. H10890057, 10 mL/times, 1 times/d) administered orally based on clinical need. Rigorous alcohol abstinence education was implemented with active family member participation. Diabetic patients received tailored insulin regimens. (3) Nutritional support began 6-12 h following bleeding cessation, starting with short-chain peptide enteral feeds (Batch No. H20170170, 500 mL/times daily divided into three nasogastric administrations). This was progressively escalated to 1500-2000 mL/times daily according to patient tolerance. Registered dietitians conducted daily evaluations of nutritional parameters and modified feed formulations accordingly. Each nutritional intervention was completed within 30 min.
2. Recovery phase
   1. The medication was strictly followed according to the doctor's advice, with assigned nurses conducting daily medication verification and monitoring for adverse drug reactions.
   2. Neurological status was assessed every 4 h, with daily blood ammonia monitoring and oral lactulose 15 mL (three times daily) to prevent hepatic encephalopathy.
   3. Psychotherapists performed twice-weekly bedside consultations (30 min/session), implementing targeted cognitive behavioral interventions, including relaxation techniques and mindfulness meditation.
3. Follow-up phase (1, 3, and 6 months after discharge)
   1. During the initial week post-discharge, the primary nurse initiated a video consultation to guide the patient in preparing nasogastric or oral meals while monitoring abdominal girth and body weight. Besides, a rebleeding alert card was issued, detailing emergency signs (e.g., frequent black stools, vomiting blood, disorientation) and emergency contact instructions. (2) Subsequent follow-ups involved tri-monthly gastroscopic examinations, liver function analyses, and nutritional assessments. Psychological status was reviewed every two weeks through telephone check-ins by a therapist, with interventions adjusted accordingly (Figure 1).

5. Follow-up for prognosis

1. All patients completed at least one year of prognostic follow-up after discharge, conducted via regular reviews and telephone follow-ups. The protocol concludes after the 1-year follow-up assessments are completed.

6. Endpoints

We statistically analyzed the hemostasis time, blood transfusion volume, and hospitalization time of patients. SBP and diastolic blood pressure (DBP) were recorded before and after nursing interventions. (2) The Exercise of Self-Care Agency (ESCA) scale¹²was employed to assess self-care ability across four domains: health knowledge (0-68 points), self-concept (0-32 points), self-care responsibility (0-24 points), and self-care skills (0-48 points). Elevated scores correlate with improved self-care proficiency (Cronbach's α = 0.89). (3) Before and after nursing, fasting venous blood was collected to determine the levels of nutritional parameters (ALB, PA, TRF, and TP) with an automatic biochemical analyzer (BS-1000M, RRID: SCR_026779). After blood samples were collected, the serum was separated by centrifugation (1505×g, 4 °C, 15min), and the serum samples were used for detection. Assays were completed within 2 h after sample collection. (4) Psychological state assessments utilized the Hamilton Depression/Anxiety Scale (HAMA/HAMD)¹³ (RRID: SCR_003686, SCR_003664). Higher scores indicate greater symptom severity (Cronbach's α = 0.81). (5) The 3-month rebleeding rate (defined as hematemesis/melena requiring emergency care or rehospitalization) and 1-year survival rate were recorded. Quality of life (QoL) was evaluated at 1-year follow-up using the 36-Item Short Form Health Survey (SF-36)¹⁴, covering eight domains: Physical Functioning (PF), Mental Health (MH), Pain (PA), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE), and Health Change (HC). Improved QoL is indicated by higher scores (Cronbach's α = 0.85).

7. Statistical methods

Data analysis was made with SPSS 25.0. Counting data [n(%)] were comparatively analyzed by chi-square tests. Measurement data underwent normality testing (Shapiro-Wilk), with parametric data (χ±s) analyzed by independent t-tests and non-parametric data [M(P25, P75)] by Mann-Whitney U tests. Statistical significance was set at P<0.05.

Results

Comparison of patient rehabilitation
The two groups did not differ significantly in hospitalization time (P>0.05); However, the intervention group showed shorter hemostasis time and lower transfusion volumes (P<0.05). In terms of blood pressure control, both groups achieved significant SBP and DBP reductions post-intervention, with greater decreases in the intervention group (P<0.05, Table 2).

Comparison of self-care ability
E...

Discussion

In this study, a prospective randomized controlled trial was conducted to explore the effect of MDT-based refined nursing on the prognosis of elderly LC patients complicated with UGIB. The results showed superior outcomes in the intervention group, evidenced by faster hemostasis, fewer blood transfusions, better blood pressure control, greater improvements in self-care ability, nutritional status, and psychological well-being, and a lower rebleeding rate, despite comparable hospitalization time, short-term complications,...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Automatic biochemical analyzer	Mindray	BS-1000M	determine the levels of nutritional parameters
Lactulose solution	Fengchen Group Co., Ltd.	H10890057	treat constipation by increasing water content in the colon.
Short-chain peptide enteral feeds	Fengchen Group Co., Ltd.	H20170170	Nutritional support