Introduction
Colorectal cancer (CRC) is one of the most common cancers in the world, ranking third and second in terms of incidence and mortality [1]. Surgery remains the primary treatment for colorectal cancer. With the promotion and application of the Enhanced Recovery After Surgery (ERAS) concept, treatment outcomes and speed of recovery for colorectal cancer patients have improved significantly [2]. However, in actual clinical practice, although the ERAS concept has reduced the average length of hospital stay for colorectal cancer patients, there is considerable variation in postoperative hospital stay between different medical institutions and teams. Healthcare professionals have different levels of understanding of ERAS discharge criteria, resulting in a lack of standardised protocols [3]. In recent years, some researchers have focused on converting colorectal cancer surgery to same-day discharge [4, 5], but only about 30% of certain patients can safely undergo same-day discharge, and close follow-up by nursing staff is required after discharge [6]. An overemphasis on shortening hospital stays may increase readmission rates and the occurrence of adverse clinical outcomes. Therefore, during the actual hospitalisation process of patients with CRC, it is imperative to accurately assess the postoperative recovery status of patients and to rapidly identify and address potential factors that may affect the recovery process, and enhance the health care quality [7]. On this basis, we should shift the goal of reducing the postoperative length of stay (PLOS) to reducing the number of ineffective hospital day (IHD), ensuring that while minimising the PLOS for patients, their safety is fully guaranteed.
Ineffective Hospital Day (IHD) refers to days during a patient’s hospitalization when, despite meeting the criteria for discharge based on their physiological status or disease progression, the patient is unable to be discharged in a timely manner due to various non-essential reasons. These reasons may include a conservative assessment of the patient’s condition by the physician, inappropriate allocation of hospital bed resources, and non-medical factors such as the wishes of the patient’s family and inadequate social support. This situation reflects an inappropriateness in the healthcare process [8]. The occurrence of IHD not only increases the medical costs for patients but may also pose potential harm that outweighs the clinical benefits for the patients [9]. Additionally, it delays the admission of other patients who require hospitalization. A recent meta-analysis indicated that the incidence of IHD ranges from 8.4 to 17.1% [10]. Therefore, reducing ineffective hospital days is of significant importance for the rational utilization of medical resources and comprehensive patient care [11].
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To identify inappropriate hospital days, Professors Gertman and Restuccia proposed the Appropriateness Evaluation Protocol (AEP) [12]. The AEP criteria serve as a comprehensive assessment tool encompassing three dimensions: medical services, nursing/life support, and patient status, comprising a total of 23 items. According to the AEP standards, if a patient meets the requirements of any one of the items, their hospitalization is deemed appropriate; conversely, if none of the items are met, it is classified as an inappropriate hospital day. Currently, the AEP has been widely applied across various countries and diseases [13‐16]. However, it must be noted that the universally applicable standards of the AEP do not entirely align with the unique characteristics of colorectal cancer (CRC), and there may be certain limitations in the AEP’s ability to assess the appropriateness of postoperative hospital days for CRC.
Therefore, this study aims to construct a scientific, reasonable, and feasible indicator system for evaluating postoperative IHD in CRC patients under the ERAS framework, based on the AEP standards and utilizing the Delphi method. The establishment of this indicator system is intended to provide the ERAS medical care team with a clear and explicit benchmark for postoperative hospitalization assessment in CRC patients. It aims to facilitate the timely identification and reduction of unnecessary hospital days, thereby exploring and achieving a rational reduction of postoperative hospitalization days while ensuring patient safety, ultimately promoting an efficient rehabilitation process.
Methods
Ethical considerations
This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the First Hospital of Jilin University (Approval No: 24K075-001). It has also been registered with the Chinese Clinical Trial Registry (Registration No: ChiCTR2400083174, Registration Date: April 17, 2024). Prior to the commencement of the study, informed consent was obtained from all participants.
Establishment of a research team
The research team consists of 12 members, led by a head nurse with 12 years of experience in managing accelerated recovery surgical wards. The team includes one department director, one nurse supervisor, five colorectal surgeons, two area nurse leaders, one colorectal cancer case management nurse, and one research nurse, with 7 members holding senior titles and 5 members holding intermediate titles. The primary responsibilities of the research team include reviewing literature, drafting the initial indicator system, determining the expert consultation questionnaire, identifying consulting experts, distributing and collecting the expert consultation questionnaires, as well as organizing, statistical analysis, and interpretation of expert opinions.
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Study design
We established a preliminary set of evaluation indicators for IHD through a literature review and group discussions. Subsequently, we invited 17 experts from relevant fields to participate in a Delphi expert consultation. This study is reported in accordance with the Conducting and REporting Delphi Studies [17]. To facilitate a more intuitive understanding of our research process, we incorporated a flowchart that outlines the study design (see Fig. 1).
Fig. 1
Flowchart illustrating the study design
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Construction of the evaluation index system
First, the team members conducted a systematic evidence search from top to bottom based on the ‘6S’ evidence model [18], using keywords such as ‘colorectal cancer’, ‘discharge criteria’, ‘appropriate length of stay’, and ‘ineffective hospital days’. The databases searched included BMJ Best Practice, UpToDate, Guidelines International Network, National institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, National Comprehensive Cancer Network, Joanna Briggs Institution, Cochrane Library, PubMed, Web of Science, Embase, Ovid, China National Knowledge Infrastructure, and Wan Fang Data, with the search period extending from the establishment of the database to April 31, 2024. Subsequently, based on the AEP indicator system framework, the team members collaboratively drafted the initial version of the IHD evaluation system. Finally, we invited statistical experts from the clinical research department of the hospital where the research team is located to assist us in designing the preliminary draft of the expert consultation survey questionnaire.
Delphi method
Inclusion criteria for expert consultation: (1) Bachelor’s degree or above, with a title of associate senior or higher; (2) At least 15 years of experience in clinical nursing, nursing management, disease diagnosis and treatment, or medical management related to accelerated rehabilitation surgery for colorectal cancer; (3) The institution must have admitted over 500 cases of colorectal cancer surgeries annually; (4) Experts must demonstrate a high level of enthusiasm and willingness to participate in the study, and be able to engage in the entire consultation process. Exclusion criteria: Experts who reported being “very unfamiliar” with research related to nursing work and nursing quality evaluation, or whose questionnaire responses were of low quality during the first round of expert consultation.
The expert consultation questionnaire consists of three parts: (1) a description of the research background, objectives, significance, and instructions for completion; (2) general information about the experts (such as name, education level, title, institution, annual number of colorectal cancer surgeries at their institution, etc.), evaluation criteria, and familiarity level. Factors influencing the evaluation criteria include theoretical analysis, practical experience, references to national and international literature, and subjective judgement. The influence of each factor on the judgement is divided into three levels: strong, medium and weak, with assigned values as follows: theoretical analysis (0.3, 0.2 and 0.1), practical experience (0.5, 0.4 and 0.3), references to national and international literature (0.1, 0.1 and 0.1) and subjective judgement (0.1, 0.1 and 0.1). Familiarity is divided into five levels, each of which is assigned a specific value (very familiar = 0.9, familiar = 0.7, somewhat familiar = 0.5, not very familiar = 0.3, unfamiliar = 0.1) [19]. (3) The evaluation index system for colorectal cancer IHD in the ERAS framework includes five medical service indicators, five care/life support service indicators, and seven patient condition indicators. The experts rate the importance of each indicator using a 5-point Likert scale, assigning scores from 1 to 5, ranging from “not important” to “very important”. In the comments section, experts can provide personal opinions or suggestions and explain the rationale for adding or removing indicators.
The expert consultation will be conducted from May to August 2024, with all researchers sending one-on-one communications via email or WeChat. Each round of questionnaires will have a return period of 15 days, and upon the completion of each round, the responses will be organised and analysed. Items with an importance or feasibility score of less than 4.0 or a coefficient of variation greater than 0.25 will be removed. The consultation is concluded when the opinions of the experts converge. The following round of consultation will incorporate the importance scores from the previous round. The evaluation index system for colorectal cancer IHD finally includes four indicators for medical services, four indicators for nursing/life support services, and seven indicators for patient condition factors.
Statistical analysis
Data analysis was conducted using SPSS 20.0 software. Continuous variables were described as mean ± standard deviation, while categorical variables were described using frequency and percentage. The enthusiasm of experts was indicated by the effective questionnaire return rate and the rate of opinions raised; the authority level of experts was represented by the authority coefficient (Cr), which was calculated using the judgment basis coefficient (Ca) and the familiarity coefficient (Cs) with the formula Cr = (Ca + Cs) / 2. It is generally required that Cr ≥ 0.7, with a higher Cr value indicating a greater level of authority [20]. The degree of consensus among expert opinions was measured using Kendall’s coefficient of concordance and the coefficient of variation, with values ranging from 0 to 1; the closer the value is to 1, the more consistent the expert opinions are, thereby enhancing the reliability of the results. A P value of < 0.05 was considered to indicate statistical significance.
Results
General information for experts
Seventeen experts from tertiary hospitals specializing in colorectal surgery participated in two rounds of consultation across 11 cities in 10 provinces or municipalities in China (Guangdong, Chongqing, Jilin, Heilongjiang, Anhui, Tianjin, Beijing, Shaanxi, Hubei, Shandong). The ages of the participating experts ranged from 30 to 50 years, with work experience spanning 20 to 40 years. The general information of the consulted experts is presented in Table 1.
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Table 1
Basic information of consulting experts (N = 17)
Variables | Classification | Number of people | Percentage |
|---|---|---|---|
Age (years) | 35~ | 3 | 17.6 |
45~ | 13 | 76.5 | |
55~ | 1 | 5.9 | |
Professional title | Associate senior | 11 | 64.7 |
Senior | 6 | 35.3 | |
Education background | Bachelor’s degree | 5 | 29.4 |
Master’s degree | 8 | 47.1 | |
Doctorate | 4 | 23.5 | |
Years of working | 15~ | 2 | 11.8 |
20~ | 8 | 47.1 | |
30~ | 7 | 41.2 | |
Specialist areas | Clinical nursing | 4 | 23.5 |
Nursing Management | 8 | 47.1 | |
Disease diagnosis and treatment | 3 | 17.6 | |
Medical management | 2 | 11.8 |
Expert engagement and authority level
This study conducted a total of two rounds of consultations, distributing 17 questionnaires in each round, with all 17 questionnaires being returned as valid, resulting in a 100% response rate. During the two rounds of consultations, 9 experts (52.9%) and 4 experts (23.5%) provided constructive feedback, respectively. The authority coefficients of the experts in the two rounds of consultations were 0.906 and 0.916, indicating a high level of expert authority, good representativeness, and high credibility of the consultations.
The degree of coordination among expert opinions
The coefficient of variation for the first round of consultation ranged from 0.07 to 0.225, with a Kendall’s concordance coefficient of 0.397 and a χ2 value of 107.932 (P < 0.01). In the second round of consultation, the coefficient of variation ranged from 0 to 0.135, with a Kendall’s concordance coefficient of 0.291 and a χ2 value of 69.259 (P < 0.01). These results indicate a high degree of consensus among experts regarding the various indicators of this study, reflecting a good level of coordination.
Expert consultation results
After the first round of expert consultation, based on the indicator screening criteria, (1) In the dimension of medical services, one indicator, “same-day gastrointestinal angiography”, was removed; Two indicators were modified: “same-day invasive procedures such as puncture” was revised to “same-day invasive procedures including puncture, gastroscopy/colonoscopy”; and “same-day necessary non-oral therapeutic medications, such as intramuscular anticoagulants” was modified to “same-day necessary intravenous therapeutic medications” as experts considered the range of non-oral medications to be too broad, and current anticoagulant options may include oral medications. (2) In the dimension of nursing/life support services, one indicator, “non-minimally invasive surgical incision drainage bleeding/fluid leakage” was removed, as experts deemed this content to be one of the postoperative complications and suggested adding a related entry to uniformly summarize complications. Two indicators were modified: “same-day need for parenteral nutrition supplementation” was revised to “same-day oral and enteral nutritional support fails to meet 60% of the patient’s nutritional target” and “same-day need to monitor 24-hour input and output” was modified to “excluding factors related to underlying diseases, same-day need for close monitoring of 24-hour input and output”. (3) In the dimension of patient condition factors, one indicator, “inability to urinate spontaneously in the past 24 hours” was removed. Two indicators were merged, as experts considered “consciousness disturbance for more than 1 hour on the same day” and “appearance of confusion on the same day” to be repetitive, recommending a merger. Following group discussion, these two were combined into “consciousness disturbance or confusion for more than 1 hour on the same day”. Two new indicators were added: “same-day CRP value ≥ 150 mg/L” and “patient develops complications”.
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After the second round of expert consultations, the experts recommended modifying “the occurrence of complications in patients” to “the occurrence of grade II or higher complications” and describing the related management measures. In accordance with the expert opinions, the CD grading criteria, and clinical practice, the research team discussed in a meeting and decided to revise this indicator to “the occurrence of the following grade II or higher complications in patients and the corresponding management measures.” The specific details are presented in Table 2. Ultimately, the evaluation indicator system for ineffective hospital days following colorectal cancer surgery under the ERAS framework was established, comprising four indicators related to medical services, four indicators related to nursing/life support services, and seven indicators related to patient condition factors, as shown in Table 2.
Table 2
Evaluation indicators for IHD postoperatively in CRC under the background of ERAS
Indexes | Importance value (points ± standard deviation) | Coefficient of variation | Weight |
|---|---|---|---|
A medical services | |||
A1 Same day surgery in the operating theatre | 5.00 ± 0.000 | 0.000 | 0.070 |
A2 Invasive procedures such as puncture, gastro/enteroscopy, etc. performed on the same day | 4.35 ± 0.493 | 0.113 | 0.061 |
A3 Treatment requiring frequent adjustment of therapeutic dose under close direct medical supervision, e.g. intravenous infusion of vasoactive drugs, electrolytes, etc. | 4.65 ± 0.493 | 0.106 | 0.065 |
A4 Intravenous therapeutic drugs required on the same day | 4.53 ± 0.514 | 0.113 | 0.064 |
B nursing/life support services | |||
B1 Mechanical ventilation/oxygen therapy required on the same day | 5.00 ± 0.000 | 0.000 | 0.070 |
B2 Continuous monitoring of vital signs for living organisms on the same day, at least once every 30 min, and lasting for 4 h | 4.59 ± 0.618 | 0.135 | 0.065 |
B3 Non-basic disease factors require close monitoring of the 24-hour input and output volume on the same day | 4.71 ± 0.470 | 0.100 | 0.066 |
B4 When oral and enteral nutritional support on the same day fails to meet 60% of the patient’s nutritional target | 4.41 ± 0.507 | 0.115 | 0.062 |
C patient condition factors | |||
C1 axillary temperature ≥ 38℃ within 24 h | 4.76 ± 0.437 | 0.092 | 0.067 |
C2 Hb < 60 g requires blood transfusion or presence of active bleeding | 4.65 ± 0.606 | 0.130 | 0.065 |
C3 The occurrence of ventricular fibrillation or acute myocardial ischemia on the same day | 4.76 ± 0.437 | 0.092 | 0.067 |
C4 Consciousness disturbance or altered consciousness lasting more than 1 h on the same day | 4.76 ± 0.437 | 0.092 | 0.067 |
C5 On the day, the CRP value is ≥ 150 mg/L | 5.00 ± 0.000 | 0.000 | 0.070 |
C6 Pain score ≥ 5 due to abdominal pain or other causes | 5.00 ± 0.000 | 0.000 | 0.070 |
C7 Patients with the following Grade II or higher complications are treated as follows: (1)Gastrointestinal-related complications: ①Anastomotic leakage, intra-abdominal/pelvic infection/abscess, chylous leakage, pancreatic fistula, or other gastrointestinal fistulas: intravenous pharmacological intervention, total parenteral nutrition, imaging-guided procedures, or puncture under general anesthesia may be required ②Hemorrhage: Requires non-oral hemostatic agents, blood transfusion, imaging, or intervention under general anesthesia, etc. ③Intestinal obstruction: Requires non-oral medication intervention, gastrointestinal decompression, total parenteral nutrition, imaging, or intervention under general anesthesia, etc. ④Anastomotic stricture or delayed gastric emptying: requires non-oral pharmacological intervention, re-insertion of gastric tube, total parenteral nutrition, imaging, or intervention under general anesthesia, etc. ⑤Diarrhea: In cases accompanied by dehydration or electrolyte imbalance, intravenous fluid replacement is required for correction ⑥Delayed wound healing (including incision fat liquefaction): requires incision opening, irrigation, and the use of antibiotics, among other interventions (2)Respiratory system complications: requiring non-oral medication treatment, local or general anesthesia interventions, mechanical ventilation, etc. (3)Cardiovascular and cerebrovascular complications: The need for non-oral cardiovascular medications that are not routinely used postoperatively (4)Embolic complications: require non-oral medication treatment (such as anticoagulants, excluding prophylactic anticoagulation for single book number), interventional therapy, and embolus retrieval, among others (5)Complications of the urinary system: Treatment requiring non-oral medications (excluding catheterization or indwelling catheters), interventions under local or general anesthesia, and renal failure necessitating blood filtration, etc. (6)Infection-related complications: require non-oral medication treatment (such as antibiotics, etc.), local anesthesia or general anesthesia interventions (such as incision and drainage, etc. (7)Other complications: requiring special non-oral medication treatment (including antibiotics, blood transfusion, total parenteral nutrition, etc.), interventions under local or general anesthesia | 4.94 ± 0.243 | 0.049 | 0.069 |
Discussion
This study, framed within the AEP program, aims to draft an evaluation index for postoperative hospital stay specific to colorectal cancer based on literature analysis, clinical practice surveys, and group discussions. The reliability of the research results was determined through the Delphi method, which assessed the sources, enthusiasm, authority, and coordination of the experts consulted. A total of 17 consulting experts were selected from 11 tertiary hospitals across 10 provinces or municipalities in China. These experts possess extensive experience in the diagnosis, treatment, nursing, and management of colorectal cancer, covering frontline work in administrative management, clinical diagnosis, and nursing; among them, 15 experts have over 20 years of work experience. Additionally, 12 experts hold a master’s degree or higher, all with associate senior titles or above, indicating high qualifications and representativeness. The effective questionnaire return rate for both rounds of consultation was 100%, with 52.9% and 23.5% of experts providing suggestions for modifications, demonstrating a high level of engagement and enthusiasm. The authority coefficients for the two rounds of expert consultation were 0.906 and 0.916, indicating high authority, while the Kendall’s W coefficients were 0.397 and 0.291, reflecting good coordination among expert opinions. This suggests that the evaluation index system for postoperative IHD in CRC, constructed within the ERAS framework, possesses good scientific validity and reliability.
This study thoroughly integrates the strategies for perioperative management of colorectal cancer as outlined in the current authoritative ERAS guidelines [21, 22]. Under the guidance of the ERAS framework, the appropriate hospitalization criteria for postoperative colorectal cancer patients were precisely defined based on the content of the AEP protocol. Ultimately, the research established 15 key indicators encompassing three dimensions: medical services, nursing/life support services, and patient condition factors. Specifically, these include 4 indicators for medical services, 4 for nursing/life support services, and 7 for patient condition factors. The weights of these indicators range from 0.06 to 0.07, with minimal variation, reflecting the equal importance assigned to each indicator by the experts.
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In the evaluation metrics of medical services (Category A), A1 and A2 focus on the necessity of hospitalization for colorectal cancer patients following surgical and post-operative invasive procedures such as colonoscopy. In contrast, indicators A3 and A4 delve into the conditions of patients requiring stringent medical monitoring and flexible treatment adjustments, highlighting the demand for immediate inpatient intervention when the physiological status of post-operative patients is unstable.
The indicators for nursing/life support services (Category B) B1 to B3 primarily focus on the degree of dependence of patients on advanced nursing and life support measures during their postoperative hospitalization. The occurrence of such conditions may suggest the presence of postoperative complications or concerns, thus warranting close observation during hospitalization. Indicator B4 establishes the assessment of achieving 60% of the target volume for enteral nutrition, focusing not only on the recovery of intestinal function but also on the nutritional intake of the patients. This setting aligns with previous research emphasizing the recovery of gastrointestinal function [3]; however, it differs in that prior consensus placed the emphasis on fluid intake and the consumption of solid foods, without addressing the intake of enteral nutrition. This discrepancy may be related to previous studies focusing on patients undergoing colorectal surgeries (including those with tumors and benign diseases), whereas this study specifically targets patients with malignant colorectal tumors. Furthermore, this study does not consider postoperative gas passage and defecation as indicators for discharge, a viewpoint consistent with previous research and the ERAS concept [23].
The patient condition factors (Class C) provides a comprehensive assessment of postoperative complications and the overall physiological state of patients. This indicator encompasses multiple critical aspects, including abnormal body temperature, low hemoglobin levels, cardiovascular events, altered consciousness, and specific measures for managing complications. The occurrence of postoperative complications is a central concern for both colorectal surgeons and nurses [24‐27], as it not only significantly affects the length of postoperative hospital stay but also serves as a major factor leading to readmission. In this field of study, experts widely agree that establishing an effective hospitalization day evaluation system must be closely linked to the occurrence of complications and their warning factors. In this process, it is crucial to identify not only the complications themselves but also the warning factors that may lead to their occurrence. These factors include the patient’s underlying disease status, persistent postoperative fever, high levels of pain perception, and abnormal elevations of key indicators such as C-reactive protein, which aligns with previous research standards for early safe discharge after colorectal cancer surgery [28]. Correspondingly, ERAS-related measures that have demonstrated efficacy in reducing postoperative complications, such as preoperative prehabilitation, should be implemented effectively [29].
This study is based on AEP and has developed a rating indicator system for ineffective hospital days after colorectal cancer surgery under the ERAS framework, which includes 15 items related to medical services, nursing/life support services, and patient condition factors. The construction method is scientific and reasonable, and the content possesses strong specialty and specificity related to colorectal cancer. However, it is important to recognize that significant disparities exist in healthcare systems globally, characterized by varying levels of ERAS implementation and resource availability across different countries and regions. This variation directly influences the applicability of our evaluation indicator system. The ineffective hospital day indicator system developed in this study may be more suited to countries and regions with abundant healthcare resources and advanced ERAS implementation. Conversely, in areas with relatively limited resources and lower levels of ERAS implementation, the direct application of this indicator system may present challenges. In the future, we intend to collaborate with medical institutions worldwide to conduct multicenter clinical trials, thoroughly assessing the practical application of this indicator system across diverse healthcare systems. Through ongoing feedback from practice and optimization adjustments, we aim to enhance the global applicability of this evaluation indicator system, thereby providing more scientifically grounded and reasonable guidance for the postoperative recovery of colorectal cancer patients worldwide. Additionally, we encourage experts and scholars from various regions to further validate and optimize this indicator system based on local conditions, ensuring its better adaptation to the local medical environment and patient needs.
Limitations
This study has several limitations. Firstly, the Delphi method, employed as the primary approach in this study, is capable of aggregating the wisdom of experts from various fields and facilitating consensus formation through multiple rounds of anonymous feedback. However, this method relies on the subjective judgment and experience of experts. Although our selection of experts encompasses individuals from 11 cities across 10 provinces in China, there may still be issues of representativeness when compared to the broader spectrum of healthcare institutions and expert resources nationwide. Secondly, the Kendall coefficients from the two rounds of Delphi consultations were relatively low, at 0.397 and 0.291, respectively, with a decline observed in the second round. This may be attributed to experts becoming more subjective during the second round of scoring, leading to a convergence in their ratings. Lastly, the indicator system constructed in this study was established under the premise of effective ERAS implementation, which may be more suitable for healthcare institutions that already possess high-level conditions and corresponding technical equipment for ERAS. For institutions that have not yet fully implemented ERAS or are limited by technical resources, this indicator system may require appropriate adjustments and optimizations based on actual circumstances to ensure its applicability and effectiveness.
Conclusions
Using the Delphi method, an evaluation index system for postoperative IHD in colorectal cancer under the ERAS framework was constructed based on AEP standards. This system encompasses three dimensions: medical services, nursing/life support services, and patient condition factors, comprising a total of 15 evaluation items. The construction method is scientific and reasonable, with content closely aligned with the characteristics of surgical treatment for colorectal cancer, demonstrating both specialty and specificity. This index system is anticipated to have a direct positive impact on patient outcomes by optimizing hospital stay, improving resource utilization, and enhancing postoperative recovery. Future research should focus on further empirical studies of the index system, modifying and refining it to provide a reference for the accurate and efficient assessment of ineffective hospital days following colorectal cancer surgery, thereby achieving standardization of discharge criteria. Additionally, we encourage other surgical centers to implement our index system to assess its generalizability and applicability within their respective settings.
Acknowledgements
The authors would like to express grateful thanks to all the experts involved in Delphi consultation.
Declarations
Competing interests
The authors declare no competing interests.
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