Background
Hospital discharge planning is the approach of the entire health and social care system [1]. Delayed hospital discharge remains an international problem, and it could be addressed by implementing multidisciplinary teams [2]. In most cases, patients are medically approved to be discharged but remain in the hospital for non-medical reasons (for example, the payment procedure is not completed, the discharge prescription is not written, waiting for the availability of a long-term care bed, and/or to transfer home with subsidiary services) [3]. During this waiting period, there is no medical or nonmedical care available through healthcare professionals [2]. In addition, this waiting period removes other upcoming patients from the necessary hospital facilities [4]. Moreover, prolonged waiting in the hospital for discharge increases patient morbidity [5]. Delayed hospital discharge leads to reduced levels of treatments, risk of functional decline, and unwanted hospital-related events [6]. In some cases, day surgery reduces the postoperative hospital stay [7]. Delayed hospital discharge is problematic, highlighting the need to identify the best practices and current initiatives that focus on this complex emerging situation [2].
Laparoscopic techniques are performed on the day and have fewer postoperative hospital stays than open surgery [8]. However, delayed hospital discharge is also a major issue in day-case surgeries [2]. Generally, consulting surgeons review admitted patients and make decisions regarding patient fitness for discharge [9]. This leads to a delay in discharge. To overcome the delay in discharge, senior nurses are permitted to discharge patients after laparoscopic techniques [10]. There is a lack of evaluation of studies regarding nurse-led discharge after laparoscopic surgery in Chinese settings. Less than 4 days is the average stay of patients after laparoscopic surgery in our institute. In addition, China’s healthcare system is not focusing on discharge planning and the role of nurses in it but in our institute, patients are discharged with the advice and education of nurses and with a doctor’s order.
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The objectives of this retrospective study were to evaluate the follow-up outcomes, readmission frequencies, cost of care, and satisfaction of patients who received nurse-led discharge compared to those of patients who received consulting surgeon-led discharge after laparoscopic surgeries following final medical examinations.
Methods
Study design, setting, and period
This was a retrospective study of electronic medical records of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China, from January 15, 2019, to August 15, 2024.
Inclusion criteria
Patients aged ≥ 18 years were admitted to the institutes for laparoscopic surgeries. Patients who required final medical examinations to decide to discharge were included in the analysis.
Exclusion criteria
Patients who left the parent hospital against medical advice and/or were transferred to other institutes for lack of facilities, resources, and/or consultants were excluded from the analysis.
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Experts were consulted for choosing the inclusion and exclusion criteria.
Sample size calculations
The study was based on the assumption that there would be 5% or less readmission (effect size), α = 0.5, and β = 0.1. The sample size (the minimum number of patients required in each cohort) was 100.
Discharge
A total of 105 patients who underwent laparoscopic surgery received a nurse-led discharge (NLD cohort). In the NLD cohort, the final medical examinations (checking of cognitive functions) of patients for the decision to discharge were performed by a senior nurse. A total of 156 patients who underwent laparoscopic surgery received consulting surgeon-led discharge (SLD cohort). In the SLD cohort, the final medical examinations of patients for the decision to discharge were performed by consulting surgeons. All patients received discharge prescriptions from consulting surgeons, with instructions. In study some patients receive nurse advice and some do not because of the availabilities of professionals in the institutes. In the study, discharge is healthcare professional’s decision. Protocols or guidelines for discharge of patients are not published, yet.
Pre-operative counseling and surgeries
Preoperative counseling was performed by consulting surgeons. It is about the risk of diseases and the need for surgery, including cost and postoperative complications. Surgeries were performed by consulting surgeons. Anesthesiologists were available for anesthesia.
Outcome measures
Demographical and clinical characteristics
Demographic and clinical characteristics of the patients at discharge were collected from their hospital records.
Follow-up outcome
After surgery, the patients were transferred to the post-anesthesia intensive care unit. The patients are then shifted to the ward when they become stable. Data on immediate and late postoperative complications, including postoperative pain frequencies and analgesic requirements, were collected from hospital records. Postoperative pain was evaluated using a visual analog scale (VAS; range, 0–10; 0, absent pain; 10, maximum possible pain; when patients became conscious). Nursing staff administered VAS to patients in ward. Fifty-milligram tramadol capsule was taken by the patient when the postoperative pain was severe. When the patients were reported to be stable and no further emergencies were required, they were discharged. Patients were available for follow-up of 4 weeks after surgeries.
Total hospital stays
From hospital admission before the operation to discharge from hospital.
Readmission (primary outcome)
Within 3 days of surgeries after discharge of patients if readmission of patients or requirement of further operation within a month of surgeries after discharge was considered as readmission of patients.
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Cost of care
The cost of care includes consultation charges, report charges, admission charges, anesthesiologist charges, surgery charges, and pharmacy charges from pre-operation to four weeks after surgery, including readmission charges.
Satisfaction of patients (secondary outcome)
There is a personalized form for patient satisfaction at our institute. A personalized form for patient satisfaction at our institute is valid and reliable for Chinese patients. Patient satisfaction was evaluated based on items it has (surgery, discharge, and follow-up). There were four answers for all three services (grading). Completely dissatisfied, 0; partially dissatisfied, 0.25; partially satisfied, 0.5; satisfied, 0.75; extremely satisfied, 1. This was evaluated after follow-up. The total score ranged from 0 to 3. Higher scores indicated higher patient satisfaction.
Clinical benefit of discharge (subsidiary outcome)
The clinical benefits for the discharge of patients after laparoscopic surgery were evaluated as a function of the beneficial scores. The beneficial scores for the discharge of patients after laparoscopic surgery were calculated from the risk of under-treatment, as expressed in Eq. (1). The risk of under-treatment was defined by a calculation that involved readmission that required further pharmacological treatments and/or laparoscopic surgeries (Eq. (2)). The percentage of readmission was considered to be a numerical value ranging from 0 to 100%. The beneficial score for discharge of patients after laparoscopic surgeries for different ways of discharge is the area above the curve of patients after laparoscopic surgeries, and the working area is the area under the curve of patients after laparoscopic surgeries with the adopted methods of discharge. For all adopted methods of discharging patients after laparoscopic surgeries, 5% or less readmission (effect size) was used as the reference standard [11].
$$\begin{array}{l}\:\text{B}\text{e}\text{n}\text{e}\text{f}\text{i}\text{c}\text{i}\text{a}\text{l}\:\text{s}\text{c}\text{o}\text{r}\text{e}=\frac{\text{T}\text{h}\text{e}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{p}\text{a}\text{t}\text{i}\text{e}\text{n}\text{t}\text{s}\:\text{w}\text{i}\text{t}\text{h}\text{o}\text{u}\text{t}\:\text{r}\text{e}\text{a}\text{d}\text{m}\text{i}\text{s}\text{s}\text{i}\text{o}\text{n}}{\text{T}\text{o}\text{t}\text{a}\text{l}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{p}\text{a}\text{t}\text{i}\text{e}\text{n}\text{t}\text{s}\:\text{i}\text{n}\:\text{t}\text{h}\text{a}\text{t}\:\text{c}\text{o}\text{h}\text{o}\text{r}\text{t}}\\-(\frac{\text{T}\text{h}\text{e}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{p}\text{a}\text{t}\text{i}\text{e}\text{n}\text{t}\text{s}\:\text{w}\text{i}\text{t}\text{h}\:\text{r}\text{e}\text{a}\text{d}\text{m}\text{i}\text{s}\text{s}\text{i}\text{o}\text{n}}{\text{T}\text{o}\text{t}\text{a}\text{l}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{p}\text{a}\text{t}\text{i}\text{e}\text{n}\text{t}\text{s}\:\text{i}\text{n}\:\text{t}\text{h}\text{a}\text{t}\:\text{c}\text{o}\text{h}\text{o}\text{r}\text{t}}\:\times\:\:\text{R}\text{i}\text{s}\text{k}\:\text{o}\text{f}\:\text{u}\text{n}\text{d}\text{e}\text{r}\text{t}\text{r}\text{e}\text{a}\text{t}\text{m}\text{e}\text{n}\text{t})\end{array}$$
(1)
$$\:\text{R}\text{i}\text{s}\text{k}\:\text{o}\text{f}\:\text{u}\text{n}\text{d}\text{e}\text{r}\text{t}\text{r}\text{e}\text{a}\text{t}\text{m}\text{e}\text{n}\text{t}=\frac{\text{\%}\:\text{r}\text{e}\text{a}\text{d}\text{m}\text{i}\text{s}\text{s}\text{i}\text{o}\text{n}}{100-\text{\%}\:\text{r}\text{e}\text{a}\text{d}\text{m}\text{i}\text{s}\text{s}\text{i}\text{o}\text{n}}$$
(2)
Statistical analyses
InStat 3.01, GraphPad Software, (San Diego, CA, USA) was used for statistical analyses. Continuous normal, continuous non-normal, and categorical variables were presented as mean ± standard deviation (SD), median (Q3–Q1), and frequencies (percentages), respectively. Fisher’s exact test or the chi-square test was used for the analysis of categorical variables. The Kolmogorov and Smirnov methods were used to evaluate the normality of continuous variables. The Mann–Whitney U test was used for non-normal continuous variables. All results were considered significant if the p-value was less than 0.05.
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Results
Study population
From January 15, 2019, to August 15, 2024, 266 patients underwent different laparoscopic surgeries for different reasons at the Department of Surgery of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China, and the referring institutes. Among them, one patient left the parent hospital against medical advice, one patient transferred to other institutes for lack of facilities, one patient transferred to other institutes for lack of resources, and two patients transferred to other institutes due to lack of consultants. Therefore, data from these patients (five patients who left the parent hospital without proper discharge) were excluded from the study. Demographic and clinical characteristics, data of immediate and late postoperative complications, including postoperative pain, and cost of care of 261 patients who underwent different laparoscopic surgeries for different reasons were included in the analyses. A retrospective study flow chart of the electronic medical records is shown in Fig. 1.
Fig. 1
Flow diagram of the study. Red color indicates worse outcomes
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Demographical and clinical characteristics
The male-to-female ratio was 1:2. The admitted patients were aged between 41 and 57 years. Most of the patients were Han Chinese. Cholecystectomy laparoscopy was the preferred surgery, followed by inguinal hernia repair. Patients had mostly the American Society of Anesthesiologists grade (ASA grade 1; a normal healthy patient). Surgery times ranged from 55 to 95 min. All surgeries were performed by consulting surgeons with a minimum of three years of experience at the institute. The anesthesiologists were full-time consultants at the institute for all surgeries. 65% of the patients had drain placement. There were no statistical differences between patients who received nurse-led discharges and surgeon-led discharges in terms of sex, age, ethnicity, type of surgical laparoscopy, ASA grade, operation time, and drain placement (p > 0.05 for all). Demographic and clinical characteristics at the time of discharge are presented in Table 1.
Table 1
Demographical and clinical characteristics of patients at the time of discharge and operational parameters of patients
Characteristics | Total | Cohorts | Comparisons between cohorts | |||||
|---|---|---|---|---|---|---|---|---|
NLD | SLD | |||||||
Professional engaged in way of discharge | - | Nurse | Surgeon | |||||
Numbers of patients | 261 | 105 | 156 | p-value | Df | Test value | 95% CI | |
Gender | Male | 107(41) | 46(44) | 61(39) | 0.5288 (χ2-test with Yate’s correction) | 1 | 0.3967 | 0.8343 to 1.509 |
Female | 154(59) | 59(56) | 95(61) | |||||
Age (years) | 47(50–45) | 47(50–45) | 47(50–45) | 0.9493 (Mann–Whitney test) | N/A | 8,152 | N/A | |
Ethnicity | ||||||||
Han Chinese | 243(93) | 97(92) | 146(94) | 0.8489 (χ2-test of independence) | 2 | 0.3277 | N/A | |
Mongolian | 15(6) | 7(7) | 8(5) | |||||
Tibetan | 3(1) | 1(1) | 2(1) | |||||
Type of laparoscopic surgeries (underwent) | ||||||||
Cholecystectomy | 104(40) | 39(37) | 65(42) | 0.1927 (χ2-test of independence) | 4 | 6.087 | N/A | |
Inguinal hernia repair | 87(33) | 30(29) | 57(36) | |||||
Axillary clearance with mastectomy | 21(8) | 12(11) | 9(6) | |||||
Benign gynecological disease surgery | 18(7) | 10(10) | 8(5) | |||||
Male urinary surgery | 31(12) | 14(13) | 17(11) | |||||
ASA grade | ||||||||
1 | 163(62) | 59(56) | 104(66) | 0.2293 (χ2-test of independence) | 2 | 2.945 | N/A | |
2 | 96(37) | 45(43) | 51(33) | |||||
3 | 2(1) | 1(1) | 1(1) | |||||
Operation time (min) | 75(85–65) | 70(85–60) | 75(85–65) | 0.6103 (Mann–Whitney test) | N/A | 7,885 | N/A | |
Drain placement | ||||||||
Yes | 170(65) | 70(67) | 100(64) | 0.7689 (χ2-test with Yate’s correction) | 1 | 0.0863 | 0.7805 to 1.468 | |
No | 91(35) | 35(33) | 56(56) | |||||
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Outcome results
Follow-up outcome results
Nausea was common in all patients during their hospital stay. In addition, nausea, vomiting, and dizziness were reported among patients during their hospital stay. The VAS was between 2 per patient to 5 per patient at the time of discharge. The total consumption of tramadol during the hospital stay was 100 to 250 mg per patient. The total hospital stay was between 1 day per patient and 4 days per patient. A total of 15 (6%) patients were readmitted to our hospital. Three (3%) patients who received nurse-led discharges and 12 (8%) who received consulting surgeon-led discharges were readmitted. The cost of care was between 4,000 ¥ per patient and 5,100 ¥ per patient. Patient satisfaction was between 1 and 2.5 per patient. None of the patients died during the 4-week follow-up period. There were no statistical differences between patients who received nurse-led discharges and consulting surgeon-led discharges for immediate postoperative complications during hospital stays (nausea, vomiting, headache, dizziness, and postoperative pain), total consumption of tramadol during hospital stays, total hospital stays, cost of care, and patient satisfaction (p > 0.05 for all). The details of immediate postoperative complications during hospital stays, total consumption of tramadol during hospital stays, total hospital stays, cost of care, and satisfaction of enrolled patients are shown in Table 2. Late postoperative complications during the 4 weeks of follow-up were mainly due to laparoscopic surgeries and, in some cases, due to patient profiles (data not presented).
Table 2
Immediate postoperative complications during hospital stays, total consumption of tramadol during hospital stays, total hospital stays, cost of care, and satisfaction of the enrolled patients
Characteristics | Cohorts | Comparisons between cohorts | |||
|---|---|---|---|---|---|
NLD | SLD | ||||
Professional engaged in way of discharge | Nurse | Surgeon | |||
Numbers of patients | 105 | 156 | p-value | Test value | 95% CI |
Nausea | 95(90) | 141(90) | 0.9999 (Fisher’s exact test) | 1.006 | 0.6075 to 1.667 |
Vomiting | 10(10) | 20(13) | 0.4375 (Fisher’s exact test) | 0.8105 | 0.4775 to 1.376 |
Headache | 25(24) | 24(15) | 0.1061 (Fisher’s exact test) | 1.352 | 0.9775 to 1.870 |
Dizziness | 14(13) | 20(13) | 0.9999 (Fisher’s exact test) | 1.027 | 0.6667 to 1.582 |
Postoperative pain (VAS) at the time of discharge | 3(4–3) | 3(4–3) | 0.955 (Mann–Whitney test) | 8,156 | N/A |
Total consumption of tramadol during hospital stays (mg) | 150(150–100) | 150(150–150) | 0.3088 (Mann–Whitney test) | 7,589 | N/A |
Total hospital stays (days) | 2(2–2) | 2(2–2) | 0.3189 (Mann–Whitney test) | 7,613 | N/A |
Readmission | 3(3) | 12(8) | 0.1125 (Fisher’s exact test) | 0.4824 | 0.1734 to 1.342 |
Cost of care (¥) | 4,500(4,500–4,500) | 4,500(4,500–4,400) | 0.4188 (Mann–Whitney test) | 7,712 | N/A |
Satisfaction of patients | 2(2.25–1.75) | 1.75(2–1.625) | 0.1757 (Mann–Whitney test) | 7,383 | N/A |
Table 3 presents the results of the assumptions tests adopted in this study.
Table 3
Results of assumption tests adopted in the study
Variables | Test adopted with reasons |
|---|---|
Categorical variables | |
2 × 2 Table | Fisher’s exact test or Chi-square test (with Yate’s corrections for sample size ≥ 5 and total sample ≥ 40) |
Large table | Chi-square with independence |
Continuous variables | |
Demographical and clinical characteristics at the time of discharge | |
Age (years) | One column failed in the normality test; p-values were 0.0813 and 0.0093, i.e. Mann–Whitney test. |
Operation time (min) | Both columns failed in the normality test; p-values were 0.0484 and 0.0406, i.e. Mann–Whitney test. |
Follow-up outcome | |
Postoperative pain (VAS) at the time of discharge | Both columns failed in normality test; p-values were < 0.0001 and < 0.0001, i.e. Mann–Whitney test |
Total consumption of tramadol during hospital stays (mg) | Both columns failed in normality test; p-values were < 0.0001 and < 0.0001, i.e. Mann–Whitney test |
Total hospital stays (days) | Both columns failed in normality test; p-values were < 0.0001 and < 0.0001, i.e. Mann–Whitney test |
Cost of care (¥) | Both columns failed in normality test; p-values were < 0.0001 and < 0.0001, i.e. Mann–Whitney test |
Satisfaction of patients | Both columns failed in the normality test; p-values were 0.0363 and 0.0002, i.e. Mann–Whitney test. |
Clinical benefit of discharge
The working area for consulting surgeon-led discharges had a beneficial score of 0–0.51 (between 5 and 11% readmission rate) and the working area for nurse-led discharges had a beneficial score of 0–0.81 (between 5 and 34% readmission rate). (When surgeries would be such type that) more than 11% and more than 34% of readmissions of patients with consulting surgeon-led discharges and nurse-led discharges, respectively, patients would have a risk of postoperative complications during follow-up. A graphical presentation of the clinical benefits of discharge after laparoscopic surgery using the different modes is presented in Fig. 2. The details of the clinical benefits of discharge are presented in Table 4.
Fig. 2
The graphical presentation of the clinical benefit of discharge after laparoscopic surgeries using different modes
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Table 4
The clinical benefit of discharge of enrolled patients
Characteristics | Cohorts | ||
|---|---|---|---|
NLD | SLD | ||
Professional engaged in way of discharge | Nurse | Surgeon | |
Numbers patients | 105 | 156 | |
Numbers of readmission | 3 | 12 | |
% readmission | Risk of re-admission | Beneficial score | |
0 | 0 | 0.971 | 0.92 |
2 | 0.02 | 0.97 | 0.92 |
5 | 0.05 | 0.97 | 0.92 |
10 | 0.11 | 0.97 | 0.91 |
15 | 0.18 | 0.97 | 0.91 |
20 | 0.25 | 0.96 | 0.90 |
30 | 0.43 | 0.96 | 0.89 |
40 | 0.67 | 0.95 | 0.87 |
50 | 1 | 0.94 | 0.85 |
70 | 2.33 | 0.90 | 0.74 |
95 | 19 | 0.43 | -0.54 |
99 | 99 | -1.86 | -6.69 |
Working area | 0–0.81 beneficial score (5–34% readmission) | 0–0.51 beneficial score (5–11% readmission) | |
Risk of complications in follow-up | > 34% readmission is possible | > 11% readmission is possible | |
Discussions
6% of the patients were readmitted after discharge through a nurse or consulting surgeon. The results of readmission of the current study are consistent with those of previous retrospective [12] and prospective [13] studies. Discrepancies from the perspectives of the patients and nurse or consulting surgeon’s decision of discharge are responsible for readmission [14]. In addition, postoperative complications are responsible for readmission of patients [13]. Appropriate final medical examinations of patients are required for the decision to discharge by a nurse or consulting surgeon.
Readmission was clinically less and statistically the same for patients who received discharge through a nurse than for those who received discharge through a consulting surgeon. The discrepancies between nurse-led and consulting surgeon-led readmissions in the current study are consistent with those of meta-analyses [15]. A consulting surgeon-led discharge increases the workload of consulting surgeons (outpatient department (OPD), surgeries, and discharge) to satisfy the needs and expectations of patients and their caregivers. The small number of patients who received nurse-led discharges would not increase the burden on the routine work of nurses (no requirements of nurses in the OPD). Nurse-led discharge is as effective as consulting surgeon-led discharge after laparoscopic surgery.
The follow-up outcomes of the NLD and SLD cohorts were statistically the same. These results indicate that nurse-led discharge is a safe means of discharge for consulting surgeon-led discharge.
All the patients experienced nausea, vomiting, and dizziness as immediate postoperative complications. Nausea, vomiting, and dizziness are mainly caused by the anesthesia itself. The discharge method had no role in this regard.
The working area for nurse-led discharge was higher than that for consulting-surgeon-led discharge after laparoscopic surgery. Nurse-led discharge involved nurses and surgeons during follow-up, so the working area increased and the risk of readmission decreased. However, consulting-surgeon-led discharge only involves consulting surgeons during follow-up, and consulting surgeons are not available for emergency readmission. Patients were available after readmission. Therefore, the working area decreased, and the chances of readmission increased.
The total hospital stay was between 1 day per patient and 4 days per patient. Laparoscopic surgery always has fewer hospital stays [8]. Patients with shorter hospital stays facilitate the management of operations through laparoscopic surgeries.
Patients in the NSD cohort had higher personal satisfaction than those in the SLD cohort. Early discharge through nurses and follow-up by surgeons increase patient satisfaction [6]. Chinese institutions prefer nurse-led discharge after laparoscopic surgery. The details of the comparative studies on the discharge of patients after surgery in different settings are presented in Table 5.
Table 5
Details of the comparative studies on discharges of patients after surgeries in different settings
Study | Published year | Patients’ ethnicity | Sample size (N; pateints) | Age (years) |
|---|---|---|---|---|
Scoping review, Cadel et al.[2] | 2021 | - | 55(19/36) | > 18 |
Retrospective cohort analysis, Rosman et al.[5] | 2015 | Israel | 245 | 76 ± 11 |
Scoping review, Everall al.[6] | 2019 | Canada | 97 | > 18 |
Retrospective study, Patel et al.[9] | 2024 | The North America | 190,699 | ≥ 18 |
Retrospective study, Aßfalg et al.[12] | 2022 | German | 920 | ≥ 18 |
Prospective study, Wang et al.[13] | 2023 | The North America | 206 | 57.25 ± 12.65 |
Qualitative, descriptive study, Vat et al.[14] | 2015 | Canada | 8 | 64–91 |
Systematic review and meta-analysis, Zhu et al.[15] | 2015 | - | 3,438 | > 18 |
The limitations of the study include its retrospective nature and the lack of randomized trials. In addition, caregivers’ parameters were not evaluated. Readmissions were the primary outcome; however, potential confounding variables (such as patient comorbidities, socioeconomic status, or preoperative risk profiles), which could substantially influence readmission rates and satisfaction outcomes [13] were not evaluated. The sample size was calculated based on the assumption that the readmission rate was ≤ 5%. However, the sample size was not calculated based on the assumption that nurse-led discharges decreased postoperative complications. A possible justification for this is that nurse-led discharges have no role in late or early postoperative complications. Postoperative complications were primarily due to the surgery itself. Moreover, by using nurse-led discharges, it is possible to decrease patient readmission rates. The finding has issue of the generalizability because of the Chinese study’s single-center setting and limited sample diversity. Furthermore, the manuscript does not acknowledge or attempt to address variability in surgeon experience, which may affect surgical and discharge outcomes [16].
Conclusions
Appropriate final medical examinations of patients are required for the decision to discharge by a nurse or consulting surgeon after laparoscopic surgery. Nurse-led discharge is as effective and safe as consulting surgeon-led discharge after laparoscopic surgery, in fact can improve patient care or cost efficiency. Chinese institutions may prefer nurse-led discharge after laparoscopic surgery. Chinese institutes have huge numbers of patients available for treatments. Nurse-led discharge decrease burden of surgeon and as safe as surgeon-led discharge. Non-randomized, non-treatment trial is required to strengthen the results of this study. The study provides the significant contribution to nursing practice.
Acknowledgements
The authors thank the medical and non-medical staff of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
Declarations
Ethics approval and consent to participate
The protocols designed for the established study were prepared by the authors. The protocols were approved by the Human Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University (approval number: FAHSySU17, dated January 1, 2019). The study follows the laws of China and the v2008 Declarations of Helinski. The need for informed consent to participate was waived by the Human Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University (because of retrospective analyses).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
All the data and related metadata underlying the reported findings have already been provided as part of the submitted article. There are no supplementary files (supplementary tables, supplementary figures, and others) referred to in this manuscript. Therefore, there is nothing to deposit in the appropriate public data repositories.
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