Nurse-Led Ward Pathway Linked to Faster Recovery After Liver Transplantation

Liver transplant recipients who skipped the routine intensive care unit stay and went straight to a specially monitored general ward began eating, doing breathing exercises and walking dramatically sooner than patients treated under the traditional ICU-first model, according to a quasi-experimental study from West China Hospital of Sichuan University in Chengdu. In the study, published in Frontiers in Public Health, recipients cared for under a nurse-led early rehabilitation pathway started oral intake a median of 13 hours after surgery, compared with 48 hours among historical controls, and took their first steps out of bed at a median of 39 hours versus 72 hours. After statistical adjustment for age, sex, body mass index, preoperative diagnosis, surgery duration and intraoperative blood loss, the intervention period remained associated with roughly four and a half fewer days in hospital. The authors are nonetheless careful about causation: because the pathway was rolled out at a fixed point in time, calendar period and the intervention were inseparable, and the findings are strictly associations rather than proof that the pathway itself caused the faster recovery.

Liver transplantation has become the definitive treatment for end-stage liver disease, and its footprint in China has grown steadily since the country’s first operations in the 1970s. According to the China Liver Transplantation Registry cited by the researchers, roughly 6,000 liver transplants were performed annually between 2018 and 2020. The surgery remains one of the most demanding procedures in abdominal medicine, with postoperative complications occurring in an estimated 14 to 35 percent of recipients. Under the traditional care model, patients received early life support in the intensive care unit and were kept on strict bed rest for about a week, a practice intended to prevent bleeding from the liver’s cut surface and from the transplant anastomoses. Yet prolonged immobility carries its own toll, increasing the risk of pulmonary infection, pleural effusion, pressure injuries and lower-limb venous thrombosis while delaying the return of gastrointestinal function. The enhanced recovery after surgery, or ERAS, movement has pushed surgical teams toward earlier feeding and mobilization, but most liver transplant rehabilitation programs still begin only after ICU stabilization.

The West China Hospital team designed a pathway in which carefully selected first-time transplant recipients were transferred directly from the operating area to a dedicated level-II monitored unit in the general ward. Nurses staffing the unit had at least six months of prior ICU experience, and the nurse-to-patient ratio was approximately 1:3 during daytime shifts and 1:6 at night. Before implementation, a panel of fourteen experts — four liver transplant physicians, six transplant nursing specialists including three advanced practice nurses, two rehabilitation therapists and two nutrition therapists — reviewed and refined the protocol draft. The final program combined early feeding with staged advancement of oral intake, respiratory training, progressive mobilization, rehabilitation exercises and timely management of invasive catheters, all tracked with a structured implementation checklist. Tracheal extubation required prior physician assessment, and decisions to start, pause or resume rehabilitation activities were made jointly by the treating physician and rehabilitation therapist according to each recipient’s condition. Patients remained eligible for unplanned ICU transfer whenever ICU-level support was clinically required.

The study compared two consecutive periods at the same tertiary hospital in Chengdu. Between July and December 2023, 47 recipients received the routine pathway, with ICU admission for postoperative monitoring and life support before ward transfer. Between July and December 2024, after ethics approval in April 2024, 59 recipients entered the new non-ICU pathway. Eligible patients were undergoing their first liver transplant for end-stage liver disease; those with previous transplants, cognitive impairment, limb paralysis, fracture or severe cardiopulmonary insufficiency were excluded. Four recipients died during hospitalization — two in each period, from sepsis, septic shock or multiple organ dysfunction syndrome — yielding similar in-hospital mortality of 3.4 percent versus 4.3 percent. Because detailed pre-death recovery trajectories were unavailable for these four patients, the main analyses of rehabilitation timing, device duration, length of stay and charges were restricted to the 102 survivors: 57 intervention-period recipients and 45 historical controls. The researchers emphasized that these estimates are therefore survivor-conditional rather than applicable to every transplant recipient.

The unadjusted contrasts were striking. Median time to first oral intake fell from 48 hours in the control period to 13 hours under the pathway, and first respiratory training showed the same shift, from 48 to 13 hours. First out-of-bed activity moved from a median of 72 hours to 39 hours. Urinary catheters stayed in place a median of 16 hours versus 96 hours, and central venous catheters 22.5 hours versus 72 hours. Hospital length of stay dropped from a median of 17 days to 13 days, and median total hospitalization charges fell from about RMB 432,476 to RMB 400,382. Time to first flatus and first defecation, by contrast, did not differ significantly between periods, nor did gastric-tube or arterial blood pressure catheter duration in the primary per-recipient analysis. Because most timing variables were non-normally distributed in at least one group, the team used two-sided Mann-Whitney U tests for these unadjusted comparisons, reporting rank-biserial correlations as effect sizes.

To account for the non-randomized design, the researchers fitted multivariable linear regressions with HC3 heteroscedasticity-robust standard errors, adjusting for age, sex, body mass index, preoperative diagnosis, surgery duration and log-transformed intraoperative blood loss. Intervention-period status remained associated with earlier oral intake (adjusted difference −51.76 hours, 95 percent confidence interval −70.71 to −32.82), earlier respiratory training (−56.58 hours), earlier first ambulation (−60.48 hours), shorter urinary catheter retention (−85.93 hours), shorter central venous catheter retention (−66.17 hours) and shorter length of stay (−4.48 days). Sensitivity analyses using log1p-transformed outcomes supported the direction and statistical significance of these associations. However, first flatus, first defecation and gastric-tube duration showed no statistically significant adjusted differences, and total hospitalization charges — lower in the raw comparison — showed no significant adjusted association with the pathway (P = 0.467). The charge confidence interval was compatible with both lower and higher costs, so the data establish neither savings nor cost-equivalence, and no formal cost-effectiveness analysis was performed.

Safety indicators were reassuring but underpowered. The median number of recorded postoperative complications was one in the intervention group versus two among controls, a difference that was not statistically significant. Unplanned ICU transfer occurred in two of 57 intervention survivors (3.5 percent) and two of 45 controls (4.4 percent). Multidrug-resistant bacterial infection was numerically less frequent under the pathway — 3.5 percent versus 13.3 percent — but with so few events the confidence interval was wide and crossed the null (risk ratio 0.26, 95 percent CI 0.06 to 1.24; Fisher’s exact P = 0.134). The authors note that these sparse binary outcomes were not multivariably adjusted, to avoid unstable overfitted models, and that the point estimate favoring the pathway should not be overinterpreted.

Two devices required special handling in the analysis. Review of the source records confirmed that a recorded duration of zero hours for gastric tubes and arterial blood pressure catheters meant the device was never inserted during the hospitalization, not that it was removed immediately or that data were missing. Gastric tubes were placed in 15.8 percent of intervention recipients versus 24.4 percent of controls, while arterial pressure catheters were more common in the intervention period, at 77.2 percent versus 57.8 percent. Among recipients in whom the devices were actually inserted, median gastric-tube retention was 13 hours versus 102.5 hours, and arterial catheter retention 34 hours versus 72 hours. The researchers caution that these conditional comparisons are exploratory, because the indications for device insertion may have differed between the two care periods, and the primary per-recipient analyses combine differences in both placement and duration rather than isolating retention time alone.

The central limitation is the design itself. Because the pathway was introduced at a single center at a fixed calendar date, intervention status was completely confounded with time, and a separate period term could not be added to the regression model without perfect collinearity. Secular changes in operative technique, staffing, infection prevention, monitoring, nutrition practice or discharge policy could therefore partly or wholly explain the observed differences. MELD scores and ASA physical-status classifications were not systematically available for severity adjustment, and the threshold for direct ward management may have evolved over time, potentially steering fitter recipients into the intervention period. Earlier initiation of feeding and mobilization is also a process outcome, not proof of improved long-term function or quality of life, and the bundled intervention cannot isolate the specific contribution of nursing leadership or ICU bypass. The authors conclude that prospective multicenter studies with contemporaneous controls, explicit device-placement documentation, predefined safety criteria and formal economic evaluation are needed before the non-ICU pathway is adopted more widely.

Subject of Research: Nurse-led non-ICU early rehabilitation after liver transplantation

Article Title: Nurse-led non-ICU early rehabilitation after liver transplantation: a quasi-experimental historical-control study

Article References: Xu, X., Xu, J., Zeng, T., Xu, G., & Yang, J. (2026). Nurse-led non-ICU early rehabilitation after liver transplantation: a quasi-experimental historical-control study. Frontiers in Public Health, 14, Article 1812156. https://doi.org/10.3389/fpubh.2026.1812156

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1812156

Keywords: liver transplantation, early rehabilitation, ERAS, nurse-led care, quasi-experimental study, historical control, ICU transition, postoperative mobilization, hospital length of stay, catheter retention, transplant nursing, China