① Preoperative diagnosis of lung cancer confirmed by CT, bronchoscopy, or biopsy, with pathological confirmation of primary lung cancer; ② Meeting the surgical indications; ③ Age between 18 and 80 years; ④ Ability to communicate effectively; ⑤ Informed consent from the patient.

① Patients who underwent thoracotomy or total lung resection during surgery; ② Patients with severe respiratory, cardiovascular, or cerebrovascular diseases, or severe liver or kidney dysfunction before surgery; ③ Non-compliance; ④ Participation in other similar clinical trials concurrently.

Both groups were managed according to the standardized ERAS nursing clinical pathway established by the department. The department team referred to the Chinese Enhanced Recovery After Surgery (ERAS) Clinical Practice Guidelines (2021) [7] , ERAS China Expert Consensus and Pathway Management Guidelines (2018) [8] [9] [10] , and other literature on perioperative accelerated recovery nursing care for lung cancer patients from domestic and foreign databases, guideline websites, domestic and foreign thoracic professional association websites, forming the “Best Evidence Summary of Perioperative Nursing Care for Lung Cancer Patients” [11] . After interviewing thoracic medical and nursing staff about existing issues in accelerated recovery practice, the “ERAS Clinical Pathway for Thoracic Lung Cancer Patients” was developed. The pathway included preoperative education, preoperative assessment, smoking and alcohol cessation, nutritional support, preoperative fasting, and other aspects; intraoperative strategies such as prophylactic antibiotic use, optimization of anesthesia, airway management, and lung protection; postoperative pain management, prevention and treatment of postoperative nausea and vomiting, early feeding, early mobilization, discharge guidance (pulmonary rehabilitation), and continuity of care management. Patients and their families were introduced to and implemented the pathway through the distribution of promotional materials and verbal education. The quality control method in the control group involved the responsible nurse implementing the “ERAS Clinical Pathway for Thoracic Lung Cancer Patients,” with the nursing team leader randomly checking the implementation of the pathway twice daily and the head nurse focusing on checking the implementation of patients, providing real-time feedback, guidance, and improvement. The intervention group implemented evidence-based PDCA nursing quality management methods as follows:

The quality control team consisted of 10 members, including 1 thoracic clinical physician, 1 thoracic nursing team leader, 3 specialized nurses, 2 nursing team leaders, 1 research nurse, and 1 ERAS navigation nurse. The nursing team leader was responsible for overall coordination, planning, and coordination of the project; the physician was responsible for formulating and optimizing the plan; the research nurse was responsible for evidence retrieval, updating evidence-based knowledge, and data analysis; specialized nurses were responsible for developing and implementing patient pulmonary rehabilitation exercises and pain management goals, as well as providing psychological and nutritional support; the nursing team leaders provided feedback and guidance to the responsible nurses on the implementation of the pathway; the navigation nurse guided nurses in using evidence-based practices to make effective decisions [12] [13] . The team established an ERAS team WeChat group for coordination and feedback within the team, held regular coordination and quality control meetings, coordinated multidisciplinary consultations based on individual patient needs, monitored the implementation of the pathway throughout, established a continuity of care information platform, developed a continuity of care plan, and addressed non-routine events that were easily overlooked but required timely resolution by medical and nursing staff [14] [15] (Table 1).

The PDCA project team members are responsible for developing: ① Further revision based on the “ERAS Clinical Pathway for Thoracic Lung Cancer Patients” in the department, to be used throughout the execution of the patient’s ERAS pathway by the responsible nurse. The new content includes: (1) Preoperative: ERAS-related education, cardiopulmonary function (6-minute walk test), physical fitness assessment, nutritional risk (NRS2002), venous thrombosis risk (Caprini), and psychological (DT psychological distress thermometer) assessment. Preoperatively, elderly lung cancer patients with high-risk factors are advised to undergo one week of pulmonary rehabilitation training. Preoperative smoking and alcohol cessation for 2 weeks, multimodal health education (pushing public accounts, audio and video guidance for breathing exercises: focusing on active breathing cycle technology), preoperative fasting and drinking prohibition (shortening preoperative fasting time to 4 hours before surgery, oral intake of clear beverages allowed, including water, cola, sugar water, and coffee without milk, excluding milk, alcoholic beverages), nutritional support (3 + 3 mode oral nutritional supplements as the main source), and psychological relaxation (promoting respiratory mindfulness intervention). (2) Anesthesia: Increase the use of epidural analgesia, minimize the use of opioid analgesics as much as possible based on the patient’s actual condition, avoid excessive or insufficient fluid replacement leading to pulmonary edema or renal failure through goal-directed fluid therapy (GDFT). (3) Intraoperative: Choose “non-endotracheal intubation anesthesia for chest surgery” according to the actual situation, wedge resection patients can choose not to place chest drainage tubes, urinary catheters, and central venous catheters, and patients undergoing lobectomy should have a single chest drainage tube with a diameter not exceeding 24F left in place, avoiding the use of two chest drainage tubes or large drainage tubes with a diameter exceeding 28F. Optimize lymph node sampling or cleaning range based on intraoperative frozen section results (such as infiltration depth, intrapulmonary spread, etc.), avoid excessive cleaning of lymph nodes and damage to the pulmonary plexus nerves, etc. (4) Postoperative: Multimodal analgesia (intravenous patient-controlled analgesia pump, drug therapy, music therapy, etc.), early postoperative feeding (water intake 2 hours postoperatively, liquid diet 4 hours postoperatively), postoperative positioning management (comfortable positions such as semi-sitting or lying down as soon as the patient wakes up postoperatively), early mobilization (ankle pump exercise for limbs when awake postoperatively, active breathing cycle technology exercise). (5) Outpatient: Discharge guidance (personalized pulmonary rehabilitation program), continued nursing management (regular telephone follow-up), use of the hospital’s intelligent management platform for patients for outpatient full-cycle management. Introduce and implement the pathway to patients and their families through distribution of promotional materials, public account push, and establishment of health education lectures. ② Develop the “ERAS Implementation Feedback Checklist”: The navigation nurse records the effectiveness of the patient’s ERAS pathway execution daily, focusing on monitoring key ERAS assessments (preoperative and postoperative pain scores, psychological distress thermometer scores, thrombosis risk scores), preoperative fasting and postoperative early feeding compliance rates, early postoperative exercise, timely postoperative ambulation, extubation status, complications, follow-up feedback issues, patient satisfaction, etc.

Unified Training Navigation nurses provide training on the research purposes and significance, accelerated recovery-related knowledge, and the use and completion requirements of relevant quality control forms to project team members and all responsible nurses.

Inspection and handling stage use a three-level quality control method to control the quality of the ERAS implementation process. Level 1 quality control: Led by the responsible nurse, assess patients jointly with the attending physician and nurse, and implement the ERAS pathway. The responsible nurse summarizes the reasons for inadequate nursing service execution during nursing handover according to the “Clinical Nursing Quality Evaluation Standards of Sun Yat-sen University Cancer Hospital” and promptly writes up the case and checks for any missed ERAS-related assessments, recording all issues on the corresponding nursing service process form and providing feedback to the nursing team leader. Level 2 quality control: Led by the PDCA project team leader, based on self-assessment feedback from nurses, use the “ERAS Nursing Pathway Execution Form” to conduct bedside rounds twice daily with the physician, spot-check during shift handover with the head nurse, provide feedback on the implementation of the ERAS pathway and assessments, attention to high-risk patients, discharge case checks, and record all issues on the ERAS Nursing Pathway Execution Form for feedback to the navigation nurse. Level 3 quality control: Led by the navigation nurse, based on guidance from the head nurse and feedback from the team leader, use the “ERAS Implementation Feedback Checklist” to analyze patient data, track feedback from level 2 quality control, address issues, coordinate multidisciplinary team follow-up on patient conditions, organize regular nursing quality control meetings monthly, propose optimization strategies, and promote homogenization.

① ERAS-related indicators: First postoperative meal, ambulation, chest tube retention time, postoperative complications. Evaluated by the navigation nurse and attending physician, recorded by research nurses. ② Length of hospital stay and hospital costs are collected by research nurses from patient hospitalization information. ③ ERAS patient satisfaction: Using the Accelerated Recovery Surgical Inpatient Satisfaction Survey developed by Wang Xiaoxiao et al., including health education (6 items), patient care (4 items), clinical nursing (4 items), introduction to accelerated recovery concepts (3 items) in 4 dimensions with a total of 17 items. Each item is scored on a Likert 5-point scale from 1 to 5, with a total score ranging from 17 to 85. A higher score indicates greater patient satisfaction with ERAS-related medical services collected by the navigation nurse on the day of patient discharge.

Data analysis was conducted using the statistical software SPSS 26.0. Normally distributed continuous data are presented as mean ± standard deviation, and independent sample t-tests are used for comparison between groups. Count data are presented as percentages, and chi-square tests or Fisher’s exact probability tests are used for statistical analysis. A P-value < 0.05 indicates a statistically significant difference.