Established enhanced recovery protocols are available in different countries and languages, however, protocols might vary at each institution [9, 17, 23]. PROSTATE care model was developed based on current evidence and clinical practice to ensure the perioperative safety and improve patient outcomes. Our findings proved this innovative model made the treatment affordability, efficiency, and effectiveness. Healthcare providers from different professions were united to provide specific support based on patients’ need, especially the pelvic rehabilitation after the surgery that most impacted health-related quality of life [24, 25]. Patients underwent most economical procedures and reached their initial expectations. Patient-orientated care was accomplished through empowerment and empathy. Efforts from both patients and healthcare providers reduced physical and emotional distress encouraged the patient participation and improved their satisfaction and experience. To our knowledge, this is the first care pathway that embed both ERAS protocols and Chinese clinical practice culture for patients after radical prostatectomy. More importantly, this model worth further promotion with several notable findings.
Need assessment is important before the surgery. Sufficient evidence [26, 27] showed that nurse-led assessment can help nurses to collect all patient data and provide patient-centered care. In addition, a nonrandomized controlled feasible study by Veronica Nanton et al.  demonstrated comprehensive assessment and enhanced communication between care providers and patients was the foundation for care integration. One and first core element in our model was ‘Patient-oriented Care’, which pointed out our philosophy of the whole model. Patient’s health literacy varies by age, educational level, financial conditions. The PROSTATE care model allows medical staff to assess patient needs and encourage engagement. Shared decision-making combines healthcare providers and patients together to fight for the same goal and stimulates a faster recovery . Efforts afterwards ensured a better patient compliance and recovery physically and psychologically. Treatment based on patients’ needs attracted their participation, accelerated functional recovery and improved their satisfaction.
The implementation of PROSTATE care model decreased LOS without increasing complication rates. The average LOS shortens from 9.19 days to 7.14 days after implementing PROSTATE care model. Our LOS was longer than some western studies [14, 23, 30] because we admitted patients one to two days before the surgery. Other similar strategies involved included early ambulation, fast bowel preparation, and specialty support from PROSTATE multidisciplinary team. However, management of pain and sexual function were our weak points due to culture difference. Chinese patients preferred to tolerate pain by themselves instead of pain killers even after prescription; and patients were reluctant to talk about sexual function with non-family members, even with professional medical staff. Despite focusing on improvement of surgical techniques, quality of life and patient outcomes were the core elements. The promising finding after three-year implementation of PROSTATE care model was a faster time to removal the urinary catheter and pelvic drainage tube. Research [31, 32] show that the discomfort after radical prostatectomy was from different tubes, and our trail made the earlier removal possible and safe. Tube-related (urinary tract infection and urinary retention) and wound complications dropped with self-engagement due to high-quality education before discharge and specialty support after discharge [33, 34]. Patient-centered PROSTATE care pathway ensures the safety after the surgery and reduces short-term complications.
Favorable results regarding the perioperative rehabilitation backed the implementation of this model. First is about the mobilization. Although there is no difference in first water intake, however, number of patients who got off the bed on the first day after the surgery raised significantly. Early ambulation might relate to no increase in venous thromboembolism, which was the same from other studies [5, 35, 36]. Second, two group of patients showed no difference in urinary leakage after urinary catheter removal, however, one month later, patient-reported ICIQ score was much better than patients before the PROSTATE care model. Moreover, 3-month pad test confirmed better continence with improved quality of life. As reported, the prevalence of post-prostatectomy incontinence could be as high as 70–80% [37, 38]. Incontinence was regarded as the bothersome cause after the surgery [39, 40]. Pelvic floor muscle exercise was the first line recommendation for post-prostatectomy incontinence , but reports about efficacy varied depending on patient compliance [40, 42]. We focused on the pelvic muscle training and made full utilization of facilities to promote fast recovery. After comprehensive assessment and physical exams, patients were first taught to use the appropriate urinary collectors and contract the right muscle with or without biofeedback. If patients suffered bothersome PPI consistently, the rehabilitation nurse would refer to other physicians for further treatment.
The successful implementation of this PROSTATE care model depended on several factors. For patients, they were strictly enrolled and undergone the radical prostatectomy by surgeons with at least ten-year experience in prostate cancer to exclude the influence of the surgical techniques. Secondly, team members were strictly trained. Every patient in the PROSTATE group received the same quality of care from the PROSTATE team. For example, in order to collect the accurate data after the surgery and improve patient compliance [43, 44], we reimbursed the participants for test fees, traffic fees, and other related medical supplies. For some missing information, trained team members and the physician assistant contacted patients and arranged the follow-ups. Lastly, one-month feedback from team members, healthcare providers and patients was important. Voices from all involved members including patients were heard. Suggestion from other professions could be discussed and promote the quality of care. This was the chance for communication and quality improvement for the safety of patients.
Our study had several limitations. First, this was a retrospective research in a single urological center. Further research was needed to evaluate long-term effects of PROSTATE care model in multi-center and whether types of surgeries affected postoperative parameters and rehabilitation. Second, cost effectiveness should be more specific analyzed including medical costs and staff costs. We believe this study is unique in its framework and contents, and has potential for further implementation in a larger scale.