Comparative evaluation of nurse-led versus traditional trauma services in plastic surgery: a retrospective cohort study

Trauma is a critical public health challenge in China, representing the fifth leading cause of death among the general population and the primary cause of mortality among Chinese youth [1]. Within the specialized field of plastic surgery, trauma-related injuries, including pediatric fractures and complex degloving skin and soft tissue injuries, constitute a substantial portion of the operative workload [2, 3]. Effective management of these cases often necessitates a multispecialty infrastructure, including dedicated isolation wards and intensive care units [4]. Despite the high volume of cases, plastic surgery teams frequently encounter difficulties in accurately determining specific service needs, often leading to surgical wait times that exceed the thresholds recommended by national Chinese guidelines [5, 6].

The current systems and structures in many Chinese hospitals are frequently insufficient to provide the personalized, person-centered care required for optimal trauma outcomes [7, 8]. Previous reports have highlighted systemic inefficiencies similar to those in other international institutes, characterized by significant delays, long wait periods, and the cancellation of consultant appointments [9, 10]. In traditional hospital settings, a limited number of full-time plastic surgeons and trainee doctors manage both elective and emergency cases, creating a significant clinical burden that often results in the postponement of essential procedures [6, 11]. However, evidence suggests that re-organizing services to provide timely, safe, same-day surgery on a “see and treat” basis can significantly improve the quality of care for minor trauma [7, 12].

Global literature increasingly supports the transition toward nursing-integrated models to address these gaps [5, 7, 13, 14]. Studies in the United Kingdom and Australia have demonstrated that nurse-led trauma services and emergency nurse practitioner-led dispositions can significantly improve waiting times, patient safety, and overall clinical experience [5, 13]. In surgical settings, nurses often possess superior skills in developing patient rapport and therapeutic communication, which are associated with reduced patient stress and improved satisfaction compared to traditional surgeon-led agreements [15‐17]. Furthermore, nurse-led interventions have shown promise in managing specific oncological and reconstructive needs, effectively bridging the gap between consultant-led care and patient requirements [14, 18].

Despite these global trends, evidence regarding the efficacy of nurse-led trauma services (NLTS) within Chinese plastic surgery departments remains sparse [1, 6]. Traditional trauma services (TTS) in China remain predominantly physician-centric, often underutilizing the leadership potential of nursing staff in perioperative management and resuscitation [11, 19]. Recent epidemiological investigations and literature reviews suggest that critical gaps remain in trauma training and the integration of military-civilian trauma care systems to achieve zero preventable deaths [1, 20, 21]. There is a pressing need to evaluate whether an NLTS model—optimizing the nursing process and prioritizing nurse-led leadership—can outperform the traditional doctor-centered multidisciplinary collaboration in a clinical setting [11, 19, 21].

The specific objectives of this study are to compare the efficacy and safety of the NLTS and TTS models in a plastic surgery department, to evaluate their respective impacts on surgical timing and patient satisfaction, and to explore the prospects of implementing nurse-led leadership as a standard clinical model in Chinese trauma care.

The evolution of trauma care in China has necessitated a shift toward integrated, multi-professional models to manage the increasing complexity of hospitalized cases [1]. Our study demonstrates that the implementation of NLTS in plastic surgery significantly optimizes clinical efficiency, achieving 100% same-day surgical readiness compared to 94% in the TTS cohort. By analyzing outcomes independently, we observed that the NLTS model’s primary strengths lie in peri-operative coordination (readiness and stay duration) and specific symptom management (nausea reduction), rather than a global reduction in all surgical risks. This distinction is crucial for identifying where nurse-led interventions provide the most significant clinical utility. This finding is particularly relevant given the high volume of traumatic injuries, such as upper limb fractures and degloving soft tissue injuries, which require rapid triage and surgical intervention to prevent long-term disability and high economic burdens on the healthcare system [2, 3]. By empowering nurses to take an active role in peri-operative strategy and resuscitation, the NLTS model aligns with global efforts to achieve “zero preventable deaths” by integrating specialized clinical skills into the immediate trauma response [11, 20].

The significant reduction in median hospital stay—from 11 days in the TTS cohort to 8 days in the NLTS cohort—highlights the efficacy of nurse-managed protocols in streamlining recovery. This reduction of approximately three days is comparable to improvements seen in tertiary plastic surgery units that restructured their services during the COVID-19 pandemic to prioritize local anesthetic pathways and telemedicine for skin cancer care [4, 7]. In our NLTS model, nurses not only facilitated faster surgical readiness but also implemented advanced wound healing technologies and proactive nutritional support. This proactive technical assistance is a hallmark of “fundamental care,” where nurses prioritize the physical and psychosocial needs of the patient to prevent the secondary complications often associated with prolonged immobilization [22].

Postoperative complication rates, specifically nausea, were significantly lower in the NLTS group (23% vs. 39%). This suggests that the continuous presence and specialized monitoring provided by NLTS nurses allow for more precise titration of postoperative care and quicker response to early signs of shock or distress [11]. Furthermore, the lack of a significant difference in infection rates (4% overall) indicates that the NLTS model maintains high standards of surgical safety while accelerating throughput. Such findings underscore the scientificity and applicability of modern Chinese nursing guidelines, which emphasize evidence-based wound care and sepsis prevention in plastic and burn surgery [6, 19]. While infection rates were comparable between the two groups (3% in NLTS vs. 5% in TTS, p = 0.522), these results must be interpreted with caution. The integration of advanced materials, such as nano-silver dressings, into the NLTS protocol may have masked or augmented the clinical efficacy of the nursing service in preventing surgical site infections [6]. Effective communication and therapeutic relationships between nurses and patients further contribute to these improved outcomes by reducing patient anxiety and enhancing adherence to recovery protocols [15, 17].

Regarding overall postoperative morbidity, the NLTS cohort exhibited contrasting clinical trends. While there were zero reported instances of DVT and pressure sores in the NLTS group compared to a 4% incidence in the TTS group, this trend toward improved immobilization safety did not reach statistical significance (p = 0.072) [5, 18]. Conversely, the incidence of postoperative infection was slightly higher in the NLTS cohort (3% vs. 5% in TTS; p = 0.522), though this also remained statistically non-significant [19]. These divergent trends suggest that while the nurse-led focus on early mobilization and pressure relief may mitigate certain secondary traumas, the overall impact on morbidity—including infection—requires further validation in larger, powered studies [10, 20]. Consequently, these findings should be interpreted with caution as indicative of potential clinical trends rather than definitive safety outcomes [14, 23].

In our study, we found that the NLTS model significantly optimized the surgical cycle. Our study utilizes same-day surgical readiness as a proxy for time-to-treatment, a standard metric in emergency medicine. In this study population, the NLTS model was associated with 100% surgical readiness highlights the effectiveness of specialized nursing in managing the ‘pre-operative bottleneck.’ By focusing on these standardized time-to-treatment outcomes, the clinical utility of the nurse-led service becomes more evident to practitioners in the trauma field. This efficiency is further reflected in the significantly shorter hospital stays observed in the NLTS group.

Finally, the significantly higher satisfaction scores among patients and caregivers in the NLTS group (p < 0.001) reflect the value of the empathetic and communicative nature of nurse-led care. The attachment styles and empathy levels of healthcare workers are known to directly influence patient outcomes and their perception of care quality [15, 24]. By integrating nurses into the leadership of the trauma cycle, the NLTS model ensures that patient education and emotional support are prioritized alongside technical surgical goals. This holistic approach, combined with the use of digital health platforms for continuing care, ensures a seamless transition from the emergency department to postoperative recovery [23, 25]. The NLTS model thus stands as a transformative framework for modern plastic surgery trauma services.

While the outcomes of this study demonstrate significant clinical improvements, this work should be considered exploratory in nature. Given its retrospective and non-randomized design, these findings provide a preliminary evaluation of the NLTS model’s potential benefits rather than definitive evidence of superiority. The greatest value of this research lies in its capacity to generate evidence-based hypotheses regarding the role of nursing autonomy in trauma outcomes. Specifically, it highlights the need for further investigation into how nurse-led organizational structures interact with advanced clinical technologies to optimize recovery. This exploratory data serves to motivate future research using more rigorous, controlled, and ideally blinded study designs to establish causal relationships in nurse-managed trauma care.

The present study has several limitations that warrant consideration. First, the retrospective nature of the investigation may introduce selection bias, as patients were not randomized to the NLTS or TTS cohorts. This lack of randomization potentially leads to differences in injury severity—such as complex degloving or multi-system trauma—that may not have been fully captured by the broad demographic data provided [1, 3]. Although the distribution of major and minor surgeries was statistically similar, satisfaction and hospital stay duration may be more dependent on the inherent complexity of the injury rather than the care model itself [2, 21]. Second, a significant confounding variable exists regarding the materials used for wound management. The NLTS cohort exclusively utilized nano-silver antibacterial dressings, which possess well-documented antimicrobial properties. Because the TTS cohort did not receive these specific dressings, it is impossible to isolate the degree to which the low infection rates in the NLTS group were due to the specialized nursing service model versus the specific dressing material itself [19]. Future studies should aim to standardize dressing materials across cohorts to more accurately assess the independent impact of the nursing model on surgical site infections.

Third, the study was conducted at a single tertiary emergency center in China, which may limit the generalizability of these results to community hospitals or systems with different staffing levels and resource availability [1, 25]. Fourth, while the sample size of 248 was statistically sufficient for primary outcomes, it may have been underpowered to detect significant differences in rare but critical complications, such as DVT, postoperative infection, or preventable mortality [8, 21]. Fifth, the evaluation of “satisfaction” was based on institutional scores, which may lack the granularity and validated psychometric depth of instruments used in modern behavioral economic health interventions [9]. Sixth, the study focused predominantly on short-term inpatient recovery metrics; long-term functional and aesthetic outcomes—which are essential indicators of success in reconstructive plastic surgery—were not assessed [18, 26]. Finally, the variability in individual skill levels, attachment styles, and therapeutic communication abilities of the nurses involved, as well as the nuances of traditional doctor-led workflows, may have introduced performance heterogeneity that the retrospective design could not fully control [15, 24]. Such variance in individual care delivery is an established factor influencing patient outcomes in emergency settings [17, 22].

This study suggests that a nurse-led trauma service model is associated with improved efficiency and quality of care for patients requiring emergency plastic surgery. By achieving higher rates of same-day surgical readiness and significantly reducing hospital stay durations, the NLTS model appears to optimize resource utilization and facilitate faster clinical throughput. However, it is important to note that these improvements—particularly the reduction in inpatient days—likely result from the synergistic impact of the proactive nurse-led organizational structure and the advanced wound care materials (nano-silver dressings) integrated into the service protocol.

While these results are promising, they must be interpreted with caution given the retrospective design, which cannot isolate the individual contribution of nursing leadership from the specific technical interventions used. Future research should prioritize multi-arm prospective trials to differentiate these variables across diverse clinical settings. Strengthening specialized trauma training programs and simulation-based interventions for nurses will be essential to sustain such high-efficiency care models. Ultimately, integrating specialized nursing roles into the trauma cycle offers a promising framework for improving global surgical outcomes and achieving the goal of zero preventable complications.