Global Pediatric Peripheral Intravenous Catheter Practice and Performance: A Secondary Analysis of 4206 Catheters

Factors associated with the disinfection of devices attached to peripheral intravenous catheters performed by the nursing team in pediatric units

Background

Peripheral intravenous catheterization, as well as drug administration through it, represents one of the most performed procedures by the Nursing team and, for that, precautions need to be adopted to offer harm-free care.

Objective

To verify the association of Nursing professionals' work shift and training time with proper disinfection of intravenous catheter devices in pediatric units.

Methods

A cross-sectional and analytical study conducted between June and August 2021 in three hospitalization units of a Pediatric Hospital. The inclusion criterion was drug administration via peripheral intravenous catheters performed by Nursing professionals. The data were analyzed according to inferential statistics, adopting p ≤ .05 as significance level.

Results

There were a total of 385 observations of drug administration procedures. The device was not disinfected in 60.3% of the cases, there was no friction at the suitable time in 86.3%, and the disinfectant was not allowed to dry in 72.5%. The work shift exerted no influence on performance of the disinfection procedure (p = .376). However, longer training time was associated with a lower rate in performing such procedure (p < .001).

Conclusion

Performing friction below the recommended time can cause a false sense of prevention of catheter-associated bloodstream infection; therefore, training sessions and strategies for adherence to the disinfection procedures should be considered, mainly for professionals with more training time.

Paediatric nurses' experiences of success and failure in first-time peripheral intravenous catheter insertion: A qualitative study

PURPOSE

To explore in-depth the thoughts, anxiety factors, and experiences of paediatric nurses regarding the success and failure of first-time peripheral intravenous catheter insertion.

DESIGN AND METHODS

The study employed a qualitative research method using the phenomenology design. Face-to-face semi-structured in-depth interviews were conducted with nurses (N = 12) working in the paediatric service and neonatal intensive care unit of a teaching and research hospital. The transcripts were analysed using a phenomenological approach and an inductive process.

RESULTS

Four themes were identified: Peripheral Intravenous Catheter Insertion, Experience of Success on the First Attempt, Experience of Failure on the First Attempt, and Proposed Solutions. Nurses felt a sense of happiness when they successfully inserted a peripheral intravenous catheter on their first attempt in paediatric patients. Conversely, they experienced emotions such as sadness, worry, stress, and anxiety when they failed and had to make repeated attempts.

CONCLUSION

Unsuccessful peripheral intravenous catheter insertions cause distress and anxiety for nurses, patients, and parents alike. Therefore, nurses' experiences of peripheral intravenous catheter insertions in healthcare settings should not be ignored and require improvement.

IMPLICATIONS FOR CLINICAL PRACTICE

Unsuccessful peripheral intravenous catheter insertions affect children, parents, and nurses negatively, thus reducing the success rate of repeated peripheral intravenous catheter insertions. Therefore, it is advisable for nurses conducting paediatric peripheral intravenous catheterisations to undergo periodic training. A specialised intervention team should be established for cases of initial failure, and a mentoring system between seasoned and new nurses is recommended.

Nomogram for Predicting the Risk of Complications in Hospitalized Children With Peripheral Intravenous Catheters

OBJECTIVE

The aim of the study is to identify the hospitalized children at risk of peripheral intravenous catheter (PIVC) complications by severity prediction.

METHODS

The study included the data of 301 hospitalized children with PIVC complications in 2 tertiary teaching hospitals. A researcher-designed tool was used to collect risk factors associated with PIVC complications. Predictors of PIVC complications at univariate analysis and multivariable logistic regression analysis by backward stepwise. A nomogram was constructed based on the results of the final multivariable model, making it possible to estimate the probability of developing complications.

RESULTS

A total of 182 participants (60.5%) had a moderate injury from PIVC complications. Multivariable logistic regression analysis indicated that the vascular condition, limb immobilization, needle adjustment in venipuncture, infusion length, infusion speed, and insertion site were independent predictors. The nomogram for assessing the severity of PIVC complications indicated good predictive accuracy (area under the curve = 0.79) and good discrimination (concordance index = 0.779). Decision curve analysis demonstrated that the nomogram was a good clinical value with a wide range of threshold probabilities (4%-100%).

CONCLUSIONS

The risk prediction model has good predictive performance, and the nomogram provides an easy-to-use visualization to identify the severity of PIVC complications and guide timely nursing care management.

Invasive device-associated skin complications and mechanical dysfunctions in paediatric healthcare: A systematic review and meta-analysis

AIM

This study aimed to estimate the proportion and rate of skin complications and mechanical dysfunction associated with indwelling invasive devices in paediatric healthcare.

DESIGN

This systematic review is reported in accordance with Cochrane standards for randomized controlled trials and the Meta-analysis of Observation Studies in Epidemiology for cohort studies.

DATA SOURCES

MEDLINE, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

REVIEW METHODS

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) paediatric participants admitted to a hospital, (3) reporting post-insertion device-associated skin complication and/or mechanical dysfunction, and (4) published in English, were included. Device-associated skin complication and mechanical dysfunction (infiltration, leakage, occlusion/blockage, dislodgement/malposition, breakage and others). Pooled proportion and incidence rate per 1000 device days are reported.

RESULTS

This review synthesized 114 studies (30,782 devices; 1,635,649 device-days). Skin complications were reported in 40 studies, but none exclusively reported individual device-related pressure injuries. Mechanical dysfunctions were well-reported for central venous access devices, peripheral intravenous catheters, nasogastric/gastric tubes and peritoneal dialysis catheters but less for arterial catheters, extracorporeal membrane oxygenation and ventricular assist devices.

CONCLUSIONS

This systematic review highlights the need for standardized definitions and reporting methods to better surveil and benchmark device-related complications, particularly for understudied device types. Device-related pressure injuries were not reported in any of the included studies, and all devices except for vascular access devices require standardized reporting of complications.

IMPACT

Despite the widespread use of invasive devices, comprehensive data on their prevalence, utility, and associated paediatric complications is limited. This review identified prevalent skin complications, occlusions and dislodgments in children with devices, underscoring the need for standardized reporting to enhance surveillance and understanding of paediatric device-related complications.

REPORTING METHOD

MOOSE (Meta-analyses Of Observational Studies in Epidemiology) Checklist.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Pediatric invasive device utility and harm: a multi-site point prevalence survey

BACKGROUND AND AIMS

Invasive devices are widely used in healthcare settings; however, pediatric patients are especially vulnerable to invasive device-associated harm. This study aimed to explore invasive device utility, prevalence, harm, and clinical practice across three Australian pediatric tertiary hospitals.

METHODS

In 2022-2023, a multi-center, observational, rolling-point-prevalence survey was conducted. Fifty-per-cent of inpatients were systemically sampled by random allocation. Patients with devices were then followed for up to 3-days for device-related complications/failures and management/removal characteristics.

RESULTS

Of the 285 patients audited, 78.2% had an invasive device (n = 412 devices), with a median of 1 device-per-patient (interquartile range 1-2), with a maximum of 13 devices-per-patient. Over half of devices were vascular access devices (n = 223; 54.1%), followed by gastrointestinal devices (n = 112; 27.2%). The point-prevalence of all device complications on Day 0 was 10.7% (44/412 devices) and period-prevalence throughout the audit period was 27.7% (114/412 devices). The period-prevalence of device failure was 13.4% (55/412 devices).

CONCLUSIONS

The study highlighted a high prevalence of invasive devices among hospitalized patients. One-in-ten devices failed during the audit period. These findings underscore the need for vigilant monitoring and improved strategies to minimize complications and enhance the safety of invasive devices in pediatric hospital settings.

IMPACT

A high prevalence of invasive devices among hospitalized patients was reported. Of the 285 patients audited, almost 80% had an invasive device (total 412 devices), with a median of 1 device-per-patient and a maximum of 13 devices-per-patient. The most common devices used in pediatric healthcare are vascular access devices (n = 223; 54.1%), however, 16% (n = 36) of these devices failed, and one-third had complications. The point prevalence of all device complications at day 0 was 10.7% (44 out of 412 devices), with a period prevalence of 27.7% (114 out of 412 devices) throughout the audit period.

The effect of the closed intravenous catheter system on first insertion success, indwelling time, and complications in pediatric hematology and oncology patients: A randomized controlled study

PURPOSE

The primary purpose of this research is to evaluate the effect of two different catheter systems (closed IV catheter system: BD Nexiva™, peripheral open IV catheter: BD Insyte™ Autoguard™) on first insertion success, catheter indwelling time, and the catheter complications.

METHOD

This randomized controlled study used a single-blind and parallel trial design guided by the CONSORT checklist. The "Peripheral Intravenous Catheter (PIVC) Bundle" was applied to all patients. A total of 214 catheters of 38 patients were included in the intervention (BD Nexiva™) (n = 107 catheter) and control (open IV catheter) groups (n = 107 catheter) of the study. The indwelling time and PIVC complications were followed.

RESULTS

The mean age of the patients in the study group was 5.9 ± 2.2, and the mean age of the patients in the control group was 5.7 ± 1.9. The PIVC was successfully placed in 68.2% of the patients in the study group and in 65.4% of the patients in the control group at the first attempt. It was determined that the indwelling time was 4.9 ± 3.9 (max. 20.25 days) in the study group and 2.9 ± 2.8 (max. 11.25 days) days in the control group. The complication rates were found to be 86.8 for the study group and 166.9 for the control group in 1000 catheter days. In this study, no difference was found in terms of complication.

CONCLUSIONS

The PIVC indwelling time is longer in patients with the closed IV catheter system. These new technology PIVCs can be used for this special patient population.

CLINICALTRIALS

GOV IDENTIFIER

NCT05769452.

Peripheral intravenous catheter insertion, maintenance and outcomes in Indonesian paediatric hospital settings: A point prevalence study

PURPOSE

This study aimed to assess peripheral intravenous catheter use, maintenance practices, and outcomes of paediatric patients in a developing country setting.

DESIGN AND METHODS

A point prevalence survey using validated checklist was conducted between March and April 2022 in ten hospitals in Indonesia. A total number of 478 participants were approached during the audit. Data were obtained from site observation and medical records.

RESULTS

Of the 386 patients surveyed, >90% (362) had one catheter in-situ. The catheters were mostly inserted by nurses (331, 86%), primarily in the dorsum of the hand (207, 54%) with the purpose of delivering intravenous infusions and medications (367, 95%). Simple transparent dressings (176, 46%) with splint and bandage (295, 76%) were predominantly used for securement methods. Insertion sites were not visible for 182 (47%) patients, and 151 (40%) of daily care practices were poorly documented. Complications were documented in the medical record for 166 (43%) catheters. Adjusted analysis indicated that patient diagnosis, ward, catheter size, location, dressings, infusate, and flushing administration were significantly associated with complications.

CONCLUSIONS

Findings indicate that issues related to paediatric intravenous catheter complications in Indonesia are comparable to developed country settings. Ongoing surveillance is important to evaluate the management practices to benchmark against guidelines, optimise patient safety, and improve outcomes.

PRACTICE IMPLICATIONS

Results demonstrate low and middle-income countries face similar challenges with catheter insertion and care. The study indicates the importance of applying vascular access needs assessments, providing training for inserters, identifying optimum dressing methods, and optimising documentation.

Midline Compared With Peripheral Intravenous Catheters for Therapy of 4 Days or Longer in Pediatric Patients: A Randomized Clinical Trial

Importance

Peripheral intravenous catheters (PIVCs) frequently fail during treatment causing therapy interruption, pain, recatheterization, and additional health care costs. Midline catheters (MCs) may improve functional dwell time and reduce failure compared with traditional PIVCs.

Objective

To compare device failure of MCs with PIVCs.

Design, Setting, and Participants

This was a pragmatic, randomized clinical superiority trial with an embedded internal pilot study conducted from July 2020 to May 2022. The study took place in a quaternary pediatric hospital in Brisbane, Queensland, Australia. Inclusion criteria were patients aged 1 to 18 years requiring peripherally compatible intravenous therapy for 4 days or longer.

Interventions

Patients were randomly assigned 1:1 to receive a PIVC or MC, stratified by age (≤5 years, >5 years). One catheter was studied per patient.

Main Outcomes and Measures

The primary outcome was all-cause device failure, defined as premature cessation of device function. Secondary outcomes included number of insertion attempts, insertion failure, pain (on insertion), procedural time, patient/parent satisfaction (with insertion), device dwell time, device complications during dwell time, additional vascular access devices required to complete treatment, clinician satisfaction (at removal), and health care costs.

Results

Of the 128 patients randomly assigned to study groups, 127 patients (median [IQR] age, 7 [2-13] years; 71 male [56%]) had a device inserted, with 65 (51.2%) in the PIVC group and 62 (48.8%) in the MC group. All patients were included in the intention-to-treat analysis. Device failure was lower in patients in the MC group (10 [16.1%]) compared with those in the PIVC group (30 [46.2%]; odds ratio [OR], 0.22; 95% CI, 0.10-0.52; P <.001). MCs were associated with fewer insertion attempts (mean difference [MD], -0.3; 95% CI, -0.5 to 0; P = .04), increased dwell time (MD, 66.9 hours; 95% CI, 36.2-97.5 hours; P <.001), and fewer patients required additional vascular access devices to complete treatment in the MC group (4 [6.5%]) and PIVC group (19 [29.2%]; OR, 0.17; 95% CI, 0.05-0.52; P = .002). Compared with PIVCs, use of MCs was associated with greater patient (9.0 vs 7.1 of 10; P = .002) and parent (9.1 vs 8.2 of 10; P = .02) satisfaction and lower health care costs (AUS -$151.67 [US -$101.13] per person; 95% credible interval, AUS -$171.45 to -$131.90 [US -$114.20 to -$87.95]).

Conclusions and Relevance

Findings suggest that MC insertion for patients requiring peripherally compatible intravenous therapy for 4 days or longer should be prioritized to reduce the resource intensive, expensive, and burdensome sequelae of device failure.

Trial Registration

Australia New Zealand Clinical Trials Registry, ACTRN12620000724976.

Implementation frameworks, strategies and outcomes used in peripheral intravenous catheter studies: A systematic review

AIMS

The aim of this study was to critically evaluate implementation frameworks, strategies and/or outcomes used to optimise peripheral intravenous catheter (PIVC) care and/or promote guideline adherence.

BACKGROUND

Although a considerable volume of research has investigated the effectiveness of PIVC interventions and treatments to promote performance and prevent harm, how to best implement this evidence into dynamic clinical settings and populations is not well understood. Implementation science is central to translating evidence-based knowledge to the bedside; however, there is a gap in identifying the best implementation framework, strategies and/or outcomes to optimise PIVC care and/or guideline adherence.

DESIGN

A systematic review.

METHOD

The review was conducted using innovative automation tools. Five databases and clinical trial registries were searched on 14 October 2021. Qualitative and quantitative PIVC intervention studies reporting implementation strategies were included in the review. Data were extracted independently by experienced researchers in pairs. The Mixed Method Appraisal tool was used to assess the quality of individual studies. Narrative synthesis was used to present the findings. The systematic review was reported following the PRISMA checklist.

RESULTS

Of 2189 references identified, 27 studies were included in the review. Implementation frameworks were used in 30% (n = 8) of studies, with most used during the preparation (n = 7, 26%) and delivery phase (n = 7, 26%) and then evaluation phase (n = 4, 15%). Multifaceted strategies were commonly adopted (n = 24, 89%) to promote PIVC care or study interventions which were clinician (n = 25, 93%) and patient-targeted (n = 15, 56%). The most commonly reported implementation outcomes were fidelity (n = 13, 48%) and adoption (n = 6, 22%). Most studies were scored as low quality (n = 18, 67%).

CONCLUSION

We call for researchers and clinicians to work together and use implementation science frameworks to guide study design, implementation and evaluation in future PIVC studies, to improve evidence translation and thereby improve patient outcomes.

The parent, child and young person experience of difficult venous access and recommendations for clinical practice: A qualitative descriptive study

AIMS AND OBJECTIVES

Explore the parent and child/young person experience of difficult venous access and identify ideas and preferences for changes to clinical practice.

BACKGROUND

Peripheral intravenous catheter insertion is one of the most common invasive procedures in hospitalised paediatric patients. Multiple insertion attempts in paediatric patients are common and associated with pain and distress. Little research has explored the parent and child/young person experience of difficult venous access nor sought to identify their suggestions to improve clinical practice.

DESIGN

Qualitative description.

METHODS

A purposive sampling approach was used to identify children and young people with experience of difficult venous access and their parents. Semi-structured interviews were conducted, with sample size based on data saturation. Transcripts were analysed using thematic analysis.

RESULTS

There were 12 participants, seven parents and five children/young people (five parent/child dyads and two individual parents). Analysis of the data revealed three main themes: (1) Distress-before, during and after (2) Families navigating the system: the challenging journey from general clinician to specialist and (3) Difficult venous access impacts both treatment and life outside the hospital A pre-determined theme, (4) Recommendations for good clinical practice is also described.

CONCLUSIONS

Multiple attempts to insert a peripheral intravenous catheter are a source of substantial distress for children/young people, leading to treatment avoidance. Effective interpersonal skills, providing choice and avoiding frightening language are important to minimise distress. Clinicians without specialist training should assess each child's venous access experience and consider immediate referral to a specialist if they have a history of difficult venous access. Cultural change is required so clinicians and healthcare services recognise that repeated cannulation may be a source of psychological distress for children/young people.

Ultrasound-guided PIVC insertion: a randomised controlled trial protocol

Ultrasound-guided insertion of peripheral intravenous catheters (PIVCs) is an alternative to traditional anatomical landmark-based insertion. However, data on its performance in paediatric patients of varying levels of difficult intravenous access are limited. The researchers hypothesise that ultrasound-guided PIVC insertion will increase first-attempt success compared with landmark technique. This randomised, parallel-group, single-centre, superiority trial commenced recruiting in July 2021, including hospitalised children (aged 0 (>37 weeks gestation) to 18 years) requiring a PIVC. It will recruit 180 children, stratified by degree of perceived difficulty, and centrally randomised into two groups (ratio 1:1). The primary outcome is first-attempt PIVC insertion success. Secondary outcomes include total number of PIVC insertion attempts, PIVC insertion failure, post-insertion complications, dwell time, patient/parent satisfaction, and healthcare costs. The current study will inform the superiority of ultrasound-guided PIVC insertion in comparison with landmark technique. Adoption by healthcare facilities might improve patient outcomes and decrease healthcare costs.

Determination of pain experienced by children during intravenous bolus treatments and its causes

OBJECTIVE

The present study aimed to determine the pain experienced by children during intravenous bolus treatment and to identify what causes it.

METHOD

In the first stage of the study, the first 40 observations were performed by two researchers. The study was continued by a single observer after the Kappa test was performed. In this study, 101 drug treatments were administered by intravenous bolus in patients aged between 1 month and 6 years. The pain experienced during treatment was assessed using pain scales according to the age group the patient was in.

RESULTS

Pain was observed in 63.4% (n = 64) of the treatments. There was a significant relationship between the type of medication administered and pain experienced during drug administration. There was also a significant correlation between the age of the children and their pain experiences. Given the location of the catheter, there was no significant difference among the children who experienced pain during intravenous treatment.

CONCLUSION

Intravenous drug therapy may cause pain in children. To minimize such pain, it is recommended to determine the drugs that cause pain during intravenous treatment and to develop application protocols to minimize pain caused by these drugs.

Effective Use of Extended Dwell Peripheral Intravenous Catheters in Neonatal Intensive Care Patients

BACKGROUND

Implementing innovative approaches to vascular access can be challenging in the newborn intensive care unit (NICU).

PURPOSE

The purpose of this project was to describe the implementation of extended dwell peripheral intravenous (EPIV) catheters, a vascular access device not widely used in the NICU. The implementation involved (1) designing clinical criteria for EPIV catheter use, (2) education of vascular access NICU nurses, and (3) comparing clinical outcomes between vascular access devices (ie, PIV and EPIV catheters).

METHODS

We developed evidence-based clinical criteria guiding the use of vascular access devices. We then developed an educational plan for NICU nurses focused on vascular access. Finally, we collected and compared demographic characteristics and clinical data on catheter type and placement attempts, dwell time, and clinical complications associated with each catheter.

RESULTS

EPIV catheters were implemented according to evidence-based criteria by a vascular access NICU nursing team. Fifteen percent of PIV catheter placements required 3 or more attempts compared with just 1% of EPIV catheter placement attempts. EPIV catheters had a longer median dwell time (3.5 vs 1 day) and fewer complications than PIV catheters (P < .001).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementation of an evidence-based approach to vascular access by a team of NICU nurses may improve clinical outcomes. EPIV catheters may be an appropriate alternative device to PIV catheters due to fewer placement attempts, longer dwell times, and overall fewer complications during use. Future vascular access research in the NICU may include a greater focus on innovative placement strategies, optimal maintenance and infection control, and prevention of complications.

Quantitative phase analysis and hyperspectral imaging for the automatic identification of veins and blood perfusion maps

INTRODUCTION

Medical workers commonly physically identify subcutaneous veins to locate a suitable vesselto implant a catheter for drug administration or blood sample. The general rule of thumb is to locate a big, clean vein that will allow the medication to readily pass within the intended blood vessel. Peripheral problematic venous access happens when a patient's veins are difficult to palpate because of factors like dark skin tone, edema or excess tissue. The ability to see how the vasculature changes to support the therapeutic methods without damaging the surrounding tissue is another challenge.

MATERIALS AND METHODS

Hyperspectral imaging (HI) is a developing technique with several potential uses in medicine. Using its spectroscopic data, veins and arterioles could be noninvasively detected and discriminated. It is frequently important to use quantitative phase analysis for vein localization. To assess hyperspectral image data for the detection of both veins and peripheral arteries, we suggest using an advanced image processing and classification algorithm based on the phase information related to the index of refraction change and associated scattering. We show that this need may be satisfied using quantitative phase imaging of forearm skin tissue at different depths.

RESULTS

To demonstrate the variations in the diffuse reflectance characteristics between skin surface and veins, phase resolved pictures were successfully produced for twelve volunteers using our imaging methodology. We found that the skin surface details are completely apparent at the unique wavelength of 441 nm. The 500-nm wavelength was the most efficient for grouping peripheral arteries and illuminating the blood perfusion maps. Using our HI experimental setup and our phase imaging procedure on the 600 nm and 650 nm visible spectral pictures, we were able to properly describe the vein map. This spectral area may be utilized as a vein locator marker which could approximately reach till 3 mm depth under skin surface.

CONCLUSIONS

Initial findings suggested that our imaging technique would be able to assist medical examiners in safely assessing the veins and arteriole's locations automatically without exposing the skin to infrared radiation. Meanwhile, our pilot research in this work to determine the best spectral wavelengths for localizing veins and mapping blood perfusion using our phase analysis imaging strategy with the HI camera. By substituting the HI camera with a custom conventional RGB camera that only functions at specific wavelengths during the discovering of blood perfusion locations or prior to intravenous catheterization, a distinctive and efficient system for precise identification may be developed to serve in the field of the vascular therapeutic methods.

Incidence, time to occurrence and predictors of peripheral intravenous cannula-related complications among neonates and infants in Northwest Ethiopia: an institutional-based prospective study

BACKGROUND

Peripheral intravenous cannulas (PIVC) are venous access devices commonly used for the administration of intravenous fluids, drugs, blood products, and parenteral nutrition. Despite its frequent use, it has complications that can seriously threaten patient safety, prolong hospital stays, and increases medical care costs. PIVC complications are associated with increased morbidity and reinsertion attempts are painful and anxiety-provoking for children and their parents. Therefore, this study was aimed to assess the incidence, time to occurrence and identify predictors for PIVC complications among infants admitted to Debre Tabor Comprehensive Specialized Hospital (DTCSH), Northwest Ethiopia.

METHODS AND SETTING

An institutional-based prospective cohort study was conducted on 358 infants admitted to a neonatal intensive care unit and pediatric ward, DTCSH from January 1 to April 30, 2022. A systematic sampling technique was employed.

RESULTS

The incidence rate of PIVC complication was 11.6 per 1000 person-hours observation. PIVC complication was observed in 56.4% (202) of PIVCs, of which infiltration (42.1%) was the most common complication followed by phlebitis (29.7%). The median time to complication was 46 h. Anatomical insertion site (AHR = 2.85, 95%CI: 1.63-6.27), admission unit (AHR = 1.88, 95%CI: 1.07-4.02), sickness (AHR = 0.24, 95% CI: 1.31-4.66), medication type (AHR = 2.04, 95%CI: 1.13-3.66), blood transfusion (AHR = 0.79, 95%CI: 0.02-0.99), clinical experience (AHR = 0.52, CI:0.26-0.84), and flushing (AHR = 0.71, 95%CI: 0.34-0.98) were potential predictors of PIVC complication.

CONCLUSION

Knowing the predictor factors helps clinicians to provide effective care and to detect complications early.

New dimension on potential factors of successful pediatric peripheral intravenous catheterization

BACKGROUND

Peripheral intravenous catheterization (PIVC) is pivotal to pediatric medical care; however, it is a challenging technique for pediatricians, and the parameters affecting successful pediatric PIVC establishment have not been fully investigated.

METHODS

This prospective observational study collected data from pediatric patients aged less than 18 years who required PIVC. The participants were categorized into five groups for subgroup analysis: newborn, infant, toddler, pre-school, and student (children and adolescent). Data on demography, biochemistry, and PIVC executors were examined to elucidate the most powerful factors affecting the success of PIVC.

RESULTS

A total of 935 peripheral venous cannulations conducted within 1 year were studied. Age-subgroup analysis showed the highest failure rate (FR) of PIVC in the infant group (18.4%). No significant difference in BMI standard deviation score was noted among the groups (p-value = 0.430). Compared with those for the success group, more attempts, longer completion time, and more medical staff were needed for the failure group (all p-values < 0.05). A high serum procalcitonin level was correlated with an increased FR (p-value = 0.016). In addition, the success rate was positively associated with the seniority of the operators, except for the 3-year experienced R3 group (93.5%) showing a higher success rate than the 4-year experienced CR group (84.2%).

CONCLUSIONS

Difficulty in setting up PIVC was the greatest in infants and even greater than that in newborns. Even though seniority was a cardinal factor in successful PIVC, a high FR was still noted despite the lack of continuous and steady practice.

Extravasation injury management for neonates and children: A systematic review and aggregated case series

BACKGROUND

Pediatric extravasation injuries are significant healthcare-associated injuries, with sometimes significant sequelae. Evidence-based guidance on management is necessary to prevent permanent injury.

PURPOSE

A systematic review of the literature, including aggregated case series, investigating extravasation injury management of hospitalized pediatric patients.

DATA SOURCES

PubMed, Cummulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica database (EMBASE) were searched on December 13, 2021.

STUDY SELECTION

Primary research investigating extravasation injury management of hospitalized pediatric patients (to 18 years), published from 2010 onwards and in English, independently screened by two authors, with arbitration from a third author.

DATA EXTRACTION

Data regarding the study, patient (age, primary diagnosis), extravasation (site, presentation, outcome), and treatment (first aid, wound management) were extracted by two authors, with arbitration from a third author.

DATA SYNTHESIS

From an initial 1769 articles, 27 studies were included with extractable case data reported in 18 studies, resulting in 33 cases. No clinical trials were identified, instead, studies were primarily case studies (52%) of neonates (67%), with varied extravasation symptoms. Studies had good selection and ascertainment, but few met the causality and reporting requirements for quality assessments. Signs and symptoms varied, with scarring (45%) and necrosis (30%) commonly described. Diverse treatments were categorized into first aid, medical, surgical, and dressings.

CONCLUSIONS

Despite infiltration and extravasation injuries being common within pediatric healthcare, management interventions are under-researched, with low-quality studies and no consensus on treatments or outcomes.

Nurses' knowledge and experiences of peripheral intravenous catheter insertion at a tertiary paediatric health centre

AIM

The aim of the study was to determine paediatric nurses' knowledge and experiences of PIVC insertion.

METHOD

In this cross-sectional study, nurses working in a paediatric hospital in Izmir, Türkiye, between May and September 2019 were included (225; 67.4%). A PIVC knowledge and experience form, and a sociodemographic characteristics questionnaire were used to collect data.

RESULTS

Nurses most often inserted the PIVC on the dorsum of the hand (83.1%). Their choice of vein was influenced by the condition of the patient's veins (91.1%), medications (72%) and the patient's activity status (70.2%). The most preferred PIVC size was 24 gauge (98.2%), and the most frequently used cannula was a short peripheral cannula (96.9%). To clean the insertion site of the cannula, 93.8% of the nurses used 70% alcohol. Distractions used while inserting the PIVC were: letting the child play with a toy (51.1%), having the child sit on the mother's lap (45.8%), letting the child watch cartoons (45.3%), and administering oral sucrose (43.6%). Of the nurses, 69.3% attached a split septum/vein valve to the PIVC insertion site, and 82.2% cleaned the split septum/vein valve with 70% alcohol and waited until it dried before administering the medication. Some 79.6% secured the cannula with a hypoallergenic nonwoven adhesive fixation tape bandage. Some 94.7% performed catheter flushing for control after inserting PIVCs, 93.8% performed catheter flushing before IV fluid treatment, 89.8% flushed the catheter before drug administration through the bolus method, 53.3% flushed the PIVC catheter with a slow technique and 42.2% flushed it with an intermittent technique.

CONCLUSION

The nurses generally acted in accordance with Infusion Nurses Society (2016) guidance. It would be helpful if the hospital developed algorithms that include standards to prevent and manage PIVC insertions and complications.

Comparison of ultrasound-guided peripheral intravenous catheter insertion with landmark technique in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult.

AIM

To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients.

STUDY DESIGN

Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound-guided PIVC insertion.

DATA SOURCES

Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase.

DATA EXTRACTION

English-language, paediatric trials published after 2000, reporting first-attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non-venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314).

RESULTS

Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first-attempt insertion success (RR 1.27; 95% CI 0.90-1.78; I²  = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90-1.44; I²  = 82%; low quality evidence), or time to insertion (mean difference -3.03 min; 95% CI -12.73 to 6.67; I²  = 92%; low quality evidence).

LIMITATIONS

Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions.

CONCLUSIONS

Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology.

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

AIM

This study aimed to identify the types of complications of peripheral intravenous catheters (PIVCs) in hospitalised children and possible risk factors for the development of extravasation, infiltration and phlebitis.

METHOD

The study was conducted in the largest children's hospital in a region of Turkey, with a bed capacity of 354 and 1400 employees, which provides care only to paediatric patients aged from newborn to 18 years old. In this 5-month prospective study, the complications of PIVCs in hospitalised children and risk factors leading to the development of extravasation, infiltration and phlebitis were recorded. During morning and afternoon daily visits, the researcher examined catheter sites for complications and indications for removal.

RESULTS

The study covered 244 patients aged from 1 month to 17 years, 575 PIVCs and 1600 catheter days. The rates of infiltration and phlebitis observed in children with PIVCs were 8.7 % and 15.8% respectively. Logistic regression revealed that using 22- and 24-gauge catheters, hospitalisation in the surgery ward and continuous infusion were significant independent risk factors for the development of infiltration (P<0.001). Direct logistic regression revealed that age in months, hospitalisation in a surgery ward and placement of the catheter in the veins of the antecubital fossa were significant independent risk factors for the development of phlebitis (P<0.001).

CONCLUSION

Catheter size, hospitalisation in the surgery ward and continuous infusion contributed to the development of infiltration. Age, hospitalisation in the surgery ward and catheter placement in the antecubital vein contributed to the development of phlebitis.

Evaluation of the Quality and Effect of 360° Safe Indwelling Infusion of Peripheral Venous Indwelling Needle in Pediatric Clinic

To evaluate the application effect of the 360° safe indwelling infusion program of peripheral venous indwelling needle in the infusion room of pediatric outpatient clinic. A total of 1,000 children who received indwelling needle infusion were randomly divided into experimental group (n = 500; 360° safe indwelling needle) and control group (n = 500; a routine indwelling needle). The incidence of indwelling needle-related complications and adverse events in the experimental group was significantly lower than that in the control group, and the number of indwelling days, indwelling needle usage rate, and parent satisfaction were significantly higher than those in the control group. The 360° safe indwelling infusion program can significantly reduce the incidence of complications and adverse events, and improve the quality of the indwelling needle infusion. The 360° safe indwelling infusion can effectively improve the comprehensive quality and safety of nursing care in the outpatient infusion room.

Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key

OBJECTIVE

To develop and validate a difficult intravenous access risk assessment and escalation pathway, to increase first time intravenous insertion success in paediatrics.

METHODS

Mixed methods underpinned by literature and co-production principles. Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia.

RESULTS

Interview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February-April 2020) involving 21 stakeholders culminating in the co-production of the "DIVA Key". The DIVA Key was evaluated between May-December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range = 81.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa = 0.71, 95% CI 0.63-0.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2-27.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR) = 10 [8-10]; 8 [8-10 respectively).

CONCLUSION

The DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.

Recognition and Management of Pediatric Sepsis in a Resource-Limited Emergency Department in Mwanza, Tanzania: A Qualitative Study

OBJECTIVE

The World Health Organization aims to reduce worldwide under-five mortality rates (U5MR), with a focus on resource-limited settings (RLS). Tanzania reports a mean U5MR of 54 per 1000 live births, largely due to treatable infectious diseases that may lead to sepsis, accounting for 40% of the under-five deaths. Bugando Medical Centre in Mwanza, Tanzania represents a resource-limited setting in Sub-Saharan Africa and estimates a 14% pediatric mortality rate. We sought to better understand provider experience in recognizing and managing pediatric sepsis in the emergency department (ED) at Bugando Medical Centre in Mwanza, Tanzania.

METHODS

We conducted a qualitative study with a purposive sampling of 14 Bugando Medical Centre ED providers from January to February 2019, via minimally structured interviews, to identify factors influencing the recognition and management of children presenting to the ED with concern for sepsis. Interviews were conducted in English, audio recorded, and transcribed. Data saturation determined the sample size. Three primary coders independently coded all transcripts and developed an initial coding list. Consensus among all authors generated a final coding scheme. A grounded theory approach guided data analysis.

RESULTS

We achieved thematic saturation after 13 interviews. Responses identified patient-, provider-, and health care system-related factors influencing sepsis recognition and management in children presenting to the ED. Patient-related factors include the use of traditional healers, limited parent health literacy, and geographic factors impacting access to medical care. Provider-related factors include limited knowledge of pediatric sepsis, lack of a standard communication process among providers, and insufficient experience with procedural skills on children. Health care system-related factors include limited personnel and resources, delayed transfers from referral hospitals, and lack of standard antibiotic-use guidelines.

CONCLUSIONS

This qualitative study identified patient, provider, and health care system-related factors that influence the emergency care of children with suspected sepsis in a quaternary hospital in Mwanza, Tanzania. These factors may serve as a framework for educational opportunities to improve the early recognition and management of pediatric sepsis in a resource-limited setting.

Risk factors for infiltration in children and adolescents with peripheral intravenous catheters

ABSTRACT Objectives: to estimate the incidence of infiltration and the factors associated with its occurrence in children and adolescents in the operative period and with peripheral intravenous catheters. Methods: a longitudinal and prospective study with children and adolescents using peripheral intravenous catheters, conducted at the surgical clinic unit of a pediatric hospital in Feira de Santana, State of Bahia, from April 2015 to December 2016. The study used Pearson’s chi-square and Fisher’s exact test for the analysis. It also applied multiple analyses using Poisson regression with robust variance. Results: the incidence of infiltration was 31.2% and was associated with female sex (RR=0.53; CI=[0.30-0.96]), non-eutrophic children (RR=2.27; CI=[1.25-4.20]), who used non-irritating and non-vesicant drugs (RR=1.72; CI=[1.03-2.87]), vesicant drugs (RR=1.84; CI=[1.05-3.22]) and irritating/vesicant electrolytes (RR=2.35; CI=[1.38-3.97]). Conclusions: the study suggests the development of strategies that will help in the prevention of this adverse event through the knowledge of the associated factors.

Techniques and Technologies to Improve Peripheral Intravenous Catheter Outcomes in Pediatric Patients: Systematic Review and Meta-Analysis

OBJECTIVE

Insertion and function of pediatric peripheral intravenous catheters (PIVCs) present challenges. We systematically reviewed techniques and technologies to improve PIVC outcomes (first-time insertion success, overall insertion success, time to insertion, dwell time, failure, and complications).

DATA SOURCES

Cochrane Central Register of Controlled Trials (CONTROL), Cumulative Index to Nursing and Allied Health (CINAHL), US National Library of Medicine, and Embase.

STUDY SELECTION

English-language pediatric trials published post 2010 reporting PIVC outcomes.

DATA EXTRACTION

Following Cochrane standards, two authors screened, extracted, and critiqued study quality (Grading of Recommendations Assessment, Development and Evaluation approach) data, random effects analysis, results expressed as risk ratios (RR), mean differences (MD) and 95% CIs.

RESULTS

Twenty-one studies (3237 children; 3098 PIVCs) were included. First-time insertion success significantly increased with ultrasound guidance (compared with landmark insertion; RR, 1.60; 95% CI, 1.02-2.50). Use of ultrasound guidance (compared with landmark insertion) did not improve overall PIVC insertion success (RR, 1.10; 95% CI, 0.94-1.28). There was no evidence of an effect of near-infrared (compared with landmark) on first-time insertion success (RR, 1.21; 95% CI, 0.91-1.59) or number of attempts (MD, -0.65; 95% CI, -1.59 to 0.29); however, it significantly reduced PIVC insertion time (MD, -132.47; 95% CI, -166.68 to -98.26) and increased first-time insertion success in subgroup analysis of patients with difficult intravenous access (RR, 2.72; 95% CI, 1.02-7.24).

LIMITATIONS

Few studies per intervention, small sample sizes, and inconsistent outcome measures precluded definitive conclusions.

CONCLUSIONS

Ultrasound and near-infrared appear to improve pediatric PIVC insertion. High-quality studies examining the full extent of techniques and technologies are needed. Registration: CRD42020175314.

Care related to peripheral intravenous catheterism in pediatrics performed by nursing technicians

OBJECTIVES

to evaluate the care practice adopted by nursing technicians before, during and after peripheral intravenous catheterization performed in hospitalized children.

METHODS

cross-sectional and descriptive research, carried out in a pediatric hospital in Bahia through non-participatory observation of peripheral intravenous catheterizations performed in children by nursing technicians. Data was collected through an instrument containing care related to the moments before, during and after insertion of the catheter, calculating absolute and relative frequencies, measures of central tendency and dispersion.

RESULTS

there were 31 nursing technicians, who performed care mainly before intravenous catheterization. Nonconformities were identified regarding hand hygiene, use of a disposable mask, selection of the catheter insertion site, antisepsis, stabilization and catheter coverage.

CONCLUSIONS

most of the precautions observed regarding peripheral intravenous catheterization are not in accordance with the standards of practice recommended by the national and international literature.

What Procedures Are Important to General Pediatricians and Why?

BACKGROUND/OBJECTIVE

Pediatric residents must demonstrate competence prior to graduation in Accreditation Council for Graduate Medical Education (ACGME) required procedures. Recent literature shows general pediatricians (GPeds) infrequently perform these procedures yet believe them important to learn. The purpose of this study was to determine why GPeds believe learning procedures was important, what barriers prevent them from developing and maintaining procedural skills, and what procedures they believe should be included in training.

METHODS

Fifty-one GPeds from the American Board of Pediatrics General Examination Committee and the central Ohio region participated in 30-minute semistructured recorded phone interviews that probed their use of procedures across training and current practice. Participants represented urban, suburban, and rural geographic regions and practiced in a variety of settings. We conducted a thematic analysis of transcribed interviews.

RESULTS

GPeds believed currently required ACGME procedures were crucial to learn for 5 reasons: 1) adaptation to change in practice type or location, 2) emergency preparedness, 3) counseling patients and families, 4) distance from a tertiary care center and specialists, and 5) professional identity as a pediatrician. Numerous barriers, particularly never learning the procedures, prevented GPeds from performing procedures in practice. Recommended procedures to be taught included high- (eg, circumcision), and low-risk (eg, cerumen removal, nasopharyngeal swabs, umbilical cauterization) skills.

CONCLUSIONS

GPeds believed procedural training was important, however may never have learned certain procedures. These findings suggest that teaching methods should be adapted or customized procedural education should be implemented to ensure relevancy of skills learned for clinical practice.

An international survey of pediatric and neonatal clinicians' vascular access practice: PediSIG assessment of vascular access, education, and support (PAVES) catheter selection

HIGHLIGHTS

There is a wide variance in neonatal and pediatric vascular access workforce models, training, and competency assessments. Pain control during procedures is critical for children, yet it is not consistently used. Procedural support has shown improved patient outcomes, yet is not standardly used for every distressful procedure. Core standards are needed to ensure proper training and support for the pediatric and neonatal vascular access clinicians.

BACKGROUND

Despite evidence to support best practice in neonatal and pediatric venipuncture delivery and procedural support, there are inconsistencies in practice. To inform future research, education, and workforce innovation, the Association for Vascular Access Pediatric Special Interest Group (PediSIG) developed and undertook a survey to describe the current vascular access practice for clinicians caring for neonatal and pediatric patients.

OBJECTIVE

Describe the current state of workforce models, training, and clinical practices surrounding pediatric and neonatal vascular access.

DESIGN

Cross-sectional, electronic survey using convenience sampling.

SETTINGS

International clinicians who provide vascular access (peripheral intravenous catheter insertion, venipuncture for blood sampling) for neonatal and pediatric patients.

METHODS

An electronic survey was developed by the PediSIG. The survey covered workforce models, clinician training and competency, pain relief, procedural support, and device securement. The electronic survey was then distributed to the PediSIG membership and shared among several neonatal/pediatric email lists. Data were analyzed descriptively, with an exploration of association between clinical outcomes, workforce, and training.

RESULTS

There were 242 responses from 5 countries showing a wide variance of practice. Workforce models showed many different team names and responsibilities along with a variance of personnel and staffing hours. Clinician training was described as 4 hours or less by 44% (n = 69) of respondents. Less than half of the responses (47%; n = 99) reported having a formal procedure to escalate a patient to an expert care and not having a set number of max attempts before escalation. Only two-thirds (n = 115) of respondents said they had a standardized protocol for pain control and procedural support, with only 13% (n = 23) and 15% (n = 27), respectively, self-reporting that they always followed the protocol.

CONCLUSIONS

The respondents reported a wide variance in neonatal and pediatric vascular access procedures and the resources used to support this practice. Core standards need to be developed to help guide neonatal and pediatric clinicians and their institutions. The standards should encompass recommendations for workforce models, proper training, competency, insertion guidelines, pain control.

Elaboration and validation of an algorithm for treating peripheral intravenous infiltration and extravasation in children

OBJECTIVE

to elaborate and validate the content and appearance of an algorithm for treating infiltration and extravasation of non-chemotherapy drugs and solutions administered to children.

METHOD

a methodological study of the technology formulation and validation type. To elaborate the algorithm, a bibliographic review was carried out to list the scientific evidence on the treatment of infiltration and extravasation. Content and appearance validation was in charge of 14 specialists in pediatric nursing, using the Delphi technique, adopting a value equal to or greater than 0.80 as Content Validation Index.

RESULTS

the algorithm was validated in the third evaluation by the judges, reaching a Global Content Validation Index of 0.99, being composed by the perception of the occurrence of the complication; discontinuation of intravenous therapy infusion; verification of signs and symptoms; measurement of edema; application of an infiltration and extravasation assessment scale and conduits to be used according to the characteristics of the fluid administered and the type of complication.

CONCLUSION

the algorithm was validated and can be used in a practical and objective way by health professionals, in order to promote safety in the care of hospitalized children, with regard to reducing harms caused by infiltration and extravasation.

Peripheral intravenous catheters in hospitalized patients: Practice, Dwell times, and factors impacting the dwell times: A single center retrospective study

BACKGROUND

Despite being the most common hospital procedure, limited information is available on the peripheral intravenous (PIV) catheter insertion practices. This study was designed to evaluate the contemporary PIV insertion practice (all age groups), and to identify the patient and device-related factors influencing the dwell times (<18 years).

METHODS

Single Center Retrospective study. Patients of all age groups admitted to the hospital for >4 midnights, from 01/2015 to 12/2019. Data extracted by automated EMR audits. Variables included patient demographics, number of PIVs inserted, PIV size, location, dwell time, and length of stay. Standard comparative analysis, including multivariable linear regression for dwell time performed for patients <18 years.

RESULTS

A total of 44,198 (39,341 (89%) adults and 4857 (11%) children) PIVs on unique patients met study criteria, with mean duration of 2.8 ± 2.4 days in children and 2.6 ± 1.3 days in adults (p < 0.001). Pediatric PIV had more dwell time variation, with a higher proportion lasting <1-day and also >2 SD of the age-specific mean, compared to adults. Adults had significantly higher number of PIVs placed/week compared to children. The failure rate for PIV was 56% in children and 76% in adults (p < 0.001). 1 out of 5 adults required >5 PIV/admission. Forty-five percent of children requiring only one PIV versus 21.8% of seniors. Discharge department, body part, and PIV size were independently associated with the dwell duration in children. No PIV size, however, had an independent increase in dwell duration over the reference of the 24 Ga cannula in children. PIVs placed in ante cubital vein and upper arm had dwell duration 26% and 20% longer than PIVs placed in the hand.

CONCLUSIONS

The failure rate of PIV is high, and patients are subjected to multiple insertions during hospitalization. Hospital unit, body part, and PIV size are associated with the dwell duration in children.

Improving Peripheral Intravenous Catheter Care for Children with Cancer Receiving Chemotherapy in Malawi

PURPOSE

To change pediatric oncology nursing management of peripheral intravenous catheter (PIVC) insertion and care based on current best evidence.

DESIGN AND METHODS

Practice change strategies were developed, and nurses completed education on proper PIVC insertion, dressing placement, and ongoing PIVC assessment with emphasis on preventing chemotherapy extravasation. Nurses also completed a chemotherapy course as part of their orientation program. The plan for PIVC practice change was based on evidence from published research and established PIVC care guidelines. Pre-assessment data revealed numerous PIVC attempts and a high incidence of extravasation (42%) in children with cancer receiving treatment in Malawi.

RESULTS

Post-assessment data nine months later resulted in a reduced extravasation rate from 42% to 4% using point prevalence assessments. PIVC insertion attempts reduced following education and guideline implementation; 81% of children required more than 3 PIVC insertion attempts before the practice change. Only 1% of PIVC insertions required more than 3 attempts after education and practice change implementation. Nurses completed a 32-item written examination before the chemotherapy course; the mean score was 50/100. Upon completion of the chemotherapy course, nurses obtained a mean score of 97/100 on the written examination.

CONCLUSIONS

Using an organized approach to nursing practice change improved PIVC care in children with cancer.

PRACTICE IMPLICATIONS

This project provides evidence that nursing practice change strategies can be used in any setting including countries like Malawi with limited resources.