Closing the gap in vascular access safety for children with cancer in LMICs: a quality improvement initiative evaluating a PICC care bundle in pediatric oncology.

backgroundPeripheral intravenous cannulas (PIVCs) are commonly utilized in pediatric oncology but are associated with a high incidence of phlebitis and recurrent venipuncture, particularly in children requiring prolonged therapy. Structured quality improvement (QI) strategies, such as standardized peripherally inserted central catheter (PICC) care bundles, have the potential to enhance vascular access safety, yet evidence from low- and middle-income countries (LMICs) remains limited. LOCAL PROBLEM: The baseline assessment of our pediatric oncology unit identified the absence of a standardized vascular access pathway, limited use of ultrasound for central access, and the occurrence of clinically significant phlebitis rates higher than 60% in children treated with routine peripheral cannulation. A context-adapted strategy was required to improve vascular access safety.

methodsWe performed a single-center quality improvement (QI) initiative in a tertiary pediatric oncology unit following the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 framework. A standardized peripherally inserted central catheter (PICC) care bundle was designed, implemented, evaluated, and sustained through iterative plan-do-study-act (PDSA) cycles over 18 months. Outcome, process, and balancing measures were tracked prospectively. For contextual interpretation, exploratory comparisons were made with routine peripheral cannula practice.

interventionsThe intervention was a nurse-led PICC care bundle including ultrasound-guided insertion, dedicated trained personnel, standardized insertion and maintenance protocols, structured staff education and competency training, and periodic audit-feedback mechanisms.

resultsPICC care bundle implementation was associated with no clinically significant phlebitis during PICC follow-up, addressing the high baseline phlebitis burden (approximately 61%) observed with routine peripheral cannula practice. Three CLABSI events occurred over 5364 observed PICC catheter-days, corresponding to a rate of 0.56 per 1000 catheter-days (95% CI 0.12-1.64). Lower rates of device-related complications and early removals were observed after PICC bundle implementation. Ultrasound guidance and SOP adherence were high (> 90%). PICC recipients reported lower pain scores and higher overall satisfaction.

conclusionImplementation of a standardized, ultrasound-guided PICC care bundle was feasible and associated with favorable vascular access and patient-reported outcomes in this resource-constrained pediatric oncology setting. Findings should be interpreted within a QI framework and do not imply causal or comparative device superiority.