A Simple Catheter-Care Bundle Nearly Eliminated Phlebitis in Children Receiving Cancer Treatment
For children with cancer, a device designed to make treatment easier can become a source of repeated pain, inflammation and infection. Chemotherapy, antibiotics, transfusions and supportive medicines often require reliable access to the bloodstream, yet many pediatric oncology units in low- and middle-income countries still depend heavily on peripheral intravenous cannulas, or PIVCs. These short tubes are inserted into small veins in the hand or arm, sometimes repeatedly over weeks or months. In a new quality-improvement study from a tertiary pediatric oncology unit in New Delhi, India, clinicians reported that replacing much of this routine peripheral access with a carefully standardized peripherally inserted central catheter, or PICC, program was associated with a dramatic reduction in phlebitis and fewer device-related complications. The study, published in Supportive Care in Cancer, offers a practical example of how improvements in training, ultrasound use and nursing protocols can change the safety of cancer care without requiring a high-tech overhaul of an entire hospital.
The problem identified by the team was stark. Before the intervention, clinically significant phlebitis occurred in approximately 61 percent of children receiving routine peripheral cannulation. Phlebitis is inflammation of the vein surrounding an intravenous catheter. It can cause pain, redness, swelling and tenderness, and may force clinicians to remove the catheter and insert another one elsewhere. In children undergoing prolonged therapy, that cycle can mean repeated needle punctures, interrupted treatment and growing anxiety around each clinical visit. Chemotherapy can make the problem more complex because some drugs irritate the lining of blood vessels or can damage tissue if they leak outside the vein. Small pediatric veins are also vulnerable to movement, catheter dislodgement and infiltration, in which fluid escapes into surrounding tissue. The authors describe the baseline figure as a signal that vascular access was not simply a technical detail but a major patient-safety issue.
The intervention centered on a nurse-led PICC care bundle. A PICC is a flexible catheter introduced through a peripheral vein, usually in the upper arm, and advanced until its tip lies in a large central vein near the heart. Unlike a standard peripheral cannula, it can remain in place for longer treatment periods and allows repeated access without a new puncture for every infusion. But a PICC is not automatically safer. Because it enters the central circulation, poor insertion or maintenance can lead to serious complications, including central line–associated bloodstream infection, known as CLABSI, thrombosis, blockage or accidental removal. The New Delhi team therefore combined the device with a system of safeguards: ultrasound-guided insertion, dedicated trained personnel, written insertion and maintenance procedures, staff education, competency assessments and regular audit-feedback cycles. The bundle was designed for the resources and workflow of the local unit rather than imported as a rigid protocol.
The investigators evaluated the program as a quality-improvement initiative under the SQUIRE 2.0 reporting framework, rather than as a randomized clinical trial. Over 18 months, they used repeated plan–do–study–act cycles to introduce the approach, examine results, identify problems and refine practice. This matters because quality-improvement work asks a different question from a conventional efficacy trial. Instead of assigning comparable patients to competing treatments under controlled research conditions, it examines whether a change can be implemented and sustained in a real clinical setting. The team prospectively tracked outcome measures, process measures and balancing measures. Outcomes included phlebitis and catheter complications; process measures assessed whether staff followed the new standard operating procedures; balancing measures helped detect whether gains in one area were accompanied by new harms. Routine peripheral cannula practice was used for contextual comparison, but the authors explicitly caution that the study does not prove that PICCs are superior in every child or circumstance.
During PICC follow-up, the researchers recorded no clinically significant phlebitis, a striking contrast with the approximately 61 percent baseline burden associated with routine peripheral cannulation. The program also produced lower observed rates of device-related complications and early catheter removals. More than 90 percent adherence was reported for ultrasound guidance and the standardized operating procedures, suggesting that the intervention was not merely a written policy but was being applied at the bedside. Ultrasound can improve insertion by allowing staff to visualize veins in real time, identify vessel size and depth, and guide the needle rather than relying solely on surface anatomy. In children, whose veins may be narrow or difficult to locate, this can reduce unsuccessful attempts and tissue trauma. Standardized maintenance procedures, meanwhile, are intended to limit contamination and mechanical problems by making dressing changes, line access, flushing and surveillance more consistent across staff members and shifts.
The central-line infection results provide a more nuanced picture. Across 5,364 observed PICC catheter-days, three CLABSI events occurred, corresponding to 0.56 infections per 1,000 catheter-days, with a 95 percent confidence interval of 0.12 to 1.64. A catheter-day is one day in which one catheter remains in place, allowing infection rates to account for different durations of device exposure. The confidence interval is wide because the number of infections was small, so the true rate could plausibly be higher or lower than the estimate. Even so, the result indicates that extended central access was feasible in the unit without an obviously large infection burden under the new system. It also underscores why PICC care requires discipline: the absence of phlebitis does not eliminate the possibility of bloodstream infection, clot formation or other complications. Infections associated with central lines can progress rapidly in immunocompromised children, making sterile technique, daily assessment and prompt removal when a line is no longer needed essential components of safe practice.
The benefits were not limited to clinical measurements. Children who received PICCs reported lower pain scores and higher overall satisfaction, according to the study. That finding is important in pediatric oncology, where the cumulative experience of care can shape whether children and families view treatment as manageable or frightening. A PICC does not remove every discomfort: insertion still requires a procedure, the site needs protection, and families must learn how to recognize warning signs. But a line that remains usable over a longer period can reduce the number of repeated venipunctures and make blood sampling or infusion more predictable. Fewer failed attempts may also reduce procedural time for nurses and distress for caregivers. The authors acknowledge that satisfaction is influenced by many factors, including communication, staff confidence and family education, so it cannot be attributed to the catheter alone. The bundle’s educational elements may have contributed as much to the experience as the device itself.
The study’s implications extend beyond one hospital because vascular access is a systems problem. In many resource-constrained settings, the barriers to safer catheter care are not a lack of sophisticated equipment alone. They may include shortages of trained personnel, inconsistent access to ultrasound, high staff turnover, absent written protocols, limited auditing and insufficient time for competency-based education. The New Delhi initiative addressed several of these weaknesses together. A nurse-led model can be particularly valuable because nurses often perform daily catheter maintenance and are positioned to detect early changes at the insertion site or in a child’s condition. Audit-feedback creates a loop in which performance data are returned to the team, allowing practical deviations to be corrected before they become routine. Training also turns ultrasound and infection-prevention procedures from individual skills into shared institutional capabilities. Such changes may be more transferable than simply purchasing a different type of catheter.
There are important limits to the conclusions. This was a single-center quality-improvement project, and the PICC results were not generated through random assignment against a contemporaneous control group. Children selected for PICCs may have differed from those treated with peripheral cannulas in diagnosis, treatment intensity, illness severity, expected duration of therapy or other characteristics. The comparison with the earlier peripheral-cannula experience may therefore be affected by differences in patient populations and clinical practice over time. The study also reports associations rather than proof that the bundle caused every improvement. Its results should be tested in other hospitals, including facilities with different staffing levels, patient volumes and infection-control resources. Longer follow-up could clarify complications such as thrombosis and catheter malfunction, while multicenter studies could establish how reliably the approach works across low- and middle-income settings. Still, the findings deliver a compelling message: when reliable vascular access is treated as a coordinated safety program rather than a series of isolated insertions, children receiving cancer treatment may endure fewer painful procedures and avoidable complications.
The researchers’ work, funded by CanKids KidsCan in New Delhi, illustrates how quality improvement can turn an everyday clinical bottleneck into a measurable target for innovation. The result was not a new drug or an experimental device, but a coordinated set of practices—ultrasound guidance, trained staff, clear procedures, competency checks, caregiver education and continuous monitoring. Together, those elements were associated with no clinically significant phlebitis during PICC follow-up, a low observed CLABSI rate and better patient-reported experiences. For pediatric oncology units facing limited resources, that combination could be more realistic than expensive technological solutions, provided that training, supplies and leadership support are sustained. The study does not establish that every child should receive a PICC, nor does it erase the risks of central access. It shows instead that safer treatment may begin with making the basics reliable, repeatable and visible—and that this kind of operational change can have consequences felt directly by children at the bedside.
