Minimum Education and Training for Pediatric and Neonatal Peripheral Intravenous Catheter Care for All Clinicians: Position Paper

Peripheral intravenous catheter (PIVC) insertion is a frequent procedure for hospitalized pediatric and neonatal patients. Timely and successful PIVC insertion can be challenging in pediatric and neonatal patients due to small or fragile veins, younger age, obesity, and patient activity.1–5 First-attempt insertion success ranges from 64% to 74%, with an average of 2.1 attempts prior to insertion of a functional PIVC.6 In children with difficult intravenous access (DIVA), the average number of attempts increases to four prior to an insertion of a functional PIVC.3,7 In addition to insertion difficulty, once a functional PIVC is successfully inserted, it is reported that 34% to 56% will fail prior to treatment completion, often necessitating the need for additional attempts to replace the failed PIVC.7–10Consideration for vessel health and preservation for pediatric and neonatal patients begins at birth, and every decision for vascular access needs should include awareness of preserving vessels for lifelong use. The vessels that children are born with are the only vessels they will have to sustain their lifetime vascular access needs. Developing a minimum competency standard is crucial in protecting and preserving the vascular system for our youngest patients.11In a global study of 4206 children in 278 hospitals, researchers concluded global inconsistency existed in pediatric PIVC practice, resulting in patient harm.12 Health care providers caring for pediatric and neonatal patients require specialized education, training, and competencies for safe delivery of care.13–15 Blended learning strategies, which include evidence-based education and hands-on training, have been shown to be effective for initial and ongoing competency assessment.13,16–18 Establishing a pediatric and neonatal vascular access curriculum to include patient assessment; vessel anatomy and physiology; appropriate selection of vein, device, catheter (length and gauge), imaging modalities, insertion techniques, dressing, and securement; and documentation is essential.7,19–21In addition to a baseline knowledge of vascular anatomy and the ability to assess neonatal and pediatric patients vasculature, understand childhood developmental levels, and identify appropriate venipuncture pain management options, comfort holds, and distraction methods is necessary to provide optimal care.15,22–25 Ensuring appropriate training and competency prior to PIVC insertion in neonatal and pediatric patients must be established to advocate for the best care for our smallest, most vulnerable patients.2Pediatric and neonatal PIVC insertion requires a high level of skill for a successful procedure.2,15 Young patients report needle pain and fear as the most stressful procedure during a hospitalization.7,15,23,26 In addition to attending to the patient, parents of hospitalized children needing a PIVC have reported high levels of fear and anxiety of insertion procedure for their ­child.7,14,15,25,26Collaboration with the multidisciplinary care team and provider to select the most appropriate device at the initiation of therapy promotes vessel preservation, reduces unnecessary needlestick procedures, and reduces wastage of scarce health care resources and overall cost.27 In June 2020, the Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC) established core concepts including vessel preservation, harm minimization, and inclusion of patient preference in device decision making.28 The miniMAGIC guide provides criteria for appropriate device selection and should be considered as a clinical decision-making guide for term neonates, infants, children, and adolescents.28The complex skill of PIVC insertion requires a broad knowledge base and clinical competence from the initial patient assessment and device decision making to the technical skill of PIVC insertion to ensure an overall positive experience. Basic education related to PIVC insertion training is limited in health care schools29 and at many health care institutions.30,31 Specialized knowledge and critical thinking improve PIVC insertion success rates.15 Standardized education, training, and simulation have been shown to decrease the number of PIVC insertion attempts.19,32Developing clinician competency in a simulated environment with mentoring provides a safe environment to develop necessary technical and critical thinking skills. Documentation of this initial competency should be assessed by a proficient inserter and documented in the health care clinician file.13,19,33 Ongoing assessment of the health care clinician's competency should be monitored and documented at regular intervals.34 Competency review should include insertion success and patient experience outcomes.15 Deficiencies should be addressed through additional training.Children experiencing needlestick pain benefit from procedural support including distraction. Distraction interventions are effective in reducing pain and distress and can be used in every setting a child might receive care. Different distractions are more effective when tailored to the appropriate developmental stage. An effective distractor stimulates the senses, is easily implemented, offers active engagement, and is interesting enough to compete with a potentially painful stimulus.35 Nonpharmacological interventions can be low cost, effective, and used by any health care worker. Parents can also be taught how to coach their children through a procedure, but the literature reports parents may not be as effective in distracting the child.35,36A wide variety of distractors are successful in supporting children and should be used.36,37 Innovative examples of distraction devices include the use of a vibrating cold device that reduces pain by blocking pain impulses and virtual reality devices.38–43 Despite a large body of evidence supporting its use to decrease pain and anxiety with procedures, distraction is not consistently used for children.7,26,44 Child life specialists are highly effective in implementing nonpharmacologic pain management and also can help psychologically prepare the child for an invasive procedure.45 It is recommended that, whenever available, a child life specialist would be best practice to support children and their families during venipuncture procedures.45 For additional recommendations on comfort and distraction modalities by age, see Table 1.Minimum education and training for the insertion of ­pediatric and neonatal PIVC should include the following recommendations and components to ensure a comprehensive training ­curriculum.Maximize first-time insertion success.a)Ensure appropriately trained clinicians.b)Use a training program that includes an evidence-based comprehensive overview of peripheral intravenous vessel assessment, insertion techniques, infection prevention, and complication prevention and management.c)Conduct an initial skill competency of PIVC insertion in a simulated environment.d)Include essential components to training:i)Preprocedural education and preparation with patient and family for PIVC insertion. Plan should be individualized based on age, developmental level, culture, and previous experiences with PIVC insertion.ii)Avoid PIVC insertion veins in an area of flexion.iii)Avoid PIVC insertion in veins in the lower extremity in crawling or ambulatory patients.iv)Use appropriately sized PIVC (gauge and length) based on the vessel size, depth, and location.v)Use real-time vessel visualization modalities (ultrasound, near-infrared, transillumination technology) during PIVC insertion.46vi)Use pharmacological (numbing cream, needle-free jet injection, vapocoolant spray)47–50 and nonpharmacological techniques to reduce anxiety and pain during venipuncture attempts. Distraction and comfort positioning techniques need to match the age and developmental level and culture of the child.Site assessment hourly during continuous infusions and at least before and after intermittent infusions52Dressing assessment daily—clean, dry, intact (all 4 edges)Daily assessment of need and appropriateness of PIVC for current treatment plan including medication type and duration.Patency—to ensure ongoing patency flush device daily or per institutional guidelines.Indication for PIVCDIVA assessmentPIVC size (length and gauge)PIVC insertion: site, date, and time of insertion; inserting clinician; number of insertion attempts; number of clinicians attempting; use of technology to assist insertionRemovala)Reason for removalb)Date and time of removalc)Insertion site post removald)Any complications noted during dwell or at removalSuccessful PIVC insertion in neonatal and pediatric patients is multifactorial and involves skilled clinicians with an understanding of the best-practice evidence to provide safe, age-appropriate care. Minimum recommendations for health care clinician proficiency with neonatal and pediatric PIVC insertion and critical thinking skills are essential in this commonly performed invasive procedure. Initial competency should be assessed by an expert inserter and documented in the staff member's records. A plan for on-going competency evaluation should be in place. Evidence-based education, policies, and procedures are expected for clinicians to remain competent with PIVC insertion in pediatric patients. Data collection, review of adverse events, and performing a gap analysis are all measures to meet performance expectations. Certification in vascular access, continuing education, and advancing knowledge by attending educational events may enhance patient outcomes and safety for the patient and the health care clinician.This document is meant to serve as a basis for evidence-based decision making. Nothing contained within this position paper should take the place of following the approved instructions for use of a medical device provided by the manufacturer. The Association for Vascular Access (AVA) was founded in 1985 to promote the emerging vascular access specialty. Today, AVA stands at the forefront of protecting and saving lives via establishing best practices and promoting patient advocacy. AVA's multidisciplinary membership advances research, provides professional and public education to shape practice and enhance patient outcomes, and partners with the device-­manufacturing community to bring about evidence-based innovations in vascular access. To learn more or join, go to https://www.joinAVAnow.com. The Pediatric Neonatal Special Interest Group (PediNeoSIG) was established as a multidisciplinary group of practitioners dedicated to best practice in the science of vascular access for children, infants, and neonates as a special interest group of AVA. Adopted by: AVA Board of Directors and PediNeoSIG.Mary Beth Hovda Davis, MSN, RN, VA-BC™, PhD(cand) has been practicing as a pediatric nurse since 2006 and specializing in vascular access since 2008. She is a Nursing Practice Leader for the Pediatric Vascular Access program at the University of Iowa Stead Family Children's Hospital. She graduated with her bachelor of science in nursing from the University of Iowa College of Nursing and completed her master's in nursing education from Mount Mercy University in 2012. She is currently a PhD candidate at the University of Iowa College of Nursing with a research program focus on pediatric vascular access. Mary Beth has been a member of AVA since 2009 and has held several leadership positions including the chair of the executive leadership council for the PediNeoSIG. She was awarded the Janet Petit Scholar Award in Neonatal and Pediatric Vascular Access in 2022.Darcy Doellman, MSN, RN, VA-BC™, is a vascular access specialist and currently is the Associate Director on the Healthcare Strategy & Innovation for B. Braun Medical (Bethlehem, PA). Previously, Darcy was the Clinical Manager of the Vascular Access Team at Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio. Her clinical experience included all aspects of vascular access, education, policy and procedures, and research for neonatal, pediatric, and adult patients. Darcy is board certified in vascular access and is a former president of AVA. She was the 2003 recipient of the Suzanne Herbst Award. She is widely published in professional journals and a coauthor of the 2012 National Home Infusion Association Central Line Guidelines, 2016 Infusion Standards and a reviewer for the 2022 National Association for Neonatal Nurses PICC Guidelines. Darcy has a bachelor of science in nursing from Capital University in Columbus, Ohio, and a master's degree in nursing from the University of Phoenix.Disclaimer: The opinions expressed herein are my own and do not reflect the views of B. Braun Medical Inc., B. Braun of North America, or any other related company.Stephanie Pitts, DNP, RN, CPN, VA-BC™, NEA-BC, practiced as a pediatric nurse for 25 years and is a nurse innovator. She developed the Pediatric Vascular Access Team at St. Joseph's Children's Hospital (Tampa, FL) in 2008 and was a member of the team for 15 years. She innovated a medical device allowing the modified Seldinger technique to be used in our smallest patients. She is currently the Senior Director on the Healthcare Strategy & Innovation for B. Braun Medical (Bethlehem, PA), stockholder of AngioDynamics, Inc. (Latham, NY), and member of the Board of Directors for Navi Technologies (Melbourne, Australia). She is a former director- at-large for the AVA Board of Directors and is a past president of the Pediatric Special Interest Group. Stephanie has multiple publications, was the 2018 Janet Pettit Scholar Award in Neonatal and Pediatric Vascular Access and the 2022 Suzanne Herbst Award recipient.Disclaimer: The opinions expressed herein are my own and do not reflect the views of B. Braun Medical Inc., B. Braun of North America or any other related company.Tricia Kleidon, RN, MSc (Nurs. Pram.), PhD(cand) is a Nurse Practitioner in Pediatric Vascular Assessment and Management at Queensland Children's Hospital and Research Fellow at The University of Queensland. Tricia is part of a dynamic clinical and research team that prides itself on achieving positive outcomes for patients and minimizing vascular access related complications. Tricia is a key opinion leader, national and international speaker, and educator for peripheral and central venous access devices. Tricia is developing a publication track record and is currently enrolled in a PhD program of research entitled "Techniques and technologies to improve PIVC first time insertion success and reduce complications and failure." Tricia is an active member of the Alliance for Vascular Access Teaching and Research (AVATAR) and was recently awarded researcher of the year, 2017; AVA Janet Petit Scholar Award in Neonatal and Pediatric Vascular Access, 2019; and HDR student of the year 2021.