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.
Singh A, Kumar R, et al. • Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer • 2026
Implementation of a standardized, ultrasound-guided PICC care bundle was feasible and associated with favorable vascular access and patient-reported outcomes in a resource-constrained pediatric oncology setting.
Key Findings
Background
Baseline phlebitis rates with routine peripheral cannulation in the pediatric oncology unit were clinically significant, exceeding 60%.
The baseline assessment identified the absence of a standardized vascular access pathway and limited use of ultrasound for central access.
Clinically significant phlebitis rates were 'higher than 60%' (approximately 61%) in children treated with routine peripheral cannulation.
This baseline burden motivated the development of a context-adapted strategy to improve vascular access safety.
Results
No clinically significant phlebitis occurred during PICC follow-up after implementation of the PICC care bundle.
This represented a complete elimination of clinically significant phlebitis events during PICC catheter follow-up.
This outcome was compared contextually against the approximately 61% baseline phlebitis burden observed with routine peripheral cannula practice.
The authors note findings should be interpreted within a QI framework and do not imply causal or comparative device superiority.
Results
The CLABSI rate associated with the PICC care bundle was 0.56 per 1000 catheter-days over 5364 observed PICC catheter-days.
Three CLABSI events occurred over 5364 observed PICC catheter-days.
The corresponding CLABSI rate was 0.56 per 1000 catheter-days (95% CI 0.12–1.64).
This rate was observed across an 18-month QI initiative at a single tertiary pediatric oncology center.
Results
Adherence to ultrasound guidance and standard operating procedures (SOPs) was high throughout the PICC care bundle implementation.
Both ultrasound guidance and SOP adherence exceeded 90% during the initiative.
These process measures were tracked prospectively as part of the QI framework.
The care bundle included dedicated trained personnel and periodic audit-feedback mechanisms to sustain adherence.
Results
Lower rates of device-related complications and early removals were observed after PICC bundle implementation.
These outcomes were tracked as part of outcome and balancing measures prospectively collected during the QI initiative.
The initiative was conducted over 18 months using iterative plan-do-study-act (PDSA) cycles.
Specific numerical rates of device-related complications and early removals are not provided in the abstract.
Results
PICC recipients reported lower pain scores and higher overall satisfaction compared to the baseline peripheral cannulation context.
Patient-reported outcomes including pain scores and overall satisfaction were tracked prospectively as part of the QI evaluation.
Lower pain scores were noted among children receiving PICCs under the standardized bundle.
These findings are described as exploratory comparisons made for contextual interpretation within the QI framework.
Results
The nurse-led PICC care bundle was feasible to implement in a resource-constrained, low- and middle-income country (LMIC) pediatric oncology setting.
The care bundle included ultrasound-guided insertion, dedicated trained personnel, standardized insertion and maintenance protocols, structured staff education and competency training, and periodic audit-feedback mechanisms.
The initiative followed the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 framework.
The study was conducted at a single tertiary pediatric oncology unit over 18 months.
The authors note that evidence from LMICs on structured QI vascular access strategies had previously been limited.
What This Means
This research describes a quality improvement project at a children's cancer center in a lower-income country setting, where the team identified a serious problem: more than 60% of children receiving chemotherapy through standard arm vein (peripheral) catheters were developing phlebitis, a painful inflammation of the vein. The team designed and introduced a structured care bundle — a set of standardized practices — for placing and maintaining a type of central line called a PICC (peripherally inserted central catheter). The bundle included using ultrasound to guide catheter placement, training dedicated nursing staff, following strict insertion and maintenance protocols, and regularly checking whether staff were following the procedures correctly.
After implementing the bundle over 18 months, no children developed clinically significant phlebitis related to their PICC lines, compared to the very high baseline rate with standard peripheral catheters. The rate of serious bloodstream infections (CLABSIs) was very low at 0.56 per 1000 catheter-days, with only 3 infections across more than 5,300 days of catheter use. Children also reported less pain and greater satisfaction with their care. Staff followed the ultrasound and protocol guidelines more than 90% of the time, showing the bundle was consistently applied.
This research suggests that a well-designed, nurse-led vascular access care bundle can be successfully implemented even in resource-limited settings and can dramatically reduce painful complications for children with cancer. The findings are particularly relevant for hospitals in lower- and middle-income countries that may lack standardized vascular access practices, showing that with structured training, clear protocols, and regular feedback, safer central line care is achievable without highly specialized infrastructure.
Singh A, Kumar R, Goel N, Bagai P, Prabhakar P, Chopra N, et al.. (2026). 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.. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. https://doi.org/10.1007/s00520-026-11145-4