Improving peripheral arterial catheter placement in critically ill children: a pre-post quality improvement study

Peripheral arterial catheter (PAC) assessment and insertion are essential but technically demanding procedures in pediatric intensive care. Practice varies widely, and inconsistent adherence to evidence-based standards contributes to preventable complications. This study aimed to improve the quality and safety of arterial catheterization in critically ill children through a structured quality improvement approach.

A pre-post quality improvement study was conducted in a pediatric intensive care unit (PICU) across three phases: baseline (April-September 2024), implementation (October 2024-February 2025), and follow-up (March-September 2025). Phase-specific samples comprised 121, 76, and 63 patients and 170, 105, and 100 catheterizations, respectively; patients could contribute to more than one phase. A structured audit-and-feedback system measured adherence to 12 operational audit criteria derived from 10 retained evidence-based recommendations. Barriers to best practice were identified through stakeholder interviews, and a multi-component intervention bundle-incorporating standardized checklists, ultrasound-guided cannulation training, electronic decision support, and tiered competency assessment-was developed and implemented. Statistical process control charts were the primary longitudinal analysis, with phase comparisons as supportive analyses.

Overall nursing adherence increased from a baseline centerline of 57.0% to a post-implementation centerline of 74.3% (baseline-to-implementation p < 0.001). Assessment adherence increased from 69.4% to 88.9%, and insertion adherence increased from 36.6% to 53.6% (p < 0.01). First-attempt success changed only from 64.1% to 68.3%, without a sustained statistical process control shift or significant phase differences (all p > 0.20). Complication rates showed a significant downward trend (Kendall's Tau = -0.432, p = 0.017).

The quality improvement bundle was associated with improved process adherence and lower observed complication rates in pediatric PAC management. However, the uncontrolled design limits causal attribution for the safety outcome. Assessment adherence responded rapidly, whereas insertion performance and first-attempt success remained operator-dependent, supporting continued competency-based training and routine ultrasound guidance.