A Prospective Cohort Study of Technique and Technology Used to Improve First Time PIVC Insertion Success in Hospitalised Paediatric Patients

ABSTRACT

Aim(s)

To determine the association between patient characteristics, techniques, and technologies with first‐time peripheral intravenous catheter insertion in paediatric acute care.

Design

Single‐centre, prospective cohort study.

Methods

Data on patient, provider, and peripheral intravenous catheter insertion characteristics were collected at a large quaternary paediatric hospital in Queensland, Australia. Inpatients aged 0 to ≤ 18 years requiring a peripheral intravenous catheter or who had one inserted in the last 24 h, were eligible. Proportionate stratified random sampling was used. Generalised linear regression with modified Poisson regression assessed associations between patient variables (e.g., age) and first‐time insertion success, along with technique (e.g., inserting clinician) and technology (e.g., ultrasound) variables. Models were adjusted for confounding variables identified through direct acyclic graphs.

Results

199 children required 250 peripheral intravenous catheters (July 2022–September 2023). In the adjusted model, each year of age increase and every 5‐kg increase in weight were associated with higher first‐time insertion success. Children with a history of prematurity had an increased risk of first‐time insertion failure. Vascular access specialists were more likely to succeed on the first attempt, as was ultrasound‐guidance when adjusted for difficult intravenous access risk.

Conclusion

We identified techniques (expert clinicians) and technologies (ultrasound guidance) that improve first‐time insertion success in paediatric patients.

Implications

A multi‐faceted approach combining technique (clinician), technology (ultrasound guidance), and standardised policy can improve first‐time peripheral intravenous catheter insertion. These strategies minimise patient discomfort, trauma, and emotional distress, enhancing the overall healthcare experience for children and their families.

Impact

This study emphasises the need to standardise healthcare policies and training, incorporating clinician expertise and ultrasound guidance to improve first‐time insertion success, particularly for high‐risk patients.

Reporting Method

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Patient or Public Contribution

No Patient or Public Contribution.

Trial Registration

Australia New Zealand Clinical Trials Registry, ACTRN12622000034730

Summary.

• What is already known?

  • ○
    Successful insertion of peripheral intravenous catheter on the first attempt in paediatric patients ranges from 33% to 50%.
  • ○
    Multiple attempts to insert a functional peripheral intravenous catheter increase the risk of complications such as infection, pain, and psychological trauma.
  • ○
    Failed insertion of peripheral intravenous catheters delays necessary clinical treatment and increases cost.
• What the paper adds?

  • ○
    Non‐modifiable factors, including patient age and weight, reduce successful insertion of peripheral intravenous catheters on the first attempt.
  • ○
    Modifiable factors, including the use of technology (ultrasound guidance), and technique (clinician), increase successful peripheral intravenous catheter insertion on the first attempt.
  • ○
    Highlights the need for standardised practices and policy support across healthcare systems to improve first‐time peripheral intravenous catheter insertion success in paediatric patients.
• Implications for practice/policy?

  • ○
    Implement specialised training for healthcare professionals on using advanced technologies, such as ultrasound guidance, for paediatric PIVC insertion.
  • ○
    Conduct comparative and longitudinal studies to assess the effectiveness, sustainability, and impact of techniques on patient outcomes, provider satisfaction, and healthcare costs.
  • ○
    Update PIVC insertion guidelines to include standardised protocols and frameworks for adopting new techniques and technologies.
• What does this paper contribute to the wider global clinical community?

  • ○
    Non‐modifiable patient factors (such as age, weight, and history of prematurity) influence paediatric first‐time peripheral intravenous catheter insertion success, highlighting the need for tailored clinical approaches to optimise outcomes in diverse healthcare settings.
  • ○
    Evidence for the global integration of vascular access specialists and ultrasound technology into clinical practice to improve first‐time peripheral intravenous catheter insertion success, particularly in children with difficult intravenous access.
  • ○
    Standardised policies and training programs for healthcare providers are essential to ensure consistent best practices in peripheral intravenous catheter insertion across diverse clinical settings to improve outcomes for all patients.

1. Introduction

Peripheral intravenous catheters (PIVCs) are the most ubiquitous vascular access devices in paediatric healthcare worldwide due to their versatility, efficiency, and cost‐effectiveness (AIHW ²⁰²⁰; Ullman et al. ^{2020, 2019}). PIVCs are purported to provide prompt and reliable intravenous access for therapies such as blood sampling and fluid or medication infusion. However, this utopian view of PIVCs is often not met. Failure to insert a PIVC regardless of the number of attempts occurs in approximately 10% of paediatric patients (de Negri et al. ²⁰¹²). Even when insertion is successful, the rate of first attempt failure ranges from 33% to 50% (Avelar, Peterlini, and da Luz Goncalves Pedreira, 2015; Benkhadra et al. ²⁰¹²; Doniger et al. ²⁰⁰⁹; Hanada et al. ²⁰¹⁷; Kleidon et al. ²⁰¹⁹; Larsen et al. ²⁰¹⁰; Sharp et al. ²⁰²³). Schults et al. (2022) reported that children with difficult intravenous access (DIVA) are likely to be those of young age (history of prematurity and less than 3 years old), disease chronicity (severe co‐morbidities and prolonged hospitalisation), and few palpable and visible veins have even lower first attempt success rates. This is the first paediatric study to specifically examine the critical factor of first‐time PIVC insertion success, a globally relevant issue for paediatric care. Unlike previous research that has primarily focused on device failure and related complications, our study aims to address the broader clinical challenge of improving first‐attempt PIVC insertion success rates across diverse paediatric populations. The findings have the potential to inform best practices and improve outcomes in hospitals worldwide, especially in regions where paediatric healthcare resources are limited, and insertion failures can lead to significant patient harm.

2. Background

The variability in first‐time PIVC insertion success is likely due to patient factors such as age and clinical group. Younger children, especially those under 3 years of age or with a history of prematurity, often experience difficult intravenous access, resulting in lower success rates (de Negri et al. ²⁰¹²). Additionally, the variability in child physiology and development across different age groups contributes to these challenges. For instance, premature infants face further difficulties due to underdeveloped vasculature, low blood pressure, and reduced circulating blood volume, which complicate vein identification and insertion. In toddlers with higher adiposity, vein palpation and access can be more difficult due to the increased subcutaneous fat, while in leaner adolescents, vein access may be less challenging. Paediatric patients with chronic conditions, severe comorbidities, or acute illnesses such as sepsis, as well as those experiencing prolonged hospitalisation or requiring intensive care, are at an increased risk of PIVC insertion failure. These patients are also more susceptible to complications, including extravasation and infection, due to the complexity of their medical conditions and the challenges associated with vascular access (McMullan et al. ²⁰²⁴).

In addition to the increased clinical workload and healthcare costs (Goff et al. 2013; Helm et al. ²⁰¹⁵; Kleidon et al. ²⁰¹⁹), these insertion failures result in immeasurable patient harm, including increased complications (extravasation and infection) (Kleidon et al. 2019; Morrell ²⁰²⁰; Reigart et al. ²⁰¹²; Schults et al. ²⁰²³) and childhood psychological trauma or paediatric medical traumatic stress (PMTS) (Kleidon et al. 2019; Price et al. ²⁰¹⁶; Sharp et al. ²⁰²³). The incidence of PMTS varies across different childhood diagnostic groups, with the highest rates observed in children admitted to the intensive care unit (up to 84%) and among survivors of childhood cancer (75%). This is likely related to the complexity and frequency of primarily needle‐based medical treatments (Christian‐Brandt et al. ²⁰¹⁹; Price et al. ²⁰¹⁶).

Clinicians have explored techniques and technologies to improve PIVC first‐time insertion success. ‘Technique’ refers to the manner of performing a procedure (Medical Dictionary for the Health Professions and Nursing ²⁰¹²) and includes the site of insertion, inserter expertise, angle of catheter insertion, catheter‐to‐vein ratio, needle tip dynamics, and comfort measures. Comparatively, ‘technologies’ are the application of scientific knowledge for practical purposes via devices (Medical Dictionary for the Health Professions and Nursing ²⁰¹²) and involve vessel visualisation (transillumination, near‐infrared, ultrasound) and catheter technology (material and length). Our systematic review (Kleidon et al. 2021) that included all children, irrespective of risk of difficult intravenous access (four studies, 592 patients), found first‐time PIVC insertion success improved with ultrasound guidance (relative risk [RR] 1.60; 95% confidence interval [CI], 1.02–2.50). The effect size increased (RR 1.87; 95% CI, 1.56–2.24) in high‐risk cohorts such as children with difficult intravenous access with characteristics such as non‐visible or palpable veins (3 studies, 309 patients. Despite the improved first‐time insertion success demonstrated using image‐guided technology such as ultrasound, first‐time insertion success remains unacceptably low. This might be due to a lack of studies comprehensively studying concurrent factors that could improve first‐time insertion success.

3. The Study

3.1. Aim

The aim of this study was to explore current practice while identifying patient characteristics that are associated with first‐attempt PIVC insertion success and techniques and technologies that are associated with first‐time insertion success in paediatric acute care.

3.2. Our Research Questions Were

1. What are the PIVC insertion characteristics (e.g., insertion site, catheter choice, use of techniques and technologies) in paediatric acute care?

2. What are the patient characteristics (including demographic information) associated with the overall first attempt PIVC insertion success in paediatric acute care?

3. What are the techniques and technological variables (including clinical expertise, PIVC characteristics, and technological aids) that are associated with first‐time PIVC insertion success by the final successful inserter in paediatric acute care?

4. Methods

4.1. Design

A prospective cohort study was undertaken between July 2022 and September 2023.

4.2. Study Setting

The study was conducted in a large quaternary paediatric hospital in Queensland, Australia. Participation was across all clinical departments within the Queensland Children's Hospital (QCH), Australia. QCH provides 359 inpatient beds and care for patients, including neonates (excluding premature neonates requiring immediate post‐birth clinical care) up to 18 years of age. QCH provides clinical care for all major clinical specialties, including oncology and cardiology. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Vandenbroucke et al. 2014). The study was prospectively registered (ACTRN12622000034730) with the Australian New Zealand Clinical Trials Registry. It was an observational study with no new interventions, and although not required, the trial was prospectively registered to promote transparent research practices.

4.3. Participants/Sampling

4.3.1. Inclusion Criteria

All inpatients aged 0 to ≤ 18 years, requiring insertion of a PIVC, or who had PIVC inserted in the last 24 h, were eligible for study inclusion. Children were excluded if PIVC insertion documentation was incomplete, they were palliative, PIVC with intended dwell of < 24 h, under the care of the Child Protection Act 1999 (Queensland Government ²⁰¹⁸) or from non‐English speaking backgrounds, and consent was not possible after attempting to contact the relevant case worker or engaging the services of an interpreter.

In addition to the inclusion criteria, participants were sampled using a proportionate stratified sampling approach (Daniel 2011) to ensure a representative sample of patients from various clinical units (medical, surgical, and critical care), and age groups (Hardin et al. 2017; Ullman et al. ^{2020, 2019}). Age was categorised by infancy (birth–2 years), childhood (> 2–12 years), and adolescence (> 12–18 years) (AIHW ²⁰²³). As per our prior observational studies (Ullman et al. 2022, 2023), patients were screened Monday—Friday, with a maximum of 10 PIVCs recruited at any one time to ensure optimal data collection with minimal data loss.

4.4. Outcome

The outcome was first‐time insertion success (dichotomous outcome; yes/no), collected at insertion by the nurse assisting with PIVC insertion. This was defined as one skin puncture to achieve successful PIVC insertion as indicated by the ability to infuse 5–10 mL 0.9% sodium chloride without resistance or evidence of external swelling at the PIVC insertion site (Kleidon et al. 2023).

4.5. Variables

Variables were selected based on characteristics previously identified in the literature as clinically significant and predictive of first‐time insertion success, as well as those associated with PIVC insertion failure resulting in multiple attempts (Cuper et al. 2012; Kleidon et al. ²⁰²¹; Schults et al. ²⁰²²; Yen, Riegert, and Gorelick ²⁰⁰⁸).

Variables were categorised into two groups:

1. Patient characteristics: age (in months), age group, history of prematurity, weight (kg), sex, number of comorbidities (Defined as acute or chronic conditions unrelated to the primary diagnosis. All comorbidities were considered equally relevant and identified and systematically collected from the patient's electronic medical records) (Tai et al. 2006), primary diagnosis group, current infection, and level of consciousness.

2. Technique and technology (incorporating provider and PIVC insertion characteristics): clinical expertise, PIVC characteristics (e.g., site of insertion), use of pain relief and anxiolysis (e.g., sedation and anaesthesia, and topical anaesthetic), department of insertion (clinical location at which the PIVC was inserted), and technological aids during insertion including use of image guidance (e.g., ultrasound).

4.5.1. Establishing Covariates

To illustrate the potential effects of various exposures of interest and their interrelationships, we created a causal directed acyclic graph (DAG) (see Figure 1 and Figures S1–S15). A DAG is a visual representation that shows how different factors are related, with arrows indicating the direction of influence. It helps identify cause‐and‐effect relationships, direct and indirect paths, and potential confounders, making it easier to understand how variables interact in a study (Ferguson et al. 2020; Tennant et al. ²⁰²¹). In the absence of a pre‐established DAG, we sought an expert consensus (three senior anaesthetists, three vascular access nurse specialists, 1 senior interventional radiologist, 1 vascular access research specialist, and 1 statistician) to focus on pre‐treatment covariates related to the exposure and identify all known prognostic factors for the outcome (Tennant et al. 2021). Most causal relationships between model variables were intuitive and clearly defined during face‐to‐face discussion, resulting in minimal disagreement among the experts. Any conflict was resolved with discussion and mutual agreement (Ferguson et al. 2020) (Table 1).

FIGURE 1.

Example of directed acyclic graph—Use of technology for insertion (Ultrasound). Green path: Represents the causal path being analysed (from exposure to outcome). Black arrows: Represent direct causal relationships between variables. Pink/red path: Indicates biasing paths that need to be blocked by adjusting for confounders. The absence of pink/red paths indicates no biasing paths that require adjustment for the analysis of interest (Textor et al. 2016).

TABLE 1.

List of confounders identified for each exposure.

Variable	Confounders
Patient clinical characteristics
Age	No confounders identified
Weight	History of prematurity
Prematurity (World Health Organization 2021)	No confounders identified
Sex	No confounders identified
Number of co‐morbidities (World Health Organization 2021)	History of prematurity, Age
Primary diagnosis	Current infection, History of prematurity
Current infection	Primary diagnosis, History of prematurity
Level of consciousness a	Sedation and anaesthesia, age, Department of insertion
Technique
Clinician	Age, DIVA classification, Department of insertion, Diagnosis, history of prematurity
PIVC insertion site	Previous PIVC, Use of technology for insertion
Department of insertion	Diagnosis and history of prematurity
Sedation and Anaesthesia	Department of insertion, Inserting clinician, Age
Level of consciousness	Department of insertion, Inserting clinician, Sedation, Age
Topical anaesthesia	Inserting clinician and Department of insertion
Technology
Ultrasound	DIVA status
Vein size	Age, weight

^a The inserting clinician wasn't included as a confounder at the patient clinical characteristics level because data was only collected on the final successful inserter. This clinician may have differed from the initial inserter due to multiple insertion attempts by different clinicians.

4.6. Data Collection

At recruitment, baseline patient information was collected by a research nurse (ReNs) (demographics, admitting diagnosis, comorbidities, difficult intravenous access risk using DIVA key (Schults et al. 2022), vein size (the diameter of the vein was measured in both horizontal and vertical directions at the time of insertion when ultrasound guidance was used, depending on the clinician's ability to consistently measure vein size during the procedure), infection at the time of insertion, and co‐morbidities) and entered into an electronic data platform supported by Research Electronic Data Capture (REDCap) (Ogundimu, Altman, and Collins ²⁰¹⁶; Vittinghoff and McCulloch ²⁰⁰⁷) Baseline data also included catheter variables (e.g., gauge, insertion site, catheterised vein) and insertion details (e.g., department of insertion, number of insertion attempts, technique (e.g., use of sedation, clinician experience), and technology (e.g., image guidance). Any insertion information that could not be collected at the time of insertion was extracted from the patient's electronic medical record (EMR) as an additional data source. Where possible, we included every PIVC the participant had during their admission until PIVC failure, end of treatment, hospital discharge, or insertion of a central venous access device.

4.6.1. Bias

To control for selection bias (Grimes and Schulz 2002), we implemented an equitable inclusion criterion, guided by the need for stratification based on the existing number of patients recruited in specific clinical or age strata. Despite this, some participants were missed due to staff availability and reaching the maximum recruitment limit. Recall bias (Grimes and Schulz 2002) was eliminated by using prospective data collection methods and electronic medical records to confirm staff and patient/parent‐reported data. Information bias (Grimes and Schulz 2002) was reduced by having two dedicated clinical research nurses collect the data with clearly defined outcome definitions.

4.7. Sample Size Calculation

The required sample size to assess 10 potential risk factors was calculated using the “10 events per variable” rule, which recommends a minimum of 10 events per predictor variable for reliable statistical analysis (Ogundimu, Altman, and Collins ²⁰¹⁶; Vittinghoff and McCulloch ²⁰⁰⁷).

This determined that 250 patients, with an expected PIVC first‐time insertion failure of 40% (Avelar, Peterlini, and da Luz Goncalves Pedreira, 2015; Benkhadra et al. ²⁰¹²; Doniger et al. ²⁰⁰⁹; Hanada et al. ²⁰¹⁷; Kleidon et al. ²⁰¹⁹; Larsen et al. ²⁰¹⁰; Sharp et al. ²⁰²³), 100 events were required.

4.8. Statistical Methods

After data collection, data were cleaned and downloaded from REDCap (Ogundimu, Altman, and Collins ²⁰¹⁶; Vittinghoff and McCulloch ²⁰⁰⁷) to Stata version 18.0 for data management and analysis (StatCorp ²⁰⁰⁶). Observations collected during daily checks were collapsed into a single observation per device. Categorical variables (e.g., site of insertion) were recoded and grouped as necessary for descriptive statistics. As a rule, the largest category was selected as the reference category for categorical variables unless the variable had ordinal levels (where the most logical reference was used, e.g., the lowest level for age groups). Continuous variables (such as age and weight) were analysed both as continuous measurements and in pre‐specified clinically meaningful categories. Continuous variables were categorised based on clinically relevant cut points from established literature and guidelines: age was categorised according to developmental stages (infancy: birth–2 years, childhood: > 2–12 years, and adolescence: > 12–18 years) (Cohen Hubal et al. 2013; Hardin et al. ²⁰¹⁷) weight categories were based on 5 kg increments for ease of clinical interpretation. The distribution of continuous variables was assessed through visual inspection of histograms and normal probability plots. Variables were kept at their original scale to maintain ease of clinical interpretation. Therefore, no transformation was applied. The percentage of devices within each variable category in the tables is reported as a row percentage to evaluate the likelihood of the outcome (Althouse, Raffa, and Kormos ²⁰¹⁶). Missing data were not imputed.

For the analysis of patient characteristics, the outcome was first‐time insertion success by the initial clinician attempting PIVC insertion. For the analysis of techniques and technological characteristics, the outcome was first‐time insertion success by the final successful inserting clinician, irrespective of attempts by previous unsuccessful inserters.

Generalised linear regression with modified Poisson regression with a robust error variance was used to analyse the association between patient variables and overall first‐time insertion success and the association between technique and technology variables (Greenland 2004; McNutt et al. ²⁰⁰³; Zou ²⁰⁰⁴). It was implemented using a log link function, which allows direct estimation of relative risks for our binary outcome. Robust error variance was used, which provides valid estimates even when standard Poisson assumptions are violated (Zou 2004). This approach is particularly important when using Poisson regression for binary outcomes, as the variance–mean relationship assumption of Poisson regression is naturally violated for binary data. Results are presented as relative risks with 95% confidence intervals (Greenland 2004; Spiegelman and Hertzmark ²⁰⁰⁵).

In our dataset, clustering was minimal, with only 26 patients (13.1%) having multiple PIVCs. Each PIVC insertion represented a distinct clinical event, often performed by different clinicians using varied techniques at different timepoints (Galbraith, Daniel, and Vissel ²⁰¹⁰). No offset term was used as we were modelling the probability of success rather than a rate. Our analytical approach focused on confounding relationships identified through DAGs rather than effect modification. Therefore, interaction terms were not included in the primary analyses. Each variable was analysed in two ways: (1) Unadjusted model including only the variable of interest; (2) Adjusted model including the variable of interest and its relevant confounders identified through DAGs. Results are presented as relative risks with 95% confidence intervals (Greenland 2004; Greenland, Pearl, and Robins ¹⁹⁹⁹; Hernán et al. ²⁰⁰²). Weight was found to be highly correlated with age and was therefore excluded from models that included age to avoid multicollinearity. Stratified analyses by age group and clinical group were conducted to examine whether associations differed across these important subgroups.

4.9. Ethical Considerations

Ethical approval was obtained from both the Children's Health Queensland Hospital and Health Service on 13th December 2021 (HREC/21/QCHQ/81465) and from The University of Queensland on 30th May 2022 (2022/HE000567). Data collected during the study period did not deviate from usual patient care and assessment; therefore, written patient consent was not required. All patient data were de‐identified, and only aggregate results are reported.

5. Results

5.1. Characteristics of the Sample

5.1.1. Patient Characteristics

A total of 199 children and 250 PIVCs were included in the analysis. Most children had one PIVC, with 26 patients (13%) requiring multiple PIVCs (2 PIVCs n = 16; 3 PIVCs n = 6; 4 PIVCs n = 4). Participant median age and weight were 48 months (IQR 5–120 months) and 17 kg (IQR 7–34 kg), respectively. Most participants were male (n = 134; 54%) without a history of prematurity (n = 188; 82%). Forty‐nine (20%) children had two or more co‐morbidities, and most children had an infection at the time of PIVC insertion (n = 140; 56%). Ninety‐two (37%) children were assessed as low risk for difficult intravenous access (see Table 2).

TABLE 2.

Baseline patient characteristics (n = 250).

Characteristics	N (%)
Age, months (median; IQR)	48 (5–120)
Sex, female	116 (46.4)
Weight, kg (median; IQR)	17 (7–34)
Patient diagnostic group stratification
Medical	118 (47.2)
Surgical	95 (38.0)
Critical Care	37 (14.8)
Patient age stratification
Infancy (birth–2 years)	104 (41.6)
Childhood (> 2–12 years)	99 (39.6)
Adolescence (> 12–18 years)	47 (18.8)
DIVA status (n = 249)
Low risk	92 (37.0)
Medium risk	74 (29.7)
High risk	83 (33.3)
Dominant side
Right	102 (40.8)
Left	20 (8.0)
Ambidextrous/too young	124 (49.6)
Unknown	4 (1.6)
Primary diagnosis
Medical – General	110 (44.0)
Surgical – General	96 (38.4)
Oncology/ haematology	3 (1.2)
Cardiac – Medical	8 (3.2)
Cardiac – Surgical	12 (4.8)
Respiratory – Chronic (e.g., Cystic Fibrosis)	10 (4.0)
Gastroenterology	11 (4.4)
History of prematurity (Yes; N = 229)	41 (17.9)
Number of co‐morbidities
0	117 (46.8)
1	84 (33.6)
2	29 (11.6)
≥ 3	20 (8.0)
Infection at time of recruitment (Yes)	140 (56.0)

Abbreviations: DIVA, difficult intravenous access; IQR, interquartile range; N, number; kg, kilogram.

5.1.2. Peripheral Intravenous Catheter Characteristics

Table 3 outlines 75% (n = 191) of the children sampled had more than one PIVC during their current hospital admission, and 40% (n = 100) had at least 10 PIVCs during their lifetime, but most patients had a history of so many PIVCs that they could not recall the exact number. Medical Officers inserted 189 (76%) of PIVCs. Most PIVCs (n = 213; 85%) were 22‐gauge or larger in diameter. Multiple insertion attempts were required prior to successful PIVC insertion in 94 (38%) of PIVCs. Ninety‐two (36%) patients needed multiple clinicians to achieve successful PIVC insertion; however, three‐quarters (197 PIVCs, 79%) of the final successful inserters succeeded on their first attempt (Table 5). Of the 150 (60%) PIVCs that were inserted while the child was conscious (maintaining their own airway), almost half (113 PIVCs; 45%) were not offered procedural support; however, 100 (40%) had topical anaesthesia applied (Table 3).

TABLE 3.

Baseline insertion characteristics (n = 250).

Characteristics	N (%)
Number of previous PIVC (ever)
None	36 (14.4)
1–5	98 (39.2)
6–10	14 (5.6)
> 10	31 (12.4)
Too many to count	69 (27.6)
Unknown	2 (0.8)
Number of previous PIVC (this admission only)
0	59 (23.6)
1	82 (32.8)
2	58 (23.2)
3	22 (8.8)
4	11 (4.4)
5	7 (2.8)
> 5	11 (4.4)
Sedation and anaesthesia
None	113 (45.2)
Gas and oral	79 (31.6)
General anaesthesia	58 (23.2)
Topical anaesthesia (Yes)	100 (40.0)
PIVC (gauge)
24 g (short) + 26 g	37 (14.8)
24 g (long)	31 (12.4)
22 g (short)	89 (35.6)
22 g (long)	16 (6.4)
22 g (long integrated)	50 (20)
16–20 g	27 (10.8)
Number of clinicians attempting insertion (N = 92) median (IQR)	2 (1–2)
Total number of attempts by successful inserter
1	197 (78.8)
2	43 (17.2)
3	6 (2.4)
4	3 (1.2)
Unknown	1 (0.4)
Post procedural pain score
FLACC (n = 90) Median (IQR)	50 (40–80)
Faces (n = 26) Median (IQR)	50 (32–80)
Numerical (n = 17) Median (IQR)	50 (4–70)

Note: Short and Long PIVC defined – 24 g short (19 mm); 24 g long (30 mm); 22 g short (25 mm); 22 g long (45 mm); 22 g long, integrated (45 mm with integrated extension).

Abbreviations: FLACC: Face, Legs, Activity, Cry and Consolability; g, gauge; IQR, interquartile range; PIVC, peripheral intravenous catheter.

TABLE 5.

Association of technique and technology on first‐time insertion success by final successful inserter.

Variable	Values	First‐time insertion success by final successful inserter		Unadjusted RR	p‐level	Adjusted RR	p‐level
		Yes (N = 197)	No (N = 53)
		N (%)	N (%)
Techniques
Clinician	Treating team	49 (74.2)	17 (25.8)	Reference		Reference
	Anaesthetic doctor	42 (75.0)	14 (25.0)	1.01 (0.82–1.24)	0.92	0.96 (0.67–1.37) a	0.82
	Intensivist – doctor	14 (63.6)	8 (36.4)	0.86 (0.61–1.21)	0.38	0.89 (0.56–1.40) a	0.61
	Vascular Access Specialist	60 (98.3)	1 (1.6)	1.32 (1.14–1.53)	< 0.001	1.52 (1.25–1.85) a	< 0.001
	Emergency Department Clinician	32 (71.1)	13 (28.9)	0.96 (0.76–1.21)	0.72	0.96 (0.72–1.26) a	0.75
PIVC insertion site	Forearm	91 (85.1)	16 (14.9)	Reference		Reference
	Antecubital fossa	37 (72.6)	14 (27.5)	0.85 (0.71–1.03)	0.10	0.89 (0.72–1.11) b	0.30
	Hand and wrist	52 (80.0)	13 (20.0)	0.94 (0.81–1.09)	0.41	1.02 (0.81–1.28) b	0.87
	Foot and leg	17 (63.0)	10 (37.0)	0.74 (0.55–0.99)	0.05	0.74 (0.54–1.01) b	0.06
Department of insertion	Bedside	73 (81.1)	17 (18.9)	Reference		Reference
	Ward treatment room	39 (88.6)	5 (11.4)	1.09 (0.94–1.26)	0.23	1.07 (0.90–1.27) c	0.45
	Paediatric Intensive Care Unit	16 (64.0)	9 (36.0)	0.79 (0.58–1.08)	0.14	0.75 (0.53–1.07) c	0.11
	Operating Theatre	38 (80.9)	9 (19.2)	0.99 (0.84–1.18)	0.97	0.89 (0.72–1.11) c	0.29
	Emergency Department	31 (70.5)	13 (29.6)	0.87 (0.70–1.08)	0.20	0.88 (0.71–1.11) c	0.31
Sedation and anaesthesia	None	93 (82.3)	20 (17.7)	Reference		Reference
	Gas and oral	59 (74.7)	20 (25.3)	0.91 (0.77–1.06)	0.22	0.88 (0.75–1.03) d	0.11
	General anaesthesia	45 (77.6)	13 (22.4)	0.94 (0.80–1.11)	0.48	0.86 (0.60–1.24) d	0.42
Level of consciousness	Assisted ventilation	50 (78.1)	14 (21.9)	Reference		Reference
	Maintaining own airway	106 (56.7)	80 (43.0)	0.99 (0.85–1.14)	0.84	0.65 (0.46–0.90) e	0.01
Topical anaesthesia	No	84 (84.0)	16 (16.0)	Reference		Reference
	Yes	113 (75.3)	37 (24.7)	0.90 (0.79–1.02)	0.09	0.96 (0.82–1.12) f	0.62
Technology
Ultrasound	No	92 (74.8)	31 (25.2)	Reference		Reference
	Yes	105 (82.7)	22 (17.3)	1.11 (0.97–1.26)	0.13	1.28 (1.11–1.49) g	0.001
Vein size		N = 68	N = 4
	East – West (mm) Mean (SD)	2.49 (0.87)	2.18 (0.81)	1.02 (0.97–1.08)	0.42	1.01 (0.91–1.11) h	0.92
	North—South (mm) Mean (SD)	2.13 (0.73)	1.95 (0.82)	1.02 (0.94–1.10)	0.64	0.99 (0.87–1.13) h	0.93

Notes: n is reported within the table if there were missing values. Row percentages are reported here to evaluate the likelihood of outcome by exposure categories (Althouse, Raffa, and Kormos ²⁰¹⁶). Bold values denote statistical significance.

Abbreviation: mm, millimetres.

^a Adjusted for Age, DIVA classification, Department of insertion, Diagnosis, history of prematurity.

^b Adjusted for ultrasound use and previous PIVC this admission.

^c Adjusted for diagnosis and history of prematurity.

^d Adjusted for age, department of insertion, and inserting clinician.

^e Adjusted for age, department of insertion, inserting clinician, and sedation and anaesthesia.

^f Adjusted for clinician and department of insertion.

^g Adjusted for DIVA status.

^h Adjusted for age.

5.2. Main Results

5.2.1. Patient Characteristics of First Attempt PIVC Insertion Success

Each patient characteristic was adjusted in a multivariable model with clinically relevant confounders (see Table 1, Figure 1, and Figures S1–S15). Every year increase in age (Figure S1), and every 5 kg increase in weight (Figure S2), children were more likely to have their PIVC successfully inserted on the first attempt (RR 1.04; 95% CI 1.02–1.05; p =< 0.001) and (RR 1.04; 95% CI, 1.02–1.06; p =< 0.001), respectively (Table 4). By age group, children aged > 2–12 years and adolescents aged > 12–18 years were more likely to have their PIVC successfully inserted on the first attempt when compared to infants (birth–2 years) (RR 1.31; 95% CI 1.03–1.67 and RR 1.66; 95% CI, 1.32–2.09, respectively). Children with a history of prematurity (Figure S3) were 35% less likely to have their PIVC inserted on the first attempt (RR 0.65; 95% CI 0.44–0.95; p = 0.03). In the unadjusted model, the RR for medical diagnosis and current infection significantly reduced the likelihood of first‐time insertion success (RR 0.79; 95% CI; 0.65–0.98, p = 0.03) and (RR 0.69; 95% CI 0.57–0.84, p =< 0.001); however, after adjusting for current infection and history of prematurity (Figure S6) and primary diagnosis and history of prematurity (Figure S7), accordingly, the effect of medical diagnosis (RR 0.86; 95% CI 0.68–1.08, p = 0.19) and infection (RR 0.83; 95% CI 0.66–1.04, p = 0.11) on first‐time insertion success was no longer significant.

TABLE 4.

Association of patient clinical characteristics with first attempt insertion success (N = 250).

Variables	Values	First attempt insertion success		Unadjusted RR	p‐level	Adjusted RR	p‐level
		Yes (N = 156)	No (N = 94)
Age (year)	Median (IQR)	12.0 (2.6–24.0)	2.8 (0.3–14.0)	1.04 (1.02–1.05)	< 0.001	1.04 (1.02–1.05) a	< 0.001
Age group	Infancy (birth – 2 years)	52 (50.0)	52 (50.0)	Reference		Reference
	Childhood (> 2–12 years)	65 (65.7)	34 (34.3)	1.31 (1.03–1.67)	0.03	1.31 (1.03–1.67) a	0.03
	Adolescence (> 12–18 years)	39 (83.0)	8 (17.0)	1.66 (1.32–2.09)	< 0.001	1.66 (1.32–2.09) a	< 0.001
History of prematurity (N = 229)	No	n = 137 120 (63.8)	n = 92 68 (36.2)	Reference		Reference
	Yes	17 (41.5)	24 (58.5)	0.65 (0.44–0.95)	0.03	0.65 (0.44–0.95) a	0.03
Weight (kg) (N = 248)	Median (IQR)	n = 155 23 (9–47)	n = 93 10 (4–23)	1.04 (1.03–1.06) every 5 kg increase	< 0.001	1.04 (1.02–1.06) b every 5 kg increase	< 0.001
Sex	Female	74 (63.8)	42 (36.2)	Reference		Reference
	Male	82 (61.2)	52 (38.8)	0.96 (0.79–1.16)	0.67	0.96 (0.79–1.16) a	0.67
Number of comorbidities	0	76 (65.0)	41 (35.0)	Reference		Reference
	1	54 (64.3)	30 (35.7)	0.99 (0.80–1.22)	0.92	0.97 (0.78–1.22) c	0.81
	> 2	26 (53.1)	23 (46.9)	0.82 (0.61–1.10)	0.18	0.87 (0.64–1.18) c	0.36
Primary diagnostic group	Surgical	67 (70.5)	28 (29.5)	Reference		Reference
	Medical	66 (55.9)	52 (44.1)	0.79 (0.65–0.98)	0.03	0.86 (0.68–1.08) d	0.19
	Critical care	23 (62.2)	14 (37.8)	0.88 (0.66–1.17)	0.38	1.10 (0.81–1.48) d	0.55
Current infection	No	83 (75.5)	27 (24.6)	Reference		Reference
	Yes	73 (52.1)	67 (47.9)	0.69 (0.57–0.84)	< 0.001	0.83 (0.66–1.04) e	0.11
Level of consciousness	Assisted ventilation	50 (78.1)	14 (21.9)	Reference		Reference
	Maintaining own airway	106 (57.0)	80 (43.0)	0.73 (0.61–0.87)	0.001	0.66 (0.39–1.12) f	0.13

Notes: n is reported within the table if there were missing values. Row percentages are reported here to evaluate the likelihood of outcomes by exposure categories (Althouse, Raffa, and Kormos ²⁰¹⁶). Bold values denote statistical significance.

Abbreviations: IQR, interquartile range; kg, kilogram; RR, relative risk.

^a No confounders to adjust; hence the adjusted RR is the same as the adjusted crude RR.

^b Adjusted for history of prematurity.

^c Adjusted for history of prematurity and age.

^d Adjusted for current infection and history of prematurity.

^e Adjusted for primary diagnosis and history of prematurity.

^f Adjusted for sedation and anaesthesia, age, and department of insertion.

5.2.2. Association of Technique and Technology Used by Successful Inserters and First‐Time Insertion Success

5.2.2.1. Technique

Table 5 reports that for the final successful clinician attempting PIVC insertion, vascular access specialist clinicians (technique) were more likely to succeed on the first attempt (RR 1.52; 95% CI, 1.25–1.85; p =< 0.001) compared to other clinicians (Figure S10). Use of other techniques, such as pain relief and mild sedation, did not significantly affect first‐time insertion success. However, some improvements were observed, which hold clinical significance for both patients and clinicians.

When children were sedated or anesthetised to a level requiring assistance to maintain their airway, they were more likely to have their PIVC inserted on the first attempt compared to those maintaining their own airway (RR 0.65; 95% CI 0.46–0.90; p = 0.01). In the unadjusted analysis (Table 5), the choice of PIVC insertion site in the foot and leg was 25% less likely to be successfully inserted on the first attempt (RR 0.74; 95% CI 0.55–0.99; p = 0.05); however, after adjusting for the use of ultrasound and previous PIVC this admission (Figure S11), the effect of the site of insertion became imprecise (RR 0.74; 95% CI 0.54–1.01; p = 0.06).

5.2.2.2. Technology

After adjusting for the risk level of difficult intravenous access (Figure 1), PIVCs inserted with ultrasound guidance were more likely to be inserted on the first attempt by the final successful inserting clinician (RR 1.28; 95% CI 1.11–1.49; p = 0.001) compared to no image‐guiding technology (Table 5).

5.2.3. Stratified Analysis by Age Group

The sensitivity analysis by age for the final successful inserter (Table 6) revealed similar estimates to the primary analysis. Adolescents (children aged 12–18 years) overall had a greater first‐time insertion success (n = 44 of 47; 94%) compared to 73% (n = 76 of 104) infants (aged birth–2 years) and 78% (n = 77 of 99) childhood (aged > 2–12 years). Level of consciousness decreased the success in infancy (RR 0.58; 95% CI 0.35–0.97) and childhood (RR 0.32; 95% CI 0.19–0.71). Once adjusted for DIVA status, ultrasound improved first‐time PIVC insertion success in infants (RR 1.38; 95% CI 1.04–1.83), and childhood (RR 1.32; 95% CI 1.01–1.72).

TABLE 6.

Stratified analysis by age group: Association of technique and technology on first‐time insertion success by the final successful PIVC inserter.

Variable	Values	First‐time insertion success by the final successful PIVC inserter		Unadjusted RR	Adjusted RR
		Yes	No
		N (%)	N (%)
Infancy (Birth–2 year)		N = 76	N = 28
PIVC insertion site
	Forearm	30 (85.7)	5 (14.3)	Reference	Reference
	Antecubital fossa	8 (47.1)	9 (52.9)	0.55 (0.32–0.93)	1.07 (0.82–1.39) a
	Hand and wrist	24 (82.8)	5 (17.2)	0.97 (0.78–1.20)	0.94 (0.66–1.36) a
	Foot and leg	14 (60.9)	9 (39.1)	0.71 (0.50–1.01)	1.00 (0.50–2.01) a
Sedation and anaesthesia
	None	26 (76.5)	8 (23.5)	Reference	Reference
	Gas and oral	36 (73.5)	13 (26.5)	0.96 (0.75–1.24)	0.88 (0.67–1.14) b
	General anaesthesia	14 (66.7)	7 (33.3)	0.87 (0.61–1.25)	0.58 (0.25–1.37) b
Level of consciousness
	Assisted ventilation	17 (73.9)	6 (26.1)	Reference	Reference
	Maintaining own airway	59 (72.8)	22 (27.2)	0.99 (0.75–1.30)	0.58 (0.35–0.97) c
Topical anaesthesia
	No	26 (86.7)	4 (13.3)
	Yes	50 (67.6)	24 (32.4)
Ultrasound
	No	33 (67.4)	16 (32.7)	Reference	Reference
	Yes	43 (78.2)	12 (21.8)	1.16 (0.91–1.48)	1.38 (1.04–1.83) d
Childhood (> 2–12 years)		N = 77	N = 22
PIVC insertion site
	Forearm	37 (78.7)	10 (21.3)
	Antecubital fossa	20 (83.3)	4 (16.7)
	Hand and wrist	17 (70.8)	7 (29.2)
	Foot and leg	3 (75.0)	1 (25.0)
Sedation and anaesthesia
	None	40 (78.4)	11 (21.6)	Reference	Reference
	Gas and oral	16 (69.6)	7 (30.4)	0.89 (0.65–1.21)	0.86 (0.65–1.13) b
	General anaesthesia	21 (84.0)	4 (16.0)	1.07 (0.86–1.34)	1.30 (0.63–2.70) b
Level of consciousness
	Assisted ventilation	22 (81.5)	5 (18.5)	Reference	Reference
	Maintaining own airway	55 (76.4)	17 (23.6)	0.94 (0.75–1.17)	0.32 (0.19–0.71) c
Topical anaesthesia
	No	38 (76.0)	12 (24.0)	Reference	Reference
	Yes	39 (79.6)	10 (20.4)	1.05 (0.85–1.29)	1.14 (0.85–1.55) b
Ultrasound
	No	35 (74.5)	12 (25.5)	Reference	Reference
	Yes	42 (80.8)	10 (19.2)	1.08 (0.88–1.34)	1.32 (1.01–1.72) d
Adolescence (> 12–18 years)		N = 44	N = 3
PIVC insertion site
	Forearm	24 (96.0)	1 (4.0)
	Antecubital fossa	9 (90.0)	1 (10.0)
	Hand and wrist	11 (91.7)	1 (8.3)
	Foot and leg	NA	NA
Sedation and anaesthesia
	None	27 (96.4)	1 (3.6)
	Gas and oral	7 (100.0)	0 (0.0)
	General anaesthesia	10 (83.3)	2 (16.7)
Level of consciousness
	Assisted ventilation	12 (85.7)	2 (14.3)
	Maintaining own airway	32 (97.0)	1 (3.0)
Topical anaesthesia
	No	20 (100.0)	0 (0.0)
	Yes	24 (88.9)	3 (11.1)
Ultrasound
	No	24 (88.9)	3 (11.1)
	Yes	20 (100.0)	0 (0.0)

Note: n is reported within the table if there are missing values. Row percentages are reported here to evaluate the likelihood of outcome by exposure categories (Althouse, Raffa, and Kormos ²⁰¹⁶). A stratified analysis was not conducted if there was a small cell size < 5.

Abbreviations: IQR, interquartile range; kg, kilogram; RR, relative risk.

^a Adjusted for ultrasound use and previous PIVC this admission.

^b Adjusted for the department of insertion and inserting clinician.

^c Adjusted for the department of insertion, inserting clinician and sedation and anaesthesia.

^d Adjusted for DIVA status.

5.2.4. Stratified Analysis by Clinical Group

Table 7 describes the sensitivity analysis by clinical group. The use of ultrasound significantly increased the first‐time insertion success by the final successful PIVC inserter in surgical (RR 1.24; 95% CI 1.02–1.51) and medical (RR 1.42; 95% CI 1.11–1.82), while there was no significant difference in critical care (RR 0.91; 95% CI 0.53–1.55).

TABLE 7.

Stratified analysis by clinical group: Association of technique and technology on first‐time insertion success by the final successful PIVC inserter.

Variable	Values	First‐time insertion success by the final successful PIVC inserter		Unadjusted RR	Adjusted RR
		Yes	No
		N (%)	N (%)
Surgical		N = 81	N = 14
PIVC insertion site	Forearm	40 (88.9)	5 (11.1)
	Antecubital fossa	14 (77.8)	4 (22.2)
	Hand and wrist	21 (87.5)	3 (12.5)
	Foot and leg	6 (75.0)	2 (25.0)
Sedation and anaesthesia	None	33 (86.8)	5 (13.2)
	Gas and oral	15 (78.9)	4 (21.1)
	General anaesthesia	33 (86.8)	5 (13.2)
Level of consciousness	Assisted ventilation	32 (86.5)	5 (13.5)	Reference	Reference
	Maintaining own airway	49 (84.5)	9 (15.5)	0.98 (0.82–1.16)	0.71 (0.37–1.36) a
Topical anaesthesia	No	33 (86.8)	5 (13.2)	Reference	Reference
	Yes	48 (84.2)	9 (15.8)	0.97 (0.82–1.15)	1.02 (0.81–1.28) b
Ultrasound	No	44 (81.5)	10 (18.5)	Reference	Reference
	Yes	37 (90.2)	4 (9.8)	1.11 (0.94–1.30)	1.24 (1.02–1.51)
Medical		N = 91	N = 27
PIVC insertion site	Forearm	45 (88.2)	6 (11.8)
	Antecubital fossa	16 (72.7)	6 (27.3)
	Hand and wrist	26 (72.2)	10 (27.8)
	Foot and leg	4 (44.4)	5 (55.6)
Sedation and anaesthesia	None	53 (82.8)	11 (17.2)
	Gas and oral	33 (71.7)	13 (28.3)
	General anaesthesia	5 (62.5)	3 (37.5)
Level of consciousness	Assisted ventilation	9 (81.8)	2 (18.9)
	Maintaining own airway	82 (76.6)	25 (18.2)
Topical anaesthesia	No	48 (82.8)	10 (17.2)	Reference	Reference
	Yes	43 (71.7)	17 (28.3)	0.87 (0.71–1.06)	0.93 (0.76–1.14) b
Ultrasound	No	37 (69.8)	16 (30.2)	Reference	Reference
	Yes	54 (83.1)	11 (16.9)	1.19 (0.95–1.47)	1.42 (1.11–1.82)
Critical care		N = 25	N = 12
PIVC insertion site	Forearm	6 (54.6)	5 (45.5)
	Antecubital fossa	7 (63.6)	4 (36.4)
	Hand and wrist	5 (100.0)	0 (0.0)
	Foot and leg	7 (70.0)	3 (30.0)
Sedation and anaesthesia	None	7 (63.6)	4 (36.4)
	Gas and oral	11 (78.6)	3 (21.4)
	General anaesthesia	7 (58.3)	5 (41.7)
Level of consciousness	Assisted ventilation	10 (62.5)	6 (37.5)	Reference	Reference
	Maintaining own airway	15 (71.4)	6 (28.6)	1.14 (0.71–1.83)	0.94 (0.47–1.88) a
Topical anaesthesia	No	3 (75.0)	1 (25.0)
	Yes	22 (66.7)	11 (33.3)
Ultrasound	No	11 (68.8)	5 (31.3)	Reference	Reference
	Yes	14 (66.7)	7 (33.3)	0.97 (0.62–1.53)	0.91 (0.53–1.55) c

Note: n is reported within the table if there are missing values. Row percentages are reported here to evaluate the likelihood of outcome by exposure categories (Althouse, Raffa, and Kormos ²⁰¹⁶). A stratified analysis was not conducted if there was a small cell size < 5.

Abbreviations: IQR: interquartile range; kg: kilogram; RR: relative risk.

^a Adjusted for age, department of insertion, inserting clinician, and sedation and anaesthesia.

^b Adjusted for the department of insertion and inserting clinician.

^c Adjusted for DIVA status.

6. Discussion

The first‐time insertion success in our study was 62%, meaning that 1 in 3 children required multiple attempts. While these results are consistent with other studies (50%–70% first attempt insertion success) across varying settings (Avelar, Peterlini, and da Luz Goncalves Pedreira, 2015; Benkhadra et al. ²⁰¹²; Doniger et al. ²⁰⁰⁹; Hanada et al. ²⁰¹⁷; Kleidon et al. ²⁰¹⁹; Larsen et al. ²⁰¹⁰; Sharp et al. ²⁰²³), the increasing medical complexity of children admitted to hospitals means this issue is only increasing the challenges faced during PIVC insertions. Despite the availability of evidence‐based practices (e.g., image guidance and insertion by expert clinicians), their slow uptake further complicates achieving higher success rates. Failed PIVC insertion attempts are frequently cited as the most painful inpatient experience, contributing to significant anxiety among children, parents, and healthcare providers (Kleidon et al. 2019; Sharp et al. ²⁰²³). As more children require multiple PIVCs during their admission, maximising first‐time insertion success is crucial to improving the patient healthcare experience and reducing potential hospital avoidance due to needle phobia, procedural pain, and PMTS (Christian‐Brandt et al. ²⁰¹⁹; Kleidon et al. ²⁰¹⁹; Price et al. ²⁰¹⁶; Sharp et al. ²⁰²³). Given the implications and widespread reliance on PIVCs in today's healthcare environment, a first‐time insertion success rate of 62% should not be considered acceptable.

National (Australian Commission on Safety and Quality in Health Care ²⁰²¹) and international (Centers for Disease Control (CDC) ²⁰¹⁷) patient safety guidelines recommend healthcare facilities implement strategies to support first‐time insertion success by ensuring clinical expertise is available to match the complexity of the patient's clinical presentation. A previous observational study on paediatric PIVC insertion in the operating theatre suggested that the likelihood of first‐time insertion success cannot be definitively predicted by patient characteristics alone (Cuper et al. 2012). However, our findings that older age, increased weight, term birth, and reduced level of consciousness at insertion were significant patient predictors of PIVC insertion success are consistent with previous studies (Schults et al. 2022; Yen, Riegert, and Gorelick ²⁰⁰⁸). Despite this, the assessment of risk for difficult intravenous access is inconsistently performed, and escalation to appropriate technical (clinician expertise) and technological (image guidance) measures is unreliable and generally influenced by the availability of expert inserters and ultrasound training and equipment (Schults et al. 2019).

The use of ultrasound to improve first‐time insertion success in children with difficult intravenous access has been well established in clinical trials (Kleidon et al. 2021); however, its implementation into healthcare has been slow. When we considered techniques and technologies associated with first‐time insertion success of the final successful inserter, we found the expertise of the operator and use of image‐guided insertion to be predictors of insertion success. Notably, vascular access clinicians were more skilled and successful at inserting PIVCs (60 of 61; 98%) on the first attempt than their medical counterparts (137 of 189; 72%), irrespective of clinical speciality. This observation aligns with a previous study by Reigart et al. (2012) which demonstrated that nurses with specialist PIVC insertion skills were more successful than physicians.

Despite the imperative of quality, first‐time PIVC insertion success, there is no internationally agreed‐upon model or workforce to support the practice of PIVC insertion. Some hospitals adopt a generalist inserter model, whereby existing clinical staff (medical officers, radiographers, nurses, and physicians' assistants) are responsible for PIVC insertion according to their clinical unit. An alternative is a specialised inserter team of vascular access specialists. This model is purported to provide improved patient outcomes, clinical efficiency, and cost savings through assumed improved first‐time insertion success and a reduction in complications and device failure (Ricou Ríos et al. 2023). In a randomised controlled trial in adult medical and surgical patients, Marsh et al. (2018) describe an increase in multiple PIVC insertion attempts in the generalist group (35%) compared to (19%) in the vascular access specialist group. Additionally, 100% (n = 69) PIVCs were successfully inserted in the vascular access speciality group compared to 38% in the generalist group. To date, no similar clinical trials in paediatric healthcare comparing the safety and efficacy of these different workforce models have been undertaken (Carr et al. 2018).

In addition to the improved first‐time insertion success achieved by vascular access specialists, a specialised workforce can effectively operationalise techniques and technologies, targeting them at the right populations (Morrell 2020; Schults et al. ²⁰²²). Schults et al. (2022) describe a difficult intravenous access algorithm with an inbuilt escalation pathway to improve first‐time insertion success by escalating those children at highest risk for difficult intravenous access to the most skilled vascular access professional. Morrell (2020) reported improved clinical outcomes, including a 30% increase in first‐time insertion success and an increase of 53 h on average PIVC dwell. Furthermore, patient and healthcare worker satisfaction improved due to reduced pain and more efficient use of clinician resources. This led to significant time savings and an annual cost savings of US$192,570 after implementing a specialist vascular access program. Improving future healthcare practices requires prioritising research strategies to understand risk factors, as well as protective factors influencing first‐time insertion success and ensuring the successful widespread implementation of these within the healthcare system. Successful integration of this technology into practice depends not only on the availability of equipment but also on the support, training, and proficiency of healthcare professionals who operate them.

Healthcare executives, clinicians, and other decision‐makers must acknowledge the iatrogenic harm resulting from current PIVC insertion practices and actively support the standardisation of successful techniques and technologies. While safety organisations in the United States have incorporated metrics for central line‐associated bloodstream infection and peripheral intravenous infiltration and extravasation, they have yet to include first‐time insertion success (Children's Hospitals' Solutions for Patient Safety ²⁰²⁴; Lyren et al. ²⁰¹⁷). Given the significant clinical and economic impacts of repeated PIVC attempts, it is critical to mandate this metric to drive improvements in patient care and resource utilisation (Goff et al. 2013; Helm et al. ²⁰¹⁵; Kleidon et al. ²⁰¹⁹). Recognising first‐time insertion success as a key performance indicator can catalyse the adoption of best practices and advanced technologies, ultimately enhancing patient outcomes and reducing healthcare costs.

6.1. Strengths and Limitations

This study is the first international study to demonstrate a causal relationship between various techniques and technologies in improving first‐time PIVC insertion success in children, with a particular emphasis on the role of expert clinicians. The strengths of this study include a powered, clinically led statistical analysis with well‐defined outcomes and variables. Data collection was limited to two experienced research nurses, which improved its reliability. The data collected were based on literature review and extensive information regarding PIVC insertion practices and collected prospectively. The limitations were primarily due to staff resources and the inability to collect insertion data on all PIVCs in situ at any one time. Patient recruitment depended on patient identification, prospective referral to the research nurse, or the availability of a complete data set of PIVC insertion. This could have introduced bias into the sample; however, given the number of discrete patients, this bias should have been minimised. Despite our intention to collect vein size at insertion, not all vein size measurements were collected, as some insertions were not performed with image guidance, which provides a means to measure vein size, or due to variability in clinician compliance with measuring vein size. The population included in this study was from a single quaternary paediatric hospital, which may limit generalisability to other settings.

6.2. Recommendations for Further Research

Research should focus on comparative and longitudinal studies to evaluate the effectiveness and sustainability of various techniques and technologies and their impact on patient and provider satisfaction, anxiety levels, and healthcare costs. Developing innovative solutions for paediatric PIVC insertions should be prioritised. Guidelines should incorporate standardised protocols and implementation frameworks to adopt new techniques and technologies (Takashima et al. 2021; Xu et al. ²⁰²³). Continuous education and training on the latest advancements in PIVC insertion techniques, along with monitoring and evaluation mechanisms, are crucial for ensuring effective guideline implementation and necessary adjustments.

6.3. Implication for Policy and Practice

Our study confirms the endemic high rate of failure to insert PIVCs in children on the first attempt. To address this, clinical practice should implement specialised training for healthcare professionals, focusing on paediatric patients and using advanced technologies like ultrasound guidance. An interdisciplinary approach involving vascular access specialists, generalist physicians, and nurses is essential for optimising PIVC use and decision‐making. Policy changes that prioritise integrating these strategies into clinical guidelines are essential, ensuring consistency across healthcare settings and improving patient outcomes.

7. Conclusion

In conclusion, our study reinforces reinforces the high rate of first‐attempt PIVC insertion failure in children and provides valuable insights into strategies that can improve first‐time PIVC insertion success. It identified techniques (expert clinicians) and technologies (ultrasound guidance) to be associated with improved first‐time insertion outcomes. To translate these findings into improved patient care, healthcare systems should prioritise the integration of these strategies into clinical practice by enhancing clinician training, adopting standardised protocols, and ensuring access to advanced technologies. Future research should focus on evaluating the long‐term impact of these interventions, developing evidence‐based guidelines for PIVC insertion, and exploring the role of organisational culture in sustaining improvements. A multifaceted approach combining technology, clinician expertise, standardised practices, and policy support is essential for improving first‐time insertion success and overall paediatric care outcomes.

Author Contributions

T.M.K. conceptualised and designed the study, methodology, investigation, data curation, and data collection instruments; carried out the initial analyses; drafted the initial manuscript, reviewed, and revised the manuscript and gave final approval for the manuscript to be published. M.T. carried out the initial analyses, draughted the initial manuscript; reviewed, and revised the manuscript; and gave final approval for the manuscript to be published. C.M.R. conceptualised and designed the study, methodology, investigation, reviewed, and revised the manuscript and gave final approval for the manuscript to be published. J.A.S. supported the study design and methodology, investigation, review, and revision the manuscript and gave final approval for the manuscript to be published. A.C.B. supported the study design, provided advice regarding, supported the development of the statistical approach, reviewed and revised the manuscript, and gave final approval for the manuscript to be published. A.J.U. conceptualised and designed the study, methodology, investigation, reviewed, and revised the manuscript, and gave final approval for the manuscript to be published. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Conflicts of Interest

T.M.K.'s employers, the University of Queensland and Griffith University, have received on her behalf unrestricted investigator‐initiated research or educational grants from product manufacturers 3M (Solventum), Adhezion, BBraun, Becton Dickenson, Eloquest Medical, and Medical Specialities Australia. C.M.R.'s employers, The University of Queensland and Griffith University, have received on her behalf unrestricted investigator‐initiated research or educational grants from product manufacturers 3M (Solventum), Angiodynamics, Cardinal Health, and ICU Medical, and consultancy payments for lectures or expert opinion from 3M, BBraun, BD, and ITL Biomedical. A.C.B.'s employer, Griffith University, on behalf of the AVATAR group, has received educational grants from ICUMedical, 3M, Solventum, Spectrum Vascular, and Eloquest Healthcare in addition to unrestricted research grants from Angiodynamics. Griffith University, on behalf of AVATAR, has also received commercialisation and consultancy grant funding from B.Braun. A.C.B.'s research group has received investigator‐initiated research grant funding from B.Braun and funding to conduct a sponsored clinical trial from Becton Dickinson. A.C.B.'s group have also received consultancy and commercialization grants from Becton Dickinson. A.J.U.'s employer, the University of Queensland, has received on her behalf unrestricted investigator‐initiated research or educational grants from product manufacturers 3M (Solventum), Adhezion, Beckton Dickenson, Biolife, Eloquest, and Medline. All other authors declare no conflicts of interest.

Peer Review

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16795.

Supporting information

Data S1

Data Availability Statement

Research data are not shared.