Purpose : Implement and evaluate near-infrared (NIR) huddles for neonatal peripheral intravenous catheter (PIVC) insertion. Methods : An implementation project investigated PIVC insertion attempts, site, inserter designation, dwell, and complications during 3 phases (baseline, education, and implementation). Implementation consisted of planning insertion site(s) and attempt frequency with an NIR device huddle. The primary effectiveness outcome was first-time insertion success. Secondary outcomes included: PIVC completion/failure, failure reason, complications. Implementation outcomes were compliance, utility, and acceptability. The association between study phase and primary outcome was assessed using logistic regression. Exploratory analyses investigated intrinsic and extrinsic risks for PIVC insertion failure. Results : Over 5 months, data from 248 (33%) neonates with 771 admissions was collected. Fifty-nine (24%) neonates required multiple PIVCs; resulting in 370 cannulations (n = 94 baseline, n = 55 education, and n = 221 intervention phases). Median birthweight was 2909 grams (IQR 2033-3499), gestation was 37.3 weeks (IQR 33.9-38.9). Length of stay, weight, gestation, and previous PIVC events were similar across phases. Insertion success was lower during education (n = 15, 39.5%) than baseline (n = 29, 56.9%), but differences were not significant. Acceptability of huddle process was higher (mean = 7.5/10, SD 2.2) than NIR device (mean = 5.0/10, SD 3.7). First time insertion failure was higher for forearm compared to hand/wrist (OR 5.94; 95% CI 1.22-28.87). Conclusion : The implementation of NIR-huddle failed to improve first-time insertion success, but PIVC dwell time and documentation were improved. Further research is needed to minimize harm and improve neonatal vascular access preservation.

Neurodivergent children face unique challenges during medical procedures due to distinct sensory processing patterns and communication difficulties. Evidence-based interventions for procedural pain/distress may inadequately address their specific needs, leading to undertreated distress and negative healthcare experiences. Following Joanna Briggs Institute methodology, we conducted comprehensive searches across six databases on January 10, 2025, for studies published 2014–2025 focusing on neurodivergent children (0–21 years) undergoing medical procedures. Two independent reviewers screened studies and extracted data, with results presented as a narrative synthesis with evidence mapping. From 14,393 initial records, 144 studies met the inclusion criteria. Most studies (n = 121, 84.0

PURPOSE:Implement and evaluate near-infrared (NIR) huddles for neonatal peripheral intravenous catheter (PIVC) insertion. METHODS:An implementation project investigated PIVC insertion attempts, site, inserter designation, dwell, and complications during 3 phases (baseline, education, and implementation). Implementation consisted of planning insertion site(s) and attempt frequency with an NIR device huddle. The primary effectiveness outcome was first-time insertion success. Secondary outcomes included: PIVC completion/failure, failure reason, complications. Implementation outcomes were compliance, utility, and acceptability. The association between study phase and primary outcome was assessed using logistic regression. Exploratory analyses investigated intrinsic and extrinsic risks for PIVC insertion failure. RESULTS:Over 5 months, data from 248 (33%) neonates with 771 admissions was collected. Fifty-nine (24%) neonates required multiple PIVCs; resulting in 370 cannulations (n = 94 baseline, n = 55 education, and n = 221 intervention phases). Median birthweight was 2909 grams (IQR 2033-3499), gestation was 37.3 weeks (IQR 33.9-38.9). Length of stay, weight, gestation, and previous PIVC events were similar across phases. Insertion success was lower during education (n = 15, 39.5%) than baseline (n = 29, 56.9%), but differences were not significant. Acceptability of huddle process was higher (mean = 7.5/10, SD 2.2) than NIR device (mean = 5.0/10, SD 3.7). First time insertion failure was higher for forearm compared to hand/wrist (OR 5.94; 95% CI 1.22-28.87). CONCLUSION:The implementation of NIR-huddle failed to improve first-time insertion success, but PIVC dwell time and documentation were improved. Further research is needed to minimize harm and improve neonatal vascular access preservation.

AIM:The study's aim is to describe workforce models and practices related to vascular access device (VAD) insertion, maintenance and monitoring across Australia and New Zealand. BACKGROUND:VAD failure is associated with device selection and insertion, factors typically determined by the inserting clinician. However, clinician training and skill in vascular assessment and insertion are often inconsistent and undervalued. DESIGN:A prospective, cross-sectional, internet-based survey of workforce models and vascular access specialist teams (VASTs). RESULTS:Among 237 participants (November 2023 to February 2024), most worked in metropolitan (n = 127; 54.0%) or regional hospitals (n = 54; 23%), caring for adult (n = 227; 95.8%) and/or paediatric (n = 170; 71.7%) patients. One-third (n = 78; 33.0%) had a VAST, primarily comprising clinical nurse specialist/consultants (n = 73; 93.6%), generalist nurses (n = 39; 50%) and anaesthetists (n = 15; 32%). VAD selection was most often performed by medical staff (n = 211; 89.0%), though 29.1% (n = 69) reported VAST-led selection. Escalation pathways for difficult vascular access (DIVA) were more common in facilities with a VAST (n = 65; 83.3%) than without (n = 55; 41.0%). Midline catheter use was higher where VAST were present (76.9% vs. 48.5%). CONCLUSION:VAST presence was associated with greater use of escalation pathways and varied device type/technique such as ultrasound guided-PIVCs and midlines. However, limited staffing restricts the broader implementation of these benefits.

Peripheral intravenous catheters (PIVCs) are extensively used in hospitals worldwide and frequently associated with complications. Phlebitis is a common complication and may indicate infection, while infectious events, although uncommon, contribute to antimicrobial use and healthcare-associated infection. Chlorhexidine gluconate (CHG) impregnated dressings effectively prevent infections in central venous catheters but evidence for PIVC use is lacking. We assessed the feasibility and preliminary clinical outcomes of CHG-impregnated dressings for PIVCs. The ProP trial was a multi-centre, open-label, two-arm, parallel adaptive randomised controlled trial (RCT) in Australia and France. Adult and paediatric patients in emergency and acute settings who were expected to require a PIVC for ≥48 hours were eligible. Randomisation was centralised (1:1 ratio; allocation concealed; stratified by site) to either a CHG-impregnated dressing or a standard polyurethane dressing. In Phase I, feasibility outcomes included eligibility, recruitment, retention, protocol fidelity, missing data and satisfaction, with exploratory analysis of clinical outcomes. Phase II was planned to definitively compare clinical outcomes (composite infectious complications of local infection, catheter tip colonisation, PIVC-related bloodstream infection (BSI), and/or phlebitis), however progression to Phase II depended on pre-defined Phase I feasibility criteria. Between May 2023 and March 2024, 300 patients were enrolled at three hospitals. Most feasibility criteria achieved pre-specified targets including 92

Peritoneal dialysis (PD) is the preferred home dialysis treatment for children awaiting kidney transplant worldwide. There is significant variance in clinical outcomes across centers, which may be related to PD training for caregivers. This scoping review provides an overview of existing research regarding characteristics of training provided to caregivers of children receiving home PD. Searches were conducted via PubMed, Embase, CENTRAL, PsycINFO, CINHAL and ProQuest electronic databases (2005–2025). Studies in children under 21 years of age were included. Characteristics of training programs were summarized and compared against the International Society of Peritoneal Dialysis (ISPD) pediatric guidelines. Implementation, clinical and service outcomes were reported. Relationships between training program characteristics and the child and family were also reviewed. Twelve articles met inclusion criteria. Overall, there was poor alignment with existing guidelines. Training programs were reported in most articles (n = 9; 75

BACKGROUND:Aboriginal and Torres Strait Islander peoples experience persistent health inequities shaped by colonisation and its ongoing impacts, including racism, and structural and social determinants of health. Culturally safe tertiary education is essential for preparing a responsive health and human services workforce. OBJECTIVES:To explore shifts in undergraduate and post-graduate nursing, midwifery, and social work students' knowledge, attitudes, beliefs and learning experiences during a mandatory Cultural Safety and Indigenous Health and Wellbeing interdisciplinary course at an Australian university. METHODS:A sequential multi-method research design used a pre-and post-curriculum online survey (Ganngaleh nga Yagaleh) alongside open-ended qualitative questions. Quantitative data were analysed using non-parametric tests and mixed-effects models; qualitative responses were analysed using reflexive thematic analysis. RESULTS:Of 481 enrolled students, 182 (37.8%) completed all survey components. While no significant change was observed in Commitment to Culturally Safe Practice (coefficient 1.11, 95% CI -0.32-2.53, p = 0.13), significant improvements were found in Understanding of History and Power (co-efficient 2.59, 95% CI 1.55-3.62, p < 0.001), and Attitudes, Values and Beliefs (coefficient 3.44, 95% CI 1.95-4.92, p < 0.001). Qualitative findings demonstrated richer, more nuanced shifts: students moved from general awareness to more contextualised understandings of colonisation, systemic inequity and their own positionality. Many described emotional journeys characterised by discomfort, vulnerability, empathy, and renewed commitment to ethical and culturally safe practice, while others expressed resistance or uncertainty. Students emphasised the importance of Indigenous-led teaching, yarning-based learning environments and relational, reflective pedagogy in supporting transformative learning. These data also indicated the need for indigenising curriculum beyond one course to enable students' earlier exposure to racially determined negative health outcomes. CONCLUSION:The course fostered meaningful cognitive, emotional and reflective shifts in students' understandings of cultural safety. Findings emphasise the value of Indigenous-led, relational, and decolonising pedagogies and the importance of embedding cultural safety education earlier and more consistently across health curricula.

Objective To compare three devices: BuzzyⓇ 15 seconds (intervention 1), PiklucⓇ (intervention 2) and BuzzyⓇ 30 seconds (control group) for non-pharmacological, non-invasive pain relief in children during intramuscular injections. Method This was a three-arm, non-masked, parallel-group, randomized equivalence clinical trial in children aged 1-11 years (stratified by: 1-3 and 4-11 years) at two Brazilian Pediatric Emergency Units. The primary outcome is pain, measured by observer-reported pain using the Face, Legs, Activity, Cry, Consolability Scale for children aged 1-3 years and by self-reported pain using the Faces Pain Scale - Revised for children aged 4-11 years. The secondary outcome is pain (parent- and observer-reported) and distress. The study is registered in the Brazilian Clinical Trials Registry under the number RBR-57m3wnw. Results Of 170 participants, 54 were allocated intervention 1, 60 intervention 2, 56 control group. For ages 1-3 years, all comparisons were equivalent: PiklucⓇ vs. BuzzyⓇ 30 seconds (mean score difference [MSD] -0.457; 95% CI: -1.191, 0.277), BuzzyⓇ 15 seconds vs. PiklucⓇ (MSD 0.296; 95% CI: -0.438, 1.030), and BuzzyⓇ 15 seconds vs. BuzzyⓇ 30 seconds (MSD -0.161; 95% CI: -0.912, 0.590). For ages 4-11 years, the primary outcome (self-reported pain) did not show equivalence for any comparison, while observer-reported assessments (secondary outcomes) suggested equivalence for PiklucⓇ vs. BuzzyⓇ 30 seconds and for BuzzyⓇ 15 seconds vs. BuzzyⓇ 30 seconds. Conclusions In children aged 1-3 years, equivalent pain relief was shown across all devices during intramuscular injections. For children aged 4-11 years, there were inconsistencies between observer, parent and self-reported assessments. Clinical Implications For children aged 1-3 years, both PiklucⓇ and BuzzyⓇ devices can be used during intramuscular injections, with PiklucⓇ offering immediate application and BuzzyⓇ 15 seconds showing similar effects to 30 seconds application.

BACKGROUND/OBJECTIVE:Despite the ubiquitous need of venous access in children, care is often highly variable, lacking standardization. Our objective was to review current venous access guides, algorithms, and other tools available for clinical implementation; map out their focus (device type, population); and identify quality gaps. METHODS:A scoping review with a systematic search of Ovid MEDLINE and other databases was completed on January 24, 2025. All study designs describing the development of venous access guides/algorithms/tools for patients aged <18 years in the emergency department or inpatient units published after 2013 in English were included. Descriptive analysis was used to summarize the results. Quality of studies was assessed using the Appraisal of Guidelines for Research Evaluation (AGREE II) tool. RESULTS:Of the 105 studies included, 18% (n = 19) involved peripheral access, 66% (n = 69) involved central access, and 16% (n = 17) involved both. Neonates were the population of focus in half the publications (n = 52), and reduction in central line-associated bloodstream infections (CLABSI) was the primary aim of 56% (n = 59) of publications. Device selection and removal were two components of care with the lowest representation, particularly for peripheral access. Based on AGREE II scoring, 50% (n = 53) of identified guides/algorithms/tools were recommended for use. The lowest scoring quality domains were rigor of development and applicability, with 25% (n = 26) and 28% (n = 29) of studies, respectively, scoring in the lowest quintile. CONCLUSIONS:Most venous access guides/algorithms/tools focus on CLABSI reduction and neonates, leaving gaps in guidance for other components of the care process and other populations.

BACKGROUND:Nurses play a central role in health education for children and adolescents, yet traditional didactic approaches often fail to engage young people, prompting growing interest in storytelling as an alternative option. OBJECTIVE:To examine the use of storytelling as a health education intervention in children and adolescents to inform nursing practice. METHODS:We searched CINAHL, Embase, MEDLINE, PsycINFO, The Cochrane Library and Web of Science for randomised controlled trials involving children (4-18 years) receiving storytelling interventions for health education. Two authors independently screened the title and abstracts and full-papers, extracted the data and assessed the risk of bias for each study. Disagreements were resolved through consultation with the third author. Data were descriptively synthesised. RESULTS:Twenty-four studies were included. Twelve studies measured knowledge, with the majority (n = 9, 75%) demonstrating significant gains in knowledge. Across the 19 studies which measured attitudes and behaviour, 89% (n = 17) demonstrated significant short-term benefits across a range of health topics, and of the seven studies which explored the impact on participants' level of anxiety, 71% (n = 5) demonstrated a significant reduction in procedural anxiety. CONCLUSIONS:Storytelling interventions demonstrated improvements in health-related knowledge, short-term changes in attitudes and behaviour, and reduced procedural anxiety across a diverse range of health topics. Further research is needed to evaluate long-term outcomes and standardise outcome measures. IMPLICATIONS TO PRACTICE:These findings support nurses in incorporating age-appropriate storytelling interventions into health education and procedural preparation to enhance understanding, engagement and short-term behaviour change in children and adolescents.

Objetivo: Relatar o protocolo de uma revisão de escopo que visa mapear e sintetizar as evidências científicas disponíveis sobre as definições de lesões de pele relacionadas a adesivos médicos e das lesões de pele associadas a cateteres em locais de inserção de dispositivos intravenosos. Métodos: Trata-se de um protocolo de revisão de escopo, desenvolvido em cinco etapas: Identificação da questão de pesquisa, utilizando a estratégia População, Conceito e Contexto; Identificação dos estudos relevantes, no qual a busca dos estudos será realizada nas principais bases de dados da área da saúde; Seleção dos estudos: será realizada a triagem inicial, a seleção dos estudos e a extração dos dados na plataforma Covidence; Análise dos dados, será realizada a caracterização e descrição dos artigos; e, Agrupamento, resumo e apresentação dos resultados de forma narrativa e quantitativa descritiva, integrando os achados aos objetivos da revisão de escopo, seguindo o Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

Background: Implementing family-centered care (FCC) presents challenges to parental-healthcare provider partnership and collaboration in newborn care in neonatal intensive care units (NICUs). Aims: To explore NICU nurses' perceptions of FCC (respect, collaboration, and support) during the COVID-19 pandemic and to compare these between nurses working in secondary and tertiary/higher care settings. Methods: A multicenter, cross-sectional exploratory online survey design study was conducted to identify Thai NICU nurses' perceptions. The online survey of the Perceptions of Family-Centered Care—Staff (PFCC-S) was distributed via a Web page and professional networks between July and September 2022. Results: Of the 187 survey respondents, most NICU nurses worked in the NICU for less than 16 years and were employed in tertiary care/higher care settings in southern Thailand. There was a significant difference in perceptions of support subscale between NICU nurses in secondary (mean: 3.32, SD ± 0.53) and tertiary/higher care settings (mean: 3.17, SD ± 0.46) (P < .05). Conclusion: Despite the challenges of the visitation restriction of COVID-19 in Thailand, nurses' perceptions of the value of FCC were maintained. Relevance to Clinical Practice: Further research is recommended to investigate how FCC can be implemented where there is a lack of material and infrastructure resources and staff shortage.

Background:Proper documentation of peripheral intravenous catheter assessment and care is essential for improving outcomes related to its use. However, adherence to peripheral intravenous catheter documentation remains low, despite nursing documentation being essential for continuity of care, timely identification of complications and safe clinical decision-making. Aim:To determine the impact of the I-DECIDED® tool on nursing staff documentation of peripheral intravenous catheter assessment in a paediatric inpatient unit and to assess its impact across different nursing roles. Methods:A quasi-experimental interrupted time series study. The sample included 810 peripheral intravenous catheters documentation observations (405 pre- and 405 post-intervention) performed by 27 nursing staff. Data were collected at six points: three pre- and three post-intervention. Data were analysed using the Generalised Estimating Equations model. Results:After the use of the I-DECIDED® tool, compliance with peripheral intravenous catheter assessment documentation significantly improved in six of the eight evaluated items overall (p < 0.05), with notable increases in device need, effective function and complications, all with p < 0.001. Documentation reliability by nursing staff, assessed by comparing their records with researcher observations, improved significantly, from 42.9% to 75.4% (p < 0.001). Conclusion:The I-DECIDED® tool increased both the compliance and reliability of nursing documentation related to peripheral intravenous catheter assessment. However, challenges remain regarding full adherence to all tool items, especially among nursing technicians/assistants.

Importance Pediatric peripheral intravenous catheter (PIVC) insertion can be difficult and time-consuming, frequently requiring multiple insertion attempts and often resulting in increased anxiety, distress, and treatment avoidance among children and their families. Ultrasound-guided PIVC insertion is a superior alternative to standard technique (palpation and visualization) in high-risk patients. Objective To compare first-time insertion success of PIVCs inserted with ultrasound guidance compared with standard technique (palpation and visualization) across all risk categories in the general pediatric hospital population. Design, Setting, and Participants An open-label, pragmatic, superiority, randomized clinical trial was conducted in an Australian quaternary pediatric hospital. Children (ages 0-18 years) requiring PIVC insertion were included between July 2021 and December 2022. One catheter was studied per patient, and analysis was by intention to treat. Data analysis was performed from April to October 2023. Intervention Eligible children were randomly assigned (1:1 using computer-generated randomization and concealed allocation) to receive ultrasound-guided or standard PIVC insertion. Randomization was stratified by insertion difficulty (low, medium, or high risk) defined using a standardized tool. Main Outcomes and Measures The primary outcome was first-time insertion success. Secondary outcomes included number of insertion attempts, insertion failure, postinsertion complications, dwell time, patient and parent satisfaction, and health care costs. Results A total of 164 children were randomly assigned to ultrasound-guided insertion (n = 84) or standard care (n = 80), with 81 (96.4%) and 78 (97.5%) receiving their allocated intervention, respectively. The median (IQR) age was 24 (10-120) months, and 93 children (56.7%) were male. First-time insertion success was higher with ultrasound-guided PIVC insertion (72 children [85.7%]) compared with standard technique (26 children [32.5%]) (risk difference [RD], 53.6%; 95% CI, 41.7%-65.4%; P < .001). Ultrasound-guided insertion led to significantly greater first-time insertion success across all risk categories, with the following RDs: low risk, 30.8% (95% CI, 8.1%-53.5%); medium risk, 56.2% (95% CI, 37.1%-75.3%); and high risk, 69.6% (95% CI, 52.3%-87.0%). Ultrasound-guided PIVC insertion had higher immediate health care costs (between group difference in total mean cost per person, A$9.33; 95% credible interval, A$8.83-A$10.86 [US $5.83; 95% credible interval, $5.52-$6.78]). Conclusion and Relevance These findings suggest that ultrasound-guided PIVC insertion improves first-time insertion success across all risk categories in pediatrics, supporting the widespread adoption of ultrasound-guided PIVC insertion in children. Trial Registration anzctr.org.au Identifier: ACTRN12621000206820

Background Intramuscular injections are among the most common and painful procedures in childhood, often associated with stress, fear, and anxiety. The Buzzy® device, which combines vibration and cold, has been proposed as a non-pharmacological strategy to reduce pain during needle-related procedures. Objective This systematic review and meta-analysis evaluated the effectiveness of Buzzy® in reducing pain, fear, and anxiety in children undergoing intramuscular injections. Methods We searched seven electronic databases and clinical trial registries (January 2015-December 2024) for randomized controlled trials including children (0-18 years) receiving intramuscular injections with Buzzy®. Standardized mean differences with 95% confidence intervals were calculated using random-effects models. Risk of bias was assessed using the Cochrane RoB 2.0 tool, and certainty of evidence with GRADE. The review followed the Cochrane Handbook for Systematic Reviews and the PRISMA guidelines. Results Twelve studies with 1,333 children were included. Buzzy® significantly reduced self-reported, parent-reported, and observer-reported pain compared to control groups. It also demonstrated benefits in lowering fear and anxiety, although evidence for these outcomes was less consistent. The certainty of evidence ranged from moderate (self- and observer-reported pain) to low (parent-reported pain, fear, anxiety). Conclusion Buzzy® is an effective, reusable, and low-resource intervention to reduce children's pain during intramuscular injections. Future high-quality multicenter randomized controlled trials are needed to confirm its effectiveness for fear and anxiety outcomes. Practical implications Buzzy® can be integrated into routine pediatric care to reduce pain during injections. Its low cost and reusability make it suitable for both high- and low-resource settings.

Objective To examine global practices for identifying and managing central venous access device (CVAD) complications-catheter-associated bloodstream infection (CABSI), thrombosis, and occlusion-in paediatric cancer care, comparing patterns between high- and other-income countries.Methods A cross-sectional international survey was conducted from 2022 to 2023 and analysed 2024 to 2025. Clinicians involved in paediatric CVAD cancer care were recruited through global networks.Results A total of 161 respondents from 38 countries completed the complication section, including 102 (63.4%) from high-income and 59 (36.6%) from other-income countries (lower- and upper-middle income). For CABSI, blood culture was the main diagnostic method (122 [75.8%]; high-income: 87 [85.3%], other-income: 35 [59.3%]). Differential time to positivity was more often reported in other-income settings (33 [55.9%] vs. 35 [34.3%]), who also more frequently initiated antibiotics based on nonspecific or immediate criteria. CABSI treatment varied, with intravenous antibiotics (68 [60.7%]) and catheter removal (47 [42.0%]) most reported. For thrombosis, anticoagulation before line removal was common (88 [54.7%]), and alteplase use was higher in high-income countries (76 [74.5%] vs. 19 [32.2%]). Thrombolytic agents were the most reported treatment for occlusion (103 [64.0%]), especially in high-income countries (77 [75.5%] vs. 26 [44.1%]).Conclusions CVAD complication management varies by country income level, highlighting the need for context-adapted guidelines, training, and equitable access to key resources.

BACKGROUND:Congenital heart defects represent the most prominent cause of mortality in a child's first year of life. Management of cardiothoracic wounds in pediatric populations is complex, attributed to the fragility of soft tissue, with healing progressing differently in adults. Understanding the breadth of wound care management is essential in establishing its applicability to clinical practice, especially in the prevention of complications. OBJECTIVE:The aim of this study was to expansively explore preoperative, intraoperative, and postoperative cardiothoracic wound care in pediatrics. METHODS:In this scoping review, a systematic search of MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature was conducted to retrieve interventional studies on pediatric cardiothoracic surgical patients (younger than 21 years) with wounds requiring intervention published in the preceding 10 years. RESULTS:A total of 2379 studies were retrieved, with 23 studies included. This review predominantly consisted of observational studies (n = 13, 57%), with 2 randomized clinical trials (8.7%). Most studies focused on procedural interventions (n = 14, 41.2%), with an equal distribution of management-focused (n = 10, 29.4%) and bundle-focused (n = 10, 29.4%) interventions. Interventions were most used in the postoperative period (n = 68, 49.6%). Study authors typically assessed the association of pharmaceutical, dressing, mechanical, and decontamination interventions with the incidence of sternal wound infections, healing, other infections, nutrition, parental outcomes, and postoperative complications. Frequency of wound surveillance and dressing changes were heterogeneous and rarely reported among studies. CONCLUSIONS:This review demonstrated the limited availability of high-level evidence evaluating the effectiveness of wound care interventions associated with pediatric cardiothoracic surgery. It is paramount that researchers leverage existing clinical networks to establish clinical trials.

OBJECTIVES:To define and reduce the incidence of severe arterial catheter-associated proximal ischemic injuries (ACAPII). DESIGN:Quality improvement (QI) initiative. SETTING:University affiliated PICU in a quaternary children's hospital. PATIENTS:All patients with indwelling arterial catheters (ACs) in the PICU at the Children's Hospital of Philadelphia from January 2020 to December 2022. INTERVENTIONS:Phase I (January 2021 to December 2021) included defining ACAPII and daily rounding on all ACs by a dedicated PICU-specific vascular access team. Phase II (January 2022 to December 2022) introduced standardized recommendations and interventions including the use of topical nitroglycerin ointment (TNG) as a therapeutic option for mild injuries. MEASUREMENTS AND MAIN RESULTS:From January 2021 to December 2022, the rounding team evaluated 1916 ACs for a total of 5793 rounding episodes (line-days). During phase I, the overall number of ACAPII increased compared with prior year pre-QI (35 vs. 11, 318%). During phase II, the administration of TNG was associated with an increase in arterial line-days per AC in patients with mild injury (6.58 line-days per line, 158 d/24 lines) compared with pre-QI, phase I, and phase II mild injuries without use of TNG (3.27, 198/61; incident rate difference [95% CI], 3.31 [2.11-4.51]; p < 0.001). Special cause indicators shifted centerline from a weighted average 33.0-342.3 line-days between severe injuries. The cumulative severe ACAPII incidence rate decreased from its peak early in phase I (April 2021: 5.65 per 1000 line-days) to the end of phase II (December 2022: 2.11 per 1000 line-days). The overall rate of arterial line-days per AC during phase II increased compared with pre-QI ( p < 0.01) and phase I ( p < 0.01). CONCLUSIONS:The development of a newly defined measurable harm index, ACAPII, and implementation of increased surveillance resulted in increased awareness and reduction of severe injury as measured by rates and line-days between severe injuries in our critically ill patients. Protocolized management during phase II, including introducing TNG as a therapeutic option, resulted in increased AC line-days per catheter with sustained reduction in severe ACAPII rates.