Building a Neonatal Vascular Access Pathway in the NICU

Part 7 of the series: Neonatal Vascular Access: A Practical Guide to PICCs and Midlines

Introduction

Neonatal vascular access is often viewed through the lens of individual devices, procedures and complications. However, the highest-performing neonatal units typically take a broader approach, implementing structured vascular access pathways that guide decision-making from admission through to device removal.

A pathway promotes consistency, supports vessel preservation and helps ensure that the right device is selected for the right patient at the right time. By reducing variation in practice, standardised pathways may improve outcomes for patients while providing clinicians with clear decision-making frameworks.

This final article brings together the key themes explored throughout this series and examines how neonatal units can build a practical vascular access pathway.

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What Is a Neonatal Vascular Access Pathway?

A vascular access pathway is a standardised framework that supports clinical decisions throughout the patient’s care journey.

Rather than approaching each access episode independently, clinicians follow a structured process that considers:

• Therapy requirements
• Device selection
• Vessel preservation
• Insertion practices
• Maintenance requirements
• Complication prevention
• Device removal

The focus shifts from individual devices to the overall vascular access strategy.

Step 1: Start With the Therapy Plan

Every pathway should begin with a simple question:

What treatment is this infant expected to receive?

Consider:

• Duration of therapy
• Need for parenteral nutrition
• Medication characteristics
• Frequency of infusions
• Future treatment plans
• Availability of venous access

Only after these factors have been assessed should device selection occur.

Step 2: Match the Device to the Therapy

Example Clinical Framework:

Duration of therapy
Expected therapy ≤5 days ⬇ Peripheral IV cannula	Expected therapy 5-14 days ⬇ Consider Midline	Expected therapy >14 days ⬇ Consider PICC

Parenteral nutrition required

⬇

PICC generally preferred

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Difficult vascular access with anticipated ongoing treatment

⬇

Consider earlier escalation to Midline or PICC

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This framework should always be adapted to local policy and individual patient requirements.

Step 3: Build Vessel Preservation Into Every Decision

A pathway should encourage clinicians to move beyond immediate access needs and consider long-term vessel health.

Before every insertion, ask:

✅ Is this the most appropriate device?

✅ Will repeated cannulation be required?

✅ Could earlier escalation preserve veins?

✅ Which vessel is most likely to support treatment successfully?

These principles help support a vessel health and preservation approach.

Step 4: Standardise Insertion Practice

Variation in insertion practice often contributes to inconsistent outcomes.

Pathways should establish expectations around:

• Vein assessment
• Device selection
• Catheter-to-vessel ratio
• Aseptic practice
• Ultrasound utilisation
• Introducer-assisted techniques where appropriate
• Competency requirements

The objective is not simply successful insertion, but successful insertion with minimal vessel trauma.

Step 5: Standardise Maintenance

Maintenance should be embedded within the pathway from the outset.

Key components include:

• Daily line review
• Dressing management
• Patency assessment
• Securement monitoring
• Infection prevention
• Documentation standards

Many complications can be prevented through consistent maintenance practices.

Step 6: Measure What Matters

A pathway is only effective if outcomes are monitored.

Suggested Vascular Access KPIs

Device Selection

• Percentage of infants requiring multiple peripheral cannulations
• Time from admission to definitive vascular access

Insertion

• First-attempt success rate
• Average number of insertion attempts

Maintenance

• Occlusion rates
• Migration rates
• Dislodgement rates

Infection Prevention

• Catheter-related infection rates

Overall Performance

• Unplanned removal rates
• Average catheter dwell times

Regular review of these metrics supports continuous improvement.

Step 7: Develop Vascular Access Champions

Many successful neonatal services identify clinicians with a particular interest in vascular access.

Responsibilities may include:

• Education and training
• Data collection
• Supporting complex insertions
• Auditing compliance
• Leading quality improvement initiatives

Local champions often help sustain pathway implementation over time.

Clinical Scenario

Improving Practice Through a Pathway

A NICU reviews its vascular access data and identifies:

• High rates of peripheral cannula replacement
• Variable PICC insertion success
• Frequent unplanned removals

Following implementation of a standardised pathway, the team:

• Introduces device-selection criteria
• Standardises daily line reviews
• Tracks insertion success rates
• Establishes vascular access champions

Within months, clinicians are able to identify trends more effectively and target improvement projects based on objective data.

Launching a Neonatal Vascular Access Pathway

Step 1

Audit current practice.

Step 2

Identify variation and recurring challenges.

Step 3

Develop evidence-based device selection criteria.

Step 4

Standardise insertion and maintenance procedures.

Step 5

Educate staff.

Step 6

Collect outcome data.

Step 7

Refine the pathway using audit findings.

Pathway development should be viewed as an ongoing process rather than a one-time project.

Key Practice Points

✅ Begin with therapy assessment.

✅ Select devices proactively, not reactively.

✅ Prioritise vessel preservation.

✅ Standardise insertion and maintenance.

✅ Monitor meaningful outcome measures.

✅ Use data to drive improvement.

✅ Create a culture of vascular access excellence.

Conclusion

Building a neonatal vascular access pathway is about creating consistency, improving decision-making and protecting the limited venous resources of neonatal patients.

By establishing clear criteria for device selection, insertion, maintenance and removal, NICUs can support safer, more effective vascular access management. Ultimately, a structured pathway helps ensure that every vascular access decision contributes to both successful treatment delivery and long-term vessel preservation.

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Supporting Materials

1. Sharpe EL, Wyckoff MM, Pettit J, et al. Peripherally Inserted Central Catheters: Guideline for Practice. 4th ed. Chicago (IL): National Association of Neonatal Nurses; 2024.
2. Sharpe EL, Pettit J. NANN neonatal peripherally inserted central catheters: clinical practice update. Adv Neonatal Care. 2024;24(4):e95-e107.
3. Infusion Nurses Society. Infusion Therapy Standards of Practice. 9th ed. Norwood (MA): Infusion Nurses Society; 2024.
4. Chen JW. Neonatal Vascular Access: Pearls, Proficiency and Innovation in Practice. Academy of Neonatal Nursing Annual Conference; 2018.