The I-DECIDED ® tool on documentation of the assessment of peripheral intravenous catheter in paediatrics: an interrupted time series study

Abstract

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.

Keywords

catheterisation documentation patient safety paediatric nursing peripheral

Introduction

The management of peripheral intravenous catheters (PIVCs) represents one of the most frequent and complex responsibilities of nursing staff, especially in paediatric patients (Shivani and Joseph, 2022). PIVC use is not without risk and may result in serious complications (Morrel, 2020). Inadequate documentation is one of the factors associated with PIVC-related complications (Indarwati et al., 2023; Morrell, 2020).

Proper documentation of PIVC assessment and care is essential for improving outcomes associated with its use, as it highlights opportunities to optimise care and track interventions provided (Bahl et al., 2024; Thompson et al., 2024). Therefore, PIVC documentation must be complete and accessible from insertion to removal, facilitating communication among the multidisciplinary team and ensuring continuity, quality and safety of patient care. Comprehensive documentation contributes to personalised care and reduces the risk of errors (Bahl et al., 2024; Nickel et al., 2024; Thompson et al., 2024).

In middle-income countries, PIVC management is carried out largely by nursing technicians and assistants, who constitute a significant portion of the healthcare workforce involved in this procedure. In Brazil, nursing technicians require at least high school education and receive approximately 24 months of nursing training, whereas nursing assistants complete about 15 months of training with a minimum of elementary school education (Walker et al., 2023). In addition, the Registered Nurse corresponds to an undergraduate bachelor’s degree in nursing, with a duration of at least 5 years for completion (Brasil, 2024). The documentation produced by nursing technicians and assistants reflects these activities and provides essential information to support registered nurses’ assessment, care planning and evaluation within the Nursing Process (Conselho Federal de Enfermagem, 2024; Ferreira et al., 2020). In this context, documentation produced by technicians and assistants is essential for continuous patient monitoring, implementation of prescribed care and to support registered nurses’ clinical decision-making (Conselho Federal de Enfermagem, 2024; Silva Júnior et al., 2022).

Although nursing staff are expected to assess and document their findings, documentation often becomes a lower priority due to workload demands (Bahl et al., 2024). Low adherence to PIVC documentation has been identified in several studies (Thomas et al., 2020; Ullman et al., 2020; Walker et al., 2023), though most of them focus primarily on documentation of insertion, leaving a gap regarding ongoing assessment and care documentation. A prevalence study conducted in Indonesia found that 39% of PIVCs lacked adequate documentation, with the most frequent omissions being dressing change intervals, reinsertion dates and flushing practices (Indarwati et al., 2023). Studies indicates that inadequate or lack of PIVC documentation compromises continuity of care and delays the identification of complications, whereas structured and standardised documentation has been associated with earlier detection of phlebitis, timely removal and improvements in overall PIVC quality indicators and patient safety (Amble et al., 2025; Bahl et al., 2024; Yagnik et al., 2017).

Due to this issue, strategies such as the I-DECIDED^® tool have been adopted. This tool is an evidence-based structured mnemonic composed of eight items that guide assessment and clinical decision-making in PIVC care, including assessment of the insertion site over the previous 48 hours (Ray-Barruel et al., 2018, 2020). An Australian interrupted time series (ITS) study showed that after the implementation of the tool in three adult hospitals, a 44.5% improvement in nursing documentation was observed (Ray-Barruel et al., 2023). However, the impact of the tool on documentation has not yet been evaluated in other healthcare settings or within paediatric contexts. Structural differences in healthcare systems, such as the use of electronic medical records, hospital organisational practices and staff characteristics, may influence the implementation and effectiveness of the tool.

Methods

Aim

This study aims to determine the impact of the I-DECIDED^® tool on nursing staff documentation of PIVC assessment in a paediatric inpatient unit, as well as to assess its impact across different nursing roles.

Design

This was a quasi-experimental study using an Interrupted Time Series (ITS) design. The ITS design was used to strengthen causal inference beyond a simple pre-post comparison, considering underlying temporal trends and distinguishing the effects of the intervention from pre-existing patterns. ITS analyses require at least three data collection points in the pre- and post-intervention periods to adequately assess trends, allowing for a more robust evaluation of whether the observed changes exceed random or transient variation (Handley et al., 2018; Miller et al., 2020; Turner et al., 2019). The Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) checklist (Des Jarlais et al., 2004) was followed to guide the reporting of the study (Supplemental Material 1).

Study instrument and outcomes

The data collection instrument was developed based on the I-DECIDED^® tool (Ray-Barruel et al., 2018), which demonstrated strong content validity, with Content Validity Index (CVI) values of 0.87 among vascular access experts and 0.96 among experienced clinicians, as well as good reliability, evidenced by an overall inter-rater agreement of 87.13% and acceptable internal consistency (Cronbach’s alpha = 0.746) in its original clinimetric evaluation (Ray-Barruel et al., 2020). The tool was subsequently cross-culturally adapted and validated for the Brazilian context, achieving high CVI (0.94) and good internal consistency and reliability (Cronbach’s alpha = 0.83; Silva et al., 2024a).

The instrument was divided into two main sections: variables related to the characteristics of the nursing staff and the clinical characteristics of the patients and variables corresponding to the eight items of the I-DECIDED^® tool: (1) identify if a device is in situ; (2) Does the patient need the IV?; (3) Effective function? (4) Complications at IV site? (5) Infection prevention; (6) Dressing and securement; (7) Evaluate and educate and (8) Document your decision. The second part of the instrument was structured into three sections: observations in the patient’s electronic medical record related to the PIVC; questions directed to staff about PIVC use and researcher observations of the PIVC. The instrument was reviewed by two experts in intravenous therapy and paediatrics.

A pilot test of the data collection instrument was conducted to assess clarity, coherence and alignment with the study aim. A total of 34 nursing record observations (6% of the sample) were conducted. Since no changes to the instrument were needed, these data were included in the final study sample (Canhota, 2008).

The primary outcome was the effect of the tool on documentation of PIVC assessment, evaluated based on compliance with the items in the I-DECIDED^® tool. Compliance was defined as the presence of documentation of the item in the patient’s electronic medical record, regardless of the accuracy of the information. Non-compliance was defined as the absence of documentation of the items (Bahl et al., 2024).

Secondary outcomes were: (1) the reliability of the documentation, assessed by comparing what nursing staff verbally reported having assessed during PIVC assessment with what they documented in the patient’s medical record; (2) the reliability of nursing documentation, defined as documentation performed by members of the nursing staff (registered nurses and nursing technicians/assistants), determined by comparing nursing records with the researcher’s direct assessment of the patient’s PIVC; (3) the frequency of documented PIVC removals and post-removal follow-up documentation and (4) the frequency of PIVC-related care prescriptions made by registered nurses. Reliability was defined as the accuracy of the documentation in the patient’s electronic record, compared with nursing staff verbal reports and direct researcher observations of the PIVC (Bahl et al., 2024).

Study setting and sampling

Participants in the study were nursing staff from a paediatric inpatient unit in a hospital located in southern Brazil, including registered nurses and nursing technicians/assistants. The staff consisted of 7 registered nurses, 18 nursing technicians and 4 nursing assistants. Nursing documentation by technicians and assistants consists of descriptive records of care activities provided to patients. These records are essential to support both the nursing progress notes and the nursing care plan, which are registered nurse responsibilities (Ferreira et al., 2020).

Nursing progress notes involve detailed assessments of the patient’s condition, whereas the care plan defines specific interventions. Both are components of the Nursing Process, a systematic methodology that organises and guides nursing care (Conselho Federal de Enfermagem, 2024). In this context, notes made by nursing technicians and assistants are essential for continuous monitoring of the patient’s condition and to ensure that the care prescribed by registered nurses is properly implemented and monitored (Conselho Federal de Enfermagem, 2024).

Sample size calculation is not required for ITS analyses, as statistical power increases with the number of observation points (Bernal et al., 2017). However, to estimate the minimum number of required observations, a 1-month count of daily PIVCs was used, totalling 1080 PIVCs annually. Using the SEstatNet^® software (http://sestatnet.ufsc.br/) and a 95% confidence level, a minimum sample size of 283 observations per study phase was determined, with an average of 94 observations per data collection point. The sample was non-probabilistic and intentional, comprising a total of 810 PIVC documentation observations performed by the nursing staff, of which 210 were completed by registered nurses and 600 by nursing technicians/assistants.

The unit of analysis was the documentation event (i.e. each recorded assessment) with multiple record observations potentially originating from the same patient or staff member. In the unit where the study was conducted, registered nurses document once every 24 hours, whereas nursing technicians/assistants document once per shift (every 6 hours during the day and every 12 hours at night). Thus, within a 24-hour period, each patient receives one documentation entry by the registered nurse and three by the nursing technicians/assistants.

Inclusion and exclusion criteria

Inclusion criteria were: being a member of the nursing staff and working in the specified unit providing care to paediatric patients at the time of the study. Exclusion criteria included: any professional who requested withdrawal from the study or who did not participate in one or more phases.

Study interventions and implementation

The intervention took place in six educational sessions to ensure all staff could participate. Sessions were held in a private room within the unit, lasted approximately 60 minutes and were structured into three phases. In the first phase, an interactive lecture was delivered on the purpose and clinical use of the I-DECIDED^® tool, using audio-visual resources and addressing participant questions. In the second phase, a low-fidelity simulation using a mannequin was conducted to demonstrate the tool’s use in assessing and documenting decisions related to PIVC use. Three clinical scenarios, representing a hospitalised child (PIVC with no complications, PIVC with complications and PIVC with substandard dressing), were developed and randomly assigned to staff, who assessed the PIVC on the mannequin and documented it in a fictitious patient record. In the third phase, educational materials such as flyers and posters were distributed throughout the unit, and each staff member received pocket-sized I-DECIDED^® cards to encourage daily use of the tool. A detailed description of the intervention components, educational strategies and implementation process has been previously published (Ray-Barruel et al., 2025).

Data collection

Data were collected between January and July 2023 across six time points: three pre-intervention and three post-intervention, each lasting 15 days with 10-day intervals in between. During the pre-intervention phase, PIVC assessment and documentation were guided by local institutional policies and individual clinical judgement, as per standard care practice. The pre- and post-intervention periods lasted 3 months each, and the intervention was carried out over 1 month. The same data were collected in the pre-intervention and post-intervention periods. No data collection took place during the implementation phase.

The data were entered into the Research Electronic Data Capture (REDCap) platform (Harris et al., 2019), and data were collected daily across three shifts (approximately 2 hours per shift) using a portable electronic device. To avoid potential biases, a single researcher (PhD student) conducted data collection for both pre-intervention and post-intervention. The instrument was applied by assessing electronic health records of patients with a PIVC in place, questioning staff about the PIVC care provided and observing PIVCs in situ or the insertion site if the catheter had been removed within the previous 48 hours, to verify the reliability of the documented information. Blinding was not performed due to the nature of the study design which may have resulted in a Hawthorne effect. However, standardised observation procedures and pre-testing were used to mitigate this risk.

Data analysis

Descriptive statistics were used to describe the characteristics of staff and patients, as well as pre- and post-intervention results. Results were reported using frequencies and percentages for categorical variables and medians with interquartile range (IQR) for continuous variables. To compare patient characteristics before and after the intervention, the chi-square or Fisher’s exact test was used for categorical variables. The Mann–Whitney test was applied to compare continuous variables between groups when normal distribution assumptions were not met, based on the Shapiro–Wilk test.

To analyse the intervention’s effects on outcomes over time, the Generalised Estimating Equation (GEE) model was used, a method particularly suited to longitudinal correlated data such as those from our ITS quasi-experimental design (Hanley et al., 2003). GEE models account for the correlation between repeated observations from the same nursing staff member over time. Subgroup analyses by nursing role (registered nurses and nurse technicians/assistants) were performed to estimate the intervention effect within each subgroup.

Analyses were conducted using the Statistical Package for the Social Sciences (SPSS), version 25 (IBM Corp, United States of America). The results were presented as odds ratios (ORs) with 95% confidence intervals (CIs), indicating the magnitude and direction of the intervention effect. For cells with zero counts, a continuity correction of 0.5 was applied. This approach enabled a robust assessment of changes in outcomes between the pre- and post-intervention periods. In addition to OR derived from GEE models, absolute differences in proportions and corresponding 95% CIs were calculated.

To evaluate the intervention’s impact, an ITS graph was constructed by calculating outcome proportions using R version 4.1.0 and epiR package. These proportions were logit-transformed to reduce the influence of extreme values and improve interpretability. Linear models were applied separately to pre- and post-intervention segments to understand changes in the logit-transformed proportions. Model estimates were then back transformed to the original proportion scale, allowing clearer visualisation of trends across the different stages of the intervention. Missing values were not imputed. Statistical significance was considered at p < 0.05.

During data collection, two nursing assistants were on medical leave. Since technicians and assistants share the same responsibilities for PIVC care and documentation, their data were analysed together.

Ethical considerations

The study complied with Brazilian regulations for research involving human subjects and was approved by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina (Ethics approval number: 5.965.146; Certificate of Ethical Review Submission: 6413.5122.9.0000.0121). Written informed consent was obtained from all participating, including healthcare professionals and parents or legal guardians of participating children. Children and adolescents also provided written informed assent, as appropriate, as required by the Brazilian resolution on research involving human subjects (Brasil, 2012).

Results

Participant and patient characteristics

A total of 27 nursing staff participated in the study, including 7 (25.9%) registered nurses, 18 (66.7%) nursing technicians and 2 (7.4%) nursing assistants. Of these, 25 (92.6%) were female, with a median age of 46 years ( IQR 40–51) and a median of 20 years (IQR 12–25) since graduation. About 23 (85.2%) participants had some form of additional training, and the median length of service in the unit was 9 years (IQR 3–20).

The electronic medical records of 65 hospitalised children in the unit were analysed, with 30 in the pre-intervention phase and 35 in the post-intervention phase. In addition, the inserted PIVC and/or the site of PIVCs removed within the previous 48 hours were directly observed. There were no refusals or attrition among the nursing staff, the patients with PIVCs, or their parents/guardians (Table 1).

Table 1.

Clinical and demographic characteristics of the children (N = 65).

Variables	Pre-interventionn (%) N = 30	Post-interventionn (%) N = 35	p-Value
Gender
Male	19 (63.3)	19 (54.3)
Female	11 (36.7)	16 (45.7)
Age (years)
Median (IQR)	1 (0–2)	1 (0–3)
Minimum–maximum	0–12	0–10
Reason for hospitalisation
Tropical disease	4 (13.3)	10 (28.6)
Gastrointestinal	9 (30)	6 (17.1)
Haematologic	2 (6.7)	0 (0.0)
Neurologic	0 (0.0)	1 (2.9)
Otorhinolaryngologic	1 (3.3)	1 (2.9)
Respiratory	9 (30)	14 (40)
Integumentary disease	3 (10)	0 (0.0)
Urologic	2 (6.7)	3 (8.6)
Length of stay (days)
Median (IQR)	3 (2 – 4.5)	3 (2–5)	0.146*
Minimum–maximum	1–7	1–15
Presence of PIVC	N = 300	N = 300
With PIVC inserted	289 (96.3)	296 (98.7)	0.114^†
Without PIVC (removed <48 hours)	11 (3.7)	4 (1.3)

IQR: interquartile range; PIVC: peripheral intravenous catheter.

The Mann–Whitney test; ^†Fisher’s exact test

PIVC assessment documentation compliance

A total of 810 nursing documentations were reviewed, and in 791 documentations, patients had a PIVC in place. After the implementation of the I-DECIDED^® tool, a statistically significant improvement was observed in six of the eight assessed items, particularly in documenting device necessity, functionality and complications (Table 2).

Table 2.

Compliance with PIVC documentation according to I-DECIDED^®..

Variables	Pre-intervention* n (%) N = 390	Post-interventionn (%) N = 401	Difference (CI 95%)	OR (CI 95%)	p-Value^†
IDENTIFY if a PIVC is in situ
Yes	219 (56.2)	280 (69.8)	13.67 (7.01 to 20.34)	1.79 (1.38 to 2.35)	<0.001
No	171 (43.8)	121 (30.2)
DOES the patient need this PIVC?
Yes	83 (31.3)	260 (64.8)	43.56 (37.36 to 49.75)	6.84 (4.85 to 9.64)	<0.001
No	307 (78.7)	141 (35.2)
EFFECTIVE function?
Yes	11 (2.8)	124 (30.9)	28.10 (23.29 to 32.91)	15.37 (6.38 to 37.06)	<0.001
No	379 (97.2)	277 (60.1)
COMPLICATIONS
Yes	10 (2.6)	119 (29.7)	27.11 (22.37 to 31.88)	15.99 (9.56 to 26.75)	<0.001
No	380 (97.4)	282 (70.3)
INFECTION prevention
Yes	0 (0.0)	5 (1.2)	1.12 (−0.02 to 2.26)	4.92 (0.53 to 45.64)	0.161^‡
No	390 (100)	396 (98.8)
DRESSING and SECUREMENT
Yes	0 (0.0)	17 (4.2)	4.11 (2.11 to 6.12)	16.61 (2.06 to 134.26)	0.008 ^‡
No	390 (100)	384 (95.8)
EVALUATE and EDUCATE
Yes	0 (0.0)	2 (0.5)	0.37 (−0.40 to 1.14)	1.95 (0.18 to 21.58)	0.585^‡
No	390 (100)	399 (99.5)
DOCUMENT the DECISION
Yes	231 (59.2)	281 (70.1)	10.84 (4.22 to 17.47)	1.60 (1.23 to 2.08)	<0.001
No	159 (40.8)	120 (29.9)

Bold values indicate statistically significant at p < 0.05.

CI: confidence interval; PIVC: peripheral intravenous catheter.

Reference: pre-intervention; ^†Generalised Estimating Equation; ^‡Continuity correction.

Of the total, 206 documentations (26%) were nursing progress notes by registered nurses (101 pre-intervention and 105 post-intervention), and 585 documentations (74%) were nursing notes by nursing technicians/assistants (289 pre-intervention and 296 post-intervention). Seven of the eight items from the I-DECIDED^® tool showed a significant increase in documentation by registered nurses after the intervention. Nursing technicians/assistants did not document three of the tool items (Infection prevention; Dressing and securement; Evaluate and educate) at any point, but all other items showed a significant increase in documentation (Table 3).

Table 3.

Compliance with PIVC documentation according to I-DECIDED^® by nursing staff role.

Documentation of I-DECIDED^® items by registered nurses
Variables	Pre-intervention* n (%) N = 101	Post-interventionn (%) N = 105	Difference (CI 95%)	OR (CI 95%)	p-Value†
IDENTIFY if a PIVC is in situ
Yes	86 (85.1)	104 (99)	13.90 (6.72 to 21.08)	18.13 (2.16 to 151.95)	0.008
No	15 (14.9)	1 (1)
DOES the patient need this PIVC?
Yes	43 (42.6)	92 (87.6)	45.04 (33.53 to 56.56)	9.50 (5.50 to 16.40)	<0.001
No	58 (57.4)	13 (12.4)
EFFECTIVE function?
Yes	4 (4)	67 (63.8)	59.85 (49.90 to 69.80)	42.60 (13.23 to 137.14)	<0.001
No	97 (96)	38 (36.2)
COMPLICATIONS
Yes	7 (6.9)	80 (76.2)	69.26 (59.73 to 78.79)	42.68 (24.09 to 75.61)	<0.001
No	94 (93.1)	25 (23.8)
INFECTION prevention
Yes	0 (0.0)	5 (4.8)	4.27 (−0.03 to 8.56)	4.97 (1.18–20.96)	0.029‡
No	101 (100)	100 (95.2)
DRESSING and SECUREMENT
Yes	0 (0.0)	17 (16.2)	15.7 (8.52 to 22.87)	18.77 (3.59–98.0)	0.001‡
No	101 (100)	88 (83.8)
EVALUATE and EDUCATE
Yes	0 (0.0)	2 (1.9)	1.41 (−1.54 to 4.36)	1.97 (0.17–22.70)	0.586 ‡
No	101 (100)	103 (98.1)
DOCUMENT the DECISION
Yes	94 (93.1)	104 (99)	5.98 (0.69 to 11.27)	7.87 (1.14–54.23)	0.036
No	7 (6.9)	1 (1)
Documentation of I-DECIDED^® items by nursing technicians/assistants
Variables	Pre-intervention* n (%) N = 289	Post-interventionn (%) N = 296	Difference (CI 95%)	OR (CI 95%)	p-Value†
IDENTIFY if a PIVC is in situ
Yes	133 (46)	176 (59.5)	13.44 (5.42–21.46)	1.71 (1.27–2.31)	<0.001
No	156 (54)	120 (40.5)
DOES the patient need this PIVC?
Yes	40 (13.8)	168 (56.8)	42.92 (36.01–49.82)	8.17 (5.03–13.26)	<0.001
No	249 (86.2)	128 (43.2)
EFFECTIVE function?
Yes	7 (2.4)	57 (19.3)	15.73 (11.11–20.35)	9.42 (2.78–31.89)	<0.001
No	282 (97.6)	239 (80.7)
COMPLICATIONS
Yes	3 (1)	39 (13.2)	12.14 (8.11–16.16)	14.48 (4.07–51.40)	<0.001
No	286 (99)	257 (86.8)
DOCUMENT the DECISION
Yes	137 47.4)	177 (59.8)	12.39 (4.37–20.41)	1.64 (1.20–2.26)	0.002
No	152 (52.6)	119 (40.2)

Bold values indicate statistically significant at p < 0.05.

CI: confidence interval; PIVC: peripheral intravenous catheter.

Reference: pre-intervention; ^†Generalised Estimating Equation ; ^‡Continuity correction.

Reliability of nursing documentation and frequency of documented PIVC removals and care prescriptions

In terms of documentation reliability, there was an increase in the consistency between what professionals verbally reported evaluating regarding the PIVC and what was documented by them in the electronic health record. Prior to the intervention, only 5.7% (22/385) of professionals documented what they reported having assessed, whereas after the intervention, this proportion increased to 26.7% (107/401) (OR = 5.99; IC 95%: 3.28–10.95; p < 0.001). During the pre-intervention phase, four (1%) nurses and one (0.3%) technician/assistant reported not having assessed the PIVC.

In addition, the reliability of the documentation, assessed by comparing nursing records with the researcher’s observation, also showed a statistically significant improvement. In the pre-intervention, 42.9% (99/231) of the documentations were considered reliable, increasing to 75.4% (212/281) in the post-intervention (OR = 4.09; CI 95%: 2.91–5.74; p < 0.001). Reliability was also assessed separately for registered nurses and for nursing technicians/assistants (Table 4).

Table 4.

Reliability of documentation by nursing staff role.

Variables	Pre-intervention* n (%)	Post-interventionn (%)	Difference (CI 95%)	OR (CI 95%)	p-value†
Professional documented what they reported having evaluated
Registered Nurses	N = 97	N = 105
Yes	7 (7.2)	70 (66.7)	59.45 (49.07–69.83)	25.44 (13.77–47.0)	<0.001
No	90 (92.8)	35 (33.3)
Nursing technicians/assistants	N = 288	N = 296
Yes	15 (5.2)	37 (12.5)	7.29 (2.733–11.85)	2.60 (1.22–5.53)	0.013
No	273 (94.8)	259 (87.5)
Reliability of documentation compared to observation
Registered nurses	N = 94	N = 104
Yes	51 (54.3)	89 (85.6)	31.32 (19.20–43.45)	4.97 (2.97–8.30)	<0.001
No	43 (45.7)	15 (14.4)
Nursing technicians/assistants	N = 137	N = 177
Yes	48 (35)	123 (69.5)	34.46 (23.98–44.93)	4.07 (2.68–6.18)	<0.001
No	89 (65)	54 (30.5)

Bold values indicate statistically significant at p < 0.05.

CI: confidence interval; PIVC: peripheral intravenous catheter.

Reference: pre-intervention; ^†Generalised Estimating Equation.

The ITS plotting showed a significant upward trend in the proportion of the reliability of professional report record and in the reliability of documentation-to-observation during the post-intervention periods for both nurses (Figure 1) and nursing technicians/assistants (Figure 2).

Figure 1.

Interrupted time-series plot – Registered Nurse.

Figure 2.

Interrupted time-series plot – Nursing Technician/Assistant.

During the data collection, 57 PIVCs were removed or replaced (18 in the pre-intervention phase and 39 in the post-intervention phase). None of the nursing technicians/assistants documented the reason for PIVC removal or replacement in either phase. In the pre-intervention phase, only 2 (11.1%) registered nurses documented the reason for PIVC removal, compared to 10 (25.6%) in the post-intervention phase. In the pre-intervention phase, the 2 (100%) PIVC removals were documented due to complications. In the post-intervention phase, 8 (80%) were also due to complications, and 2 (20%) due to accidental dislodgement. Among the PIVCs removed, 16 (59.3%) showed post-removal complications in the pre-intervention phase and 18 (60%) in the post-intervention phase. However, there was only one record of follow-up related to post-removal complications, which was made by a nurse during the shift following catheter removal.

In addition, regarding nursing care prescriptions made by registered nurses, there was a statistically significant increase in the prescription of care for three of the eight items on the tool. However, for the items ‘Does the patient need this PIVC?’ and ‘DOCUMENT the DECISION’, there were no nursing care prescriptions in either phase (Table 5).

Table 5.

Nursing care prescriptions for PIVCs made by registered nurses.

Variables	Pre-intervention* n (%) (N = 101)	Post-interventionn (%) (N = 105)	Difference (CI 95%)	OR (CI 95%)	p-Value†
IDENTIFY if a PIVC is in situ
Yes	4 (4)	13 (12.4)	8.42 (1.06 to 15.78)	3.42 (1.16 to 10.05)	0.025
No	97 (96)	92 (87.6)
EFFECTIVE function?
Yes	0 (0.0)	18 (17.1)	16.65 (9.31 to 23.99)	20.77 (2.39 to 180.49)	0.006 ^‡
No	101 (100)	87 (82.9)
COMPLICATIONS
Yes	7 (6.9)	34 (32.4)	25.45 (15.22 to 35.68)	6.40 (1.82 to 22.40)	0.004
No	94 (93.1)	71 (67.6)
INFECTION prevention
Yes	1 (1)	20 (19)	18.06 (10.30 to 25.81)	24.12 (4.22 to 137;87)	<0.001
No	100 (99)	85 (81)
DRESSING and SECUREMENT
Yes	1 (1)	11 (10.5)	9.49 (3.32–15.65)	11.66 (1.40–97.19)	0.023
No	100 (99)	94 (89.5)
EVALUATE and EDUCATE
Yes	1 (1)	0 (0.0)	−0.52 (−2.85 to 1.82)	0.96 (0.63 to 14.64)	0.977^‡
No	100 (99)	105 (100)

Bold values indicate statistically significant at p < 0.05.

CI: confidence intervals; PIVC: peripheral intravenous catheter.

Reference: pre-intervention; ^†Generalised Estimating Equation;; ^‡Continuity correction.

Discussion

This study aimed to assess whether the use of the I-DECIDED^® tool influenced documentation related to the assessment regarding PIVC use in the paediatric setting. Regarding the primary outcome, the implementation of the I-DECIDED^® tool was associated with a significant increase in documentation compliance across most assessment items. These findings are consistent with previous studies on the effects of structured interventions on PIVC documentation and clinical practice (Høvik et al., 2019; Ray-Barruel et al., 2023; Shivani and Joseph, 2022; Silva et al., 2025).

These findings align with, and extend, the results of Ray-Barruel et al. (2023), who implemented the I-DECIDED^® tool in three adults’ hospitals in Australia exclusively among registered nurses and observed significant improvements across most documentation items. Similarly, in our paediatric setting, a statistically significant improvement was identified in six of the eight I-DECIDED^® items when results were analysed across nursing roles combined, demonstrating that the tool was transferable to paediatric care. The wide CIs observed for selected items (e.g. dressing and securement) likely reflect very low baseline documentation rates and zero cells prior to the intervention.

When documentation outcomes were examined by professional category, important role-specific patterns emerged. Compared with the adult Australian implementation, the Brazilian paediatric study demonstrated statistically significant changes across a greater number of I-DECIDED^® items. For the items that were statistically significant in both studies (documentation concerning infection prevention and dressing and securement), the Australian study showed larger absolute improvements in documentation (Ray-Barruel et al., 2023), possibly reflecting differences in healthcare contexts, including variations in clinical protocols, resource availability and institutional support between countries.

In contrast, documentation gaps among nursing technicians/assistants persisted for selected I-DECIDED^® domains, particularly those related to Infection prevention, Dressing and securement and Evaluate and educate. These findings are likely related to differences in training, scope of practice and professional responsibility, given that technicians and assistants are primarily involved in task-oriented care and descriptive documentation, rather than clinical assessment and decision-making (Conselho Federal de Enfermagem, 2024; Silva et al., 2023; Walker et al., 2023).

The technical and scientific qualification of the nursing staff is fundamental to ensuring complete and accurate documentation of PIVC care, as is the implementation of strategies to improve the quality of nursing care prescriptions (Faeda and Perroca, 2017). It is crucial that healthcare institutions promote and reinforce professional development initiatives (Faeda and Perroca, 2017; Ferreira et al., 2020), especially since most educational institutions do not offer specific courses on intravenous therapy (Silva et al., 2023).

A paediatric point prevalence study in Indonesia reported poor documentation of PIVC care, particularly for dressing changes (16%), PIVC reinsertion dates (31%) and PIVC flushing practices (31%) (Indarwati et al., 2023). Similar gaps have been documented internationally (Høvik et al., 2024; Walker et al., 2023; Wilson et al., 2022) and have been associated with organisational barriers and the low prioritisation of documentation, potentially compromising patient safety and care quality (Berger et al., 2022; Xu et al., 2023). Therefore, it is essential to implement ongoing interventions that aim to raise awareness among professionals about the importance of complete and accurate documentation.

Regarding the secondary outcome of documentation reliability, significant improvements were observed post-intervention in the documentation of items that nursing professionals reported having assessed on the PIVC, as well as in the recording of appropriate clinical decisions. A prospective observational study evaluating the reliability and compliance of PIVC-related documentation found significant variability, with inconsistencies in maintaining accurate and complete records (Bahl et al., 2024). Improved documentation reliability is essential to ensure accurate clinical decision-making and continuity of care.

In relation to documentation of PIVC removal and post-removal follow-up, important gaps persisted despite the intervention. Improving the documentation of removal reasons is essential for more accurately identifying the incidence and complications (Bahl et al., 2024). In this study, no nursing technicians/assistants documented reasons for PIVC removal, and although registered nurse documentation improved significantly post-intervention, it remained insufficient. A study demonstrated that even after implementing PIVC care policies and updating those policies, a substantial number of PIVCs are still removed without proper documentation (DeVries and Strimbu, 2019). This highlights that complications related to removal as well as PIVC failures are often underreported in records (Høvik et al., 2024).

Strengths and limitations

This study offers significant contributions to nursing practice regarding PIVC care. It stands out by exploring the documentation of assessment, care, decision-making and nursing prescriptions related to PIVCs, especially in the paediatric context, thus addressing a key gap in the literature. The use of an evidence-based tool reinforces the importance of standardised interventions that support paediatric nursing staff beyond initial PIVC insertion documentation. This not only promotes patient safety but also reduces the risk of complications associated with improper device management, improves communication among professionals and enhances overall quality of care.

This study has limitations. The use of a non-probabilistic sample and the fact that it was conducted in only one paediatric inpatient unit limit the generalisability of the results. Another limitation was the relatively short follow-up period, which limits the ability to determine whether the observed improvements represent enduring changes in practice attributable to the intervention or a Hawthorne effect associated with being assessed. Therefore, regular auditing is recommended to support long-term adherence. Furthermore, future studies should incorporate qualitative data to further explore the barriers and facilitators in the adoption of the I-DECIDED^® tool by Brazilian nursing professionals, contributing to the development of more effective strategies for implementation and use across different care settings.

Conclusion

This study showed that the use of the I-DECIDED^® tool in the paediatric setting was associated with significantly improved nursing documentation related to the PIVC assessment and enhanced the reliability of documentation by nurses, technicians and assistants. Although some challenges remain (such as documentation of infection prevention and reasons for removal), the findings highlight the importance of structured, evidence-based interventions to improve documentation, care and paediatric patient safety. Although these findings indicate meaningful improvements in the PIVC care, they should be interpreted considering the study’s limitations. Future studies should examine whether improvements in documentation translate into reduced PIVC-related complications and enhanced patient safety.

Key points for policy, practice and/or research

Implementation of the I-DECIDED^® tool significantly improved compliance with PIVC documentation in the paediatric context, particularly regarding device need, functionality and complications, supporting safer and more standardised nursing practice.

Reliability between professional reporting, documentation and direct observation has increased significantly, strengthening transparency, continuity of care and the validity of nursing records.

Registered nurses demonstrated greater adherence to documentation standards compared to technicians/assistants, highlighting the need for role-specific training.

Documentation of PIVC removal reasons and post-removal monitoring remained limited, revealing a gap in patient safety and continuity of care that requires targeted policy and practice interventions.

Supplemental Material

sj-pdf-1-jrn-10.1177_17449871261429815 – Supplemental material for The I-DECIDED® tool on documentation of the assessment of peripheral intravenous catheter in paediatrics: an interrupted time series study

Supplemental material, sj-pdf-1-jrn-10.1177_17449871261429815 for The I-DECIDED® tool on documentation of the assessment of peripheral intravenous catheter in paediatrics: an interrupted time series study by Thiago Lopes Silva, Gillian Ray-Barruel, Amanda Ullman, Mari Takashima, Sabrina de Souza, Jefferson Wildes da Silva Moura, Sayonara Stéfane Tavares de Moura, Luciano Marques dos Santos and Patrícia Kuerten Rocha in Journal of Research in Nursing

Footnotes

Author contributions

Thiago Lopes Silva: Conceptualisation; Data curation; Formal analysis; Funding acquisition; Methodology; Resources; Writing – original draft; Writing – review & editing.

Gillian Ray-Barruel: Conceptualisation; Methodology; Writing – original draft; Writing – review & editing.

Amanda Ullman: Formal analysis; Supervision; Writing – original draft; Writing – review & editing.

Mari Takashima: Formal analysis; Writing – original draft; Writing – review & editing.

Sabrina de Souza: Writing – original draft; Writing – review & editing.

Jefferson Wildes da Silva Moura: Writing – original draft; Writing – review & editing.

Sayonara Stéfane Tavares de Moura: Writing – original draft; Writing – review & editing.

Luciano Marques dos Santos: Writing – original draft; Writing – review & editing.

Patrícia Kuerten Rocha: Conceptualisation; Formal analysis; Funding acquisition; Methodology; Supervision; Writing – original draft; Writing – review & editing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was carried out with the support of Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) under CNPq call No. 26/2021 awarded to Thiago Lopes Silva. Additionally, the research is linked as a subproject to two projects led by Prof. Patrícia Kuerten Rocha. The first project, titled ‘Educational and Assistive Technologies for the Prevention of Adverse Events in Vascular Access Devices in Pediatric Patients’, was submitted to CNPq call No. 09/2022 Productivity Scholarship in Research. The second project, titled ‘Technological Interventions for the Prevention of Adverse Events in the Use of Vascular Access Device in the Pediatric Population’, submitted to CNPq/MCTI call No. 10/2023 – UNIVERSAL.

Ethical approval

Approval was granted by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina (Ethics approval number: 5.965.146; Certificate of Ethical Review Submission: 6413.5122.9.0000.0121). And the informed consent was provided to all participants in the study.

ORCID iDs

Thiago Lopes Silva

Amanda Ullman

Mari Takashima

Sabrina de Souza

Jefferson Wildes da Silva Moura

Sayonara Stefane Tavares de Moura

Luciano Marques dos Santos

Patrícia Kuerten Rocha

Supplemental material

Supplemental material for this article is available online.

Thiago Lopes Silva is a postdoctoral researcher at the University of Queensland, focusing on patient safety and intravenous therapy.

Gillian Ray-Barruel is a Senior Research Fellow at the University of Queensland and Herston Infectious Diseases Institute and Director of Education at AVATAR. She created the I-DECIDED^® tool for vascular device assessment.

Amanda Ullman is a Professor and Chair in Paediatric Nursing at the University of Queensland and Children’s Health Queensland. She leads research on paediatric patient safety and hospital care optimisation.

Mari Takashima is a Research Fellow at the University of Queensland and Children’s Health Queensland, focusing on invasive devices, paediatric respiratory infections and implementation science.

Sabrina de Souza is a Research Fellow at the University of Queensland and Children’s Health Queensland, focusing on vascular access technologies for children and neonates

Jefferson Wildes da Silva Moura is a PhD candidate, with a visiting period at the University of Queensland. He researches child health, pain management and intravenous therapy.

Sayonara Stéfane Tavares de Moura is a PhD candidate. She is a specialist in emergency care, working in paediatric emergency and researching intravenous therapy and paediatric skin injuries.

Luciano Marques dos Santos is a Professor in Paediatric Nursing and leads research in innovation, healthcare safety, intravenous therapy and care for children, women and families.

Patrícia Kuerten Rocha is a Professor in Paediatric Nursing and Vice-leader of the Laboratory of Teaching, Research and Extension in Child and Adolescent Health, focusing on paediatric emergency, intravenous therapy and patient safety.

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