Epicutaneo-caval catheters (ECCs) have been widely used in neonatal intensive care units (NICUs) for intravenous nutritional support and long-term drug infusion (1). Maintaining the catheter tip within the superior or inferior vena cava is critical because malposition may induce adverse outcomes (2, 3). Clinically, chest radiography (CR) has been used as the “gold standard” to confirm the site of the catheter tip (4, 5). However, accumulating evidence has shown the drawbacks of tip positioning by CR, including special requirements for the imaging room, retrospective imaging, ionizing radiation, and a time-consuming operation. Comparatively, ultrasonography (US) has many virtues, such as allowing for an easier operation at bedside, using non-ionizing radiation, and allowing real-time imaging and direct visualization of the catheter tip and cardiovascular structures. In fact, it has recently been used, with success, for the evaluation of ECC location in adult and child patients (6, 7). However, as a new and promising technology, there is still little known about its application in neonatal medical centers. Few reports have focused on this topic. For this reason, this study conducted a cross-sectional survey on the practice status of neonatal US-guided PICC placement at 91 hospitals in 31 provinces and municipalities in China, aiming to provide detailed data on the application of this project and to better understand the factors affecting its application.

ECCs have been used in Chinese health institutions for approximately 30 years. US-guided ECC placement was first introduced in the early 21st century but adopted much later for neonatal patients. Beginning last year, it was formally recommended in Operation and Management Guidelines for Peripherally Inserted Central Catheter in Neonates by the Neonatologist Society of Chinese Medical Doctor Association (8). To understand more about the practice status quo of neonatal US-guided ECC tip location in China, we launched this survey that involved 182 nursing managers and ECC team leaders from 91 hospitals in 31 provinces and municipalities in China. The survey demonstrated that only 16 tertiary hospitals (17.6%) have adopted neonatal US-guided ECC tip location. This may be due to the medical staff's unawareness of or reluctance to carry out novel services in neonates, more difficult imaging operations for the small blood vessels of neonates, and the lack of technology and management promotion.

In this study, 96.7% of the respondents expressed that they knew about neonatal US-guided ECC tip location; 94.5% supported it, and 73.6% had ever attended a training lesson. However, only 35.2% of the respondents hold the knowledge, and 25.8% hold sufficient skills to launch such an imaging projection. The low recognition of neonatal US-guided ECC tip location ranks among the three independent risk factors counteracting its popularization, which would mean that there are cause fewer chances to be trained in this technology. Therefore, it is necessary to strengthen publicity and promotion efforts of this technology (9, 10). Limited ward conditions and insufficient funds are also independent factors. The limited conditions of the ward mainly include the increased expenditure caused by the purchase of ultrasonic examination instrument, couplant and paper, as well as the training expenses caused by the training of professionals. According to our experience, domestic secondary hospitals are fully capable of purchasing Doppler ultrasound machines. The real causes of equipment shortages could be investment, bonus distribution, cost deductions, incentives and other institutional problems. Thus, we argued that project leaders should actively talk with hospital leaders to straighten out these interests. Insufficient human resources may also hinder the implementation of US in neonatal ECC catheterization, albeit no statistical significance was found in this study. Currently, the lack of medical nursing staff has become a global problem. Especially for neonatal specialist nurses, high work pressure and professional requirements have caused a critical shortage of workers (11). Therefore, we argue that it is essential that hospital leaders give full consideration to satisfying nurses' career demands, improving nurses' job satisfaction and reducing factors affecting nurses' career achievement, and establish a reasonable compensation mechanism, a scientific performance evaluation mechanism and a personnel salary system adapted to the attributes of the profession (12). Under the guidance of these beneficial systems, more nursing staff would be attracted to participate in pediatric and newborn nursing work.

The respondents agreed that the top three strategies to promote the application of neonatal US-guided ECC tip location were separately setting up a special team to organize, plan and implement the project (153, 83.6%), supplying systematic training for the people in the process (146, 80.2%), and gaining financial and institutional support from the hospital or department (145, 79.7%). Undoubtedly, the establishment of a set of targeted management systems at the hospital level would be greatly conducive to the development and continuous improvement of the project (13, 14), and ECC-specialized management would offer accurate and timely supervision and control throughout the ECC process, ensuring that the procedures are well-regulated to better reduce the risks (7, 15). Avoiding X-ray exposure, providing a real-time dynamic display, and the timely finding and reducing the chances of misplaced tips during catheter use rank among the top three merits of US-guided ECC tip location as recognized by the respondents. These merits of US have also been verified in publications (16–18). However, according to this study, neonatal US-guided ECC tip location is seldom used in Chinese medical institutions, and there are some deficiencies presented in the project's promotion and management. Therefore, it is suggested that the administrators and nursing experts of tertiary hospitals jointly formulate a unified standardized workflow and effectiveness evaluation index system for neonatal US-guided ECC tip location (19), construct clinical practice guidelines, and promote its standardization and scientific process (13, 14).

In this study, the questionnaire was distributed through the committee group of the pediatric nursing group of the Chinese Medical Association and other platforms, which may have led to fewer secondary hospitals being reached by the survey. In addition, the respondents of this study did not involve medical insurance policy-makers, medical insurance management departments or insurance companies, so the impact of medical insurance policy on technology popularization and development was not investigated.

This study investigated the practice status quo of neonatal US-guided ECC tip location of 125 hospitals in 31 provinces, which revealed that the development of the project was seriously hindered by factors such as a low awareness rate of the project, the low qualification certification rate of the nursing staff, flawed performance allocation system, and lack of a professional team. It is suggested to strengthen the training, learning and qualification certification of medical staff, increase the sense of professional achievement of nurses, and establish a professional team to promote the publicity of neonatal US-guided ECC tip location and provide high-quality, standardized and scientifically-based services for neonatal patients.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

The institutional review board has approved the study: Approval No. 2021-342. Written informed consent was obtained from individual or guardian participants.

XL contributed to acquisition, analysis and interpretation of the data and acquisition, analysis and interpretation of the data and the drafting, and final approval of the manuscript. XT, YX, and XZ provided technical support and conceptual advice. LW designed the study. All authors made substantial contributions to the study and manuscript and met the criteria for authorship defined in the author instructions, read, and approved the final manuscript.

This work was supported by the Chongqing Science and Technology Commission (2020MSXM028).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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