Research ArticleOpen access
From Standards to Sustainable Practice: A Hospital-Wide Quality Improvement Program for Infusion Management in a Resource-Conscious Multispecialty Hospital in India
T.P. Shedin Bharathan
Journal of Infusion Nurses Society, India|Vol. 1 · Issue 1 · 2026 · 1 November 2026
Introduction: Vascular access is one of the most frequently performed interventions in hospitalized patients. Variation in device selection, insertion technique, securement, maintenance, access and documentation can contribute to preventable infectious, mechanical, and patient-experience complications. Contemporary standards provide an evidence-based framework, but translating them into routine practice in a resource-conscious hospital requires more than procurement of products.
Objectives: To describe the implementation of a hospital-wide infusion management quality improvement program in a 250-bed multispecialty cooperative-sector hospital in Kerala, India, and to evaluate post-implementation adherence and vascular-access surveillance findings. Material &
Materials And Methods: The program incorporated hospital-wide education, establishment of a seven- member infusion management team, standardized vascular-access terminology, aseptic non-touch technique, standardized skin antisepsis, dedicated vascular-access trays, standardised catheter selection and securement, closed intravenous systems, structured PICC and long peripheral catheter services, ultrasound-guided subclavian central venous access, and weekly digital auditing. Post-implementation audit data were collected from 2 December 2025 to 13 September 2026. A staged, hospital-wide infusion management program was successfully implemented through structured staff education, competency- based training, multidisciplinary governance, standardization of vascular access devices and procedures, development of advanced vascular access services, and continuous digital surveillance. A total of 5159 audit observations were recorded following implementation, demonstrating sustained integration of the program into routine clinical practice.
Results: Audit findings showed high adherence to key infusion-care processes, including dressing integrity (~99%), catheter patency (~95%), and documented hand-hygiene compliance (~91.5%), with the majority of observations showing VIP score 0.
Conclusion: A hospital-wide infusion management program can be implemented in a resource-conscious Indian hospital through structured education, standardization, dedicated clinical ownership, selective technology adoption, cost-conscious procurement and continuous audit. The post-implementation dataset demonstrates high adherence to several core infusion-care processes and provides a practical framework for longitudinal surveillance. The program illustrates that contemporary infusion standards need not be restricted to high-resource corporate hospitals.
Introduction
Vascular access is fundamental to modern hospital care. Peripheral and central vascular-access devices are used for administration of medications, fluids, blood products, parenteral nutrition and other therapies. Because these devices are so ubiquitous, rela-
tively small variations in insertion and maintenance practice can affect a large number of patients. Internationally, unwarranted variation in vascular-access practice has been associated with preventable infectious complications such as catheter-related bloodstream infection, mechanical complications in-
cluding infiltration, dislodgement and occlusion, and patransparent reporting of what was achieved, where gaps
tient-experience harms such as pain, repeated venepuncpersisted, and how the program was evaluated over time.
ture and treatment interruption.
Phlebitis in particular Accordingly, this quality improvement program was remains one of the most common and under-recognized undertaken to implement and describe a hospital-wide inperipheral-catheter complications, and structured visual fusion management system in a resource-conscious multiscoring tools have been developed specifically to allow specialty hospital in India, and to evaluate post-implemenbedside nursing staff to detect it early and act before it protation adherence and vascular-access surveillance findings, gresses.
including areas of variation warranting continued attention.
Over the past decade, vascular-access practice has Objectives moved from fragmented, institution-specific conven-
To describe the implementation of a hospital-wide tion toward a body of consensus, evidence-based stan-
infusion management quality improvement programme dards. Contemporary infusion standards provide an
in a 250-bed multispecialty cooperative-sector hospital evidence-based framework for infusion therapy and vas-
in Kerala, India, and to evaluate post-implementation cular-access device management, while WHO recommen-
adherence and vascular-access surveillance findings dations emphasise education, asepsis, device selection,
surveillance, and multimodal implementation.
Spe- Materials and Methods cialty consensus statements have further refined specif- This quality improvement program was implemented at ic domains: the GAVeCeLT consensus for central venous Indira Gandhi Cooperative Hospital (IGCH), Kadavanthra, the ERPIUP consensus for access in critically ill patients, Kochi, Kerala, India, a 250-bed multispecialty hospital peripheral and midline device selection, and the NAVfunctioning in the cooperative healthcare sector. The IGATE project's proposed standardized nomenclature for institution provides relatively affordable healthcare to a vascular-access devices, intended to improve communilarge and socioeconomically diverse patient population in cation, reproducibility and comparability across studies the district. Post-implementation audit data reported here and institutions.
Taken together, this literature offers a were collected from 2 December 2025 to 13 September reasonably mature evidence base for what good vascu- 2026. Before implementation, infusion practices varied lar-access practice looks like.
between clinical areas. Variation was identified in What remains far less established is how these vascular-access terminology, insertion-site selection, standards can be implemented and sustained outside equipment preparation, securement, dressing practice, high-resource settings.
Much of the published connector use, flushing, administration-set management implementation literature originates from well-resourced and documentation. The challenge was not simply a lack corporate or academic hospitals, where procurement of of willingness to provide good care but variable exposure premium devices, dedicated vascular-access teams, and to contemporary vascular-access standards, persistence continuous electronic surveillance infrastructure can often of traditional practices, inconsistent availability and be assumed. This leaves an important gap for hospitals arrangement of equipment, and financial constraints operating with real financial constraints and an explicit affecting procurement decisions. In a cooperative hospital affordability mandate to the populations they serve, which serving a large population for whom affordability is is common across much of India's cooperative, trust and important, quality improvement required deliberate public hospital sectors. The challenge, however, is not cost-benefit assessment. The program, therefore sought simply knowing what constitutes good practice. The to avoid a false choice between quality and affordability. more difficult question is how contemporary standards The guiding principle was to invest in interventions with can be implemented and sustained in a hospital where meaningful clinical value, standardise processes in which resources are limited and affordability of healthcare is an variation created risk, and eliminate avoidable expenditure important institutional responsibility. In such settings, without compromising safety. This report follows the adopting every high-cost product or practice described in SQUIRE 2.0 reporting guidelines. international standards is neither feasible nor necessarily The program was based principally on the Infusion the correct quality-improvement strategy. However, Therapy Standards of Practice, the CDC guideline for resource constraints are not an acceptable reason to defer prevention of intravascular catheter-related infections, standardization, given the scale of preventable harm the WHO guideline for peripheral catheters, the recent that unwarranted vascular-access variation can cause.
WHO guideline for central venous catheters, the There is therefore a need for documented, real-world GAVeCeLT consensus for central venous access in critically accounts of how evidence-based infusion standards can ill patients, the ERPIUP consensus for peripheral venous be translated into a sustained hospital-wide practice access devices and the NAVIGATE project nomenclature through a deliberately resource-conscious systems for vascular-access devices . The NAVIGATE project was approach that can combine education, standardization, particularly relevant because it proposed standardized dedicated clinical ownership, selective rather than nomenclature for vascular-access devices, supporting blanket technology adoption and continuous audit, with
clearercommunication,reproducibilityandcomparability. The ERPIUP consensus provided a framework for selection and management of short peripheral, long peripheral and midline devices.
The intervention combined hospital-wide education, standardization of equipment and terminology, and development of advanced vascular-access capability. The first phase was deliberate, pan-hospital education. Training was not restricted to intensive care or highdependency areas. The nursing workforce was taught from fundamental concepts to practical application, including vascular-access terminology, device selection, peripheral catheter insertion, central venous access, aseptic non-touch technique, hand hygiene, skin antisepsis, securement, dressing management, needle-free connectors, flushing, administration-set management, phlebitis and infiltration recognition, documentation, and catheter removal. Multiple sessions were conducted over approximately two months, followed by mandatory hands-on training through external agencies using practical skill workstations. A seven-member infusion management team was established, including senior nursing personnel, the Nursing Superintendent and the Infection Control Nurse. The governance structure placed the Medical Superintendent at the level of major institutional approvals, the Senior Infusion Management Consultant/Adviser as clinical adviser, the Nursing Superintendent as implementation and oversight lead, and the Infection Control Nurse as infusion-team lead. The team was responsible for education, implementation, bedside support, audit, identification of practice gaps, corrective teaching, maintenance of standards and review of complications, and was designed primarily as an educational and improvement resource rather than a policing mechanism. When a deviation was identified, the preferred response was targeted bedside teaching or a focused mini-training session. Hospital-wide terminology and aseptic was aligned with the NAVIGATE project, non-touch technique was incorporated into peripheral and central vascular-access procedures.
Standardization extended to antisepsis, equipment and devices. A 2.5% chlorhexidine-containing alcohol preparation was adopted as the institutional antiseptic for peripheral and central vascular access. It was procured in bulk by the central store as 5-liter containers and stored in air-conditioned storerooms, with the aim of maintaining the manufacturer's recommended storage temperature of 8–24 °C. It was then issued to ward in-charges, who transferred it into labeled, supplier-provided dispensing bottles for use in the clinical areas. Dedicated peripheral vascular-access trays were introduced in clinical areas, each containing a defined minimum inventory with labeled components, and a dedicated central vascular-access trolley with printed, photograph-illustrated inventory lists was introduced in the intensive care environment. Dedicated reusable trays were established for long
peripheral catheter, centrally inserted central catheter, femorally inserted central catheter and arterial catheter procedures, with contents standardized, displayed, and sterilisation quality monitored using autoclave sterilization indicators. For short peripheral catheters, the forearm was established as the preferred initial site where clinically appropriate, with avoidance of placement over joints, representing a change from the traditional approach of cannulating the most immediately accessible vein. All short peripheral vascular-access devices were progressively transitioned from polytetrafluoroethylene to polyurethane catheter material, considered together with catheter size, site selection, securement, dwell strategy and surveillance rather than as an isolated product substitution. The program also initiated a transition towards injection-portfree short peripheral catheters, incorporated into a closed extension-and-needle-free-connector configuration, to minimise unnecessary manipulation and the mechanical irritation associated with an integrated injection port.
For central venous access, ultrasound guidance was adopted as an institutional capability. For adult patients requiring a centrally inserted central catheter, the subclavian vein was established as the preferred insertion site wherever clinically appropriate, with a deliberate transition from conventional landmark-based subclavian access towards real-time ultrasound-guided subclavian venous access, incorporating both infraclavicular and supraclavicular approaches. All anesthesiologists involved in central catheter insertion were progressively trained in real-time ultrasound-guided subclavian access, requiring deliberate training in venous identification, dynamic ultrasound imaging, probe optimization, needle-tip tracking, guidewire handling and recognition of anatomical variation. A large proportion of centrally inserted central catheters at the institution are now performed using real-time ultrasound-guided subclavian venous access. The CDC recommends the subclavian site over jugular or femoral sites in adult patients to reduce infection risk for non-tunneled central venous catheters, while also requiring consideration of mechanical risks and patient-specific factors.
Securement, dressing, flushing and administration-set practices were standardized hospital-wide. Stabilization securement was introduced for peripheral vascular-access devices, and transparent semipermeable dressings were standardized, with chlorhexidine-containing transparent dressings used for selected higher-risk vascularaccess devices. Vascular-access dressing changes were transitioned from a routine time-based practice to an INS Standards–aligned approach, with dressings maintained for up to 7 days and replaced earlier if soiled, loose, damp or compromised.
Normal saline was adopted as the standard flushing solution, with sterile single-use prefilled normal-saline syringes introduced for selected higher-risk central vascular-access devices. The hospital transitioned towards a closed intravenous system,
with neutral-displacement needle-free connectors system, including infusion-management records and IV
standardized across clinical areas, disinfecting caps flow sheets, designed around local workflow to create a
introduced for central vascular-access devices, and common language between nurses, physicians, infection-
alcohol disinfection of the connector incorporated before control personnel and the infusion team.
access to peripheral devices. Peripheral vascular-access Because no pre-implementation audit dataset was devices were connected to approximately 10-cm extension available for comparison, this analysis is descriptive and systems with needle-free connectors, reducing repeated longitudinal within the post-implementation period rather direct manipulation of the catheter hub. Continuous than a controlled pre/post evaluation, and the findings administration sets were managed on a 96-hour schedule should be interpreted accordingly. and intermittent sets on a 24-hour schedule under Post-implementation audit data were extracted institutional protocol. Peripheral vascular-access devices from the institutional electronic audit workbook. The were transitioned from routine time-based replacement dataset contained 5,159 observations recorded between to clinically indicated removal, in accordance with the 2 December 2025 and 13 September 2026. Audit-level INS Standards and ERPIUP recommendations, with compliance was calculated as the proportion of applicable devices removed in the presence of phlebitis, infiltration, checklist items answered 'Yes' (items answered 'Not occlusion, dislodgement, suspected infection, loss of applicable' were excluded). Ward-level and overall function or completion of therapy, aiming to avoid compliance are the mean of audit-level scores. Two unnecessary venepuncture, preserve peripheral venous single observations recorded from the operating theater access and reduce avoidable consumption of vascularand emergency department were grouped as 'Other' in access materials.
ward-level analyses. The unit of analysis was an audit Advanced vascular-access capability was developed observation rather than a unique patient or unique alongside these standardization measures. An Advanced catheter episode. It included process measures (site Vascular Access Service was established to provide visibility, site condition, dressing integrity, line labeling, ultrasound-guided difficult peripheral access, long administration-set interval, patency, insertion-date peripheral catheter placement, PICC insertion, assessment documentation and hand hygiene), patient-reported of difficult intravenous access and structured follow-up.
symptoms, and a Visual Infusion Phlebitis (VIP) score. VIP A structured PICC insertion service incorporated preoutcomes are reported only for peripheral catheters, for insertion assessment and a standardized procedural which the scale is intended. VIP percentages are expressed protocol, using the PICC Zone Insertion Method (ZIM)
as a proportion of peripheral-catheter audit observations to select the optimal upper-arm insertion zone. PICC and are not patient-level or catheter-level incidence rates. insertion was performed under strict aseptic conditions in Ethical Considerations the operating theater using real-time ultrasound guidance
for venous access and fluoroscopy for catheter-tip This manuscript reports an institutional quality improveposition, with intra-procedural trimming and structured ment programme based on routine clinical practice and follow-up documented in a dedicated PICC register. Long quality-assurance surveillance. No experimental interperipheral catheters, including both Seldinger-based and vention was undertaken, and no patient was subjected mini-midline/bullpup-type devices, were introduced to an intervention solely for research purposes. The audit as an intermediate option between conventional short formed part of routine hospital quality-improvement acperipheral access and central vascular access.
tivities. The programme and the audit were approved by
the Medical Superintendent before implementation, and Continuous surveillance underpinned the program.
the existing and the new methods of documentation were The infusion team performed weekly audits using an explained to and approved by the institutional authorities electronic data-collection system, capturing timestamp, before the programme began. No separate Institutional device type, insertion date and location, insertion site, site Ethics Committee review was undertaken, as this was a visibility, site condition, dressing condition, line labeling, routine quality-improvement activity. Separate, individual administration-set status, catheter patency, insertionpatient consent for participation in the audit itself was not date documentation, hand hygiene compliance, patientsought, as the audit involved routine review of device-care reported pain or burning, VIP score, comments and and process-of-care checklist items rather than any paphotographs where necessary. Audits were carried out by tient-directed intervention, and no patient-identifiable innurses assigned to each ward, who periodically visited the formation was recorded in the audit dataset or is reported ward and audited patients with vascular access devices in this manuscript. Informed consent for peripheral vasselected at random; repeat audits of the same catheter cular-access devices continued to be obtained as part of were not deliberately sought. Hand hygiene compliance routine admission procedure, and separate informed conwas assessed by direct observation by the auditor at sent continued to be obtained and maintained for central the time of the audit and recorded as compliant or nonvascular-access devices, independent of and unaffected by compliant. A separate infusion-management component the audit described here. was developed within the hospital's documentation
Table 1: Monthly audit volume and VIP ≥1 among peripheral-catheter observations (n=5159) Month Audit observations
December 2025 January 2026 February 2026 March 2026 April 2026 May 2026 June 2026 July 2026 August 2026 September 2026* Total 5,159 *September 2026 includes data through 13 September only.
Results
A total of 5,159 audit observations were recorded during the study period. The program generated sustained surveillance across the implementation period, providing a large body of post-implementation observations for feedback and subsequent improvement cycles. Monthly audit volume alongside the corresponding VIP ≥1 flag rate is presented in Table 1.
The device mix audited across the study period is summarized in Table 2. Short peripheral catheters accounted for the large majority of observations, consistent with their status as the most frequently used vascular-access device hospital-wide. Central venous catheters, PICCs, hemodialysis catheters and long peripheral catheters together made up the remainder, reflecting the smaller but clinically important caseload served by the advanced vascular-access and PICC services described in methods. Table 2: Vascular-access device distribution (n=5159) Device Observations Percentage Short peripheral catheter (SPC)
4,830 93.62% Central venous catheter (CVC)
4.21% PICC 1.90% Hemodialysis catheter (HD)
0.16% Long peripheral catheter (LPC)
0.12%
Table 3 summarizes adherence across the nine core infusion-care process measures captured at each audit. Compliance was consistently high for measures related to site and dressing integrity such as site visibility, cleanliness, absence of local inflammatory signs, and dressing condition all exceeded 98.5%, as was adherence to line labeling and administration-set interval. The three measures with the lowest compliance were catheter patency (94.96%), insertion-date documentation (94.17%) and hand hygiene compliance (91.48%). Although still rela-
Peripheral-catheter VIP ≥1 observations
4,836
tively high in absolute terms, these represent the largest residual gaps identified by the audit and are the measures most directly implicated in the ward-level findings reported below. Table 3: Core infusion-care process compliance (n=5159) Audit measure
IV site visible and accessible Site clean, dry and intact No redness, swelling or discharge Dressing dated and intact Line labeled (applicable) Administration-set interval compliant (applicable) Catheter flushed and patent Insertion date documented Hand hygiene compliant (recorded responses)
The distribution of VIP scores among the 4,836 peripheralcatheter observations is shown in Table 4. The large majority (98.61%) recorded a VIP score of 0; scores of 3 or higher were rare (3 observations, 0.06%). Table 4: Visual Infusion Phlebitis (VIP) score distribution among peripheral-catheter observations (n=4,836) VIP score Observations 4,769
VIP ≥1 (% of peripheral observations) 2.84% 2.77% 1.79% 1.08% 1.02% 0.75% 0.57% 0.50% 1.00% 0.70% 1.39%
Compliant/ Compliance applicable 5,130/5,159 99.44% 5,127/5,159 99.38% 5,097/5,159 98.80%
5,107/5,159 98.99% 4,531/4,588 98.76% 4,066/4,143 98.14%
4,899/5,159 94.96% 4,858/5,159 94.17% 4,541/4,964 91.48%
Percentage 98.61% 0.91% 0.41% 0.02% 0.02% 0.02% Contd...
VIP score Observations Percentage VIP ≥1 1.39% VIP ≥2 0.48%
Monthly VIP ≥1 among peripheral-catheter observations (Table 1) declined from 2.84% in December 2025 to approximately 1% in March and April 2026 (1.08% and 1.02%), and was at or below 1.0% from May 2026 onward. Pain or burning was reported in 578 of 5,159 audit observations (11.20%) and no pain or burning was recorded in 4,581 observations (88.80%). Patient-reported symptoms were retained as a separate audit domain because symptom reporting and visual phlebitis assessment are not necessarily concordant.
Because pooled, hospital-wide averages can obscure meaningful differences between clinical units, compliance, phlebitis flags and patient-reported pain were additionally examined across the 13 audited wards (two single observations recorded from the operating theatre and emergency department are grouped as 'Other') as shown in the ward scorecard in Table 5. Table 5: Ward-level scorecard (2 December 2025 to 13 September 2026; n=5,159), sorted by compliance. (n=5,159)
Ward Audits Compliance* VIP ≥1 G 1,471 91.8% SICU 96.8% E 97.1% CCU 97.1% E Cubicle 97.6% MICU 97.8% B 99.0% C 99.2% H 99.4% A 1,353 99.7% F 100.0% D 100.0% Onco ICU 100.0% Other (OT, ED)
100.0% Total 5,159 97.0%
*Compliance is the mean audit-level proportion of applicable checklist items answered 'Yes' Ward G accounted for 1,471 of the 5,159 audit observations (28.5%) and was the clear outlier, at 91.8% compliance against 97.0% overall. Its hand hygiene noncompliance (25.1%), undocumented insertion dates (19.0%) and flush/patency failures (14.5%) were severalfold higher than in all other wards combined (1.9%, 0.6% and 1.2%, respectively). Ward G accounted for 84% of all hand hygiene non-compliance, 93% of undocumented insertion dates and 82% of flush/patency failures. Ward G's compliance rose from 67.6% in December 2025 and
71.3% in January 2026 to 99.4–100% from February to July 2026, dipped to 91.7% in August (n=42), and was 98.5% in September (n=15). Ward H, a paediatric ward, recorded pain or burning in 186 of 227 observations (81.9%), far above other wards, although none of its observations scored above VIP 0. Pain or burning during infusion may be reported more often in pediatric patients, and this finding is therefore presented descriptively and should not be interpreted as evidence of a clinical problem in this ward.
Discussion
The central finding of this quality improvement program is the development of a hospital-wide infusion governance system rather than the introduction of any single product or procedure. The program combined evidence-based standards, education, standardization, dedicated clinical ownership, selective technology adoption, cost-conscious procurement and continuous audit. This approach is consistent with the contemporary direction of vascular-access guidance, particularly the WHO emphasis on education and training, asepsis, appropriate catheter selection, surveillance, and multimodal implementation.
The program deliberately began with education rather than procurement. Introducing a new catheter, connector or dressing without changing the underlying knowledge and behavior of the workforce would not be expected to produce sustainable improvement. Training was therefore designed to explain what had changed, why it had changed and how the new practice should be performed.
A key philosophical decision was that the infusion team should not function primarily as an enforcement agency. An audit finding was treated as an opportunity for education. The intended cycle was observation, identification of the gap, bedside explanation, corrective practice and reassessment, designed to create compliance through knowledge and ownership rather than fear of inspection.
Several interventions were deliberately simple: standard terminology, standard trays, standard antisepsis, standard connectors, standard extensions, standard documentation, and standard audit questions. Individually, each may appear modest; collectively, they reduce unwarranted variation. The NAVIGATE project similarly highlights the importance of standardized terminology for Catheter maclear communication and reproducibility. terial and configuration were also treated as system-level variables. Replacing PTFE with polyurethane and moving towards injection-port-free short peripheral catheters were not isolated procurement decisions; they were integrated into the broader strategy of reducing mechanical irritation, standardizing the vascular-access platform and simplifying a closed IV system.
IGCH functions within the cooperative healthcare sector and serves a population for whom affordability is important. The program, therefore did not equate quality
with maximum expenditure. Bulk procurement, reusable procedure trays, selective use of higher-cost prefilled flushes and targeted introduction of advanced vascularaccess technology were used to align expenditure with clinical value. The underlying principle was that the objective is not to provide the most expensive infusion care possible, but the safest sustainable infusion care possible within the resources available. This distinction may be particularly relevant to healthcare institutions across India and other resource-conscious healthcare systems.
The 5,159 post-implementation observations provide a substantial surveillance base. Several core measures demonstrated high adherence, including site visibility, site integrity, absence of visible local inflammatory findings, dressing integrity, line labeling and administration-set compliance. The audit also identified areas requiring continued attention, particularly hand hygiene, insertion-date documentation and catheter patency. It also identified where continued attention should be targeted rather than distributed evenly: one ward, disproportionately represented in the dataset, accounted for a substantial share of the hospital's residual compliance and documentation gaps. This finding would have been invisible in the hospital-wide averages alone and illustrates why unit-level reporting is a necessary companion to aggregate quality metrics in infusion-surveillance programs, not an optional elaboration of them. A mature quality-improvement audit should not merely demonstrate success; it should identify the next problem to solve. The present dataset therefore functions as both an assessment of implementation and a baseline for the next improvement cycle.
Pain and burning were incorporated into the audit because vascular-access quality is not limited to infection prevention.
Repeated cannulation, catheter failure, phlebitis and infiltration can cause discomfort and interrupt treatment. Including patient-reported symptoms alongside objective site assessment provides a more patient-centred surveillance model.
This quality improvement program is supported by a large post-implementation surveillance dataset of 5,159 audit observations, generated through hospital-wide implementation rather than a single-unit intervention. It was underpinned by a dedicated infusion-management governance structure and integrated education, standardization, advanced vascular-access services, and continuous audit into a single coherent system. The program also gave explicit consideration to affordability and resource utilisation throughout, and combined patient-reported symptoms with VIP scoring alongside conventional process measures, offering a more patient-centred view of vascular-access quality than process compliance alone would provide.
However, this remains a single-centre quality improvement experience, and the absence of a pre-inter-
vention audit dataset means causal pre/post comparisons cannot be made; the marked early decline in VIP scores and one ward's rapid compliance recovery, both concentrated in the first three months of surveillance, cannot be distinguished from an audit-reactivity (Hawthorne-type) effect or the progressive completion of training and equipment roll-out during that same window, and should be read descriptively rather than as evidence of causal improvement. Audit observations are not necessarily unique patients or unique catheter episodes, and the dataset does not contain central-line days or the information required to calculate CLABSI rates. Ward-level findings reported here also reflect audit observation counts rather than adjustment for patient acuity, staffing ratios, or case mix, and the disproportionate audit volume in the lowest-performing ward may itself partly reflect ward size or audit scheduling rather than practice alone; both should be accounted for in any follow-up analysis targeting that ward specifically. Audit volume also varied substantially between wards and over time. Ward G contributed approximately 45–51% of audits in January to March 2026 but 5–10% from June 2026 onward, so the early pooled trends partly reflect one ward's audit intensity and performance rather than a uniform hospital-wide change. Because the unit of analysis was the audit observation and repeat audits of the same catheter could not be distinguished, VIP rates represent the proportion of peripheral-catheter observations with a score rather than phlebitis incidence per patient, per catheter or per catheter-day.
Conclusion
The implementation of evidence-based infusion practice in a resource-conscious hospital is challenging, but achievable. The experience at IGCH demonstrates that a hospital does not require unlimited financial resources to establish a meaningful infusion-management program.
The principal intervention was not a particular catheter, dressing or connector. It was the creation of a system in which infusion care was deliberately examined, standardized, taught, audited and improved. Education created knowledge, standardization reduced variation, the infusion team created ownership, advanced vascularaccess services provided escalation pathways, and continuous audit provided feedback. That same audit also showed that improvement was not uniform across the hospital, and that acting on unit-level findings and not just hospital-wide averages, will determine whether the gains reported here are sustained and extended.
In a developing healthcare system, quality improvement must be designed around the realities of the population being served. The objective is not to reproduce the most expensive model of infusion care, but to achieve the highest sustainable standard of safe infusion care for the resources available.
Conflict of Interest
The author declares no conflict of interest related to this quality improvement program.
Funding
No external funding was received for this quality improvement program.
Acknowledgements
The author gratefully acknowledges the Secretary, Medical Superintendent, Nursing Superintendent, Infection Control Nurse, members of the Infusion Management Team, and the nursing personnel of Indira Gandhi Cooperative Hospital for their valuable support, active participation, and contribution to the implementation and continued development of the infusion management program.
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