Effects of two securement methods on peripherally inserted central catheter stability and skin integrity in very low birth weight infants: a retrospective study

Introduction

Very low birth weight infants (VLBWIs) are physiologically immature, with underdeveloped organ systems. This prolonged clinical course frequently necessitates sustained intravenous nutritional support and targeted anti-infective therapy, driving the widespread adoption of the peripherally inserted central catheter (PICC) as an indispensable tool for establishing long-term venous access in this population (1,2). However, VLBWIs present with distinct physiological challenges, including fragile skin, high levels of spontaneous limb movement, and small peripheral vessel diameters. These factors predispose them to complications after PICC placement, such as catheter dislodgement and skin injury at the puncture site (3,4). Such complications not only increase the rate of unplanned PICC removal and elevate the procedural risk and difficulty of reinsertion but also prolong hospital stays and drive up healthcare costs, ultimately hindering treatment efficacy and recovery in VLBWIs (5).

Currently, conventional securement methods for PICC in VLBWIs typically involve standard transparent dressings combined with ordinary adhesive tape. Although this approach is easy to perform, it lacks effective skin protection at the puncture site and fails to provide tension-free catheter stabilization, making it insufficient to counteract the pulling forces generated by limb movement. As a result, the incidence of catheter dislodgement and skin injury remains high (6-8). Recent years have witnessed the introduction of refined concepts, such as layered fixation and pressure injury prevention, into neonatal specialty nursing. Specialized neonatal consumables including hydrocolloid pressure-relief pads, hypoallergenic non-woven reinforcement tapes, and sterile cotton cushion strips have made it possible to optimize PICC fixation methods. However, clinical studies on the effectiveness and cost-effectiveness of modified combination fixation techniques in VLBWI remain limited. Their practical value is yet to be sufficiently validated, and clinical data on their application remain limited.

Through a single-center retrospective cohort design, we compared the effects of conventional and modified combination securement methods on PICC dislodgement and skin injury in VLBWIs. Additionally, we conducted a multidimensional cost-effectiveness analysis and explored the correlation between securement-related costs and clinical outcomes. Our objective is to perform a clinical and economic comparison of the two securement methods to inform the selection of a safe, effective, and cost-efficient PICC securement strategy for VLBWIs in the neonatal intensive care unit (NICU). We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0376/rc).

Methods

Study design and participants

This was a single-center, retrospective cohort study. Sample size was estimated using a two-independent-proportions formula, with the incidence of PICC dislodgement as the primary outcome. Based on findings from previous studies, we set α=0.05, β=0.2, and an effect size of 0.3 between the experimental and control groups. The calculation indicated that a minimum of 70 participants was required per group. Accounting for potential missing data, we added a 10% buffer to the calculated sample size, resulting in a target of at least 154 participants. The study was approved by The Medical Ethics Committee of the Second Hospital of Tianjin Medical University (approval No. KY2026K319) and adhered to the principles of the Declaration of Helsinki and its subsequent amendments. The requirement for informed consent was waived due to the retrospective nature of the study. All data were anonymized prior to analysis to protect patient privacy. Before PICC insertion, intravenous access was maintained using peripheral intravenous catheters or umbilical venous catheters (UVCs) as clinically indicated. A total of 181 VLBWIs who underwent PICC placement in the NICU of The Second Hospital of Tianjin Medical University between January 1, 2018 and December 31, 2025 were enrolled. After rigorous screening, eligible cases were included. Participants were divided into two groups based on the securement method used after PICC placement. The conventional securement group (conventional group) consisted of 102 cases from January 1, 2018 to December 31, 2021, who received conventional securement. The modified combination securement group (modified group) comprised 79 cases from January 1, 2022 to December 31, 2025 who received the modified combination securement method.

Inclusion criteria: (I) diagnosis of VLBWI, defined as a birth weight <1,500 g; (II) undergoing PICC placement in the NICU of our institution during hospitalization due to clinical treatment requirements; (III) availability of complete post-procedural clinical data, including detailed records of securement method, routine PICC maintenance, catheter dislodgement, and skin condition at the puncture site, with traceable records of related medical costs and consumables; (IV) absence of skin injury, such as breakage or infection, at the intended puncture site prior to catheter placement.

Exclusion criteria: (I) birth weight ≥1,500 g (i.e., not meeting the definition of VLBWI); (II) presence of skin damage, eczema, infection, or other skin injuries at the intended puncture site prior to catheterization (PICC placement was deferred until skin integrity was restored, and such infants were excluded from this study); (III) coexisting congenital skin disorders, immunodeficiency, or generalized severe edema that could interfere with skin assessment or catheter securement; (IV) death or discharge against medical advice within 24 hours after catheterization, precluding completion of clinical outcome evaluation; (V) missing key information in medical records, unclear documentation of the securement method, or non-standard routine PICC maintenance procedures; (VI) multiple PICC placements during the same hospitalization (only data from the first catheterization were included); (VII) missing records of relevant medical costs, making cost-effectiveness analysis impossible.

Core interventions

Patients in the conventional securement group received the standard approach using a transparent semipermeable membrane dressing (6 cm × 7 cm) combined with ordinary non-woven fabric tape. Following successful PICC insertion, the puncture site and the external portion of the catheter were fully covered with the transparent dressing. The external catheter was not required to be coiled in a standardized manner. Ordinary non-woven fabric tape was used for supplementary reinforcement. No protective materials such as skin barrier films or foam pressure-reducing pads were applied in this group (9).

All PICC insertions were performed under ultrasound guidance to confirm vessel selection and catheter tip positioning. For the modified group, the procedure was performed in accordance with the Neonatal Peripherally Inserted Central Venous Catheter: A Practice Guide (10) and consisted of a multi-layer securement strategy: (I) pressure relief protection: cut a 1.5 cm × 1 cm hydrogel pressure-reducing pad and attach it to the point where the catheter comes into contact with the skin to distribute the pressure and reduce friction injuries. (II) Tension-free fixation: naturally coil the exposed catheter at a 30° angle, and use low-allergen non-woven fabric to reinforce and secure the tension-free adhesive. (III) Buffer reinforcement: add a 0.5-cm-wide sterile cotton pad buffer strip at the coil part of the catheter to counteract the tension caused by limb movement. (IV) Sealing coverage: cover the fixed area with a sterile transparent semi-permeable film dressing to ensure no edge rolling or tension.

PICC insertion and maintenance training protocols remained unchanged throughout the study period. All nurses completed the same standardized training program and competency assessment. Central line bundles (including hand hygiene, maximum sterile barrier precautions, chlorhexidine skin antisepsis, and daily line necessity review) were consistently applied in both time periods.

Data collection and outcome measures

Study data were retrieved from three institutional databases: the electronic medical record, the medical consumables management system, and the hospital financial system. Strict source verification was performed to ensure data accuracy and authenticity. The data were collected by two nurses with at least 5 years of clinical experience in the NICU. Before collection, they both received unified training and passed the pre-collection assessment. Additionally, a senior nurse was assigned to ensure data quality control and to conduct regular spot checks of the data forms, verifying the consistency between the original records and the collected data.

The following data were collected:

• Demographic and baseline characteristics: birth weight, gestational age, 1-minute and 5-minute Apgar scores, postnatal age at the time of catheterization, sex, and mode of delivery.
• Causes of unplanned PICC removal: catheter dislodgement, skin injury, catheter-related bloodstream infection (CRBSI), phlebitis, and other causes.

Skin injury assessment: a three-tier classification system was used to evaluate the severity of skin injury at the puncture site (Grade I: mild erythema or indentation, no skin breakdown; Grade II: moderate erythema with minor epidermal abrasion; Grade III: severe erythema with epidermal tearing or exudative injury) (11).

Cost-effectiveness analysis metrics: direct medical costs were evaluated. Clinical and economic benefits were considered as outcome measures. All cost data were calculated to the nearest yuan and adjusted to the 2025 benchmark value using the medical industry price deflator to account for inflation (12).

Propensity score matching (PSM) implementation

PSM was applied to minimize baseline imbalances between the groups. The following variables were included in the propensity score model: birth weight, gestational age, 1-minute and 5-minute Apgar scores, postnatal age at catheterization, sex, and mode of delivery. A 1:1 nearest-neighbor matching algorithm was applied, with a caliper width set at 0.2. After matching, covariate balance between the two groups was assessed using the standardized mean difference (SMD), with a value <0.1 indicating acceptable balance. The patient screening and PSM matching process is illustrated in Figure 1. Following matching, 78 patients were included in each group, yielding a total sample size of 156 for the final analysis.

Figure 1 Flowchart of participant screening and PSM matching. PSM, propensity score matching.

Statistical analysis

All statistical analyses were performed using SPSS version 26.0. Continuous baseline variables were first tested for normality; all were found to be normally distributed (P>0.05). Baseline characteristics with a P value <0.05 in the pre-matching comparison between groups were included as covariates in the propensity score model. A 1:1 nearest-neighbor PSM algorithm was then applied to balance these covariates between groups. After matching, covariate balance was assessed using the SMD and P values, with SMD <0.1 and P>0.05 indicating acceptable balance. Continuous data are presented as mean ± standard deviation (SD) and were compared using independent-samples t-tests. Categorical data are presented as counts (percentages) and were compared using the chi-square (χ²) test. Fisher’s exact test was used for categorical variables with expected cell counts <5 or an observed incidence of zero. Multivariable logistic regression analysis was performed to identify factors associated with unplanned PICC removal, which was set as the dependent variable. Direct medical costs were presented as median (interquartile range) and compared using the Mann-Whitney U test; median values were used for ICER calculation. A P value <0.05 was considered statistically significant.

Results

Comparison of baseline characteristics between the two groups before and after PSM

After PSM, comparisons of baseline characteristics between the two groups indicated no statistically significant differences (all P>0.05). Furthermore, the SMD for all covariates was <0.1, confirming adequate balance between the groups (Table 1, Figure 2).

Figure 2 Covariate balance plot.

Comparison of clinical outcomes, causes of unplanned PICC removal, and severity of skin injury between the two groups

After matching, the unplanned extubation rate and the incidence of skin damage in the modified combined fixed group VLBWI were significantly lower than those in the conventional group (P=0.02 and P<0.001, respectively). Although the proportions of unplanned PICC removals attributed to skin injury and catheter dislodgement were lower in the modified group, the overall distribution of causes for unplanned PICC removal did not differ significantly between the two groups (P=0.08). Notably, the severity of skin injury was significantly milder in the modified group, with no cases of grade III injury observed. This difference in severity distribution was statistically significant (P=0.008). PICC duration: The mean PICC dwell time was significantly longer in the modified group compared with the conventional group (P<0.001) (Table 2).

Logistic regression analysis

Baseline characteristics that differed significantly between the two groups were included in a multivariable binary logistic regression analysis. The results demonstrated that the modified combination securement method was an independent protective factor against unplanned PICC removal of PICC in VLBWIs [odds ratio (OR) =0.275, P=0.005] (Table 3).

Comparison of direct medical cost details and total costs per catheterization episode between the two groups

Given that direct medical cost data exhibited a skewed distribution, descriptive statistics are presented as median (interquartile range), and intergroup comparisons were performed using the Mann-Whitney U test to ensure robust statistical inference. The modified combination securement group demonstrated significantly lower securement consumable costs, maintenance procedure costs, complication management costs, and total direct medical costs per catheterization episode compared with the conventional securement group (all P<0.001). However, there was no statistically significant difference between the two groups in other costs associated with prolonged hospitalization (P=0.32) (Table 4).

Incremental cost-effectiveness ratio (ICER) analysis

The ICER was used to evaluate the cost-effectiveness difference between the modified combination securement method and the conventional securement method. The ICER was calculated using the following formula: ICER = (C₁ − C₀) / (E₁ − E₀), where C₁ and C₀ represent the median direct medical costs in the modified and conventional groups, respectively, and E₁ and E₀ represent the incidence rates of unplanned PICC removal in the modified and conventional groups, respectively. Applying the formula: ICER = (¥1,009.68 − ¥1,308.04)/(21.79% − 8.97%) ≈ −¥2,327.30 per patient.

Discussion

This study employed a single-center retrospective cohort design. We included VLBWIs who underwent PICC placement in our NICU and used 1:1 nearest-neighbor PSM to balance baseline covariates between groups. After matching, the two groups were well balanced with respect to baseline characteristics. We then compared the clinical outcomes and direct medical costs associated with the conventional and modified combination securement methods. Our findings demonstrated that the modified combination securement method was associated with significantly lower rates of unplanned PICC removal and skin injury, as well as reduced severity of skin injury, compared with the conventional method. Multivariable logistic regression confirmed that the modified securement method was an independent protective factor against unplanned PICC removal in VLBWIs with PICC. Although the modified combination securement method resulted in slightly higher consumable costs per catheterization, it significantly reduced total direct medical costs per episode by lowering costs associated with maintenance procedures and complication management. This distinction between upfront material costs and total episode costs is critical for hospital management and financial decision-making, as it demonstrates that higher initial investment leads to overall cost savings through complication reduction. The negative ICER value indicates that the modified securement method is a cost-saving intervention. Specifically, the cost saved per unplanned PICC removal avoided was substantially lower than the average additional medical expenditure associated with a single episode of unplanned PICC removal in Chinese NICUs, suggesting favorable clinical acceptability. From a health economics perspective, this securement strategy achieves superior clinical outcomes without requiring additional healthcare investment. It aligns with the core criteria for cost-effectiveness and further supports the economic feasibility of this approach.

Conventional securement using a transparent semipermeable membrane dressing combined with ordinary non-woven fabric tape lacks tension-free design and specific skin protection measures. Limb movements generate traction forces on the catheter, which can easily lead to dislodgement. Moreover, adhesive dressings tend to irritate and cause skin tears in the fragile, delicate skin of VLBWIs. These limitations contribute to persistently high rates of catheter-related complications (13,14). The improved combined fixation method achieves this through the layered collaborative application of hydrocolloid pressure-reducing pads, low-allergen non-woven fabric reinforcement patches, sterile cotton padding buffer strips, and sterile transparent semi-permeable film dressings, forming a “protection-pressure reduction-fixation-sealing” full-process intervention system. The hydrocolloid pressure-reducing pad directly forms the protective and pressure-reducing layer, dispersing the pressure of the catheter, reducing the irritation and friction damage caused by the dressing; the sterile cotton padding buffer strip further counteracts the tension caused by limb movement (15,16). The non-tension fixation design of the hypoallergenic non-woven fabric reinforcement patch eliminates the pulling tension caused by limb movement, preventing the catheter from shifting or dislodging (17,18). Finally, the occlusive coverage of the sterile transparent dressing maintains a sterile environment at the insertion site, reducing infection risk (19,20). By targeting multiple contributing factors, this precise intervention effectively reduces the triggers for catheter dislodgement and skin injury. Consequently, it lowers the rate of unplanned PICC removal and minimizes the procedural risks and healthcare resource consumption associated with repeated catheterization. These findings are highly consistent with conclusions from recent studies in the field of neonatal PICC care. For instance, van Rens et al. (14) reported that cyanoacrylate glue for PICC securement reduced dislodgement rates from 14.2% to 5.3% in a cohort of 400 neonates, while Van Rens et al. (21) noted that accidental dislodgement occurs in 20–50% of cases with conventional dressing methods. Unlike these studies that primarily used tissue adhesive, our modified method achieved comparable outcomes (dislodgement reduced from 10.26% to 2.56%) using a non-adhesive multi-layer approach, which may offer an alternative strategy for VLBWIs with fragile skin.

The modified combination securement method features a standardized procedure that is easy to master, aligning well with the practical needs of NICU nursing. This approach not only improves the quality of PICC care in VLBWIs but also enables appropriate control of medical costs, striking a balance between clinical effectiveness and efficient resource utilization. When considered alongside the health economics evidence from the ICER analysis, this securement method demonstrates clinical outcomes superior to those of conventional securement, while its cost-saving nature makes it particularly suitable for dissemination across primary and specialized neonatal units. By reducing clinical complications, it alleviates the financial burden on both healthcare institutions and families. By providing evidence-based rationale for standardizing PICC securement protocols in VLBWIs within the NICU, this method holds promise for further reducing the incidence of PICC-related complications and improving the treatment and recovery process for VLBWIs upon broader clinical implementation. These features underscore its significant clinical application value.

However, this study has several limitations. First, as a single-center retrospective study, the sample size was limited, which may affect the generalizability of the findings across different regions and clinical settings. Nevertheless, multivariable logistic regression identified the modified securement method as a significant independent protective factor against unplanned PICC removal (OR =0.275, P=0.005), which supports the robustness of our findings. While multicenter validation would be ideal, this statistical evidence suggests that the observed benefits are primarily attributable to the securement method itself rather than institution-specific expertise. Second, we did not conduct long-term follow-up of the infants, precluding analysis of the impact of securement methods on growth, development, and long-term outcomes in VLBWIs. Third, the historical control design—with the conventional securement group drawn from 2018–2021 and the modified group from 2022–2025—may introduce temporal bias. During this period, natural improvements in overall NICU nursing practices, PICC insertion protocols, and complication prevention strategies may have contributed to some of the observed outcome differences beyond the modification of securement method alone. Fourth, although PSM was used to balance key baseline variables such as birth weight and gestational age—achieving SMD <0.1 for all covariates and thus reducing confounding to some extent—residual bias cannot be completely ruled out. Fifth, the ICER analysis included only direct medical costs, without accounting for indirect costs or family time costs. Future studies could broaden the scope of cost assessment to further validate the health economic value of this intervention. Sixth, the specific indications for PICC placement (e.g., parenteral nutrition, antibiotic therapy, management of specific organ conditions) were not systematically recorded in the medical records, precluding a subgroup analysis by indication. However, the two groups were well balanced for all baseline characteristics after PSM, supporting the comparability of overall disease severity between groups.

Future research may involve multicenter, prospective cohort studies with larger sample sizes to confirm our findings. Extended follow-up protocols could be implemented to better understand the effects of the modified combination securement method on long-term outcomes in VLBWIs. Additionally, further optimization of securement consumable combinations may help identify strategies for cost control while maintaining clinical effectiveness. Subgroup analyses stratified by regional medical pricing standards could also be conducted to provide more precise health economic evidence for tailoring PICC securement protocols across different levels of healthcare institutions.

Conclusions

In this study, PSM was used to control for baseline confounding factors. The results confirmed that the modified combination securement method reduced the incidence of catheter dislodgement, skin injury, and unplanned PICC removal. Although consumable costs for securement were slightly higher with this method, overall direct medical costs were reduced due to lower maintenance and complication management expenses. This fixation method is based on the synergistic mechanism of hydrocolloid pressure reduction protection, cotton pad cushioning, and low-allergy, tension-free adhesive. It fully considers both clinical effectiveness and economic rationality, providing an evidence-based optimized solution for PICC catheterization care among VLBWIs in the NICU, and has significant value for clinical promotion.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0376/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0376/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0376/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0376/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by The Medical Ethics Committee of the Second Hospital of Tianjin Medical University (approval No. KY2026K319) and adhered to the principles of the Declaration of Helsinki and its subsequent amendments. Given the retrospective observational nature of this study and the absence of additional interventions, the requirement for informed consent was waived. All data were anonymized prior to analysis to protect patient privacy.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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