Intravenous specialist nursing teams in Qingdao’s tertiary hospitals: current status, resource stratification, and global implication

Introduction

Intravenous (IV) therapy serves as a cornerstone of modern clinical practice and plays an irreplaceable role in emergency resuscitation, critical care management, pharmacotherapy, and nutritional support (1). The quality of IV therapy directly affects patient safety and treatment outcomes. For instance, an open-label, prospective cohort study demonstrated that closed infusion containers significantly reduce the central line-associated bloodstream infection (CLABSI) rate (2). Furthermore, the International Nosocomial Infection Control Consortium reported that adherence to evidence-based IV therapy can reduce the incidence of CLABSIs by more than 40.0%, underscoring the clinical significance of standardized management (3).

To ensure the high-quality and safety of IV therapy, the role of IV specialist nurses has become critical. IV specialist nurses in China are registered nurses who have completed standardized professional training and coursework in IV therapy and obtained relevant qualifications, and their professional practice is the core guarantee for the standardized management of clinical IV therapy (4). Since 2000, China has launched systematic training of IV therapy specialist nurses, which has become a crucial step to improve the safety of clinical infusion and a key symbol of the professionalization of nursing (5). However, the uneven distribution of IV specialist nursing resources among different levels of hospitals in China is prominent, and there are significant disparities in the team scale, professional structure, and training system of IV specialist nurses among hospitals with different grades (6). A 2024 national survey covering 958 tertiary hospitals revealed that only 23.0% of the research subjects were prefecture-level tertiary hospitals, and none of these studies has conducted quantitative analysis on the impact of hospital grade on the core quality indicators of IV therapy (7). A 2025 multicenter cross-sectional study by Song et al. further confirmed that there are significant disparities in nurses’ IV therapy core competency, and most studies overlook the subgroup differences in competency of nurses in prefecture-level hospitals (8). In terms of global research, the World Health Organization pointed out that most upper-middle-income countries lack quantitative data on IV therapy quality based on resource stratification, and the research on the correlation between clinical experience of IV specialist nurses and safety management of IV therapy is also relatively scarce (9), which seriously hinders the formulation of context-adapted IV therapy optimization strategies for different regions and hospital levels.

Qingdao is an important economically developed coastal prefecture-level city in Shandong Province, China, and a typical representative of upper-middle-income regions with balanced medical resource development and hierarchical distribution (10). Its tertiary hospital system forms a “dual-engine” development model led by Qingdao Municipal Hospital and the Affiliated Hospital of Qingdao University, and the development of IV therapy in its tertiary hospitals positively reflects the common challenges faced by prefecture-level regions in upper-middle-income countries: balancing the limited medical resource input with the growing clinical demand for standardized IV therapy (10). However, there is a lack of recent [2024–2025] cross-sectional quantitative data on the current status of IV therapy, resource stratification, and quality control in Qingdao’s tertiary hospitals, and there is no relevant research to clarify the key influencing factors of IV therapy quality in this region. Led by the Intravenous Infusion Therapy Professional Committee of Qingdao Nursing Association, this study conducted a comprehensive questionnaire survey on tertiary hospitals in Qingdao, aiming to fill the above research gaps through in-depth analysis of the current status of IV therapy hardware configuration, specialist nursing team construction, technical application, and quality control indicators in the research setting.

This study aimed to answer the following research questions: (I) what is the current status of IV therapy (hardware configuration, technology application, infection control, specialist nurse team) in prefecture-level tertiary hospitals in Qingdao? (II) Are hospital grade and nurse experience correlated with key IV therapy quality indicators? In this study, “IV therapy quality” is conceptualized and measured through structural indicators [e.g., IV specialist nurse allocation, Pharmacy Intravenous Admixture Service (PIVAS) configuration] and process indicators (e.g., adoption of ultrasound-guided puncture, establishment of complication reporting systems). These indicators reflect a hospital’s organizational readiness, resource stratification, and degree of practice standardization-key prerequisites for safe and effective IV therapy. IV specialist nursing teams are positioned as the core drivers in optimizing these structural and procedural domains, thereby creating the necessary conditions for improved patient outcomes. Therefore, the inferences drawn from this study are primarily confined to these organizational and process levels, rather than directly measured patient clinical outcomes (e.g., CLABSI rates, phlebitis incidence). For the second research question, we selected three core indicators for statistical testing, namely IV specialist nurse allocation rate, ultrasound-guided puncture rate, and complication reporting system establishment rate. These indicators were chosen because they cover three critical dimensions of IV therapy quality (workforce allocation, technical application, and safety management), are closely related to the core responsibilities of IV specialist nursing teams, and are widely recognized as key quality markers in international guidelines (e.g., Infusion Therapy Standards of Practice, 9^th edition). Additionally, these indicators had complete and comparable data across all participating hospitals, ensuring the reliability of statistical analysis.

We hypothesized that: (I) a higher hospital grade is positively correlated with advanced technology application (e.g., ultrasound-guided puncture) and PIVAS configuration, as well as higher IV specialist nurse allocation rate; and (II) longer working experience of IV specialist nurses is positively correlated with the establishment of complication reporting systems. We present this article in accordance with the STROBE reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-126/rc) (11).

Methods

This study adopted a cross-sectional descriptive design. The design was selected for its suitability to systematically investigate the current status of IV therapy and specialist nursing teams in tertiary hospitals, and to explore the correlation between influencing factors and IV therapy quality indicators at a specific time point. The STROBE checklist was strictly followed in all research processes, including study design, participant selection, data collection, statistical analysis, and result reporting, to ensure the comprehensiveness and standardization of the research report.

Sample size calculation

On the basis of indicators from a preliminary survey, including a PIVAS configuration rate of 60.0%, an IV specialist nurse allocation rate of 40.0%, and an ultrasound-guided puncture rate of 80.0%, the sample size was calculated using the coefficient of variation (CV =0.25) of the PIVAS configuration rate (7). An allowable error of 10% was set to ensure the statistical power of the sample size (1 − β =0.85), resulting in a minimum required sample size of 26 hospitals. To ensure robust representation, we expanded our sample. From the 46 tertiary hospitals registered in the health administrative department of Qingdao, we used stratified random sampling from September 1, 2024 to December 31, 2024. Stratification factors were: (I) hospital type (general vs. specialized) and (II) hospital grade (tertiary Grade A vs. Grade B). The specific sampling steps were: first, stratify the 46 tertiary hospitals according to the two factors, obtain four strata (Grade A general, Grade A specialized, Grade B general, Grade B specialized); second, use a random number table to extract hospitals from each stratum according to the pre-determined sampling ratio (1:1.5 for Grade A:Grade B); finally, check the extracted hospitals against the inclusion criteria, and replace non-eligible hospitals with the next random number until the sample size of 30 hospitals is reached (18 Grade A, 12 Grade B; 20 general, 10 specialized).

The inclusion criteria for hospitals were as follows: (I) obtained provincial or municipal certification as a tertiary hospital; (II) had more than 500 beds; (III) acknowledged full cooperation from the hospital administration and provided necessary data support; and (IV) no major personnel changes or operational changes occurred during the survey period.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was reviewed and approved by the Institutional Review Board of No. 971 Hospital of the People Liberation Army Navy (approval No. 2024-032; approval date: June 13^th, 2024).

All participants (head nurses of the included hospitals) provided online written informed consent before data collection. The informed consent form included the research purpose, research content, data collection methods, potential risks and benefits, the right to withdraw from the research at any time without affecting the normal work of the hospital, and the protection measures of data anonymity and confidentiality. Participants could only proceed to the questionnaire filling page after clicking the “agree” button on the informed consent form.

Anonymity and confidentiality of research data were strictly guaranteed through the following measures: (I) de-identifying all research data: replacing hospital names with serial numbers (H1–H30), and removing all personal identifiable information of nurses (e.g., name, employee number, contact information); (II) data storage: all questionnaire data were stored in a password-protected cloud server with dual encryption (software encryption + hardware encryption), and only the principal investigator and two data analysts had the access password; (III) data analysis: all statistical analyses were conducted on aggregated data, and no individual hospital or nurse data was disclosed in the research results; and (IV) data retention: the original data will be retained for 5 years in accordance with ethical requirements, and will be destroyed by permanent deletion after the retention period.

Survey instrument

The “National Questionnaire on the Current Status of IV Infusion Therapy in Hospitals at All Levels”, issued by the Intravenous Infusion Therapy Professional Committee of the Chinese Nursing Association (https://www.wjx.cn/xz/235787438.aspx; an online questionnaire in Chinese, see appendix available at https://cdn.amegroups.cn/static/public/jhmhp-2025-1-126-1.pdf), was revised through a systematic literature review (retrieving databases such as CNKI, WanFang, PubMed, and CINAHL) and expert consultation (10 experts, including 5 IV therapy nursing specialists with senior professional titles, 3 clinical nursing managers, and 2 biostatisticians), The expert consultation adopted the Delphi method, with two rounds of consultation to revise the questionnaire items, delete invalid items, and modify ambiguous expressions, and the final version was confirmed as the “Questionnaire on the Current Status of IV Infusion Therapy in Tertiary Hospitals in Qingdao”. Prior to the formal survey, a pilot test was conducted using 2 non-sample tertiary hospitals (1 Grade A general hospital, 1 Grade B specialized hospital), with a total of 2 valid questionnaires collected. The pilot test results showed that the questionnaire had good preliminary reliability (Cronbach’s α=0.85) and content validity [scale-content validity index (S-CVI) =0.88], and the average completion time of the questionnaire was 35 minutes, with no ambiguous or difficult-to-answer items reported by the respondents. Based on the pilot test results, no further revision was made to the questionnaire, and the final version of the questionnaire had good reliability (Cronbach’s α=0.87) and content validity (S-CVI =0.90).

The questionnaire consists of 4 main sections with a total of 68 closed-ended questions (single choice or multiple choice) and 3 open-ended questions: (I) general information (12 questions), including hospital grade, the establishment of an IV specialist nursing teams, hospital bed size, and annual IV therapy volume; (II) the composition of the IV specialist nursing team (18 questions), including the number of in-service nurses, educational background and professional title composition, and training experience of IV specialist nurses; (III) the provision of the IV specialist nursing service (25 questions), including the work scope and operation of IV specialized nursing clinics, application of IV therapy technologies, and configuration of IV therapy hardware; and (IV) remuneration and support for IV specialist nursing teams (16 questions), including reimbursement of training expenses, salary and bonuses, and remuneration after training of IV specialist nurses. The three open-ended questions are about the main difficulties in the development of IV specialist nursing teams, the needs for IV therapy training, and the suggestions for optimizing IV therapy management.

Data collection and quality control

Online questionnaires were distributed, and the data were collected mainly via the Wenjuanxing online platform (https://www.wjx.cn/). Data on objective indicators including peripherally inserted central catheter (PICC), implantable venous access port (IVAP) and midline catheter configuration were required to be filled in with reference to the hospital’s medical equipment procurement ledgers and clinical device management system to ensure the objectivity of hardware data. We contacted the head nurse(s) of each tertiary hospital to obtain their official informed consent. Prior to the start of the survey, we provided systematic online training to these head nurses of each hospital, covering content such as precautions for questionnaire completion and collection and quality control standards.

The trained head nurses then took charge of data collection in their respective hospitals and provided answers during the questionnaire completion process to ensure the accuracy and standardization of the responses. For the configuration status of ultrasound-guided puncture equipment and the use of standardized dressing change kits, the respondents were required to provide supporting materials such as hospital administrative approval documents and on-site use records for verification. After the survey, the collected questionnaires were subjected to strict screening and organization; duplicate submissions and questionnaires with a completion time of 20 minutes or less were excluded to guarantee the integrity and reliability.

In addition, the following control measures were implemented to ensure data quality: (I) the questionnaire system was configured to allow only one submission per internet protocol (IP) address, and set up mandatory filling for key variables (e.g., hospital grade, IV specialist nurse allocation rate) to avoid missing key data; (II) after the questionnaires were retrieved, two independent researchers verified the data double-blindly and excluded questionnaires with obvious logical errors (e.g., the number of IV specialist nurses is greater than the total number of ward nurses); and (III) for the data with inconsistent answers, the researchers contacted the corresponding head nurses by phone to verify and correct the data. The 10% of responses cross-verified with hospital administrative records focused on objective indicators such as PICC/IVAP configuration types, the purchase and use of needle-stick prevention steel needles, and the allocation of IV specialist nurses, with verification materials including medical device purchase contracts and equipment storage ledgers. Missing data for key variables were minimal: hospital-level variables (e.g., PIVAS configuration) had 0 missing, and nurse-level variables (e.g., working years) had 0 missing. For the few missing non-key variables (e.g., annual training times of IV nurses), no imputation was performed, and missing data was handled via listwise deletion, as it did not exceed 5% (12). The flowchart of hospital enrollment and data collection process is shown in Figure 1, which includes the whole process of hospital stratification, random sampling, eligibility screening, informed consent, questionnaire filling, data verification, and data inclusion.

Figure 1 Flowchart of hospital enrollment and data collection process. IP, internet protocol.

Statistical analysis

All statistical tests were two-sided, and a P value <0.05 was considered statistically significant. The data were processed using SPSS 26.0 software.

Data types and descriptive methods

Categorical variables were expressed as “n (%)”, for proportion-type data (e.g., PIVAS order processing rates), the 95% confidence intervals (CIs) were calculated using the Wilson score interval method (without continuity correction) to ensure estimation accuracy under small sample sizes (n<50), which is in line with the requirements of the STROBE guidelines for the statistical description of categorical variables (13).

Group comparisons were performed using the Chi-squared test or Fisher’s exact test where appropriate: the Pearson Chi-squared test was used for 2×2 contingency tables, and the likelihood ratio Chi-squared test was used for R×C contingency tables; if more than 1/5 of the cells had an expected frequency <5 or the expected frequency of any cell <1, Fisher’s exact test was applied for 2×2 contingency tables, and the Freeman-Halton extension of Fisher’s exact test was applied for R×C contingency tables.

Continuous variables (e.g., working years of IV specialist nurses) were first tested for normality using the Shapiro-Wilk test (suitable for small sample sizes n<50) with the test level set at α=0.05: if P>0.05, the data were considered to be normally distributed; if P≤0.05, the data were considered to be non-normally distributed. Homogeneity of variance was tested for normally distributed data using the Levene test: if the variance was homogeneous, normally distributed data were presented as mean ± standard deviation (SD) and compared using the independent samples t-test; if the variance was inhomogeneous, the Welch t-test was used. Non-normally distributed data were presented as median [interquartile range (IQR)] and compared using the Mann-Whitney U test (for two independent samples).

Variable assignment analysis

For correlation analysis, variables were coded as follows:

• Hospital grade: assignment was based on the official grading standards for tertiary hospitals in China (issued by the National Health Commission), which evaluate hospitals on comprehensive structural and operational dimensions including funding scale, medical staffing quality, technological equipment investment, governance infrastructure, and clinical service capacity: 1, tertiary Grade B hospitals; and 2, tertiary Grade A hospitals. Grade A tertiary hospitals represent the highest level of tertiary care in China, with superior resource allocation, staffing pipelines, and training opportunities compared to Grade B tertiary hospitals.
• Working years of IV specialist nurses: an ordinal variable referencing the Infusion Therapy Standards of Practice 9^th edition (14,15): 1, 5–10 years (growth stage); 2, 11–15 years (mature stage); and 3, >15 years (expert stage). This classification aligns with international competency frameworks, ensuring global comparability (16).
• Core outcome indicators: three key IV therapy quality indicators were selected for statistical testing, including IV specialist nurse allocation rate, ultrasound-guided puncture rate, and complication reporting system establishment rate. The selection of these indicators was based on three principles: (I) relevance: they are closely associated with the core functions of IV specialist nursing teams (workforce allocation, technical operation, and safety management); (II) evidence-based: they are recognized as key quality indicators in international IV therapy guidelines; and (III) feasibility: complete and comparable data were available for all participating hospitals. A dichotomous assignment was based on the “Standards for the Construction of Intravenous Therapy Specialist Nursing Teams in Tertiary Hospitals” issued by the Chinese Nursing Association: 1, compliant (IV specialist nurse allocation rate ≥5%); and 0, noncompliant (IV specialist nurse allocation rate <5%).

Correlation analysis

Spearman rank correlation analysis was used to explore the correlation strength between hospital grade (ordinal variable), IV specialist nurses’ working years (ordinal variable), and IV therapy quality indicators (dichotomous/ordinal variables), as the research variables did not meet the normal distribution requirement of Pearson correlation analysis. The test level was set at α=0.05, and the 95% CI of the correlation coefficient was calculated using the Fisher z-transformation method.

The criteria for interpreting correlation coefficients (r_s) were as follows: weak positive correlation, 0.1≤r_s<0.3; moderate positive correlation, 0.3≤r_s<0.5; strong positive correlation, r_s≥0.5; weak negative correlation, −0.3≤r_s<−0.1; moderate negative correlation, −0.5≤r_s<−0.3; and strong negative correlation, r_s≥−0.1.

Statistical power analysis

A post-hoc power analysis was conducted using G-Power 3.1 software to verify the statistical power of the study. The specific analysis parameters were set as follows: for the Chi-squared test (primary outcome: specialist nurse allocation rate), the effect size was set at 0.3 (medium effect), the number of groups was 2 (Grade A vs. Grade B), the degrees of freedom was 1, and α=0.05; for the Spearman rank correlation analysis, the effect size was set at 0.4 (medium effect), the sample size was 30, and α=0.05. The results showed that the power of the Chi-squared test for the primary outcome (specialist nurse allocation rate) was 89.2%, and the power for the correlation analysis was 86.7%, both exceeding the conventional threshold of 80.0% for clinical research, indicating that the sample size of this study was sufficient to detect the medium effect between variables.

Results

Basic information of tertiary hospitals in Qingdao

This survey enrolled 30 tertiary hospitals in Qingdao, with a 100% effective questionnaire response rate. General characteristics of the enrolled hospitals and respondents are summarized in Table 1. Briefly, the sample was dominated by tertiary Grade A hospitals and general hospitals; respondents were predominantly female (96.7%) with a bachelor’s degree (86.7%), and most held the title of charge nurse (53.3%) or associate chief nurse and above (46.7%), working as head nurses (63.3%) or IV therapy team leaders (30.0%). All respondents had a median clinical nursing working experience of 18 (IQR, 12–25) years, with over 80% having more than 10 years of experience in vascular access nursing.

Core IV therapy hardware/service configuration in tertiary hospitals in Qingdao

Core IV therapy hardware and service configuration of the enrolled hospitals are shown in Table 2, with notable heterogeneity in service coverage. The establishment rate of IV specialist teams and emergency infusion services reached a high level (86.7%; 95% CI: 70.9–95.5%), while the infusion services and chemotherapy daily IV centers had relatively low coverage (56.7% and 40.0%, respectively). The overall PIVAS configuration rate was 60.0% (95% CI: 42.1–75.8%), with most PIVAS-equipped hospitals providing long-term (70.0%) and temporary (60.0%) order preparation; however, PIVAS services for outpatient and emergency infusion were extremely limited (16.7% and 22.2%, respectively). Tertiary Grade A hospitals had a significantly higher PIVAS configuration rate than Grade B hospitals (77.8% vs. 33.3%; χ²=6.48; P=0.01), indicating a grade-based disparity in core hardware configuration.

Application of IV therapy tools and maintenance tools

Application of IV therapy tools in the enrolled hospitals is detailed in Table 3, with a high degree of standardization in most core tools and notable deficiencies in safety-oriented basic tools. For basic infusion tools, disposable IV steel needles were configured in 80.0% of hospitals, but the adoption rate of needle-stick prevention steel needles was extremely low (8.3%), with regular steel needles accounting for 91.7% of the configured steel needles. Peripheral venous catheters and IV infusion sets achieved 100% configuration coverage, with safety-type peripheral venous catheters (93.3%) and precision filter infusion sets (86.7%) as the dominant types, indicating the popularization of safety-oriented and contamination-preventive infusion tools in line with international clinical guidelines.

For mid-to-long-term venous access tools, the configuration rates of midline catheters, PICCs, and IVAPs were 66.7%, 83.3%, and 73.3%, respectively. Configured tools exhibited high standardization: over 90% of midline catheters were conventional catheters >15 cm; PICCs were predominantly made of polyurethane materials (96.0%) with three-way valve tips (84.0%), consistent with international PICC selection recommendations (16); all IVAP-equipped hospitals used chest wall ports, and 90.9% followed the 4-week maintenance standard in line with the 2021 Infusion Therapy Standards of Practice (16). Multiple selections for midline catheter types led to a cumulative proportion exceeding 100%, reflecting flexible configuration for diverse clinical scenarios. Notably, the extremely low adoption rate of needle-stick prevention steel needles (8.3%) is a key descriptive finding of this study, reflecting a notable gap in the safety configuration of basic infusion tools in the surveyed hospitals; no inferential statistical analysis was performed for this indicator due to its purely descriptive nature.

Application of maintenance tools in tertiary hospitals in Qingdao

Distribution of maintenance tools (dressing change kits) for PICC, central venous catheter (CVC), and IVAP is shown in Table 4, with consistent application characteristics across the three types of CVCs. Disposable dressing change kits (dedicated + general surgical) were the dominant choice for all three catheters, with a cumulative application rate of 73.3–86.7%; reusable sterilizable dressing change kits had a uniformly low adoption rate (<10%) across all catheters.

The most prominent issue was the non-standard use of dressing change kits: 20.0–26.7% of hospitals did not use any specialized dressing change kit for CVC maintenance, with the highest non-standard rate in PICC maintenance (26.7%) and consistent rates in CVC and IVAP maintenance (20.0% each). Disposable dedicated dressing change kits were the primary choice for PICC and CVC maintenance, while IVAP maintenance had nearly equal application rates of dedicated and general surgical disposable kits, reflecting insufficient standardization in IVAP maintenance tool selection.

This is a core descriptive finding of this study, which directly reflects the non-standard application status of catheter maintenance tools in tertiary hospitals in Qingdao; no inferential statistical analysis was conducted for this indicator as it only serves to present the actual clinical practice status.

Correlations between hospital grade, IV specialist nurse allocation rate, and ultrasound-guided puncture rate

Spearman rank correlation analysis was conducted to assess the association between hospital grade (coded as 1, Grade B; 2, Grade A) and two key IV therapy quality indicators (specialist nurse allocation rate ≥5% vs. <5%; ultrasound-guided puncture implemented vs. not implemented), with results shown in Table S1.

Tertiary Grade A hospitals had a significantly higher IV specialist nurse allocation rate than Grade B hospitals (66.7% vs. 33.3%; χ²=4.80; P=0.03). Spearman correlation analysis confirmed a moderate positive correlation between hospital grade and IV specialist nurse allocation rate (r_s=0.48; 95% CI: 0.18–0.70; P=0.006), in line with Cohen’s criteria. For ultrasound-guided puncture, the adoption rate was nearly twice as high in Grade A hospitals as in Grade B hospitals (94.4% vs. 58.3%; χ²=7.24; P=0.007), with a weak-to-moderate positive correlation between hospital grade and ultrasound-guided puncture rate (r_s=0.39; 95% CI: 0.05–0.66; P=0.03). These results indicate that hospital grade is a key factor influencing the allocation of IV specialist nurses and the adoption of advanced IV therapy technologies.

Correlations between IV specialist nurses’ working years and key IV therapy quality indicator (complication reporting system establishment rate)

Spearman rank correlation analysis was used to examine the association between IV specialist nurses’ working years (ordinal variable: 1, 5–10 years; 2, 11–15 years; 3, >15 years) and the establishment of a complication reporting system (dichotomous: 0, not established; 1, established), with results shown in Table S2. The median working years of IV specialist nurses in the enrolled hospitals was 16 (IQR, 11–20) years, with 30.0% in the 5–10-year group, 33.3% in the 11–15-year group, and 36.7% in the >15-year group.

The establishment rate of complication reporting systems increased significantly with the increase of specialist nurses’ working years (χ²=12.36; P=0.002): 45.5% in the 5–10-year group, 80.0% in the 11–15-year group, and 100.0% in the >15-year group (100% establishment in the expert stage). Spearman correlation analysis confirmed a moderate positive correlation between specialist nurses’ working years and the establishment rate of complication reporting systems (r_s=0.52; 95% CI: 0.21–0.74; P=0.003), in line with Cohen’s criteria. These findings indicate that increased clinical experience of IV specialist nurses is associated with stronger risk control awareness, which promotes the establishment of standardized complication monitoring and reporting mechanisms, thereby improving IV therapy safety management quality.

Discussion

This study provides a comprehensive snapshot of the IV therapy landscape in tertiary hospitals in Qingdao, a representative economically developed coastal city in China. We selected three key IV therapy quality indicators (IV specialist nurse allocation rate, ultrasound-guided puncture rate, and complication reporting system establishment rate) for statistical testing, based on their relevance to IV specialist nursing practice, alignment with international guidelines, and data availability. Our findings confirm both hypotheses: a higher hospital grade is positively correlated with the allocation of specialist nurses and the adoption of advanced technologies (two of the key indicators), and more experienced specialist nurses are associated with stronger quality control systems (reflected by the third key indicator).

Resource stratification and its global parallel

A principal finding of this study is the significant resource stratification between Grade A and Grade B tertiary hospitals. Grade A hospitals demonstrated superior allocation of IV specialist nurses and higher adoption rates of ultrasound-guided puncture technology. This observed disparity in IV-service-specific features is not an isolated phenomenon, but rather a direct reflection of the upstream structural advantages inherent to higher hospital grades in China’s healthcare system. Hospital grade in China is a composite measure of comprehensive structural capacity-encompassing government and institutional funding scale, high-quality staffing pipelines, dedicated technology investment, standardized governance infrastructure, and formalized clinical training opportunities-all of which constitute upstream structural factors that directly shape the capacity of hospitals to establish and sustain high-quality IV therapy services. This hierarchical distribution of resources is a defining feature of China’s healthcare system, where higher-grade hospitals receive more funding and attract more qualified personnel, creating a tiered system of care quality (6). This phenomenon is not unique to China but mirrors challenges in other healthcare systems, albeit through different mechanisms. Compared with a recent national survey involving 958 tertiary hospitals in China (7), which reported an average IV specialist nurse allocation rate of approximately 40.0%, our study found a higher rate in Qingdao’s Grade A hospitals (66.7%), but a significantly lower rate in Grade B hospitals (33.3%). This intra-city disparity reinforces that grade-linked structural factors (rather than regional differences alone) are a key driver of IV therapy quality, and that the associations between hospital grade and our measured IV quality indicators are plausibly attributable, at least in part, to these pre-existing structural advantages. This disparity highlights that even within a single city, resource stratification can be as pronounced as national-level variations, reinforcing the need for region-specific and tier-specific resource allocation policies. For instance, in the United States, disparities in care quality are often observed between urban academic medical centers and rural community hospitals, driven by market forces, patient demographics, and workforce availability (17). Similarly, Australia faces significant challenges in providing equitable healthcare to rural and remote areas, relying heavily on foreign-trained nurses to fill workforce gaps, which creates its own set of inconsistencies in practice and training (18). In the UK’s National Health Service (NHS), while care is ostensibly universal, “postcode lotteries” result in variations in access to specialist services and technologies based on regional funding and commissioning priorities (19,20). Our finding that hospital grade in China is a strong predictor of IV therapy quality (r=0.48 for IV specialist nurse allocation rate) provides a quantifiable example of how systemic structure is associated with specialized care delivery. This suggests that for upper-middle-income countries developing their healthcare infrastructure, simply increasing the total number of IV specialist nurses may be insufficient without policies that ensure their equitable distribution across different tiers of the healthcare system.

The emergence of IV specialist nurses in Qingdao, China: a step towards international standards

Our study reveals a high rate of IV team establishment (86.7%) in Qingdao’s tertiary hospitals, indicating that the concept of specialized vascular access care is well-integrated. This aligns with a broader national trend in China, where the number of specialist nurses has grown significantly since 2000, driven by national health policies like the “Healthy China 2030” plan and the National Nursing Career Development Plan [2021–2025] (4,5,21). The positive correlation between nurse experience and the establishment of complication reporting systems (r=0.52) underscores the value of this specialization. Experienced nurses, transitioning from a task-oriented role to a quality oversight function, are crucial for embedding safety culture within institutions.

Internationally, the value of Vascular Access Specialist Teams (VASTs) is well-documented (4,22). Systematic reviews and meta-analyses consistently show that VASTs improve first-attempt insertion success, reduce complications like CLABSI and phlebitis, and are cost-effective (23,24). The development of IV specialist nurses in China can be seen as an organic, policy-driven parallel to the VAST model prevalent in North America and Europe. However, a key difference lies in the standardization of training and certification. In the US, the Certified Registered Nurse Infusion (CRNI^®) credential, offered by the Infusion Nurses Certification Corporation (INCC), provides a nationally recognized, rigorous standard of expertise based on a comprehensive job analysis and examination (25). Similarly, the UK has developed the “IV Therapy Passport”, a competency-based framework designed to standardize training and facilitate workforce mobility across NHS trusts (26). In contrast, specialist nurse training in China, as noted in our reference materials, is often led by provincial nursing associations (7), which may lead to variability in curriculum and competency standards. Our findings, therefore, advocate for China to move towards a more unified, national certification system, drawing inspiration from the CRNI^® or IV Therapy Passport models to ensure consistent quality and facilitate the professional advancement of specialist nurses.

Adherence to and gaps in international practice standards

The study highlights a commendable adherence to certain international best practices. The near-universal adoption of safety-type peripheral IV catheters (93.3%) and precision filter infusion sets (86.7%) aligns with the recommendations of the Infusion Therapy Standards of Practice, which emphasize using safety-engineered devices to protect both patients and clinicians (14). The high compliance with the 4-week maintenance schedule for IVAPs (90.9%) also reflects the successful integration of evidence-based guidelines into clinical practice (16).

However, this study also identified critical descriptive gaps (no inferential statistical analysis conducted for these indicators) that deviate from international practice standards, which are of great clinical concern for patient and clinician safety. Specifically, the adoption rate of needle-stick prevention steel needles was only 8.3%, which runs counter to the global initiative to eliminate preventable sharps injuries and poses a potential occupational safety risk for clinical staff. In addition, 20.0–26.7% of hospitals did not use specialized dressing change kits in a standardized manner for central line maintenance-a descriptive observation that is inconsistent with the requirements of international guidelines (e.g., INS, epic3) that mandate aseptic non-touch technique (ANTT) and standardized sterile supplies for all vascular access procedures to prevent CLABSI (14,27). Previous evidence has confirmed that standardized sterile dressing supplies (e.g., chlorhexidine-impregnated dressings) can reduce the risk of catheter-related infections by 60.0% (28), so the non-standard use of dressing change kits in partial hospitals may increase the potential risk of infusion-related infections. From a practical perspective, these descriptive gaps may be related to cost control pressures in medical institutions and insufficient clinical awareness of the importance of standardized infusion tools, and they also provide clear and actionable targets for subsequent IV therapy quality improvement initiatives in the region and other upper-middle-income countries with similar socioeconomic backgrounds.

Implications for policy and practice in a global context

Our study offers a “gradient development model” for IV therapy quality improvement that is highly relevant for other upper-middle-income countries. It shows that foundational elements, such as establishing IV teams and adopting basic safety devices, can be achieved widely. To address the grade-linked structural inequities that underpin IV therapy resource stratification, the next tier of advancement, including universal adoption of advanced technologies like ultrasound guidance and the development of robust, nurse-led quality control systems, is more resource-dependent and requires targeted investment and policy support (29). For countries in Southeast Asia, Eastern Europe, or Latin America facing similar resource constraints, the Qingdao experience—rooted in the observed grade-based resource stratification (moderate correlation between hospital grade and specialist nurse allocation rate, r=0.48) and differential advanced technology adoption (weak-to-moderate correlation with ultrasound-guided puncture rate, r=0.39)—suggested a data-driven approach: first,, scale the establishment of IV specialist nursing teams (86.7% adoption in Qingdao’s tertiary hospitals) and basic safety-oriented IV infrastructure (e.g., 93.3% adoption of safety-type peripheral venous catheters); second, formulate tiered resource allocation policies to narrow the gap in specialist nurse staffing and advanced technology access between hospital tiers, and mandate the adoption of underutilized safety tools (needle-stick prevention steel needles) and standardized maintenance supplies (specialized dressing change kits).

Furthermore, the study, based on the moderate correlation between IV specialist nurses’ working years and complication reporting system establishment (r=0.52), highlights the critical need for a hospital and national-level “training-certification-benefits” loop to sustain and advance the specialist nurse workforce. The national survey in China revealed that while 66.7% of hospitals reimbursed training fees, nearly 48.0% offered no change in remuneration or career prospects post-training (7). This disconnect, paired with the observed link between nurse experience and quality control capacity, demotivates nurses and hinders the long-term development of the specialty. Establishing clear, experience-aligned career pathways for IV specialist nurses (e.g., Advanced Nurse Practitioner roles in the UK and US) with commensurate salary and expanded quality control responsibilities is essential for retaining expert nursing talent and strengthening nurse-led complication monitoring systems (30). Without this, the investment in training is lost, and the quality of care stagnates. This is a universal challenge, and our data provides evidence from Qingdao, China to support the global call for greater recognition and reward for nursing specialization.

Study limitations

This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design limits our ability to infer causality between hospital grade, nurse experience, and IV therapy quality indicators. Longitudinal studies are needed to examine how changes in resource allocation or nurse staffing impact patient outcomes over time. Second, the study was conducted in a single coastal city in China (Qingdao), which may limit the generalizability of findings to inland or rural regions with different socioeconomic and healthcare infrastructure profiles. However, the consistency of our findings with national surveys (7) supports the external validity of the observed resource stratification patterns. Third, although we attempted to minimize recall bias by cross-verifying 10% of responses with administrative records, self-reported data-particularly regarding nurse remuneration and training reimbursement-may still be subject to social desirability bias, potentially leading to overestimation of compliance rates. The 10% verification sample was selected via simple random sampling: after de-identifying all 30 participating hospitals (coded as H1–H30), we used a random number table to generate 3 unique random numbers corresponding to three hospitals, ensuring the sample was unbiased and representative of the overall study population without considering hospital grade or type. The verified variables focused on core indicators prone to bias, including IV specialist nurse allocation rate, ultrasound-guided puncture adoption status, training fee reimbursement, and standardized dressing change kit use. Verification results showed high consistency (91.7%) between self-reported data and administrative records (e.g., training expense reimbursement vouchers, equipment procurement records), with only one minor discrepancy: one Grade B hospital self-reported “partial reimbursement of training fees” while administrative records confirmed “full reimbursement”, which was corrected in the final dataset and did not affect the study’s conclusions. Future studies should incorporate direct observational methods and administrative data linkage to enhance data accuracy. Finally, the study did not collect patient-level outcome data (e.g., CLABSI rates, phlebitis incidence), which limits our ability to directly link the observed structural and process indicators to clinical endpoints. Future research should adopt a multilevel design to explore how hospital-level and nurse-level factors jointly influence patient safety outcomes.

Conclusions

This cross-sectional study systematically analyzed IV therapy status in 30 tertiary hospitals in Qingdao, China. Key findings include: (I) a solid foundation for IV therapy in the surveyed hospitals (high establishment rate of IV specialist nursing teams and high adoption rate of ultrasound-guided puncture technology); (II) significant resource stratification between Grade A and Grade B tertiary hospitals (validated by Spearman rank correlation analysis); and (III) critical descriptive gaps in the clinical application of IV therapy tools (low adoption of needle-stick prevention steel needles, non-standard use of specialized dressing change kits, no inferential statistical analysis conducted for these gaps).

Unique contributions to the international nursing community: (I) a replicable gradient development model for resource-constrained settings; (II) evidence for policy-driven specialist nurse training in non-European/American regions; and (III) a low-cost CLABSI prevention strategy. Future research should validate the gradient model via multicenter cross-country studies and explore long-term impacts of nurse incentives. Targeted optimization measures anchored in study findings-including enhancing IV therapy management informatization, mandating the adoption of underutilized safety tools and standardized maintenance supplies, and establishing clinical experience-tied “training-certification-benefits” incentive loops for IV specialist nurses-will address the identified gaps and improve IV therapy quality and patient safety in Qingdao and other upper-middle-income country settings with similar socioeconomic and medical resource profiles.

Acknowledgments

We thank the Intravenous Infusion Therapy Professional Committee of Qingdao Nursing Association for supporting the questionnaire development and data collection. We also acknowledge the head nurses of participating hospitals for their contributions to data collection.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-126/rc

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-126/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-126/prf

Funding: This work was supported by the Qingdao Municipal General Program of Medical and Health Research (No. 2025-WJKY226 to Y.Y.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-126/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 conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of No. 971 Hospital of the People’s Liberation Army Navy (No. 2024-032, approval date: June 13^th, 2024), and all participants provided online written informed consent.

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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