From ICU Initiative to a Growing Hospital-Wide Practice: The Evolution of the Nurse-Led Midline Insertion Program at King Faisal Specialist Hospital and Research Center-Jeddah

Authors:

Mahasen Segovia Juaton, BSN, RN, PGDipN, MN, MCSc

Fadi Numan Alshatarat, BSN, RN, CM, CCNE

Noha Mohammed Alharazi, BSN, RN, PGDipME, MSc, CCNE, CSCP

Raghda Jamil Nazer, BSN, RN, MPA, CCNE, CPHQ

Background

Central venous catheters (CVCs) are important medical devices. However, their use is associated with an inherent risk of central line-associated bloodstream infection (CLABSI), which is linked to prolonged hospitalization, increased health care costs, and patient morbidity.^1-3 Similarly, at King Faisal Specialist Hospital and Research Center-Jeddah (KFSH-J), we utilize CVCs especially for critically ill hospitalized patients. However, despite implementation of evidence-based CLABSI prevention bundles, KFSH-J observed an increase in CLABSI rates, requiring a review of vascular access practices.

Current evidence identified that one of the best practices in reducing CLABSI is reducing CVC days.² Therefore, the nurses at KFSH-J thought of finding an alternative vascular access device to the CVC. The Infusion Therapy Standards of Practice 9^th edition emphasized that infusion therapy and vascular access decisions is a collaborative process, among the health care team, patient, and caregiver.⁴

Within this context, nurse-performed ultrasound-guided midline insertion emerged as a potential program to reduce unnecessary central venous catheters while addressing challenges related to difficult intravenous (IV) access among hospitalized patients and to provide a safer alternative to repeated peripheral cannulation. Bae et al⁵ highlighted that utilizing a multidisciplinary approach and evidence-based practices may lead to a reduced CLABSI rate.

Identifying the Professional Practice Gap

At KFSH-J, patients with difficult venous access frequently required multiple peripheral IV insertion attempts or escalation to CVC insertion. This resulted in patient discomfort, increased workload for health care providers, and potential risks associated with central catheter placement. A need was identified for an advanced vascular access option that could bridge the gap between peripheral and central venous access. Although midline catheter insertion represented an evidence-based alternative, nurses lacked standardized education, competency validation, and clinical privileging to independently perform midline insertion. This professional practice gap created an opportunity to develop a structured nurse-led competency program.

Through recognizing this gap, a KFSH&RC-J accredited provider identified an opportunity to utilize the Nursing Continuing Professional Development (NCPD) criteria to build nursing capability while improving patient care.

Initiative and Implementation

Instead of providing an isolated training for nurses, the accredited provider decided to design a longitudinal competency-based continuing professional development training program to prepare intensive care unit (ICU) nurses for ultrasound-guided midline insertion.

The training program was developed using the latest evidence-based practices guided by the Infusion Therapy Standards of Practice, 9^th edition,⁴ which served as the primary professional competency for vascular access assessment, device selection, insertion techniques, maintenance, and competency development. Additional guidance was obtained from the Centers for Disease Control and Prevention (CDC) recommendations for the prevention of intravascular catheter-related infections,⁶ the PowerGlide™ Midline Instructions for Use (IFU) (Bard Access Systems),⁷ and the Aseptic Non-Touch Technique (ANTT®) Clinical Practice Framework.⁸ These resources were incorporated into the education program, competency assessment, clinical privileging process, and KFSH-J policy to ensure nurses were prepared to deliver safe, consistent, and evidence-based midline insertion and care. The training program was completed over 90 days. During this period, participants completed didactic education, supervised clinical practice, and successfully performed 5 ultrasound-guided midline catheter insertions before undergoing competency validation and receiving clinical privileges for midline catheter insertion and maintenance.

In 2024, a small group of nurses from the Medical Surgical Intensive Care Unit (MSICU) and Surgical Intensive Care Unit (SICU) were selected as the first cohort to receive midline insertion training. The initial educational activity was delivered in collaboration with the device manufacturer and included theoretical instruction on vascular access principles, ultrasound guidance, patient selection, and insertion techniques, followed by hands-on simulation and supervised ultrasound-guided insertion clinical practice. Six nurses became the program’s pioneer members.

Following successful implementation, the program subsequently became a professional development pathway for selected ICU units in 2025, encouraging nurses to gain competence and privilege in midline insertion. As the team gained experience, members began supporting patients outside their own units and providing access services across the organization.

Capacity Building and Knowledge Transfer

Recognizing that midline insertion required advanced technical skills, the original team established a structured mentorship approach to support other nurses’ development. Newly enrolled nurses progressed through coaching and supervised clinical practice, direct observation, performance feedback, and competency validation before independent practice. Experienced nurses served as mentors, facilitating the transfer of practical experience and skills related to ultrasound use, vein assessment, and insertion techniques.

Continuous evaluation of learner performance and participants’ feedback informed improvements in the education program, including recommendations to:

• Strengthen anatomy and vascular access theory
• Enhance ultrasound training
• Involve ICU physicians in teaching ultrasound-guided techniques
• Standardize competency development for new practitioners.

Policy Development and Process Improvement

As the number of trained nurses increased and utilization expanded, the team continuously monitored outcomes, identified challenges and opportunities to improve workflow, and collaborated to refine clinical policies and procedures. Their experience informed the development and finalization of a comprehensive midline insertion policy.

To further support service delivery and improve accessibility and documentation, an electronic Midline Insertion Referral Form was developed in collaboration with information system stakeholders. The form enabled the following:

• Formal referral requests.
• Screening for contraindications.
• Prioritization based on clinical urgency.
• Standardized documentation of insertion details and outcomes.

Expansion Across the Organization

What began as an ICU-based initiative gradually expanded beyond MSICU and SICU. Growing recognition of the clinical value of midlines and increasing demand for the service encouraged other departments to adopt the program. Other areas, such as the Acute Care Admission (ACA) unit, were among the first to adopt the practice, with support and mentorship from the original core team. Additional units, including medical wards and oncology services, also expressed interest due to the clinical value of midline access for their patient populations.

Clinical and Professional Outcomes

The Midline Insertion Program resulted in several significant improvements in vascular access practice and professional nursing outcomes:

• Improved access for patients with difficult IV cannulation
• Reduced reliance on CVC insertion when clinically appropriate
• Enhanced nursing autonomy and advanced practice capabilities
• Strengthened interdisciplinary collaboration among nurses, physicians, educators, and informatics personnel
• Development of standardized policies, referral pathways, and documentation processes
• Expansion of expertise from a small ICU team to multiple clinical areas across the organization:
  • February 2025: Trained 25 nurses across the MSICU, MICU, and SICU units
  • May 2025: Another group of nurses from MSICU, MICU, and SICU were trained
  • July 2025: Trained 32 nurses from MSICU, MICU, SICU, and ACA 
  • Additional Training:  Prepared 19 midline nurses as train-the-trainer educators through specialized training in midline catheter care and removal, enabling them to educate and mentor bedside nurses across inpatient units.
  • May 2026: Expanded training to 33 nurses from ACA, Medical-North and South, and Renal Transplant Unit.

Driven by this initiative, total device days steadily decreased from 40,138 in 2024 to 37,659 in 2025, reaching a low of 17,716 by June 2026. This downward trend was mirrored in CLABSI counts, which fell from 18 in 2024 to 14 in 2025, and down to just 6 by June 2026. Consequently, the key performance indicator of the CLABSI rate improved from 0.45 to 0.37 in 2025, dropping further to 0.34 in 2026.

Key Success Factors

1. Strong clinical leadership and vision
2. Nurse empowerment and professional development
3. Hands-on competency-based training
4. Continuous policy review and process improvement
5. Multidisciplinary collaboration
6. Commitment to mentoring and dissemination of expertise across units.

Conclusion

The Midline Insertion Program demonstrates how a focused nursing-led innovation can evolve into a hospital-wide service that improves vascular access care, enhances patient outcomes, and promotes professional growth. Beginning with a small group of ICU nurses in 2024, the initiative grew into a structured, policy-driven program with expanding organizational reach, establishing a sustainable model for advanced nursing practice and collaborative patient care.

References

1. Alomari S, Yahya M, Alabadlah N, et al. Central line-associated bloodstream infections (CLABSI) in critical care: understanding incidence, and risk factors in Palestine. BMC Infect Dis. 2025;25(1):463. doi:10.1186/s12879-025-10855-0
2. Beville ASM, Heipel D, Vanhoozer G, Bailey P. Reducing central line associated bloodstream infections (CLABSIs) by reducing central line days. Curr Infect Dis Resp. 2021;23(12):23. doi:10.1007/s11908-021-00767-w
3. Urtecho M, Roldan VDT, Nayfeh T, et al. Comparing complication rates of midline catheter vs peripherally inserted central catheter. A Systematic Review and Meta-analysis. Open Forum Infect Dis. 2023;10(2):ofad024. doi:10.1093/ofid/ofad024
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