Objectives: The difficult intravenous access (DIVA) score, a proportionally weighted four-variable (vein palpability, vein visibility, patient age, and history of prematurity) clinical rule, has been developed to predict failure of intravenous (IV) placement in children. This study sought to externally validate and refine the DIVA score.Methods: Patients undergoing peripheral IV placement by pediatric emergency department (ED) nurses were enrolled. The outcome of interest was defined as failure of cannulation on first attempt. Proposed refinement predictor variables include history of newborn intensive care unit (NICU) stay, operator experience characteristics (years since graduation, years of pediatric nursing experience, and IVs started per month), and skin shade. Adjusted multivariate models were constructed using logistic regression. Receiver operating characteristic (ROC) curves were constructed and areas under the curve (AUC) calculated for each model. Results:A total of 366 subjects were enrolled (mean age = 5.4 years, SD ± 5.6 years) and of them, 118 (32.2%) subjects failed the first IV attempt. The original four-variable model tested in this data set resulted in an AUC of 0.72 (95% confidence interval [CI] = 0.67 to 0.78). Patients with a DIVA score of 4 or greater had more than 50% likelihood of failed first IV attempt. A three-variable rule (vein palpability, vein visibility, and patient age) was evaluated and found to possess similar discriminating ability (AUC = 0.72, 95% CI = 0.67 to 0.78).Conclusions: This study validated the previously derived four-variable DIVA score. A simpler threevariable rule was as predictive of failed IV placement on first attempt as the four-variable rule. Validation in nonpediatric EDs is needed to thoroughly evaluate generalizability.

Intimate partner violence screening protocols in the pediatric emergency department should take into consideration the beliefs and attitudes of both those doing the screening and those being screened. Those developing screening protocols for a pediatric emergency department should consider the following: (1) that those assigned to screen must demonstrate empathy, warmth, and a helping attitude; (2) the importance of addressing the child's medical needs first, and a screening process that is minimally disruptive to the emergency department; (3) a defined, organized approach to assessing danger to the child, and how and when it is appropriate to notify child protective services when a caregiver screens positive for intimate partner violence; and (4) that resources must be available immediately to a victim who requests them.

Air guns are associated with serious and fatal injuries. Families should be counseled that air guns may cause serious injuries and even death. Furthermore, pediatric care givers should advocate for increased regulation of air guns and expansion of safety standards.

A triage protocol for rapid influenza testing for febrile infants and children appears to significantly decrease additional testing, time in the ED, and charges in children testing positive for influenza.

Rapid confirmation of influenza virus type A infection seems to decrease ancillary tests and antibiotic use in febrile infants and toddlers in the ED. A prospective study with a larger group is needed to confirm these findings.

The American Academy of Pediatrics and its members recognize the importance of improving the physician's ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children.

Traumatic injury is the leading cause of death in children after infancy. The leading causes of childhood injury deaths are motor vehicle crashes, submersion injury, homicide, suicide, and fires. Injuries are not random events. Factors associated with injuries allow identification of high-risk populations and targeted interventions. Injury research includes development of conceptual models to include preinjury, event, and postevent features that can be modified to prevent or limit injuries. Successful prevention strategies often include multifaceted approaches such as education, incentives for safe human behavior, legislation/enforcement, and environmental changes. Preventive programs must weigh both societal and economic values and costs. Careful evaluation for effectiveness of injury prevention programs to decrease or limit injury continues to be a challenge. Generally, passive measure such as improved engineering are more effective than measures that require modification of human behaviors. Childhood injury prevention programs have reduced deaths from some causes such as motor vehicle crashes, but deaths from gun-related homicide and suicide remain high. Critical care providers can actively engage in both prevention efforts and improved acute care of the severely injured child.

OBJECTIVES. This study sought to determine the degree to which injury hospitalization, especially for assaultive injury, is a risk for subsequent hospitalization due to assault. METHODS. A New Zealand hospitalization database was used to perform a retrospective cohort study. Exposure was defined as an injury hospitalization, stratified into assaultive and nonassaultive mechanisms. Hospitalizations for an assault during a 12-month follow-up period were measured. RESULTS. Individuals with a prior nonassaultive injury were 3.2 times more likely to be admitted for an assault than those with no injury admission (95% confidence interval [CI] = 2.7, 3.9). The relative risk associated with a prior assault was 39.5 (95% CI = 35.8, 43.5), and the subsequent admission rate did not vary significantly by sex, race, or marital or employment status. Among those readmitted for an assault, 70% were readmitted within 30 days of the initial hospitalization. CONCLUSIONS. Prior injury is a risk for serious assault, and the risk is even greater if the injury is due to assault. Risk of readmission for assault is largely independent of demographic factors and greatest within 30 days of the initial assault.