Difficult Peripheral Venous Access in Children: An International Survey and Critical Appraisal of Assessment Tools and Escalation Pathways

Abstract

Background Peripheral venous cannulation is considered a routine procedure, yet 50% of first attempt insertions fail, necessitating repeat insertion attempts. Identification of children with difficult intravenous access (DIVA) can help promote prompt escalation to an appropriately skilled clinician. Objective To describe current international practice regarding the identification and management of children with DIVA, and to systematically review clinical tools and clinical pathways for children with DIVA. Methods A cross‐sectional, international survey; followed by a systematic review and critical appraisal of clinical pathways using the Appraisal of Guidelines for Research Evaluation (AGREE) II checklist. Results A total of 148 clinicians from eight countries completed the survey. The majority were nurses (n = 92; 62%), practicing as vascular access specialists (n = 27; 18%). Twenty‐three respondents (16%) reported using a DIVA tool, of which the DIVA Score was most common (n = 5; 22%). Five clinical pathways were identified from the survey and review. Based on the AGREE II domains, pathways generally scored well for scope and purpose, and for clarity of presentation areas. Information on the rigor of development and editorial independence was infrequently detailed. Based on AGREE II findings, one pathway was recommended for clinical practice, and four were recommended for use with modification. Conclusions Resources for the identification and escalation of children with DIVA are not standardized or consistently used. Further work is needed to streamline processes for DIVA identification and escalation to the appropriate clinician, with technology‐assisted insertion capability. This will enhance patient experiences and reduce harm from multiple insertion attempts. Clinical Relevance Multiple failed insertion attempts come at great cost to the child, family, and healthcare service. Early identification and management of the child with DIVA can ensure prompt escalation and management, improving the patient and family experience.

Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key

“…This project co-produced and validated the DIVA Key instrument to support the assessment and subsequent escalation of PIVC insertion care in children with DIVA. Consistent with the evidence-base around DIVA risk factors and existing DIVA instruments [ 10 , 11 , 13 – 18 ], the DIVA Key included objective descriptions of vessel quality (e.g., appearance) and practice variables (e.g., acuity, previous access history). These indicators were uniquely complemented by rating the child’s reported or perceived anxiety, along with the clinician’s self-assessment of ability, and recommendations for management of procedural pain and anxiety.…”

“…Workshops were carefully planned using a scripted approach (example Supplementary material 1) and focused on joint decision-making between the research team, stakeholders, and consumers [ 28 ]. Workshop participants were provided an evidence summary (literature review findings [ 13 ]), excerpts from interview texts summarising desired instrument requirements, and an overview of current local DIVA policy. Expert opinion was an important consideration for co-production of instrument inclusions, with clinician gestalt linked with DIVA status prediction and first attempt insertion failure [ 29 ].…”

“…Historically, DIVA status is retrospectively assigned after the patient has endured multiple failed PIVC insertion attempts. As a result, there has been a recent surge in the development of DIVA decision-making resources for paediatric patients [ 13 ]. Processes to identify children with DIVA have been attempted, primarily within emergency departments [ 14 ] with the development of three [ 11 ], four [ 10 , 11 , 15 ] and five variable DIVA Scores [ 16 ]; a Peripheral Venous Grading System [ 17 ] and a Peripheral Vein Assessment Instrument [ 18 ].…”

Acceso venoso difícil en pediatría

“…L a obtención de un acceso venoso periférico es un procedimiento de rutina que se realiza en los pacientes pediátricos que ingresan al hospital con el fin de administrar un tratamiento médico. Sin embargo, 50% de las veces la canulación de la vía venosa al primer intento es frustra, por lo que es necesario repetir la punción [1], [2], siendo necesario muchas veces el uso de punciones múltiples, resultando el procedimiento complejo, frustrante y todo un desafío para el personal médico y de enfermería [3].…”

An international survey of pediatric and neonatal clinicians' vascular access practice: PediSIG assessment of vascular access, education, and support (PAVES) catheter selection

“…There was a wide variation in practice as to how many total attempts the clinician performs before escalating to a central venous access device or alternative access. Similarly, Schults et al 14 recently reported only 16% of clinicians (n=23) globally used a DIVA scale, with resources used for the identification and escalation of children with DIVA are unstandardized or are inconsistently used. Further study is needed to streamline processes for DIVA identification and escalation to the appropriate clinicians, to improve patient safety and experience.…”