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

Abstract

Objective To develop and validate a difficult intravenous access risk assessment and escalation pathway, to increase first time intravenous insertion success in paediatrics. Methods Mixed methods underpinned by literature and co-production principles. Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia. Results Interview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February–April 2020) involving 21 stakeholders culminating in the co-production of the “DIVA Key”. The DIVA Key was evaluated between May–December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range = 81.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa = 0.71, 95% CI 0.63–0.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2–27.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR) = 10 [8–10]; 8 [8–10 respectively). Conclusion The DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.

A survey of paediatric difficult peripheral intravenous access in the emergency department and use of point‐of‐care ultrasound

“…8 Early escalation to advanced inserters after identification of a potential child with DIVA could potentially avoid multiple failed attempts. 6,15 However, escalation pathways should always consider the resources available when developing local policy, which include staff and POCUS availability. 16 While clearly recognised as a useful tool in our study and having a strong evidence base, POCUS was used infrequently for paediatric DIVA patients.…”

“…5 The early identification of children with DIVA has been shown to avoid multiple failed PIVC insertion attempts. 6 Once identified, escalation measures can be taken to increase the likelihood of success with the minimum number of attempts. This includes escalation to a more experienced operator or use of an adjunct, such as transillumination, infrared or point-ofcare ultrasound (POCUS).…”

The parent, child and young person experience of difficult venous access and recommendations for clinical practice: A qualitative descriptive study

“…Difficulty inserting PIVCs or difficult venous access (DVA) in paediatric patients is common, with more than half of the patients requiring two attempts, and some requiring 10 attempts or more (Kleidon et al, 2019; Schults et al, 2022). Difficulty accessing the venous system also delays and disrupts the provision of time sensitive treatments, such as antibiotics and hydration fluids (Schults et al, 2022).…”

“…Difficulty inserting PIVCs or difficult venous access (DVA) in paediatric patients is common, with more than half of the patients requiring two attempts, and some requiring 10 attempts or more (Kleidon et al, 2019; Schults et al, 2022). Difficulty accessing the venous system also delays and disrupts the provision of time sensitive treatments, such as antibiotics and hydration fluids (Schults et al, 2022). This device insertion process often needs to be repeated, due to high rates of PIVC failure during treatment necessitating repeated insertions to complete treatment schedules (Indarwati et al, 2020; Malyon et al, 2014; Ullman et al, 2020).…”

Difficult Intravenous Cannulation in Children: Role of Assisting Devices

“…Children with chronic diseases undergoing repeated cannulation for chemotherapy, antibiotics courses, and repeated infusions, usually have difficult cannulation [1]. Difficult intravenous access (DIVA) score (components-vein visibility after tourniquet, palpable or not after tourniquet, age <3 y, and prematurity) ≥4 is associated with difficult cannulation [2]. Cannulation success also depends on the skill of the operator; health workers in peripheral settings and students/ residents joining pediatric courses during initial months find it difficult to cannulate children.…”