Validation and Refinement of the Difficult Intravenous Access Score: A Clinical Prediction Rule for Identifying Children With Difficult Intravenous Access

Abstract

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.

The Use of the Needle‐free Jet Injection System With Buffered Lidocaine Device Does Not Change Intravenous Placement Success in Children in the Emergency Department

“…6 Prior to the study, first attempts success was estimated to be 55–70% and a 15% improvement was determined by experts in the field to be clinically important. 4,5,6 A change of 15% required 134 patients in each group to obtain an alpha of 0.05 (two-sided) and a beta of 0.20. An additional 10% were enrolled.…”

“…5,6 For children in particular, pain experienced during IV placement can result in increased movement and lack of cooperation, making success more difficult. 3 A study of topical lidocaine found improved IV placement success in children was associated with analgesic use suggesting an intervention to decrease pain may increase placement success.…”

The prehospital intravenous access assessment: a prospective study on intravenous access failure and access delay in prehospital emergency medicine

“…In a similar manner, a recent study by Riker et al [10] has simplified previous multifactorial paediatric prediction rules into a three-factor scoring system without forfeiting accuracy. Predictors in the Riker model are: (1) Vein visible with tourniquet in place.…”

“…In addition, these guidelines suggest a pre-emptive use of alternatives (again intraosseous access) in situations where cannulation failure seems likely. However, although predictors for a difficult intravenous access have been investigated for in-hospital settings [8][9][10][11][12], only little data are available on the special environment of prehospital emergency care. In summary, there is a profound lack of evidence to base the above-mentioned prediction of success on anything but one's own gut feeling.…”

Grade Management in Establishing Pediatric Peripheral Venous Access

“…IV placement can be challenging in pediatric patients; the failure rate can reach 47% on the first attempt, and 9% of patients require more than four attempts before peripheral IV access is obtained (2). The data from an emergency department reported a success rate of 67.8% on the first catheterization attempt in pediatric patients (3). Even when interventions such as venous imaging ultrasound are used, two or more attempts are still required for 15% of children to achieve access (4).…”