Identification and management of children with difficult intravenous access


Identification of children with difficult intravenous access (DIVA) can help promote prompt escalation to an appropriately skilled clinician” Schults et al (2019).


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.

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Schults, J., Rickard, C., Kleidon, T., Paterson, R., Macfarlane, F. and Ullman, A. (2019) Difficult Peripheral Venous Access in Children: An International Survey and Critical Appraisal of Assessment Tools and Escalation Pathways. Journal of Nursing Scholarship. August 1st. doi: 10.1111/jnu.12505. .


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