Related Experiment Video
Updated: May 27, 2026
Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound
Published on: August 9, 2024
Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying
Michael W Riker1, Chris Kennedy, Brad S Winfrey
1Division of Emergency and Urgent Care, The Children's Mercy Hospital, Kansas City, MO, USA. mwriker@cmh.edu
Insights
The difficult intravenous access (DIVA) score effectively predicts failed IV placement in children. A simplified three-variable rule showed similar accuracy to the original four-variable DIVA score, suggesting potential for easier clinical use.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support Tools
- Vascular Access
Background:
- The Difficult Intravenous Access (DIVA) score was developed to predict intravenous (IV) cannulation failure in children.
- External validation and refinement of the DIVA score are crucial for its clinical utility.
Purpose of the Study:
- To externally validate the existing four-variable DIVA score.
- To refine the DIVA score by evaluating additional predictors.
- To assess the predictive accuracy of a simplified DIVA score.
Main Methods:
- A prospective study enrolled 366 children undergoing peripheral IV placement in a pediatric emergency department.
- Logistic regression and receiver operating characteristic (ROC) curves were used to analyze data.
- The original DIVA score and a proposed three-variable model were evaluated.
Main Results:
- 32.2% of children experienced failed first IV attempts.
- The original four-variable DIVA score demonstrated an area under the curve (AUC) of 0.72.
- A simplified three-variable rule (vein palpability, vein visibility, patient age) achieved an equivalent AUC of 0.72.
Conclusions:
- The four-variable DIVA score was validated in this cohort.
- A simpler three-variable rule is as effective as the four-variable DIVA score for predicting failed IV placement.
- Further validation in non-pediatric emergency departments is recommended to assess generalizability.
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 three-variable 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.
