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Difficult Peripheral Venous Access in Children: An International Survey and Critical Appraisal of Assessment Tools
Jessica Schults1, Claire Rickard2, Tricia Kleidon3
1Research Fellow, PhD Candidate, Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Queensland, and Alliance for Vascular Access Teaching and Research Group (AVATAR), Menzies Health Institute Queensland, and School of Nursing and Midwifery, Griffith University, Queensland, Australia.
Insights
Identifying children with difficult intravenous access (DIVA) is crucial. Current practices are not standardized, highlighting the need for improved tools and pathways to reduce harm from repeated cannulation attempts.
Area of Science:
- Pediatric emergency medicine
- Vascular access
- Clinical practice guidelines
Background:
- Peripheral venous cannulation is a common procedure with a high failure rate for first attempts.
- Difficult intravenous access (DIVA) in children leads to repeat insertions, causing distress and potential harm.
- Early identification of DIVA facilitates prompt escalation to skilled clinicians.
Purpose of the Study:
- To survey international practices for identifying and managing children with DIVA.
- To systematically review and appraise existing clinical tools and pathways for DIVA.
- To identify areas for improvement in DIVA management protocols.
Main Methods:
- International cross-sectional survey of 148 clinicians across eight countries.
- Systematic review and critical appraisal of identified clinical pathways using the AGREE II checklist.
- Analysis of survey data on current DIVA identification and management strategies.
Main Results:
- Only 16% of surveyed clinicians reported using a DIVA identification tool, with the DIVA Score being most common.
- Five clinical pathways were identified; most scored well on scope, purpose, and clarity, but lacked detail on development rigor.
- One pathway was recommended for practice, and four for modified use based on AGREE II appraisal.
Conclusions:
- Standardized and consistently used resources for DIVA identification and escalation are lacking.
- Further development is needed to streamline DIVA identification and escalation processes.
- Improved management, potentially with technology-assisted insertion, can enhance patient experience and reduce harm.
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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