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External validation of the DIVA and DIVA3 clinical predictive rules to identify difficult intravenous access in
Cristian Girotto1, Marta Arpone2, Anna Chiara Frigo3
1Division of Paediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy.
Insights
Difficult intravenous (IV) access in children is common. The Difficult IntraVenous Access (DIVA) and DIVA3 scores showed similar accuracy in predicting difficult IV access, aiding clinicians in first-attempt success.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Prediction Tools
- Vascular Access
Background:
- Intravenous (IV) cannulation is challenging in pediatric emergency departments, causing distress.
- Clinical prediction tools aim to identify children with difficult IV access to improve first-attempt success.
- External validation of the Difficult IntraVenous Access (DIVA) and DIVA3 scores was performed.
Purpose of the Study:
- To externally validate the DIVA and DIVA3 scores for predicting difficult IV access in children.
- To assess the accuracy of these scores in a real-world pediatric ED setting.
- To identify factors that may refine risk prediction for difficult IV access.
Main Methods:
- A cross-sectional study involving children undergoing IV cannulation in a tertiary-care pediatric ED.
- Data were collected by nurses at the time of the IV cannulation procedure.
- The DIVA and DIVA3 scores were evaluated using diagnostic accuracy measures.
Main Results:
- 23.4% of 440 children experienced difficult IV access (requiring >1 attempt).
- DIVA and DIVA3 scores demonstrated similar diagnostic accuracy, with specificity above 92%.
- Nurses' prediction of difficulty and dehydration were predictors of difficult IV access, with prediction of difficulty being independently associated with higher odds.
Conclusions:
- External validation confirmed the DIVA and DIVA3 scores have comparable accuracy to their derivation cohorts.
- The scores' accuracy was similar to each other.
- Identifying predictors like nurses' assessment of difficulty can help optimize strategies for successful first-attempt IV cannulation.
Background:
Intravenous (IV) peripheral access is often a difficult procedure in the paediatric ED, causing pain and significant distress. Clinical prediction tools including reproducible variables have been developed to help clinicians identify children at risk of difficult IV access, likely to need additional resources/interventions to maximise success at first attempt. We aimed to externally validate the Difficult IntraVenous Access (DIVA) and DIVA3 scores developed for this purpose.
Methods:
Cross-sectional study of children undergoing IV cannulation by nurses in a tertiary-care paediatric ED. Data were collected at the time of the procedure in a clinical report form.
Results:
Of 440 children included (56.8% males; median age 4.7 years (IQR 1.5-9.5)), 23.4% had a difficult IV access (defined as requiring >1 attempt). Diagnostic accuracy measures for a DIVA cut-off ≥4 and their 95% CIs were sensitivity 24.3% (16.4% to 33.7%), specificity 92.6% (89.2% to 95.1%), positive and negative predictive value 50.0% (35.3% to 64.5%) and 80.0% (75.7% to 83.9%), respectively. The same measures for the DIVA3 were 22.3% (14.7% to 31.6%), 93.5% (90.3% to 95.9%), 51.1% (35.8% to 66.3%) and 79.8% (75.4% to 83.6%). The area under the receiver operating characteristic curve was 0.652 (95% CI 0.591 to 0.712) for the DIVA and 0.649 (95% CI 0.589 to 0.709) for the DIVA3 score. In patients with DIVA and DIVA3 <4, nurses' prediction of greater difficulty in IV placement and moderate/severe dehydration were common independent predictors of difficult IV at multivariate analysis. Only nurses' prediction of greater difficulty in IV placement were associated with higher odds of difficult cannulation for both DIVA/DIVA3 scores ≥4.
Conclusion:
We externally validated the DIVA and DIVA3 showing a similar accuracy compared with the DIVA derivation cohort and between DIVA and DIVA3. We identified factors that can help refine further the risk of difficult IV access and support decision making on the best strategy to maximise the chances of cannulation success on first attempt.
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