Modified DIVA Score: An Improved Clinical Predictive Tool for Detecting Difficult Access in Children
Munaza Batool Rizvi, Ellen J Silver1, Hnin Khine1
1Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
Insights
The modified DIVA score (m-DIVA), incorporating a history of difficult intravenous access, significantly improves the identification of pediatric patients needing IV access. This enhanced tool shows higher sensitivity for predicting difficult IV access in children.
Area of Science:
- Pediatric Emergency Medicine
- Vascular Access
- Clinical Assessment Tools
Background:
- Difficult intravenous (IV) access is a common challenge in pediatric emergency care.
- The Difficult Intravenous Access (DIVA) score aims to predict and identify patients with challenging IV access needs.
- Validation of existing tools and exploration of new predictors are crucial for optimizing patient care.
Purpose of the Study:
- To validate the DIVA score in a pediatric population.
- To identify additional patient characteristics associated with difficult IV access in children.
- To develop an improved tool for predicting difficult IV access.
Main Methods:
- A cross-sectional study of 300 pediatric patients (age < 21) in a quaternary pediatric emergency department.
- Data collected included DIVA score components, history of difficult access, hydration status, skin shade, comorbidities, and technology dependence.
- Difficult access was defined as ≥2 attempts or >30 minutes for IV cannulation.
Main Results:
- The original DIVA score showed 51% sensitivity and 83% specificity for difficult IV access.
- "History of difficult access" was the only additional characteristic that improved prediction (61% sensitivity, 76% specificity).
- The modified DIVA (m-DIVA) score, including "history of difficult access," demonstrated 78% sensitivity and 67% specificity, a 52.9% improvement in correct identification.
Conclusions:
- The m-DIVA score, by incorporating prior IV access history, enhances the sensitivity of screening for difficult IV access in pediatric patients.
- The m-DIVA score shows promise as a valuable clinical tool for improving the prediction of difficult IV access.
- Further investigation and validation of the m-DIVA score in clinical practice are warranted.
Objective:
This study aims to validate the DIVA (Difficult Intravenous Access) score in our population and to identify any additional patient characteristics that may be associated with difficult access in children.
Methods:
This was a cross-sectional study in an urban quaternary pediatric emergency department with patients younger than 21 years and Emergency Severity Index ≥2 who require intravenous (IV) access for their management. In addition to patient characteristics comprising the DIVA score, data were collected on patient "history of difficult access," hydration status, skin shade, history of sickle cell disease or diabetes, technology dependence, and body mass index. The number of IV cannulation attempts and total time taken were recorded for each patient. "Difficult access" was defined as ≥2 or more attempts or time >30 minutes to achieve successful IV cannulation.
Results:
A convenience sample of 300 pediatric patients was enrolled. The DIVA score had a sensitivity of 51% (95% confidence interval [CI], 40.8%-61.14%) and a specificity of 82.99% (95% CI, 76.95%-87.99%) for predicting "difficult access" in our population. Among all patient characteristics examined in this study, only "history of difficult access" improved the identification of "difficult access" patients. The "history of difficult access" variable had a sensitivity of 61% (95% CI, 50.7%-70.6%) and a specificity of 75.7% (95% 95% CI, 69.12%-81.62%) in predicting "difficult access." With the addition of "history of difficult access" to the original DIVA score, we developed a "modified DIVA score (m-DIVA)." The m-DIVA score had a sensitivity of 78% (95% CI, 68.6%-85.6%) and specificity of 67% (95% CI, 59.9%-73.58%), representing a 52.9% improvement in correctly identifying "difficult access" patients over the original DIVA score.
Conclusions:
The m-DIVA score, which incorporates prior history, increases the screening test's sensitivity in identifying "difficult access" patients and should be further investigated as clinical tool.
