Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key

Jessica A Schults,Steven Mctaggart,Adam Keys,Karina Charles,Victoria Gibson,Robert S Ware,Emily Monteagle,Tricia M Kleidon,Rebecca Paterson,Claire M Rickard,Craig A Mcbride,Amanda J Ullman,Chloe Sells,Benjamin Lawton,Fiona Macfarlane

doi:10.1186/s12913-022-07605-2

Abstract

ObjectiveTo develop and validate a difficult intravenous access risk assessment and escalation pathway, to increase first time intravenous insertion success in paediatrics.MethodsMixed methods underpinned by literature and co-production principles. Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia.ResultsInterview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February–April 2020) involving 21 stakeholders culminating in the co-production of the “DIVA Key”. The DIVA Key was evaluated between May–December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range = 81.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa = 0.71, 95% CI 0.63–0.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2–27.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR) = 10 [8–10]; 8 [8–10 respectively).ConclusionThe DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.

Highlights

Insertion of a peripheral intravenous catheter (PIVC) is almost synonymous with hospitalisation [1, 2]
PIVC insertion failure contributes to significant usage and wastage of healthcare resources, costing the Australian health care system nearly $450 million [AUD] annually [9]
DIVA status is retrospectively assigned after the patient has endured multiple failed PIVC insertion attempts

Summary

Introduction

Insertion of a peripheral intravenous catheter (PIVC) is almost synonymous with hospitalisation [1, 2]. For children with DIVA, successful PIVC insertion may require upwards of nine attempts (needle sticks) [5]. Processes to identify children with DIVA have been attempted, primarily within emergency departments [14] with the development of three [11], four [10, 11, 15] and five variable DIVA Scores [16]; a Peripheral Venous Grading System [17] and a Peripheral Vein Assessment Instrument [18]. While many have been based on sizeable cohorts, their clinical generalisability in general hospital wards can be limited [10, 11, 15] They are i) limited in their capacity to direct clinicians on how to manage these ‘DIVA’ patients once identified; and ii) typically do not feature consumer engagement, or patient centred principles such as procedural pain, or skill and confidence of the inserter. The reliability, reproducibility, and acceptability of the DIVA Key, as a strategy to identify children with DIVA, was evaluated to assess clinical utility and application feasibility in paediatric settings

Methods

Results

Discussion

Conclusion