Difficult Intravenous Access Score Research Articles

Outcomes of a Comprehensive Ultrasound Guided Peripheral IV Insertion (USGPIV) Training Program in a Pediatric Emergency Department

IntroductionTimely and reliable peripheral intravenous cannulation is an imperative skill in a pediatric emergency department. Utilization of point-of-care ultrasound guidance has proven to significantly improve first-attempt peripheral intravenous cannulation insertion rates in pediatric patients. We sought to develop, implement, and evaluate an ultrasound-guided peripheral intravenous training program for emergency nurses in a tertiary care pediatric center. MethodsTwelve emergency nurses underwent a training program that consisted of an interactive asynchronous learning module followed by 8 hours of training by a vascular access clinical instructor. Data was collected on each ultrasound-guided peripheral intravenous insertion via survey methodology. ResultsComplete data for a total of 210 ultrasound-guided peripheral intravenous were recorded over the 9-month period. A total of 65.2% (137/210) of patients who received an ultrasound-guided peripheral intravenous had known difficult intravenous access on history. A total of 89.5% (188/210) of patients had a difficult intravenous access of ≥4. The mean difficult intravenous access score for the patients in which ultrasound-guided peripheral intravenous insertions were attempted was 4.78 (95% confidence interval, 4.55-5.01). A total of 193 of 210 (91.9%) of ultrasound-guided peripheral intravenous were attained successfully. On the first attempt, 86.5% (167/193) ultrasound-guided peripheral intravenous were attained, and 98.96% (191/193) were attained within the first 2 attempts. ConclusionWe found that implementing a comprehensive ultrasound-guided peripheral intravenous training program for emergency nurses in a pediatric tertiary care center led to a high first-pass success rate in attaining peripheral intravenous cannulations. It also facilitates vascular access in patients with known difficult intravenous access. Consideration should be made to implementing point-of-care ultrasound intravenous training programs to improve pediatric vascular access in the emergency department, particularly in patients with known difficult intravenous access.

Evaluation of the difficult intravenous access (DIVA) scoring in hospitalized pediatric patients

The DIVA scoring tool has previously been validated in the pediatric ED setting. Our project applied DIVA to an inpatient pediatric sample. DIVA may not predict likelihood of PIV success in the inpatient setting.

DIVA SCORE AND PEDIATRIC PATIENTS: A BIBLIOMETRIC ANALYSIS OF THE LITERATURE

The aims of this research were to analyse the DIVA score publications in pediatric patients and to guide future research. Web of Science (WoS) All Databases collection was searched for publications related to DIVA score and pediatric patients. The keywords used during this search were; DIVA score, difficult intravenous access score, DIVA, difficult venous access, and/or paediatric, pediatric, children, child. Publications were scanned one by one to determine whether they were suitable for the present study. The authors, countries, journals, document types, publications dates, most used keywords were obtained from the Web of Science (WoS) All Databases collection. In total, 15 publications related to DIVA score and pediatric patients were identified. These publications were published in 12 different journals and the most publications on this subject were published in the "PEDIATRIC EMERGENCY CARE" journal. The country with the highest number of publications on this subject was the USA. The most preferred 5 key words in publications related to DIVA score in pediatric patients were as follows: 1-Difficult intravenous access / DIVA / difficult venous access (n=10), 2-Paediatric / pediatric / children / child (n=9), 3 -Peripheral intravenous access (n=5), 4-DIVA score (n=4), 5- Peripheral catheterization (n=3). We analyzed all articles about DIVA score in pediatric patients published to date in the WoS All Databases collection. Most publications on this subject were made in pediatric emergency departments. It is expected that there will be developments regarding both the number and content of studies in pediatric patients.

The effect of “pediatric peripheral intravenous access (PPIVA) pathway” on the success of vascular access in children

PurposeDetermine the affects of the developed “Pediatric Peripheral Intravenous Access (PPIVA) Pathway” on the success of the vascular access in children. Design and methodsA quantitative approach was used using a quasi-experimental single-group post-test design involved pediatric patients. The patients who were first attempted for peripheral vascular access were subjected to the procedure in accordance with the “PPIVA Pathway”. The data was collected via a form on which we recorded down the patients' characteristics alongside their procedural data, as well as the Difficult Intravenous Access (DIVA) Score. For statistical analysis, the R vers. 2.15.3 program was utilized. ResultsThe patients who applied to the pediatric observation clinic had a mean age of 8.14 ± 5.01 years. The DIVA total mean score of the patients was 1.73 ± 1.79. 89.1% (n = 163) of pediatric peripheral intravenous procedures were successfully completed on the first access. The logistic regression analysis model was found to be statistically significant to identify the factors that affect pediatric peripheral intravenous success on the first attempt (χ2 = 24.701; p < 0.001). A one-point increase in the DIVA score was found to reduce the likelihood of success on the first attempt by 56.1% [OR (95% CI) = 0.439 (0.280, 0.686), p < 0.001]. ConclusionsUsing an algorithm to perform a peripheral intravenous intervention in children increases the likelihood of success on the first attempt. Practice implicationsUsing PPIVA Pathway shall improve the provision of atraumatic care for children, as the success rate of pediatric peripheral intravenous access on the first attempt is high.

The Effect of Virtual Reality and Buzzy on First Insertion Success, Procedure-Related Fear, Anxiety, and Pain in Children during Intravenous Insertion in the Pediatric Emergency Unit: A Randomized Controlled Trial

IntroductionDistraction methods such as virtual reality and cold vibration device are recommended during intravenous interventions. Few studies have focused on the impact of nonpharmacological interventions on intravenous insertion success. MethodsA randomized controlled study evaluated effect of virtual reality and cold vibration device application on first-attempt intravenous insertion success and procedure-related pain, fear, and anxiety during intravenous insertion in children. Children aged 4 to 10 years (N = 150) undergoing peripheral intravenous catheterization insertion in the pediatric emergency department were randomized to 1 of 3 groups: virtual reality, cold vibration (Buzzy), and control group. Distraction technique of talking and asking questions of children was used in control group. Primary outcome was first-attempt intravenous insertion success; secondary outcomes were procedure-related pain, fear, and anxiety. Study data were collected using Difficult Intravenous Access score, Emotional Appearance Scale for Children, Wong-Baker Faces Pain Rating Scale, Color Analog Scale, Children's Anxiety Meter-State, and Child Fear Scale. Data were analyzed using chi-square test, Fisher exact test, and Kruskal–Wallis test. ResultsThere were no significant differences in first-attempt intravenous insertion success rates (virtual reality = 47.2%, Buzzy® = 50%, control = 46.9%), preprocedural emotional appearance scores, and procedure-related pain and anxiety scores. There was no difference between groups for vital signs before, during, and at fifth minute of procedure. DiscussionVirtual reality and Buzzy may decrease procedure-related fear in children during intravenous insertion. This research has shown that pediatric emergency nurses can reduce pain and anxiety by talking to children, and simple distractions such as asking questions are as effective as more technological ones.

Modified DIVA Score: An Improved Clinical Predictive Tool for Detecting Difficult Access in Children.

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. 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. 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. 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.

Evaluation of the Difficult Intravenous Access (DIVA) Scoring in Hospitalized Pediatric Patients

Highlights Abstract Background: First-attempt success rate for placing pediatric peripheral intravenous (PIV) catheters ranges from to 24% to 52%. Multiple attempts can increase risk of deleterious outcomes. It is essential to screen pediatric patients appropriately to identify those who will require additional resources for successful PIV placement. Methods: A convenience sample of hospitalized pediatric patients 0 to 18 years of age on a general care unit was used in this performance improvement project. Prior to attempting PIV access, nurses completed a data collection tool that included elements of established difficult intravenous access (DIVA) tools as well as first-attempt successful PIV placement. The primary outcome measure was to determine if each DIVA scoring tool is accurate in predicting the need for additional resources to achieve successful first-attempt PIV placement. The secondary outcome measure was to compare the predictive value of each DIVA scoring tool among an inpatient pediatric population. Following data exploration and cleaning, a correlation analysis was performed with logistic regression to assess DIVA score effectiveness in predicting success of PIV insertion on the first attempt. Results: Out of 133 children, 167 PIV attempts were analyzed with 150 PIV attempts included in the final data analysis. Of the 150 PIV attempts analyzed, 60% (n = 90) were successful on the first attempt. Performance of prediction for first-time insertion success was comparable among all 4 DIVA scoring tools. Conclusions: None of the 4 DIVA scoring tools were superior in predicting first-time PIV placement among hospitalized children. Vein palpability was more predictive, although not statistically significant.

CUIDADOS DE ENFERMAGEM NA CATETERIZAÇÃO INTRAVENOSA PERIFÉRICA EM CRIANÇAS HOSPITALIZADAS: REVISÃO INTEGRATIVA

ABSTRACT Objective: to describe nursing care in peripheral intravenous catheterization in hospitalized children. Method: integrative review carried out in November 2020 in LILACS, CINAHL, MEDLINE, SciELO, BDENF and COCHRANE databases. The analysis was constructed from the processes of this review. Results: 19 articles were analyzed, classified according to the level of evidence: level II (5%), level IV (21%), level V (5%), level VI (63%) and level VII (5%). Analytical category "Care for hospitalized child requiring peripheral intravenous catheter". Ultrasound was considered a useful technology. The most used and recommended catheter is the 24 Gauge caliber and the ideal dressing is to use sterile transparent film. Venipuncture in children is more difficult than adults and is often associated with adverse events. Elective catheter replacement is not recommended in children, but there are still doubts. The Difficult Intravenous Access score determines the probability of catheterization failure. Specialized and trained nursing professionals make a difference in this procedure. One should be concerned with pain, using pharmacological and non-pharmacological devices to minimize it. Conclusion: this review contributes to good practices in the care of peripheral intravenous catheterization in children and was based on data on the main technologies used, forms of prevention of adverse events, as well as nursing actions that ensure the safest and least stressful process for children and their families.

Outcomes of a Pediatric Ultrasound-Guided Short Peripheral Catheter Training Program and Hands-On Poultry Simulation Course.

Ultrasound guidance is an effective technique for obtaining short peripheral catheter (SPC) access but requires training and practice for proficiency. The aim of this quality improvement initiative was to develop and assess a formal training program to increase the confidence and competency of intravenous (IV) therapy nurses in the placement of ultrasound-guided SPCs. IV therapy nurses completed a didactic and hands-on training course where they practiced ultrasound-guided SPC placement techniques on a poultry phantom during simulation, followed by performing ultrasound-guided SPC insertion on patients proctored by an interventional radiology physician. Data collection included preintervention and postintervention confidence self-assessment, frequency tracker, Difficult Intravenous Access (DIVA) scale scores, and total number of ultrasound-guided SPCs placed by the nurses. Ultrasound-guided SPC placement increased significantly after the training program. The IV therapy nurses placed 29 ultrasound-guided SPCs in 2017, 391 ultrasound-guided SPCs in 2018, and 711 ultrasound-guided SPCs in 2019. Mean DIVA scores rose from 4.54 in May 2018 to 5.17 in July 2018, indicating success in placing SPCs in more difficult patients. Implementation of an ultrasound-guided SPC placement program using poultry phantom simulation is a recommended nursing resource for increasing competency in ultrasound-guided SPC placement in pediatric patients.

Evaluation of the difficulty of peripheral venous cannulation during anesthesia induction in children: Is DIVA score sufficient?

The primary objective of the present study was to determine the rate and the independent predictors of the difficult peripheral intravascular access (PIVA) in the operating room (OR). The secondary objective was to validate the ability of the difficult intravenous access (DIVA) scoring system in the detection of difficult PIVA in the operating room. In this prospective observational study, patients between 0 and 18 years old who were operated in the pediatric hospital were evaluated. Peripheral intravenous cannulation performed during inhalation induction in 1008 patients were recorded. The following data were collected: demographic characteristics, the presence of a chronic disease, the DIVA score, operating room temperature, the area of PIVA application, the duration of PIVA and the number of PIVA attempts. The independent determinants of the difficult PIVA were determined with multivariate logistic regression. A total of 1008 patients (82% boys) with a median age of 4 (range 0.04-17 years) were included in the study. The median number of PIVA attempts was 1 whereas the median duration for successful PIVA was 15 s (range 4-2100). PIVA was successful at the first attempt in 75.3% of patients. Among patients who required more than two PIVA attempts, the most common adjunctive method was to seek help from another operator (80.8%). In the multivariable logistic regression model, only the presence of chronic disease, being underweight, and DIVA score ⩾4 (OR 6.355, CI 4.57-9.486) remained to be the significant determinants of difficult PIVA. The success rate of anesthesiologist-performed PIVA at the first attempt in the OR was 75.3%. Having a chronic disease, a DIVA score ⩾4 and being underweight appeared as the independent predictors for difficult PIVA.

Utility of the DIVA score for experienced emergency department technicians.

The DIVA score is validated for predicting success of the initial attempt at peripheral intravenous insertion by nurses and physicians. A score of 4 or greater is 50% to 60% likely to have a failed first attempt. The study objective was to assess the validity of this score for emergency department technicians. This study used a prospective convenience sample of 181 children presenting to the emergency department with intravenous access attempt by one of 29 emergency department technicians. DIVA score, total number of attempts, and median time to successful intravenous cannulation were obtained. Comparing patients with a DIVA score <4 to ≥4, first-time IV placement failure rates were lower (9% [95% CI, 3-24] vs. 41% [95% CI, 33-49]) and median time to IV placement was shorter (75 [interquartile range (IQR) 42-157] vs. 254 [IQR 91-806]) seconds. In patients with scores ≥4, emergency department technicians with ≥5 years of experience were significantly more likely to be successful on the first attempt (OR 2.8; 95% CI, 1.03-7.63). For every year of technician experience, the time to catheter placement, adjusted for DIVA score, decreased by 25 minutes (P≤0.05, R2=0.05). Comparing our receiver operating curve to the derivation study, the areas were similar (0.67 vs. 0.65). This study provides preliminary evidence for the validity of the DIVA score when applied to IVs placed by emergency department technicians. For patients with high DIVA scores, ≥5 years of IV experience was associated with higher odds of successful first-time IV placement and shorter time to placement. HIGHLIGHTS The difficult intravenous access (DIVA) score may be generalizable to IVs placed by experienced emergency department technicians (EDTs) Higher odds of first-time success in difficult patients with ≥5 years EDT experience Early identification of difficult access may allow for aid of alternative technology Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.

Difficult Peripheral Venous Access in Children: An International Survey and Critical Appraisal of Assessment Tools and Escalation Pathways.

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. 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. 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. 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. 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. 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.

The Efficacy of Near-Infrared Devices in Facilitating Peripheral Intravenous Access in Children: A Systematic Review and Subgroup Meta-Analysis

Peripheral intravenous access is a common and invasive procedure that is performed in pediatric clinical settings. Children often have difficult intravenous-access problems that may not only increase staff stress but also affect the timeliness of immediate treatments. To determine the efficacy of near-infrared devices in facilitating peripheral intravenous access in children, using a systematic review and meta-analysis. Six databases, namely the Index to Taiwan Periodical Literature System, Airiti Library, CINAHL, Cochrane Library, PubMed/MEDLINE, and ProQuest were searched for related articles that were published between the earliest year available and February 2017. The search was limited to studies on populations of children that used either a randomized controlled trial or controlled clinical trial approach and used the key words "near-infrared devices" AND "peripheral intravenous access." The 12 articles that met these criteria were included in the analysis. The Cochrane Collaboration bias assessment tool was used to assess the methodological quality. In addition, RevMan 5.3.5 software was used to conduct the meta-analysis. The near-infrared devices did not significantly improve the first-attempt success rate, number of attempts, or the procedural time of peripheral intravenous access in children. However, the subgroup analysis of difficult intravenous-access factors revealed a significant improvement in the first-attempt success rate of children with difficult intravenous access scores (OR = 1.83, p = .03). Near-infrared devices may improve the first-attempt success rate in children with difficult intravenous access by allowing healthcare professionals to visualize the peripheral veins. Therefore, we suggest that the difficult intravenous-access score be used as a screening tool to suggest when to apply near-infrared devices to children with difficult peripheral intravenous access in order to maximize efficacy of treatment.

Cross-cultural adaptation and content and semantic validation of the Difficult Intravenous Access Score for pediatric use in Brazil

ABSTRACTObjective:present the cross-cultural adaptation and content and semantic validation of the Difficult Intravenous Access Score for current use in Brazil. Method:cross-cultural adaptation and validation study, structured in six phases: initial translation, synthesis of translations, back-translation, assessment of documents by expert committee of specialized judges, pretest and presentation of the documents to the expert judges and to the author of the original instrument. Twenty health professionals were randomly recruited from a public hospital in the South of Brazil, working in pediatrics, in order to assess the agreement level with the variables in the instrument. In addition, a convenience sample of 30 pediatric patients was selected for the face validation of the same instrument. Cronbach’s alpha coefficient, simple and percentage frequencies, the Shapiro-Wilk and Fisher’s exact tests were used for the data analysis and reliability measures. Results:the cross-cultural adaptation phases were executed with totally clear translated variables, demonstrating satisfactory results in the content and semantic validation process. Conclusions:the Difficult Intravenous Access Score was adapted and its content and semantics were validated. External clinical validity, measuring equivalence and reproducibility analyses are needed.

Ultrasound guidance versus transillumination for peripheral intravenous cannulation in pediatric patients with difficult venous access

Objective Venous access can be technically difficult in pediatric patients because of the small size and impalpability of their veins. The aim of this prospective randomized study was to compare the use of ultrasound (US) guidance and transillumination as aids to facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access. Patients and methods We included 80 children, less than 6 years of age, undergoing elective surgery, and having difficult venous access as predicted by a Difficult Intravenous Access score of at least 4. The patients were randomized to either US guidance (the US group, n = 40) or transillumination using the Veinlite EMS (the Veinlite group, n = 40). Cannulation was performed after inhalation induction of anesthesia. The primary outcome measure was the first-attempt success rate of cannulation. The secondary outcome measures were the overall success rate of cannulation, number of attempts, and time required to achieve successful cannulation. Results The first-attempt success rate was significantly higher in the US group (82.5%) compared with the Veinlite group (57.5%, P Conclusion Both US guidance and transillumination facilitate peripheral intravenous cannulation in pediatric patients with difficult venous access, resulting in a high overall success rate of cannulation. US guidance is superior as it results in a higher first-attempt success rate with less time required to achieve successful cannulation compared with transillumination.

Validating the Difficult Intravenous Access Clinical Prediction Rule

This study aimed to evaluate the difficult intravenous access (DIVA) score, a clinical prediction rule, which states that children with a score of 4 or more will have a 50% higher rate of a failed intravenous placement on the first attempt compared with the mean failure rate. This was a prospective cohort study in children 0 to 14 years, undergoing peripheral intravenous placement by doctors in the emergency department of a medium-sized general hospital. Before intravenous placement attempts, demographic data inclusive of age and DIVA score were recorded. A maximum of 3 attempts per doctor were allowed, after which a more senior doctor undertook subsequent attempts. The site of successful placement was recorded. Five hundred children were enrolled. The male-female ratio was 1.3:1. One hundred thirty-three (26.6%) were less than 1 year, 103 (20.6%) were aged 1 to 2 years, and 264 (52.8%) were 3 years or older. One hundred ten children (22%) had a failed intravenous placement on the first attempt. Of the 151 children with a DIVA score of 4 or more, 57 (37.7%) had a failed intravenous placement, validating the clinical prediction rule. Only 5 subjects (1%) did not have intravenous placement after 6 attempts. This study validates DIVA score and provides a simple tool that can enhance the accuracy of the information offered to parents as it relates to the success rates of intravenous placement in children.

Efficacy of VeinViewer in pediatric peripheral intravenous access: a randomized controlled trial

Peripheral venous access in infants and children is technically challenging, because their veins are small and located deep in subcutaneous tissue, which makes them difficult to palpate or visualize. The VeinViewer® (Luminetx Corporation, Memphis, TN, USA) is a near-infrared light device that delineates the running course of subcutaneous veins. In this study, we investigated whether the use of the VeinViewer® in infants and children facilitated peripheral venous access, especially in difficult cases. This study was a randomized, controlled trial of a convenience sample of pediatric patients between the ages of 1 month and 16 years who required peripheral venous access in the pediatric ward. Prior to randomization, difficult intravenous access (DIVA) score, a four-variable clinical prediction rule for first-attempt success, was estimated. We compared the first-attempt success rates and procedural times between the VeinViewer® group and a control group. We evaluated 111 patients: 54 in the VeinViewer® group and 57 in the control group. Patient demographics and factors related to the success of vein access were similar for both groups. The overall first-attempt success rate was 69.4%: i.e., 77/111 in the VeinViewer® group and 38/57 in the control group, a difference that was not statistically significant. However, the first-attempt success rate increased from 5/20 in the control group to 14/24 in the VeinViewer® group for difficult veins with a DIVA score greater than 4 (p=0.026). There were no significant differences in procedural time between the two groups. The VeinViewer® facilitated peripheral venous access for pediatric patients with difficult veins, which enhanced first-attempt success rates.

Validation and Refinement of the Difficult Intravenous Access Score: A Clinical Prediction Rule for Identifying Children With Difficult Intravenous Access

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. 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. 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). 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.

AP072 VeinViewer-assisted peripheral venous access in pediatric patients: A randomized controlled trial

Background: Peripheral venipuncture in infants and children is technically challenging because their veins are small and located deep in the subcutaneous tissue which makes them difficult to palpate or visualize. In this study, we sought to determine if the use of the VeinViewer (Luminetx Corporation, Memphis, Tenn) in children facilitates peripheral venous access. Materials and Methods: This was a nonblinded, randomized controlled trial of a convenience sample of pediatric patients younger than 20 years old requiring intravenous access in the pediatric ward. Prior to the randomization, the DIVA (difficult intravenous access) score of 4-variable proportionally weighted rule (3 points for prematurity, 3 for younger than 1 year, 1 for 1–2 years of age, 2 for vein not palpable, and 2 for vein not visible) was estimated. We also decided vein categories (easy, intermediate and difficult) according to nurse opinion. Then patients were randomly allocated to undergo VeinViewer-assisted or standard peripheral venous access. Primary end point was the first-attempt success rate. Stepwise logistic regression analysis was used to identify factors associated with the first-attempt success. Results: A total of 111 patients were evaluated: 54 in the VeinViewer group and 57 in the traditional group. Patient demographics and factors related to the success of vein access were similar in both groups. Analysis by vein assessment category yielded a similar rate of successful first-attempt in both groups for easy veins. However, for difficult veins over DIVA score 4, first-attempt success rate increased from 25% in the traditional group to 58.3% in the VeinViewer group (p=0.026). Factors associated with the first-attempt success were patient age and type of delivery. Patient body mass index and the experience of nurse had no significant impact on the first-attempt success. Conclusion: The VeinViewer facilitates the peripheral venous access in pediatric patients with difficult veins enhancing the first-attempt success rate.