Difficult Intravenous Access Research Articles

The Adult Difficult Intravenous Access (DIVA) Cognitive Aid: An Evidence-Based Cognitive Aid Prototype for Difficult Peripheral Venous Access.

Difficult intravenous access (DIVA) is common, with imperfect solutions. Cognitive aids are widespread in anaesthesia; however, a standard DIVA cognitive aid is lacking. This article describes a cognitive aid for DIVA. It has been developed using evidence-based techniques for DIVA. The effects of heuristics, biases, and automatic thinking on procedural decision-making are briefly discussed. While often useful, shortcut decision-making can impair the performance of apparently simple tasks. Cognitive aids may lead to better outcomes by providing choice architecture. This resource is intended as a cognitive aid prototype for difficult peripheral venous access, incorporating both modern behavioural psychology principles and evidence-based medicine. It may be used as both an educational tool, or as a cognitive aid to assist in situations where DIVA is encountered or expected. The adult DIVA cognitive aid is intended for use in both elective and emergency scenarios by practitioners adequately trained in ultrasound-guided or ultrasound-assisted vascular access and Seldinger-based techniques. Clinical implementation and audit of the adult DIVA cognitive aid, or similar locally developed cognitive aids based on this prototypeare recommended.

Micro-Stick to Rapid Infusion Catheter (RIC): Ultrasound-Guided Rapid Infusion Catheter Insertion Using a Micropuncture Kit.

Ultrasound-guidance improves success for difficult intravenous access (DIVA), particularly when difficulty is anticipated. However, insertion of a wide-bore sheath, such as a rapid infusion catheter, is likely to pose additional problems and unique challenges in this context, despite ultrasound guidance. With the aid of a video clinical simulation, this article describes an ultrasound-guided technique for inserting a proprietary rapid infusion catheter (RIC) or similar wide-bore sheath using the micropuncture kit.

Peripheral Insertion of Pediatric Central Venous Catheters in Adults with Difficult I.V. Access

BackgroundDifficult intravenous access is a frequent occurrence in critical care and emergency medicine. Prior intravenous access, chemotherapy use, and obesity are a few factors associated with difficult access. Alternatives to peripheral access are often contraindicated, not feasible, or not readily available. ObjectivesTo describe the feasibility and safety of peripheral insertion of peripherally inserted pediatric central venous catheters (PIPCVC) in a cohort of adult critical care patients with difficult intravenous access. MethodsProspective observational study of adult patients with difficult intravenous access who underwent peripheral insertion of pediatric PIPCVCs at a large university hospital. ResultsDuring a 1-year period, 46 patients were evaluated for PIPCVC; 40 catheters were placed successfully. The median age of the patients was 59 years (range 19–95 years) and 20 (50%) were female. The median body mass index was 27.2 (range 17.1–41.8). The basilic vein was accessed in 25/40 (63%) patients, the cephalic in 10/40 (25%), and the accessed vessel was missing in 5/40 (13%) cases. The PIPCVCs were in place for a median of 8 days (range 1–32). One superficial thrombosis and one deep occurred; pulmonary embolism did not occur. ConclusionsPIPCVC placement seems to be a feasible option in patients in whom peripheral intravenous access is difficult. The safety of this technique needs to be evaluated in prospective studies.

Midline catheters – what could be done better? A retrospective evaluation of clinical registry

Abstract Introduction. Midline catheters (MCs) are an option for vascular access alongside the commonly used short peripheral intravenous catheters, centrally and peripherally inserted central catheters. Aim. The aim of this study was to evaluate the solution implemented during the COVID-19 pandemic in a centre where MC access had not been used before. Material and method. It was an observational retrospective evaluation of the 98 medical registries of adult patients. Results. The mean time from hospital admission to midline catheter insertion was 15 days. The most common indications for the catheter implementation were: difficult intravenous access (83%) and expected time hospital stay >6 days (17%). The mean dwell time of the catheters was 9 days. The most common reasons for removal were: the end of intravenous therapy (44%) and catheter blockages (36%). Conclusions. A high level of prematurely removed catheters was observed, despite the existence of a hospital protocol. The high percentage of MCs removed before the end of intravenous therapy may be indicative of the poor quality of care and the need for continuous education of medical staff. The results obtained should be confi rmed in a prospective study planned on their basis in order to identify interventions which are necessary to improve the quality of vascular access care.

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.

The effects of ultrasound guidance on first-attempt success for difficult peripheral intravenous catheterization: a systematic review and meta-analysis.

Identifying patients at risk of difficult intravenous access (DIVA) and increasing the success rates of peripheral intravenous catheterization (PIVC), preferably on the first catheterization attempt, is of clinical importance. The aim of this study was to compare the use of dynamic ultrasound guidance for PIVC with the traditional technique of visualization and palpation in patients with predicted DIVA. A systematic review and meta-analysis comparing ultrasound-guided PIVC with the traditional technique was performed. Data were systematically collected through MEDLINE and EMBASE databases from inception to March 2021. Eligibility criteria included randomized controlled trials performed on patients meeting criteria for difficult catheterization comprising either (a) no palpable or visible veins, (b) previous history of difficult venous catheterization, (c) patient age less than 4 years, (d) suspicion of difficult catheterization by operator, or (e) two or more unsuccessful attempts using the traditional technique before enrollment were included. For all outcomes, a random-effects meta-analysis using the DerSimonian and Laird method was performed. The primary outcome was the first-attempt success rate, and the secondary outcomes were the overall success rate and the number of attempts for successful intravenous catheterization. Bias was assessed using the Revised Cochrane Risk of Bias tool. Seven studies with a total of 994 patients were included. Patients comprised both children and adults and settings included operating rooms, emergency departments, and intensive care units. Ultrasound guidance was associated with a higher first-attempt success rate (OR, 3.07; 95% CI, 1.66-5.65; P < 0.001). For the secondary outcomes, ultrasound guidance was associated with a higher overall success rate (OR, 3.02; 95% CI, 1.04-8.79; P = 0.04); however, this finding did not meet statistical significance in a sensitivity analysis (OR, 2.90; 95% CI, 0.71-11.93; P = 0.14). Ultrasound was not associated with a significantly different number of attempts compared with the traditional technique (difference in means, 0.14; 95% CI, -0.32 to 0.05; P = 0.15). The use of ultrasound guidance resulted in a three-fold increase in odds for the first-attempt success rate in patients with predicted DIVA compared with the traditional technique of PIVC.

HoloVein—Mixed-Reality Venipuncture Aid via Convolutional Neural Networks and Semi-Supervised Learning

Attaining venous access is a common requirement for clinical care worldwide, with a non-negligible portion of cases often being categorized as ‘difficult intravenous access’. Such complications result in far-reaching consequences affecting clinicians and patients alike. We propose a mixed-reality-based vein detection and visual guidance system that provides several key advantages, including a wider field of view, flexible operating distance, and hands-free, intuitive usage compared to existing solutions. A semi-supervised learning approach was used in model training to circumvent dataset availability limitations. Quantitative evaluation showed that the semi-supervised approach improved vein detection performance and temporal consistency. The system was also implemented and trialed in a clinical setting to assess real-world usability. Initial, preliminary assessment of HoloVein by medical professionals in a clinical setting showed improvements in detection quality using the semi-supervised approach over the baseline model. This result was deemed to be promising from a clinical perspective and could set the stage for more widespread mixed-reality venipuncture guidance tools in the future.

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.

Comparative Effectiveness, Efficiency, and ED Nurse Preference Between Two Methods of Visualization for Midline Catheter Insertion: A Pilot Study.

Rapid and reliable peripheral IV access is essential for many patients admitted to the emergency department (ED) to ensure administration of life-saving medications, and successful intravenous cannulation can significantly affect patient care. The objective of this study was to assess the impact of a continuous needle tracking system on the accuracy, speed, and quality of ultrasound-guided peripheral venous catheter insertions. A convenient sample study based on the study setting using simulated tissue was conducted with 49 US-based ED nurses to compare the insertion of a midline catheter using traditional ultrasound guidance versus an advanced needle-tracking technology along with ultrasound guidance. The purpose of this evaluation was to assess the impact of continuous needle tracking system. Informed consent was obtained from all individual participants involved in this study. All participants were made aware that the results may be published. There was no IRB approval for this study. All sources were properly disclosed within the text. The addition of the advanced needle-tracking technology significantly reduced total insertion attempts, insertion time, backwall penetrations, and redirects (probes to hit the target vein), while improving image clarity and confidence for participants. The innovative needle-tracking system evaluated in this pilot study has the potential to improve emergent difficult vascular access. EDs should assess the value of this technology to potentially improve the management of difficult intravenous access patients in their settings.

Improving Time to Stat Intravenous Antibiotic Administration: An 8-Year Quality Initiative.

Prompt antibiotics have been shown to improve outcomes in pediatric sepsis, which continues to be a leading cause of death in children. We describe the quality improvement (QI) efforts of a single academic children's hospital to improve antibiotic timeliness. Using the electronic health record, we report time from order to the administration of stat intravenous (IV) antibiotics from 2012 to 2020 using statistical process control charts. We describe QI interventions initiated over the study period. These include the formation of a Pediatric Sepsis Committee, routine use of automated dispensing machines for stat IV antibiotics, creation of sepsis order sets, manual and automated sepsis screening implementation, participation in national sepsis QI collaboratives, creation of difficult intravenous access guidelines, and an automated notification system for charge nurses. As a balancing measure, we assessed stat IV antibiotic use normalized to total emergency department visits and inpatient days. Multiple quality improvement interventions were initiated and sustained under the direction of the hospital Pediatric Sepsis Committee. We improved our stat IV antibiotics given within 1 hour of order from 33% in 2012 to 77% in 2019 and maintained this through the end of the study period in July 2020. By using a multipronged quality improvement approach, we demonstrated consistent and sustained improvement in the timely administration of stat IV antibiotics over an 8-year period at our institution. Further study is needed to assess whether this is associated with reduced length of stay or improved survival in children with sepsis.

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.

The case for implementing nurse-led vascular access service teams.

British Journal of NursingVol. 31, No. 19 CommentThe case for implementing nurse-led vascular access service teamsAndrew BartonAndrew Barton(E-mail Address: [email protected])Nurse Consultant IV Therapy and Vascular Access, Frimley Health NHS Foundation Trust, and Chair, NIVASSearch for more papers by this authorAndrew BartonPublished Online:28 Oct 2022https://doi.org/10.12968/bjon.2022.31.19.S6AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Barton A; for National Infusion and Vascular Access Society. The benefits of a nursing led vascular access service team: a white paper to outline a standardised structure and approach for the NHS to deliver vascular access services in every hospital, 2022. https://tinyurl.com/NIVAS-whitepaper-2022 (accessed 20 October 2022) Google ScholarCarr PJ, Moureau NL. Specialized vascular access teams. In: Moureau NL (ed). Vessel health and preservation: the right approach for vascular access. Cham, Switzerland: SpringerOpen; 2019 Crossref, Google ScholarGuerrero MA. National evaluation of safety peripheral intravenous catheters in a clinician-led project. Br J Nurs. 2019;28(2):S29-S32. https://doi.org/10.12968/bjon.2019.28.2.S29 Link, Google ScholarHamilton H, O'Byrne M, Nicholai L. Central lines inserted by clinical nurse specialists. Nurs Times. 1995;91(17):38–39 Medline, Google ScholarHarnage S. Seven years of zero central-line-associated bloodstream infections. Br J Nurs. 2012;21(21):S6-S12. https://doi.org/10.12968/bjon.2012.21.Sup21.S6 Link, Google ScholarHelm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015;38(3):189-203. https://doi.org/10.1097/NAN.0000000000000100 Crossref, Medline, Google ScholarJackson A, Coop S. Zero central-line infections in a 550-bedded district general hospital. Br J Nurs. 2012;21(14):S24, S26-S28. https://doi.org/10.12968/bjon.2012.21.Sup14.S24 Link, Google ScholarLoon FHJV, Puijn LAPM, Houterman S, Bouwman ARA. Development of the A-DIVA scale: a clinical predictive scale to identify difficult intravenous access in adult patients based on clinical observations. Medicine (Baltimore). 2016;95(16):e3428. https://doi.org/10.1097/MD.0000000000003428 Crossref, Medline, Google ScholarMoore A. Roundtable: ensuring safe vascular access. HSJ Guides. 2021. https://guides.hsj.co.uk/5921.guide (accessed 20 October 2022) Google Scholar FiguresReferencesRelatedDetails 27 October 2022Volume 31Issue 19ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 28 October 2022 Published in print 27 October 2022 Information© MA Healthcare LimitedPDF download

Use of point of care ultrasound (POCUS) by intensive care paramedics to achieve peripheral intravenous access in patients predicted to be difficult: An out-of-hospital pilot study

IntroductionIntravenous cannulation is a common procedure for paramedics. Difficulty is often encountered and may result in escalation of care to an intensive care paramedic (ICP). Ultrasound-guided peripheral intravenous access (USGPIVA) is used in-hospital as an alternative approach. Historically limited to physicians, it is increasingly embraced by non-physicians, with point of care ultrasound (POCUS) devices more affordable, portable, and suited to the out of hospital environment. ObjectiveTo explore the utility of ICP-performed USGPIVA for patients who are predicted to be difficult according to a difficult intravenous access scoring tool. MethodsThis was a prospective observational pilot study of ICPs who used the adult difficult intravenous access (A-DIVA) scale to predict difficulty and perform USGPIVA using a contemporary POCUS device. ResultsFor the 32 patients enroled, the overall success rate was 50% of which 87% were successful on the first attempt. Mean A-DIVA score was 4.1/5, and paradoxically, success improved with A-DIVA-predicted difficulty. ConclusionICPs can perform USGPIVA with moderate success. The A-DIVA score could be useful for paramedics to predict difficult cannulation. Future research should focus on increasing exposure, training time and enhancing feedback to paramedics performing USGPIVA.

External Validation of the Difficult Intravenous Access (DIVA3) Score as a Clinical Predictive Rule for Identifying Difficult Intravenous Access in Children

External Validation of the Difficult Intravenous Access (DIVA3) Score as a Clinical Predictive Rule for Identifying Difficult Intravenous Access in Children

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.

PEDIATRIC AND MEDICINE RESIDENTS’ PERCEPTIONS OF ULTRASOUND VASCULAR ACCESS AND RESULTS OF AN INTERSPECIALTY, SIMULATION-BASED ULTRASOUND VASCULAR ACCESS WORKSHOP

PEDIATRIC AND MEDICINE RESIDENTS’ PERCEPTIONS OF ULTRASOUND VASCULAR ACCESS AND RESULTS OF AN INTERSPECIALTY, SIMULATION-BASED ULTRASOUND VASCULAR ACCESS WORKSHOP

Remotely supervised ultrasound-guided peripheral intravenous cannulation training: A prospective cohort study examining success rates and patient experience.

Ultrasound-guided peripheral intravenous cannulation (USGPIVC) benefits patients with difficult intravenous access (DIVA) through visualising otherwise non-visible and non-palpable veins. Supervised live-case training is an important component of learning this skill, but supervisor availability can present a barrier limiting or delaying staff completing their training. The aim of this study was to determine the first-attempt success rate of newly trained USGPIVC inserters using remote supervision and timely written feedback based on app-based screen recordings taken during insertion. Secondary aims were overall procedural success, and inserter and patient experiences. This study is an observational cohort study carried out between October and December 2021. Fourteen newly trained junior medical officers (JMOs) were eligible to utilise USGPIVC on a minimum of five consenting patients while simultaneously recording the ultrasound screen during insertion to capture their technique. Feedback was generated following expert review of these recordings against a standardised feedback tool. Average first-attempt success was 71% (n = 72) in the 102 patients recruited. The average time for JMOs to receive feedback was 30 h, and 13 JMOs (93%) felt well supported and completed the remote training pathway. The majority of patients were female (n = 59; 58%), were aged 41-80 years (n = 75; 74%) and had ≥2 risk factors for DIVA (n = 57; 56%). First-attempt success rates were similar when comparing remote supervision used in this study to direct supervision used by other studies.This finding supports incorporating remote supervision into training guidelines for USGPIVC as an alternative method of supervision, particularly when supervisor availability is limited.

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data.

Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity. This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival. Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02). This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

Evaluation Factors Affect Difficult Intravenous Access in the Prehospital Setting

Background: Environmental factors such as the lighting of the scene, time of the day, and physical surrounding of the patient and healthcare providers in the prehospital setting can affect difficult intravenous access (DIVA). The study aimed to evaluate the association of environment, patient, and emergency medical services (EMS) technicians on the DIVA in the prehospital setting.&#x0D; Methods: Six-hundred adult patients (aged ≥18 years) who necessitated prehospital peripheral IV access and were transferred to the Sina and Shariati hospitals by EMS technicians from June 2018 to October 2018 were included. There were seven research nurses for interviewing the EMS technicians. Patients were examined using the prepared checklists.&#x0D; Results: Overall, there were 125 (20.83%) DIVA cases. There was a significant relationship between DIVA and the higher respiratory rate of the patients, lower the blood pressure of the patient, prior cannulation of the targeted limb, time since the last meal of EMS technician, and untidiness of the environment (Odds Ratio=1.75, 1.3, 9.4, 3.84 and 7.01, respectively).&#x0D; Conclusion: The results showed fasting of EMS technicians affects DIVA and the study suggests it can be resolved by proper scheduling of the working hours of EMS technicians. Also, some risk factors of DIVA can help the paramedics to predict the DIVA and take the necessary measures.