Validation and Refinement of the Difficult Intravenous Access Score: A Clinical Prediction Rule for Identifying Children With Difficult Intravenous Access
ACADEMIC EMERGENCY MEDICINE 2011; 18:1129–1134 © 2011 by the Society for Academic Emergency Medicine Abstract
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.
Methods: 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.
Results: 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).
Conclusions: 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.
Document Type: Research Article
From the Division of Emergency and Urgent Care (MWR, CK, MDD), Emergency Room Education (BSW), The Children’s Mercy Hospital, Kansas City, MO; and the Medical College of Wisconsin, Section of Emergency Medicine and the Children’s
Research Institute, Children’s Hospital and Health System (KY), Milwaukee, WI.
From the Division of Emergency and Urgent Care (MWR, CK, MDD), Emergency Room Education (BSW), The Children’s Mercy Hospital, Kansas City, MO; and the Medical College of Wisconsin, Section of Emergency Medicine and the Children’s Research
Institute, Children’s Hospital and Health System (KY), Milwaukee, WI.
Publication date: November 1, 2011