Article Text

Download PDFPDF
External validation of the DIVA and DIVA3 clinical predictive rules to identify difficult intravenous access in paediatric patients
  1. Cristian Girotto1,
  2. Marta Arpone2,
  3. Anna Chiara Frigo3,
  4. Matteo Micheletto2,
  5. Alessandro Mazza1,2,
  6. Liviana Da Dalt1,2,
  7. Silvia Bressan1,2
  1. 1 Division of Paediatric Emergency Medicine, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
  2. 2 Department of Women's and Children's Health, University of Padova, Padova, Italy
  3. 3 Biostatics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
  1. Correspondence to Dr Silvia Bressan, Department of Women's and Children's Health, University of Padova, Padova 35128, Italy; silviabress{at}


Background Intravenous (IV) peripheral access is often a difficult procedure in the paediatric ED, causing pain and significant distress. Clinical prediction tools including reproducible variables have been developed to help clinicians identify children at risk of difficult IV access, likely to need additional resources/interventions to maximise success at first attempt. We aimed to externally validate the Difficult IntraVenous Access (DIVA) and DIVA3 scores developed for this purpose.

Methods Cross-sectional study of children undergoing IV cannulation by nurses in a tertiary-care paediatric ED. Data were collected at the time of the procedure in a clinical report form.

Results Of 440 children included (56.8% males; median age 4.7 years (IQR 1.5–9.5)), 23.4% had a difficult IV access (defined as requiring >1 attempt). Diagnostic accuracy measures for a DIVA cut-off ≥4 and their 95% CIs were sensitivity 24.3% (16.4% to 33.7%), specificity 92.6% (89.2% to 95.1%), positive and negative predictive value 50.0% (35.3% to 64.5%) and 80.0% (75.7% to 83.9%), respectively. The same measures for the DIVA3 were 22.3% (14.7% to 31.6%), 93.5% (90.3% to 95.9%), 51.1% (35.8% to 66.3%) and 79.8% (75.4% to 83.6%). The area under the receiver operating characteristic curve was 0.652 (95% CI 0.591 to 0.712) for the DIVA and 0.649 (95% CI 0.589 to 0.709) for the DIVA3 score. In patients with DIVA and DIVA3 <4, nurses’ prediction of greater difficulty in IV placement and moderate/severe dehydration were common independent predictors of difficult IV at multivariate analysis. Only nurses’ prediction of greater difficulty in IV placement were associated with higher odds of difficult cannulation for both DIVA/DIVA3 scores ≥4.

Conclusion We externally validated the DIVA and DIVA3 showing a similar accuracy compared with the DIVA derivation cohort and between DIVA and DIVA3. We identified factors that can help refine further the risk of difficult IV access and support decision making on the best strategy to maximise the chances of cannulation success on first attempt.

  • paediatrics
  • emergency department
  • children
  • Difficult IV access
  • clinical practice

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Handling editor Gene Yong-Kwang Ong

  • Contributors CG conceived and designed the study, contributed to data collection and drafting of the manuscript; MA supported the drafting of the manuscript, contributed to data analysis and critically revised the manuscript; ACF contributed to the study design, carried out the statistical analysis and critically revised the manuscript; MM contributed to data collection, entered the data into the electronic database and critically revised the manuscript; AM critically revised the manuscript; LDD contributed to the study design and critically revised the manuscript; SB conceived and designed the study, supervised data collection, contributed to data analysis, and drafted and critically revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The use of de-identified data for the present study was approved by the hospital ethics committee (protocol 35732/2019) with waiver for written informed consent from patients and their caregivers.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Should readers wish further details on any results, these can be obtained by contacting the corresponding author.