Derivation of the DIVA score - A clinical prediction rule for the identification of children with difficult intravenous access

Objective: To develop a clinical prediction rule that would be easy to apply and be useful for predicting success or failure of peripheral intravenous line insertion in children. Methods: This was a prospective cohort study of children aged 0 to 21 years undergoing peripheral intravenous placement by staff nurses in a pediatric emergency department. Information on candidate predictor variables was obtained before attempting intravenous placement, and the outcome was successful on first attempt. Backward stepwise logistic regression was used to identify factors independently predictive of success. Those factors remaining in the model were used in a set of linear scores. Receiver operating characteristic curves were constructed for each model, and the areas under the curve were calculated. Results: Six hundred fifteen subjects were enrolled. Success rate for intravenous insertion on first attempt was 75%. A 4-variable proportionally weighted rule (known as the difficult intravenous access [DIVA] score) was created (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). The area under the receiver operating characteristic curve was 0.67. Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt. Conclusions: A clinical prediction rule that is easy to apply and is useful for predicting success or failure of peripheral intravenous insertion has been created. If externally validated, this DIVA score can be used to predict which children will have difficult intravenous access.