Division of Emergency and Urgent Care, The Children's Mercy Hospital, Kansas City, MO, USA.
Acad Emerg Med. 2011 Nov;18(11):1129-34. doi: 10.1111/j.1553-2712.2011.01205.x.
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.
困难静脉穿刺（DIVA）评分是一种比例加权的四变量（静脉可触性、静脉可见性、患者年龄和早产儿病史）临床规则，用于预测儿童静脉（IV）置管失败。本研究旨在对 DIVA 评分进行外部验证和改进。
纳入在儿科急诊室（ED）由儿科护士进行外周静脉置管的患者。感兴趣的结局定义为首次尝试置管失败。提出的改进预测变量包括新生儿重症监护病房（NICU）住院史、操作人员经验特征（毕业年限、儿科护理经验年限和每月开始的 IV 数量）和皮肤色调。使用逻辑回归构建调整后的多变量模型。为每个模型构建接收者操作特征（ROC）曲线并计算曲线下面积（AUC）。
共纳入 366 名患者（平均年龄=5.4 岁，标准差±5.6 岁），其中 118 名（32.2%）患者首次 IV 尝试失败。在本数据集测试的原始四变量模型的 AUC 为 0.72（95%置信区间[CI]为 0.67 至 0.78）。DIVA 评分≥4 分的患者首次 IV 尝试失败的可能性超过 50%。评估了一种三变量规则（静脉可触性、静脉可见性和患者年龄），发现其具有相似的鉴别能力（AUC=0.72，95%CI=0.67 至 0.78）。
本研究验证了先前推导的四变量 DIVA 评分。一种更简单的三变量规则与四变量规则一样，可以预测首次尝试 IV 置管失败。需要在非儿科 ED 中进行验证，以充分评估其普遍性。
