Implementation of the enhanced adult DIVA score in an emergency department: A prospective observational study

Background: Short peripheral catheter (SPC) placement is a routine invasive procedure in clinical settings that is crucial for administering fluids, medications, or blood components. Approximately 11% of adult patients arriving at the Emergency Department (ED) experience difficulties with intravenous access (DIVA), necessitating advanced techniques for successful placement. The Enhanced Adult DIVA (EA-DIVA) score serves as a validated tool to promptly identify patients with DIVA. This study aimed to determine the prevalence of DIVA in the ED by using the EA-DIVA scale, evaluate the time required for venous cannulation in patients with and without DIVA, and establish EA-DIVA score thresholds for the adoption of ultrasound-guided techniques. Methods: This prospective observational study was conducted from May 2023 to January 2024 at the ED of Empoli Hospital, Italy. This study focused on adult patients requiring SPC placement. The nursing staff at the ED performed SPC placements using standard techniques according to clinical protocols. Results: Among 1280 patients, 29.22% required more than one attempt at cannulation independently from their EA-DIVA score, with 12.58% scoring an EA-DIVA of 8 or higher. The time and attempts needed for successful cannulation increased with higher EA-DIVA scores, and ultrasound-guided techniques were more time-consuming but beneficial for these patients. An optimal threshold of 6 on the EA-DIVA scale balanced high sensitivity (96.52%) and specificity (81.37%) for identifying patients who would benefit from ultrasound guidance, minimizing failed attempts and optimizing resource use. Conclusion: The EA-DIVA scale, originally validated in a preoperative setting, was effectively implemented for the first time in the ED. This study established a lower cutoff score for expert intervention utilizing ultrasound guidance compared with previous applications of the EA-DIVA scale. Further validation across diverse clinical settings and among healthcare providers with varying expertise in vascular access is necessary to confirm these findings and broaden their applicability.