Abstract:
Background: Peripheral intravenous catheter (PIVC) insertion is routine in emergency care, but first-attempt success can be challenging, especially in patients with difficult intravenous access (DIVA). Multiple insertion attempts in patients with DIVA can cause pain and lead to delays in care.
Objectives: The Emergency Nurses Association (ENA) recommends standardizing how DIVA is identified and subsequently using ultrasound-guided PIVC (USGPIV) insertion methods to improve DIVA identification and first-attempt success rates. Our project addressed the question: To what degree will the implementation of the ENA’s Clinical Practice Guideline for Difficult Venous Access to identify DIVA patients and use USGPIV insertion impact the identification of DIVA patients and first-attempt success rates for PIVC cannulation among adult patients in an emergency department in Maine?
Methods: The project employed a quality improvement approach. Educational materials were developed using the ENA’s Clinical Practice Guideline for Difficult Intravenous Access and the validated A-DIVA scale. The training program incorporated didactic sessions, hands-on skills laboratories, and mentored clinical insertions using a simulation-based mastery learning approach. Eight education sessions were held to cover all staff and foster proficiency, enhance clinical decision-making, and promote consistent application of the USGPIV technique across the entire team.
Results: During the comparison period, 1197 PIVC insertion attempts were documented; in the implementation period, 1254 attempts were recorded, with no patient contributing more than 1 encounter. Comparative data show that 4 of 1197 attempts (0.3%) were flagged as DIVA and 955 of 1197 attempts (79.8%) were successful on the first attempt. After guideline implementation, 564 of 1254 attempts (45%) were identified as DIVA, and 1075 of 1254 attempts (85.7%) were successful on the first attempt. A χ2 test of independence revealed a statistically significant association between guideline implementation and DIVA identification, χ2(1, N = 2451) = 685.5, P = 0.001. A second χ2 test demonstrated a significant relationship between implementation status and first-attempt success, χ2(1, N = 2451) = 15.2, P = 0.001, corresponding to a 5.9-percentage-point absolute improvement. No outliers were detected, and expected cell counts for both analyses exceeded the minimum threshold.
Conclusions: The statistically significant improvements in DIVA identification and first-attempt success rates support integrating the ENA guidelines into rural emergency care.
Reference:Hotchkiss, J. B. et al. (2026) ‘Using Ultrasound Guidance for Difficult Venous Access in the Emergency Department,’ Journal of the Association for Vascular Access, 31(2), pp. 12–17. Available at: https://doi.org/10.2309/1557-1289-31.2.12 (Accessed: 11 July 2026).