diva in the ed
Evidence Spotlight: A Nurse-Driven Approach to Difficult IV Access in the Emergency Department
Peripheral intravenous catheter placement is one of the most common procedures performed in emergency care, yet it can become a major source of pain, delay, and frustration when patients have difficult intravenous access, or DIVA.
A recent quality-improvement project published in the Journal of the Association for Vascular Access examined whether a structured DIVA screening process, combined with nurse-performed ultrasound-guided peripheral IV placement, could improve outcomes in a rural emergency department. The results offer a practical model for emergency departments seeking to reduce repeated insertion attempts and strengthen vascular access practice.
Why This Study Matters
Patients with DIVA are more likely to experience multiple unsuccessful insertion attempts, delays in treatment, increased discomfort, and escalation to more invasive forms of vascular access.
At the project site, DIVA was traditionally identified only after multiple failed attempts by different nurses. This reactive approach meant patients often endured repeated needlesticks before ultrasound guidance or another escalation strategy was considered.
The project team replaced that process with earlier identification using the validated A-DIVA scale and a standardized pathway for ultrasound-guided peripheral IV insertion.
What the Team Implemented
The project took place in a rural critical access emergency department in Maine. Adult patients requiring peripheral IV access were assessed using the A-DIVA scale during the implementation period.
Patients who scored 4 or 5 were considered eligible for ultrasound-guided peripheral IV placement. Patients with lower scores continued through the traditional cannulation pathway.
To support the new workflow, staff completed a three-hour training program that included:
Didactic instruction
Hands-on skills laboratories
Mentored clinical insertions
Simulation-based mastery learning
Education on the ENA Clinical Practice Guideline for Difficult Intravenous Access
Eight training sessions were offered across morning and evening schedules so that both day- and night-shift staff could participate.
This detail is important. The intervention was not simply the introduction of an ultrasound machine. It combined structured patient assessment, staff education, competency development, documentation, and clinical escalation.
Key Findings
The researchers compared 1,197 peripheral IV insertion encounters before implementation with 1,254 encounters after implementation.
Before the new protocol, only 0.3% of encounters were identified as DIVA. Following implementation of the A-DIVA screening process, 45% were identified as DIVA.
First-attempt success also improved:
Before implementation: 79.8%
After implementation: 85.7%
That represents a 5.9-percentage-point absolute improvement. The authors reported that the odds of first-attempt success were 1.51 times higher after implementation, with a number needed to treat of 17.
In practical terms, the project demonstrated that earlier identification and appropriate escalation could improve first-attempt success while reducing unnecessary repeated attempts.
The Bigger Lesson: Ultrasound Training Needs a System
One of the strongest lessons from this project is that ultrasound-guided IV placement should not be treated as an isolated technical skill.
Successful implementation requires a complete clinical system:
Identify patients at risk before repeated failures occur.
Establish a clear escalation pathway.
Train clinicians using both didactic and hands-on instruction.
Validate competency.
Document outcomes.
Audit adherence and provide continued support.
This is especially relevant in emergency departments, where competing priorities and time pressure can make new practices difficult to sustain. A well-designed protocol reduces ambiguity and helps nurses know when ultrasound guidance should be used.
The project also reinforces the value of nurse autonomy. When nurses are equipped with validated assessment tools and competency-based ultrasound training, they can take a more proactive role in managing difficult vascular access.
Limitations to Consider
The authors identified several limitations.
The implementation period lasted only eight weeks, so the project did not evaluate long-term outcomes such as catheter dwell time, complication rates, or sustained adherence.
Documentation was completed manually, and compliance varied between shifts. The project was also conducted in a rural emergency department serving a predominantly White population, which may limit how broadly the results can be applied to larger or more diverse health systems.
Resistance to practice change and the demands of a busy emergency environment were additional barriers.
These limitations do not erase the improvement seen in first-attempt success, but they highlight the importance of ongoing education, leadership support, workflow integration, and data monitoring.
Practice Takeaway
The central message is straightforward:
Difficult IV access should be identified early, not only after repeated failed attempts.
Combining a standardized DIVA assessment with nurse-performed ultrasound-guided IV placement can improve first-attempt success, reduce patient discomfort, support more efficient care, and strengthen nursing practice.
For organizations developing an ultrasound-guided vascular access program, the evidence supports moving beyond informal training. The strongest programs pair hands-on technical education with clear escalation criteria, competency validation, and measurable clinical outcomes.
Evidence Spotlight Source
Hotchkiss JB, DiFilippo MB, Campos C, Dickson M. Using Ultrasound Guidance for Difficult Venous Access in the Emergency Department. Journal of the Association for Vascular Access. 2026;31(2):12–17. doi:10.2309/JAVA-D-26-00003.
