604 - Improving Pediatric Peripheral IV Access through a Learning Team and DIVA Scoring System at a Children’s Hospital

Publication Number: 2589.604

Weijen W. Chang, Baystate Children's Hospital, Longmeadow, MA, United States; Lauren Sweetser, Baystate Children's Hospital, Springfield, MA, United States; Shannon Rowland, Baystate Children's Hospital, East Longmeadow, MA, United States

Background: Obtaining peripheral IV (PIV) access in children is challenging due to patient anatomy, distress, and limited specialized staff. At our children's hospital, frontline nurses raised concerns about repeated IV attempts, lack of standard escalation processes, and absence of a pediatric vascular access protocol. Using the Solutions for Patient Safety (SPS) Learning Team framework, a multidisciplinary group initiated a quality improvement (QI) project to quantify the problem, design system-wide interventions, and reduce patient harm.

Objective: Our SMART aim is to reduce the mean number of peripheral IV attempts per patient by 20% (from 1.63 to ≤ 1.3) by June 2025 through implementation of a Difficult IV Access (DIVA) scoring tool, standardized pediatric IV access guideline, and escalation algorithm.

Design/Methods: Baseline data were collected over a two-month period (April-May 2024) using a bedside PIV tracker across all pediatric units, capturing age, unit, number of attempts, and success rate. A standardized IV access guideline incorporating DIVA scoring and an escalation pathway was developed. Educational modules and visual job aids were deployed to nursing and resident teams. Run-chart analysis (Figure 3) was used to identify variation in mean sticks per patient by unit (PICU, CHAD, ED) and by age group (≤ 2 years vs. 3-21 years). The 2025 pilot phase is focused on adherence to DIVA documentation, algorithm use, and ultrasound-guided IV access. Process measures include DIVA documentation rate, algorithm adherence, and ultrasound utilization. The outcome measure is the mean number of sticks per patient; the balancing measure is staff time away from their primary unit assisting with IV placement.

Results: Baseline analysis included 777 patients requiring 1,010 IVs and 1,266 attempts (mean 1.63 sticks/patient), primarily in the inpatient unit and pediatric ED (Figure 1). Patients ≤ 2 years required 2.1 attempts compared with 1.4 for those aged 3-21 years (p < 0.00001). Six percent of patients required ≥ 4 attempts, and 0.5% required > 10. Approximately 5% of IV placements required cross-unit support, resulting in 10-20 minutes away from their home units, primarily the PICU (Figure 2). Thirty nurses and eight residents completed ultrasound-guided IV training in preparation for guideline implementation.

Conclusion(s): Pediatric patients-especially those under 2 years-experience multiple IV attempts, and cross-unit resource use is frequent. This learning team-led evaluation provides the foundation for implementing a Difficult IV Access (DIVA) scoring system and guideline, currently being piloted in 2025.

Figure 1: Breakdown of PIV attempts by unit
NICU=neonatal intensive care unit
PICU=pediatric intensive care unit
Pedi ED=pediatric emergency dpartment
CHAD=children's and adolescent inpatient unit

Figure 2: Original unit from where additional staff resources were pulled for IV placement
Pedi ED=pediatric emergency department
PPU=pediatric procedure unit
NICU=neonatal intensive care unit
VAST=vascular access service team (for children>2 years of age)
PICU=pediatric intensive care unit

Figure 3: Number of sticks per patient by week in each unit during baseline period