Securing vascular access is a routine but critical step in patient care. For many, it’s straightforward. For others, it can become a source of anxiety, repeated attempts, delays in treatment and, ultimately, poorer outcomes. These patients fall into a group widely referred to as Difficult Intravenous Access (DIVA)[1]
It is important for clinicians to understand who these patients are, why they are difficult to cannulate and what techniques improve success rates is help them deliver safer, more comfortable care.
What Does DIVA Mean?
DIVA describes patients for whom achieving successful peripheral IV cannulation is significantly more challenging due to factors relating to their anatomy, physiology or clinical condition.[2] DIVA is not one patient type, it’s an umbrella term covering several groups, each with unique requirements.
Patients may be considered DIVA if:
- Peripheral veins are not visible or palpable²
- Previous attempts have failed (often multiple times)²
- Access requires adjuncts, escalation or specialist intervention²
- Their clinical needs demand more durable or alternative access options[3]
Why Identifying DIVA Patients Early Matters
Early recognition of a DIVA patient helps clinicians:
✅ Reduce the number of painful and unnecessary cannulation attempts²
✅ Improve first‑time success rates²
✅ Reduce procedural delays and escalation²
✅ Select the right device first time[4]
✅ Improve the patient and family experience²
✅ Preserve valuable veins for future care[5]
It is therefore important to place emphasis on good decision‑making, reducing pain and improving patient outcomes.[6]
Types of DIVA Patients
Below is an overview of the most commonly recognised DIVA groups, what makes them challenging and what clinicians can consider when planning vascular access.
Paediatric Patients (Difficult Venous Access in Children, DVAC)
Children represent one of the most significant DIVA populations. Their veins are small, mobile and easily damaged. Anxiety from both the child and the parents can compound the difficulty in placing a line.[7]
Key challenges:
- Tiny, fragile veins⁷
- High fear response and movement⁶
- Limited tolerance for repeated attempts⁶
- Clinical urgency in some cases (e.g., sepsis, dehydration)⁶
Best practice considerations:
- Skilled, experienced operators⁶
- Child‑friendly explanation and communication⁶
- Ultrasound guidance when appropriate⁶
- Minimising the number of attempts⁶
- Correct device choice e.g. cannula, midline, or intraosseous in emergencies⁶
This is exactly the gap addressed by Sean O’Donnell’s Difficult Vascular Access in Children (DVAC) course, which focuses on practical skills, ultrasound proficiency, decision‑making and communication strategies to limit trauma and improve care.⁶,⁷
Patients with Chronic Illness or Frequent Access Requirements
Patients undergoing repeated treatments such as chemotherapy, long-term antibiotics, renal failure management or chronic conditions, may have:
- Scarred or thrombosed veins⁵
- Previously failed cannulation attempts⁵
- Central lines, ports or midlines in place⁵
- Limited peripheral veins due to repeated use⁵
Planning:
- Assess for durable devices early⁵
- Avoid over‑using fragile veins⁵
- Consider midlines, PICCs or ports depending on therapy duration⁵
- Follow “right line, right time” principles⁴
Older Adults and Frail Patients
Ageing changes the vascular landscape, see below the potential challenges and considerations for this patient population[8]
Challenges:
- Veins that are fragile, sclerosed or prone to “blowing”
- Loss of subcutaneous fat making veins mobile
- Comorbidities including dehydration, oedema or peripheral vascular disease
Considerations:
- Using warm packs or ultrasound to improve visualisation
- Choosing smaller gauge devices
- Avoiding areas of compromised skin
- Employing gentle technique to reduce trauma
Patients with Higher BMI
For patients with obesity, peripheral veins can be deep and poorly palpable. Strategies include2:
- Ultrasound guidance
- Longer cannula lengths
- Selecting alternative vein sites (upper arm, cephalic, basilic)
- Positioning to maximise venous return
Patients with a History of IV Drug Use
These patients may present with2:
- Scarred, collapsed or thrombosed veins
- Infection risk
- Venous access in unconventional or high‑risk sites
Management requires2:
- Thorough assessment
- Safety‑first decision‑making
- Consideration of alternative access devices
The Role of Ultrasound in DIVA Patients
Ultrasound guidance is one of the most impactful tools in improving DIVA patient care, as highlighted in the Campus Vygon article on ultrasound‑guided vascular access[9].
Benefits include:
- Reduced number of attempts
- Higher first‑time success
- Better vein selection
- Lower complications
- Improved patient satisfaction
Read more about the role of Ultrasound-Guided Vascular Access and how it is transforming care: https://campusvygon.com/uk/vascular-access/illuminating-the-path-to-better-patient-outcomes-how-ultrasound-guided-vascular-access-is-transforming-care/
DIVA Support Tools: DIVA Bands
Some Trusts, for example, Gloucestershire Hospitals NHS Foundation Trust, have introduced DIVA alert wristbands to help identify patients with known difficult access early in their care journey[10]. These bands help clinicians:
- Prevent unnecessary attempts
- Trigger escalation pathways
- Ensure the right staff and equipment are used
- Protect patient wellbeing
Education Matters
The DVAC programme, led by paediatric registrar Sean O’Donnell and supported by Vygon UK, is a national example of how structured training reduces failed attempts and improves the overall experience for patients, families and staff.⁶
The course teaches:
- Difficult cannulation
- Portacath access
- Ultrasound-guided access
- Intraosseous techniques
- Troubleshooting central lines
- Device selection
- Communication strategies
As Sean frequently emphasises, technical skill is only part of the answer. Managing frightened children and anxious families is equally vital.⁶
Conclusion: Getting The Right Vein, Right Line, First Time
Whether encountering a frightened child, a frail older adult or a patient with complex clinical needs, DIVA challenges demand:
- Strong assessment²
- The correct device⁴
- Skilled operators⁶
- Ultrasound when needed9
- Compassionate communication⁶
Every successful first attempt is a win for the patient, the family and the clinical team. It is therefore important for clinicians to build their confidence and competence needed to deliver “right vein, right line, first time” care.
References
[1] Doellman D., Wuerz L., et al. Difficult IV Access (DIVA) Position Paper, AVA, 2025.
[2] Bahl A., Johnson S., et al. Defining Difficult Intravenous Access (DIVA): A Systematic Review, Journal of Vascular Access, 2021.
[3] Bell J., Campos C., Moureau N. Comprehensive Difficult IV Access (C‑DIVA) Tool Validation, 2023.
[4] Ascension Health. DIVA Pathway – Device Selection Guidance, 2021.
[5] CNSA. Patients with Difficult Intravenous Access – Vessel Health & Preservation, 2024.
[6] DVAC YouTube Channel – Difficult Vascular Access in Children Course Overview.
[7] DREEAM Nottingham. DVAC Course Description and Curriculum.
[8] Neonatal vascular access guidelines (CNSA & related sources).
[9] Campus Vygon. Ultrasound Guided Vascular Access – Improving Patient Outcomes.
[10] Vygon UK & Gloucestershire Hospitals NHS Trust. DIVA Wristband Programme, 2025
