Difficult IV Access (DIVA): Strategies and Solutions for Insertion Success Position Paper

ABSTRACT Peripheral intravenous catheter (PIVC) insertion is among the most common hospital procedures worldwide, yet first-attempt success rates remain inconsistent. Difficult intravenous access (DIVA), defined as two or more failed attempts combined with non-visible or non-palpable veins or a history of difficult access, is linked to treatment delays, vessel trauma, patient anxiety, and higher costs of care. Patients at greatest risk include those with obesity, chronic illness, prior DIVA, intravenous drug use, and advanced age. The impact of DIVA extends beyond procedural challenges. Repeated failures contribute to unnecessary central line use, increased supply consumption, and diminished patient trust, while also influencing hospital performance metrics tied to patient experience and reimbursement. Evidence supports early identification of at-risk patients and structured intervention as key to improving outcomes. Risk assessment tools, escalation pathways, and vein visualization technologies such as ultrasound and near-infrared imaging improve first attempt success and reduce complications. Longer PIVCs and midline catheters further support vessel preservation in appropriate patients. This position paper, endorsed by the Association for Vascular Access (AVA) outlines the scope and consequences of DIVA in hospitalized adult populations and proposes a comprehensive, evidence-based framework to support earlier recognition and more effective vascular access planning. Key strategies include use of validated risk assessment tools, structured escalation pathways, vein visualization technologies such as ultrasound, and device selection guided by vessel health and preservation principles. The paper also emphasizes the importance of patient-centered communication, clinician education and competency validation, and integration of documentation and clinical decision support tools within the electronic medical record. Together, these practices aim to improve first-attempt success, preserve vascular access sites, enhance patient experience, reduce complications, and promote more efficient use of healthcare resources. Implementing a standardized approach to DIVA supports both safer clinical care and better patient outcomes.