Commentary: Validity and reliability of the Turkish version of the Difficult Intravenous Access Scale for adult patients

I’m sure most of us have at some point experienced having a cannula inserted into our arm. Many of us may insert these devices as part of our routine work. As the authors of this article explain, peripheral intravenous catheter (PIVC) insertion is one of the most common invasive procedures carried out in hospital. However, despite its routine nature, the procedure is associated with a high failure rate. This can be due to a number of clinical and demographic factors, and individuals at increased risk of failure are said to have Difficult Intravenous Access (DIVA). Failure to insert the cannula on the first attempt is not only inconvenient, but it can also lead to complications, which may compromise treatment, lead to pain and anxiety for the patient and have financial implications for healthcare organisations.

Amid calls for the prospective identification of individuals with DIVA, van Loon et al. (2019) developed and validated the A-DIVA scale, which stratifies individuals into risk groups using easily obtainable clinical data. Identifying high-risk patients prospectively allows for action to be taken to increase the chance of successful first-time insertion and reduce the risk of negative outcomes associated with insertion failure. The original scale was developed in the Netherlands, and it has been subsequently adapted for use in Portugal (Santos-Costa et al., 2020). The current study aims to validate the use of this scale in Turkey.

The authors are very thorough in their analysis, using a range of statistical tests to establish validity and reliability of the scale. The study setting (Emergency Department) is likely to be the reason for the high percentage of patients classified as high risk (73% compared with 10% in van Loon et al.’s 2019 study). Those individuals placed in the high-risk group had a much lower first-time success rate, reinforcing the importance of evaluating vein structure before attempting to insert a PIVC. That said, the first-time success rate in the moderate-risk group was also low at 48%. Thus, although this tool will be valuable in allowing healthcare professionals to prospectively identify patients with DIVA, there must also be a focus on improving practice.

Simple techniques, such as heat application, topical vasodilators, clenching the fist and holding the arm below chest level, can all increase the chance of success, as well as more specialist techniques such as imaging devices and ultrasound (Eren, 2021). There may also need to be a change of culture where nurses can feel pressured to perform the task themselves, rather than ask for help.

Interestingly, expectations of the practitioner based on their experience is one of the more reliable predictors of risk. Patient history is only a weak predictor as venous integrity can be situation-dependent, particularly in the emergency department. This reinforces the value of ‘gut feeling’ when making patient assessments.

This study makes a valuable contribution to the literature, by providing further validation of van Loon et al.’s (2019) A-DIVA scale. It will also have a positive impact on practice by providing healthcare professionals in Turkey with a validated tool for prospectively identifying patients with DIVA. However, to make a meaningful difference, use of the scale must be combined with best practice guidelines and education to ensure appropriate facilitative techniques are applied in a timely manner. Moreover, future research should focus on the effectiveness of using the scale in clinical practice.

Biography

Toni McIntosh is a staff nurse, currently working in Ayrshire and Arran. She has a strong interest in research alongside her clinical work to ensure she provides the best care that she can to patients.