Difficult intravenous access (DIVA) in the adult population: an umbrella review.

Clinical Snapshot

Key Findings

• Effect Size: Not applicable for umbrella review synthesis

• Primary Outcome: Three analytical dimensions of DIVA: definitions (≥2 failed attempts, invisible/non-palpable veins, documented history), risk factors (obesity, chronic diseases, chemotherapy), and interventions (escalation protocols, ultrasound guidance, specialised teams)

• Nnt Or Sensitivity: Limited validation of diagnostic tools noted, specific sensitivity/specificity values not reported

• Confidence Interval: Not reported

Clinical Application

Interventions appear feasible with appropriate training and equipment, particularly ultrasound guidance and escalation protocols Highly relevant to Australian practice - ultrasound guidance increasingly available, aligns with patient safety initiatives, could inform development of national clinical guidelines through NHMRC All adult patients requiring peripheral venous access across hospital, emergency, and outpatient settings

Abstract

OBJECTIVES: To synthesise evidence from systematic reviews on difficult intravenous access (DIVA) in adults, focusing on definitions, diagnostic criteria, risk factors and clinical interventions to guide clinical practice and health policy. DESIGN: Umbrella review of systematic reviews and meta-analyses. SETTING: Any clinical setting involving adult patients requiring peripheral venous access (including hospital, emergency and outpatient care). DATA SOURCES: A systematic search was performed in PubMed, CINAHL, Cochrane, Scopus and Web of Science in July 2025. ELIGIBILITY CRITERIA: Systematic reviews and meta-analyses published from 2014 to 2025 that addressed DIVA in the adult population were included. Primary studies and protocols were excluded. DATA EXTRACTION AND SYNTHESIS: Methodological quality was assessed using the Risk Of Bias In Systematic Reviews tool. Data extraction followed the Joanna Briggs Institute methodology for overviews and the Preferred Reporting Items for Overviews of Reviews reporting guideline. RESULTS: Seven reviews (six systematic reviews and one meta-analysis) were included. Three analytical dimensions emerged: (1) the conceptual and operational definition of DIVA, identifying common elements such as ≥2 failed attempts, lack of visible or palpable veins and a documented history of difficult access; (2) risk factors and clinical assessment, highlighting obesity, chronic diseases, prior chemotherapy, venous invisibility or non-palpability and the limited validation of diagnostic tools and (3) interventions, including organisational strategies (escalation protocols, specialised teams), technological resources (ultrasound guidance) and clinical measures (pain management and technique optimisation). CONCLUSIONS: DIVA is a multifactorial challenge that requires a standardised definition to improve clinical identification. Effective management relies on a combination of specialised training, the use of ultrasound technology and the implementation of escalation protocols to ensure patient safety and efficiency. PROSPERO REGISTRATION NUMBER: CRD420251084947.

References

1. 1.Torné-Ruiz, A., Delgado, M., Moreno, S., Corral-Núñez, A., Cemeli, T., & Roca, J. (2026). Difficult intravenous access (DIVA) in the adult population: an umbrella review. BMJ Open. https://doi.org/10.1136/bmjopen-2026-121458