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Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Interview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February\u2013April 2020) involving 21 stakeholders culminating in the co-production of the \u201cDIVA Key\u201d. The DIVA Key was evaluated between May\u2013December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range\u2009=\u200981.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa\u2009=\u20090.71, 95% CI 0.63\u20130.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2\u201327.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR)\u2009=\u200910 [8\u201310]; 8 [8\u201310 respectively).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>The DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.<\/jats:p><\/jats:sec>","DOI":"10.1186\/s12913-022-07605-2","type":"journal-article","created":{"date-parts":[[2022,2,17]],"date-time":"2022-02-17T12:06:09Z","timestamp":1645099569000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":37,"title":["Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key"],"prefix":"10.1186","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5406-9519","authenticated-orcid":false,"given":"Jessica A.","family":"Schults","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tricia M.","family":"Kleidon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victoria","family":"Gibson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert S.","family":"Ware","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Monteagle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca","family":"Paterson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karina","family":"Charles","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Keys","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Craig A.","family":"McBride","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven","family":"McTaggart","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin","family":"Lawton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fiona","family":"Macfarlane","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chloe","family":"Sells","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claire M.","family":"Rickard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda J.","family":"Ullman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2022,2,17]]},"reference":[{"key":"7605_CR1","doi-asserted-by":"publisher","first-page":"e18","DOI":"10.1016\/j.pedn.2019.09.023","volume":"50","author":"AJ Ullman","year":"2020","unstructured":"Ullman AJ, Takashima M, Kleidon T, Ray-Barruel G, Alexandrou E, Rickard CM. 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Aust Crit Care. 2021;34(3):226\u201334.","journal-title":"Aust Crit Care"}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-022-07605-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-022-07605-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-022-07605-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,9,18]],"date-time":"2024-09-18T20:34:00Z","timestamp":1726691640000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-022-07605-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,2,17]]},"references-count":50,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,12]]}},"alternative-id":["7605"],"URL":"https:\/\/doi.org\/10.1186\/s12913-022-07605-2","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,2,17]]},"assertion":[{"value":"3 August 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"31 January 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 February 2022","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethical approval to conduct the study was obtained from the Children\u2019s Health Queensland Human Research Ethics Committee (LNR\/19\/QCHQ\/55326) and Griffith University (2019\/797). Written informed consent was obtained from all study participants.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Jessica Schults reports grants from Becton Dickinson unrelated to the current project.Tricia Kleidon has received grant funding from Children\u2019s Hospital Foundation, Griffith University, National Health and Medical Research Council (NHMRC), Emergency Medicine Foundation and investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers 3\u2009M Medical, Access Scientific, Angiodynamics, BD-Bard, Baxter, Cardinal Health, Medical Specialties Australia, Vygon.Claire Rickard reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3\u2009M, BD-Bard; Cardinal Health), unrelated to this project.Amanda Ullman reports fellowships and grants by the National Health and Medical Research Council (NHMRC), employment by Griffith University, grants by the Children\u2019s Hospital Foundation, the Royal Brisbane and Women\u2019s Hospital Foundation, Emergency Medicine Foundation, and the Australian College of Critical Care Nursing, and investigator-initiated research grants and speaker fees provided to Griffith University from 3\u2009M, Cardinal Health, and Becton Dickinson.VG, RW, EM, RP, KC, AK, CM, SM, BL, FM, CS have no conflicts of interest to declare.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"220"}}