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Peripheral Venous Access

Pathway Background and Objectives

Peripheral venous access is a frequently performed procedure, and the most common source of pain, for children in the hospital. Pain control is a high priority for patients and families and pain experiences can have long term effects on children. The use of topical anesthetics prior to venous access and procedure planning with the use of behavioral techniques can improve the experience for patients and their families. Difficult venous access can lead to multiple failed attempts at venous access, which can delay care, be traumatic to patients and families, and cause them to lose trust and confidence in medical providers and the institution.

The Difficult Venous Access (DIVA) score is a validated prediction rule to determine likelihood of failure of peripheral IV placement on first attempt.

The specific objectives of this pathway are to:

  • Standardize and increase the use of topical anesthetics for venous access procedures
  • Reduce number of venous access attempts
  • Identify patients with difficult venous access
  • Improve documentation of venous access procedures
  • Standardize and increase the use of child life /behavioral support techniques for venous access procedures


Quality Metrics

  • Average number of attempts per procedure (per week)
  • Number of procedures with a documented attempt in nursing flowsheet
  • Number of procedures with 3 or more attempts
  • Percentage of patients with documentation of use of topical anesthetics
  • Percentage of patients with documentation of use of comfort measures
  • Percent utilization of LMX or J-Tip lidocaine for IV placement
  • Percent utilization of Pain Ease for IV placement
  • Percent utilization of sucrose for IV placement
  • Percentage of IVs placed for which any topical anesthetic used
    • Total, stratified by inpatient floor, stratified by day/night
  • Number of patients/families offered and declined topical anesthetics

Educational Module

Download Peripheral Venous Access Educational Module Updated June 20, 2022 

Key References

  1. Zempsky, WT. Optimizing the management of peripheral venous access pain in children: evidence, impact, and implementation. Pediatrics. 2008 Nov;122(3). S121-4.
  2. Rauch D, Dowd D, Eldridge D, Mace S, Schears G, Yen K. Peripheral difficult venous access in children. Clin Pediatr (Phila). 2009 Nov;48(9):895-901.
  3. Riker M, Kennedy C, Winfrey, BS, Yen K, Dowd MD. Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access. Acad Emerg Med. 2011 Nov;18(11):1129-34.
  4. Leahy S, Kennedy RM, Hesselgrave J, Gurwitch K, Barkey M, Millar TF. On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics. 2008 Nov;122(S3):s161-70.
  5. Rosenberg RE, Klejmont L, Gallen M, Fuller J, Dugan C, Budin W, Olsen-Gallagher I. Making comfort count: using quality improvement to promote pediatric procedural pain management. Hosp Pediatr. 2016 Jun;6(6):359-68.

Pathway Contacts

  • Ilana Waynik, MD
  • Stacy Elliot, RN
  • Ryan O’Donnell, RN
  • Bill Zempsky, MD
  • Jill Herring, APRN


The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.

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