Every service that provides peripheral venous access meets difficult moments: veins that cannot be found, a cannula that will not go in, or a patient who has been through it all before. What happens next is shaped not only by an individual practitioner's skill, but by the system around them.

A note from Sarah

Years ago, I worked with Imperial College's medical school, based at Chelsea and Westminster, to establish a structured programme through which medical students progressed in venepuncture and cannulation. It gave the students the opportunity to work in phlebotomy over the summer and helped set them up for vascular access excellence over the year.

This was at a time when competency logbooks were not widely thought necessary in medicine. Imperial and Chelsea and Westminster set the standard anyway, to the benefit of patients and, as it turned out, the careers of those students.

Around the same period, I led a large project training all the nurses in venepuncture and cannulation at a hospital, for the simple reason that I did not want standards to drop. What happened was better than that: the nurses themselves became leaders in vascular access.

Some time later, I found myself on an expert panel alongside Yvonne Harding. Yvonne said it was a pleasure to see me because I had trained her, and that no one went near a cannula unless they knew what they were doing. I will admit that landed particularly well. Not long before, I had returned from maternity leave to clinical A&E work with a serious case of imposter syndrome, quietly convinced everyone else had been given a manual I had somehow missed. Shortly afterwards, I was sitting on an expert panel for national competency work. The gap between how capable we feel and how capable we are can be surprisingly wide, and it rarely favours the feeling.

That is partly why this article matters to me. Safe practice in difficult moments is not about heroic individuals. It is about structures that hold the standard when confidence wobbles, staff change and pressure rises.

What happens in those difficult moments matters. Not just clinically, but for the patient's experience of care and for the organisation's record of safe, governed practice.

Many services need clearer escalation routes for difficult IV access. That is not a criticism of individual practitioners. It is a structural observation. The moment when peripheral access is proving difficult is precisely the moment when an unclear or absent escalation pathway creates the most risk.

Repeated attempts are not just a technical issue, they are a governance, patient experience and service-design issue.

This article explores what good practice looks like when IV access is difficult, why escalation needs to sit in policy as well as in culture, and how organisations can build the conditions for difficult access to be managed safely and consistently.

When access is difficult: what the situation actually involves

Difficult IV access means different things in different contexts. It can mean:

• Veins that are hard to find or feel, particularly in patients who are dehydrated, have had previous extensive IV treatment, or have conditions affecting vascular integrity.
• Veins that are present but difficult to cannulate due to fragility, depth, tortuosity or small calibre.
• A situation where the peripheral venous route is technically possible but not the most appropriate choice for the treatment being given.
• A patient who has experienced difficult access before and whose anxiety about the procedure itself now adds to the challenge.

Each of these calls for a slightly different response. What they share is that the default response, trying again with the same approach, is often not the right one.

Good practice starts before the procedure: assessing the patient's veins and access history, considering the purpose and expected duration of access, choosing the most appropriate site and device, and preparing the patient for what might happen if the initial approach is not successful. These are clinical judgements that belong in training rather than being improvised on the spot.

Escalation: a clinical skill, not a last resort

Escalation tends to be framed in clinical culture as an admission of difficulty. A practitioner who escalates is sometimes perceived, or perceives themselves, as having failed where a more skilled colleague would have succeeded.

This framing is counterproductive. It discourages timely escalation. It increases the number of attempts. And it places the burden of a systemic gap on the individual practitioner.

The clinical argument for timely escalation is straightforward. Each insertion attempt carries a risk of pain, bruising, phlebitis, infection and vessel damage. A patient who has experienced multiple failed attempts at peripheral access faces cumulative pain and a risk of vessel damage and other complications, some of which may be avoidable through timely escalation.

The NIVAS Standards, first edition (2026), make the organisational expectation explicit. Standard 14.2 (page 31) states that difficult IV access pathways must be in place to reduce cannulation and venepuncture attempts.

The accompanying practice guidance says vein visualisation technology should be used routinely for the first attempt in patients with difficult IV access. It also says that after a total of four failed attempts in the same clinical episode of care by two healthcare professionals, the patient should be classified as having difficult IV access and escalated to a vascular access service or a healthcare professional experienced in ultrasound-guided cannulation for difficult access. Implementation should be aligned with current local policy, available expertise, the clinical context and the individual patient's needs.

Escalation is the decision to stop, reassess and involve a more experienced colleague or a different route of access. That is a clinical skill. It requires judgement, communication with the patient, and the confidence to act on that judgement. It also requires an organisational environment in which making that decision feels safe and normal, not like a failure.

Building that environment is not a training problem alone. It is a service design question. Local champions need tools, language and escalation prompts, not just more content.

Research in focus

Research examining structured escalation pathways supports the value of systematic, documented approaches to difficult access. In a retrospective study of patients referred through a formal DIVA escalation pathway at a specialist hospital centre, the pathway and its documentation generated data that highlighted resource-allocation challenges and indicated targeted training needs among ward-level nurses (Saad et al., 2025). This was a single-site study in Abu Dhabi, so its findings need to be understood in that local context.

Paterson et al. (2022) systematically reviewed assessment instruments, clinical practice guidelines and escalation pathways for adults with difficult intravenous access. Their work highlights variation in current approaches and supports the case for more structured practice, although the methodological quality of the resources was mixed and standardisation was limited.

VAD selection: beyond the peripheral default

Peripheral IV cannulation is the default vascular access route. In the majority of cases it is the right one. But for some patients and some treatment plans, it is not the most appropriate choice.

Vascular access device selection involves considering:

• The nature of the treatment (vesicant medications, long-term infusions and certain concentrations or pH values may not be suitable for peripheral access).
• The expected duration of access (short-term peripheral access is different from access needed over days or weeks).
• The quality and quantity of available peripheral veins.
• The patient's previous access history and current condition.
• Patient preference and communication.

None of this is a reason for a practitioner to delay or withhold access in a clinical emergency. It is a framework for thinking about access decisions carefully in non-emergency contexts, and for ensuring that escalation pathways are available when peripheral access is not the right answer.

For organisations running structured vascular access training, these considerations belong in how training is designed, not just in specialist policies for specific treatment types.

Vessel health: thinking ahead

A patient's peripheral veins are a finite clinical resource. Unnecessary trauma, repeated attempts and poor device siting all reduce the quality and availability of peripheral venous access over time.

This matters most for patients who will need repeated or long-term IV access. Oncology patients, patients with chronic conditions, and patients who have had extensive medical treatment over years may have limited peripheral venous options by the time they reach a service.

Thinking ahead about vessel health means: selecting an appropriate site for each procedure with the patient's longer-term access needs in mind, using the smallest, shortest appropriate device, limiting the number of attempts, and escalating early when access is genuinely difficult.

This is not a specialist concept. It is part of good IV Cannulation practice for all practitioners.

Organisational governance: where individual skill meets system design

Individual clinical skill is necessary for safe IV access. It is not sufficient.

The NIVAS Standards for Infusion Therapy and Vascular Access (2026) are an important current UK professional framework for IV therapy and vascular access.

Standard 3.1 (page 11) states:

"Education and competency in vascular access and IV therapy must be standardised for all HCPs within an organisation."

This is a clear organisational standard. It is not a recommendation for individual practitioners simply to seek additional learning. What Standard 3.1 does not prescribe is one delivery mechanism. Each organisation remains responsible for determining how the standard is applied through its own governance, policy, training and competency arrangements.

For vascular access teams, Standard 28.1 (page 69) states:

"Healthcare organisations must consider the development of a dedicated vascular access service team (VAST)."

The wording matters. Organisations must consider a VAST, but the standard does not say that every organisation must establish one. The accompanying practice guidance identifies education and training oversight as one of the potential benefits of a VAST.

VeinTrain's position is that where NIVAS sets an organisational standard, VeinTrain can provide structured education and supporting governance infrastructure. Local policy, supervision, scope of practice, employer assurance and final competency confirmation remain with the employer, supervisor or clinical organisation.

The conditions that allow individual skill to translate into reliably safe practice across a team and an organisation include:

A clear escalation pathway. This does not mean a long policy document. It means a visible, current, accessible description of what happens when peripheral IV access is difficult or not possible: who to call, in what order, and what the next access option is.

A named IV lead or equivalent. Someone who owns the governance of vascular access training and policy for the service, holds the version-controlled policy, reviews and updates training, and provides a point of escalation for complex cases.

A team culture where escalation feels normal. This is built by the most experienced practitioners in a team modelling it visibly. When a senior clinician says "I am going to ask a colleague to take a look at this" in a calm, routine way, it gives everyone else permission to do the same.

Version-controlled, current training. Guidance, devices and local policies change. Training that is aligned with current evidence and current local policy is a patient safety requirement, not an administrative nicety.

A training record system that supports governance. Not just to document that training happened, but to support the employer's role in confirming competence and to provide an evidence base for audit and review.

For most delegates, a VeinTrain certificate records structured learning or training completion. Employer sign-off, local policy and scope of practice continue to govern authorisation to practise. For organisations operating through approved HALO Centres, a VeinTrain Certificate of Competency is available as a separate, controlled outcome, but final competency confirmation remains with the employer, supervisor or clinical organisation. The employer's role is not a formality. It is the closing step in a structured pathway from learning to safe, confirmed practice.

What HALO supports

HALO by VeinTrain is the organisational deployment model for structured, governed vascular access training. It is designed to support organisations in building not just a well-trained team but the conditions that keep practice safe, current and governed over time.

In the context of difficult access and escalation governance, HALO supports:

Champion-led escalation culture. Identifying and equipping local champions who model and sustain escalation as a clinical norm rather than a last resort.

Inside-out implementation. Building the conditions for practice change from within the organisation, led by people who understand the local context and culture.

Local escalation pathway design. Supporting HALO Centre leads in building and maintaining a practical escalation pathway that fits their service.

Practice intelligence. VeinTrain Intelligence, the practice-intelligence layer of HALO, is designed to support organisations in identifying patterns, gaps and opportunities for improvement in their vascular access governance, with humans governing every interpretation and decision.

Structured handover and continuity. When staff move on, the HALO governance structure helps organisations retain knowledge and standards.

Conclusion

Difficult IV access is a clinical reality in every service that provides peripheral venous access. Most of the time, skilled, well-trained practitioners manage it well.

What makes the difference in organisations that manage it consistently well is not just individual skill. It is the combination of skilled practitioners, a clear escalation pathway, a supportive team culture, current version-controlled training and named ownership of vascular access governance.

That is the whole system. Not just one layer of it.

For organisations that want to build that system, VeinTrain provides the structured pathway. HALO builds the organisational conditions. And the employer confirms competence.

VeinTrain provides structured IV Cannulation, venepuncture and phlebotomy training and, through HALO, supports the organisational conditions that help keep practice safe. To discuss an escalation-ready pathway for your service, explore the HALO organisational pathway or book a conversation with VeinTrain.

Related reading

• From programme completion to clinical competency: the HALO pathway
• Explore the Clinical & Learning Toolkits in the VeinTrain Knowledge Hub

Join the Community of Practice

VeinTrain is launching a Community of Practice. It welcomes open debate and discussion about what standards, guidelines and policies actually mean in practice for different organisations. You do not have to be a VeinTrain member to join.

The purpose is to get research and evidence out into the field quickly, share honest experience of how things work on the ground, and improve collectively.

This is an OD-style (organisational development) Community of Practice. It will use complex facilitation and a dialogic approach in support of global transition and innovation in vascular access practice. It is intended to be a place for genuine dialogue, not simply broadcast.

To join, email This email address is being protected from spambots. You need JavaScript enabled to view it. with your name and the word COP.

Part of the HALO Interactive Intelligence Hub

This article, and the wider Knowledge Hub, sit within the HALO Interactive Intelligence Hub (HIIH), which brings research, training, partners, maps and impact together in one place. The hub launches on 26 August 2026.

Evidence and references

This article draws on VeinTrain's clinical and operational experience in structured vascular access training and governance, informed by the following sources.

UK professional standards

NIVAS (2026). Standards for Infusion Therapy and Vascular Access. First edition. Lead Author/Editor: Andrew Barton, NIVAS Board Chair. National Infusion and Vascular Access Society. Available from: NIVAS Standards for Infusion Therapy and Vascular Access (PDF)

Relevant sections: Standard 3.1 (page 11), Standard 14.2 (page 31) and Standard 28.1 (page 69).

Research

Saad AA, Simsekler MCE, Ahmed S, Ouda R, Khaddam O, Sanousi M, Benny M, Sunbati HA, Kashiwagi D, Al Rifai A, Ahmad M, Anwar S (2025). Optimizing Strategies for Managing Difficult Intravenous Access. Risk Management and Healthcare Policy, 18, 1147-1157. DOI: 10.2147/RMHP.S500340

Note: single-site retrospective study conducted at Sheikh Shakhbout Medical City, Abu Dhabi (UAE). Findings reflect that local context.

Paterson RS et al. (2022). Peripheral intravenous catheter insertion in adult patients with difficult intravenous access: a systematic review of assessment instruments, clinical practice guidelines and escalation pathways. Emergency Medicine Australasia, 34(6), 862-870. DOI: 10.1111/1742-6723.14069

A VeinTrain certificate records structured learning or training completion. For most delegates, employer sign-off, local policy and scope of practice continue to govern authorisation to practise. A VeinTrain Certificate of Competency is a separate, controlled outcome, available only through approved HALO Centres and specifically approved organisations and routes. Final competency confirmation remains with the employer, supervisor or clinical organisation.