Problem & Purpose: Obtaining peripheral intravenous (PIV) access is a frequent, but challenging procedure in difficult access patients (DIVA). Emergency medical care frequently requires PIV access to administer medications and perform diagnostic testing. Traditional methods for obtaining PIV access have resulted in repeated painful attempts and treatment delays in this tertiary care emergency department. The purpose of this quality improvement project was to implement and evaluate a nursing-initiated clinical pathway directing the use of ultrasound-guided intravenous techniques for DIVA patients to increase first attempt success rates and reduce treatment delays. Methods: A departmental policy was created to support the practice change. The policy provided an illustration of the DIVA clinical algorithm and specified training and competency validation expectations. Training included 30-minutes of didactic instruction followed by 60-minutes of hands-on training. Competency validated operators documented DIVA screening, ultrasound utilization rates, pain scores, number of venous attempts, and treatment delays. Project compliance and outcome measures were collected over 14-weeks and converted into run charts for weekly unit dissemination. Chi-squared and independent samples t-tests were used to compare pre-and post-implementation results. Results: Sixteen operators completed the education and training program which included nurses (n=8) and technicians (n=8). Operator compliance to DIVA screening and ultrasound-guided intravenous algorithm utilization suggested early adoption (M = 89.25, SD = 7.45). First-attempt success rates for DIVA patients increased from 57% to 87% (p = 0.03) and treatment delays decreased from 20% to 0% (p = 0.01). There was a significant reduction in pain scores (M = 2.2, SD = 1.17) compared to baseline (M = 5.3, SD = 1.65) data; t(58) = 8.08, p < 0.001. Conclusions: The use of a nurse-initiated clinical pathway to identify difficult access patients requiring ultrasound-guided intravenous cannulation increases the likelihood of first attempt access success and ensures timely medication administration, laboratory analysis, and diagnostic testing in the emergency department. The reduction in cannulation attempts optimizes patient outcomes by decreasing pain experienced by the patient, and treatment delays.