Problem: Half of emergency department patients will require a peripheral intravenous (IV) cannulation during treatment with the majority completed by nursing staff. At a rural freestanding emergency center (FMF) in Maryland, no registered nurse (RN) had completed formal competency to perform ultrasound guided IVs (USGIV). Lack of nurses performing USGIV results in multiple traditional IV attempts which is painful, increases supply waste, and delays patient care. Difficult intravenous access (DIVA) leads to increased staff frustration, delays in patient care, and increased ED burden. Purpose: The aim of this quality improvement initiative was to assess nurse adherence to USGIV techniques for successful IV access of individuals with DIVA. Methods: USGIV techniques include a DIVA algorithm developed based on a statistically validated and reliable Comprehensive DIVA score tool. A USGIV procedure checklist developed using the validated Delphi Method Validation of Procedural Checklist. Implementation included hands-on in-person USGIV training including ultrasound equipment and vascular anatomy, DIVA algorithm, procedural checklist, and procedure. Data was gathered weekly via self-reported questionnaires. Results: Training was completed by 55% of staffed RNs; however, 100% of the RNs who signed up completed training. RNs report utilizing the DIVA algorithm 93.2% of the time to determine which IV technique to use. A run chart showed non-random variation signaling change above the average of algorithm use. The procedural checklist was used 100% of the time prior to USGIV attempts. Conclusion: Findings indicate that RNs are adhering well to DIVA algorithm and procedure checklist at the FMF per the project goal. Findings suggest that USGIV techniques are being utilized by RNs. Adherence to techniques suggests that RNs will be less frustrated with DIVA and less traditional IV supplies will not be wasted.