When it comes to delivering medication and enteral nutrition in healthcare, safety is one of the highest goals. Thanks to many new advances over the years, NICU professionals and patients have had access to quality medical devices which prioritize safety, as well as functionality and quality. An example of these evolving tools is the syringe infusion pump.
One of the initial purposes of infusion pumps was to deliver medication fluids. Due to the exact nature of medication delivery, a reliable technology was needed—not only the hardware, but the software to go with it. It went through many incarnations before landing into its most popular current state, primarily as a syringe or peristaltic pump.
These technologies have become useful and necessary for delivering minute enteral nutrition volumes in neonatal intensive care. Most often used are syringe infusion pumps to manage these small feeding amounts. While enteral feeding does not necessarily require the specific approximation of dosing needed for medication, enteral pumps should still follow best practices and recommendations, especially for these smaller patients. There are three considerations you should keep in mind to maximize positive patient outcomes and safety when using enteral infusion pumps.
1. Ensure all nursing infusion pump users are fully educated (again… and again)
As infusion pumps in general were increasingly utilized for efficiency, new statistics came to light: Infusion pumps could also be a real threat to patient safety. The FDA found that safety issues related to infusion pumps could lead to over- or under-infusion, missed treatments and even delayed therapy. The FDA states, “From 2005 through 2009, (the) FDA received approximately 56,000 reports of adverse events associated with the use of infusion pumps, including numerous injuries and deaths.” (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/)
The FDA says these events arose from multiple issues: design deficiencies, user error, user interface issues, or mechanical or electrical failures. While some things on this list are out of your immediate control, a few are not. Help your team to avoid user error and user interface issues with not only introductory training, but routine retraining and updates. If you don’t have an annual retraining exercise already in place, begin one now with an infusion pump refresher course. Make it even more interactive by including the product manufacturer, who should assist your team with programming reviews, updated security measures (particularly for EMR connected devices), and best safety practices.
2. Verify if your existing pumps, or pumps under consideration, meet the recommended standards for enteral delivery
Syringe infusion pumps are the pump method of choice for neonatal intensive care, as bag delivery cannot meet the small volume requirements. Neonatal patients have particular needs when it comes to enteral delivery, and the syringe infusion pump plays a large part in meeting those needs. Due to the much smaller patient size and fragile state, the American Society for Parenteral and Enteral Nutrition (ASPEN) recommends the following for neonatal enteral feeding pumps:
- Specific delivery accuracy: An enteral pump should deliver within 5% of set volume. The concern here is the brain growth priority for at-risk infants, who are already at peril for development issues. If an enteral feeding pump is off by as much as 10%, it can cause underfeeding issues, which may have immeasurable impact to patient health and growth.
- Feeding pumps should be calibrated periodically for accuracy: Work with your product manufacturer and biomed departments to schedule routine calibrations.
- Syringe elevation: Human milk infusions delivered in low volumes should be administered with the syringe tip elevated. Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities from the American Dietetic Association states “Tilting the delivery system so that the exit point of the feedings is elevated minimizes the loss of fat” (page 92). Many syringe pumps allow users to rotate the syringe pump with a rotating pole clamp mechanism attached to an IV pole. This allows for elevation of the syringe tip.
3. Avoid using an IV syringe infusion pump for enteral feeding delivery when possible
Using a medication delivery syringe pump for enteral feeding can create opportunity for error, with high risk to the patient. It is recommended that medication delivery pumps not be used or repurposed for enteral delivery.
Guidelines published by The Joint Commission, American Dietetic Association (ADA) and the American Society for Parenteral and Enteral Nutrition (ASPEN) are clear on recommended policies for improved enteral feeding safety:
The Joint Commission
- “Do not use IV tubing or IV pumps for enteral feedings.”
- “Use distinctly different pumps for IV applications.”
– The Joint Commission, 2006, p. 4
American Dietetic Association
“In general, intravenous pumps should not be used for enteral feeding when enteral feeding pumps designed for infants or pediatrics are available. Caution must be exercised if an intravenous pump is used for enteral feeding because the pump should be used only for enteral delivery and not accidentally connected to an intravenous line. Unique tubing for enteral feedings-e.g., one with a unique color and connector designed for feeding tubing-is strongly suggested.” – American Dietetic Association, 2011, p. 99
American Society for Parenteral and Enteral Nutrition
“Enteral feeding pumps are used to administer bolus and continuous drip feedings. While the gravity method is often used for bolus feedings, enteral pumps have been shown to result in a decrease in adverse events. When syringe pumps are used in neonatal ICUs for human milk or other feedings, they should be clearly distinct from syringe pumps used for IV or other medical purposes. Ideally, they should be a different model, color, or as different in appearance from IV pumps as possible. The enteral feeding pumps should be clearly labeled as enteral feeding pumps.” – American Society for Parenteral and Enteral Nutrition, 2009, p. 152
While there are more considerations for neonatal enteral feeding syringe pump best practices above and beyond the three mentioned here, this is a good place to start. Implementing additional education, verifying pump accuracy, and separating medication and enteral pumps are impactful efforts you can begin today for improved future performance and outcomes.
Looking for more reading on this subject?
Read Is Your NICU Connected?
The American Society of Parenteral and Enteral Nutrition. (2009). ASPEN Enteral Nutrition Practice Recommendations.
American Dietetic Association. (2011). Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities.
The Joint Commission. (2006, April) Managing risk during transition to new ISO tubing connector standards. Sentinel Event Alert, Issue 53. Retrieved from www.jointcommission.org