The Misconnection Prevention Revolution: What I’ve Learned Working with ENFit

Kathy Quellen, RN, BSN / March 2017

The Misconnection Prevention Revolution: What I’ve Learned Working with ENFit

I’ve been a NICU/PICU nurse for a long time – since 1981 – and I’ve worked with plenty of NGT’s and enteral feedings and medications. Very little has changed with enteral products since I began practicing. They were just staple items on every unit, like having sugar or flour in your pantry at home.

NGT’s, extension sets, and syringes were not something that most clinicians thought about redesigning, even though we knew a possible misconnection hung around as a possibility (with potentially horrendous outcomes for the patient). We just used enteral products like we used those cooking basics… It was always tucked away in the pantry, called for in many recipes, and made cooking a lot easier.

In 2014, after 30+ years in the Neonatal/Pediatric field, I started hearing about safety changes for enteral products. I thought, “What changes could they possibly do to make them safer?”

Well, by now we all know the main ENFit design change of switching the male/female hubs was quite unique and did seem to solve the misconnection problem. I can hear the many voices of fellow RN’s saying (as we do many times):  “Why didn’t I think of that?”  It’s such a simple solution to the potentially huge negative outcomes of using enteral products.

I started working as a NICU Specialist with a company that provided many products to the NICU, including traditional enteral products, just as the ENFit change began. I was able to see firsthand the hard work from everyone involved in the development and implementation of ENFit.

These were the players:

  • GEDSA (Global Enteral Device Association), the agency responsible for making ENFit a reality.
  • Vendors – the companies that were responsible for participating in the design of ENFit. Not every vendor decided to participate, but many did and this allowed for the product to move forward in development.
  • End Users – the hospitals. Clinicians and hospital administrators that needed to participate in discussions and were willing to adopt ENFit into their facility.
  • Legislators – one state, California, enacted a law requiring healthcare facilities to adopt enteral connectors which could not connect with other application connectors. ENFit was a solution for this.

The overall goal for everyone involved was to provide patient safety and avoid deadly misconnections. Was the roll out easy? It sounds like it should have been, considering it was a simple design change with almost no necessary learning curve for use, a much safer product, not much change in price, and the many organizations working with being involved in the decision-making process at all levels.

So what did I see? Well, the industry-wide roll-out for ENFit in general was not easy, but in my opinion it was not easy along the lines of “no change is ever easy,” and not because of any problem with ENFit.

I feel the bottom line is that clinicians and hospitals have really embraced the idea of this change because they understand the safety. But actually making this change means taking that old brand of sugar you’ve been buying for years out of the pantry and throwing it away. You then have to replace it with a new brand that’s ultimately better for you but looks a little different. This equals:  Change!

Most of us all say “yes, I want a better, healthier product, I read all about it, did the research, tested it and I’m making the switch.”  Then suddenly you look in the pantry and the old sugar you looked at for 40 years is gone and replaced with a new bag of sugar that you can’t use in exactly the same way. Suddenly you’re not sure if you like this so much: “What was I thinking? Is this really better for me?  Can I use this? Will using this give me new problems? “

I’ve been involved with converting ENFit in the NICU for over a year now, and what I’ve seen and heard from others about the issues center around four main themes:

1. ENFit connectors twist to connect

The ENFit design is a twist connector system. Nurses love to over-twist when tightening, which in turn makes ENFit harder to un-tighten. Nurses do this once, get out the Kelly Clamps to solve the issue, and hopefully remember to not do it again.

2. ENFit feeding tubes have male connectors

The ENFit design switched male/female connectors. The male connector is now on the feeding tube (NGT / OGT). This connector has a “moat-like” design and milk can pool and dry in this “moat” if precautions are not taken. As a result, attention needs to be given to the cleaning of the hub.

Remember, we did clean feeding tube hubs before as they got dirty, and this process should be continued with whatever cleaning protocol you’ve used before… but done more regularly. The problem has always been there. For more tips on how to avoid milk build-up, read Purging the Line: Keeping the ENFit Hub Clean.

3. ENFit change management

Both ENFit and non-ENFit designs will be floating around the hospital and non-hospital market until everything is switched over. This opens the possibility of having non-matching tubes come into your unit. You may want to consider having adaptors available that make ENFit hubs non-ENFit and vice versa. If you don’t like adaptors, be sure to keep some boxes of old product on the unit or in central supply.

4. ENFit low dose syringes

NICU and Pediatrics need to have a low dose syringe for medications 2 mL and under. This is an issue that Pharmacy and NICU/Pediatrics need to have clear communications around, and how they want to move forward with a vendor. Do they keep their current pharmacy vendor and adapt the low dose syringes? Or do they change to a new vendor with a low dose syringe? It’s an issue that may be easily solved, and with problems avoided if discussed up front.

The ENFit change to enteral products has been rolling out slowly since 2015. The goal is primarily safety for patients. It’s also providing safety for the nurses and clinicians who use enteral products and could help to avoid potentially fatal mistakes.

My recommendation is to consider making this change. Work through the uncertainty and fears that change brings. The trusty enteral feeding products you’ve used for years are ready for an update, just like that sugar staple item in your home cabinet. In the end you’ll find it is much more palatable than you thought.

 

About the Author

Kathy Quellen, RN, BSN, has been a NICU/PICU RN since 1981. She has worked in hospitals all over the U.S., including Georgetown University Hospital, DC Children’s, Cedars Sinai and Children’s Hospital of NJ.  She worked as a Clinical Specialist for Abbott Labs/Hospira and has been a NICU Clinical Specialist for Medela since 2014. She covers hospitals all throughout the western United States.

9 thoughts on “The Misconnection Prevention Revolution: What I’ve Learned Working with ENFit

  1. You speak of “deadly miss connections”. In 40 years in the NICU I have not witnessed a deadly miss connection. I have had messy miss connections. Please explain the mortality involved with an enteral disconnection.

  2. Hi Marlene,

    Thanks for your comment and I’d be happy to address it.

    I too have been practicing for many years in the NICU and luckily have also not personally experienced a misconnection.
    But statistics do show that enteral misconnections do occur meaning that an enteral line is inserted into an IV line. A disconnection is when an enteral line disconnects from an NGT or at some connection site. This is indeed messy as milk is then infused onto the sheets and
    I have experienced many of these. But a misconnection is when 2 different lines not meant to be connected are, and this can be deadly.

    I’ve included some information below that addresses the misconnection alerts from JCAHO/ASPEN and a video from GEDSA with the families of patients discussing the loss of a loved one because of a misconnection. This should explain how deadly these incidents can be and the alerts address
    what steps need to be taken to avoid them.

    Thanks again for the comment and I appreciate your input.

    https://pdfs.semanticscholar.org/6e79/c797fa9a6e0eda835235b9e59a1262b291b1.pdf

    https://youtu.be/feyBYIl1QDg

    https://www.jointcommission.org/sea_issue_53/

    http://www.nutritioncare.org/guidelines_and_clinical_resources/toolkits/enteral_nutrition_toolkit/enteral_nutrition_connectors_and_misconnections/

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