Adopting ENFit in the NICU: Problem Solving Common ENFit Challenges

What are Common ENFit Challenges Associated with Transition?

If your unit is considering or already navigating down the path of an ENFit conversion, you are probably now aware of some innate challenges that come along with this transition, especially in the neonatal population. “While the ENFit design addressed one primary patient safety concern, another concern has come to light: how to clean the distal end of the feeding tube that contains a moat, allowing the accumulation of residue from enteral formula or a liquid medication.” (Lyman, B., Rahe, K., Keeler, D., Sherman, A., & Abdelhadi, R., 2020). Expanding on this, there are 3 key areas of focus when adopting ENFit in order to actively problem solve known challenges:

1. Cleaning

Address cleaning of feeding tube hubs, particularly the “moat” that gets dirty.

• In an ENFit system, all administration sets and ENFit Tip Syringes have a female connector that mates to the male connector on the feeding tube. With this gender reversal, the feeding tubes now feature a “moat” that is prone to debris build-up, including human milk, formula, and/or medications. Studies reveal this build-up and the challenges of routine cleaning to maintain hygiene of the device. Lyman et al (2020) offer an assessment of two cleaning regimens for ENFit Connectors, including a more diligent and a less diligent regimen. The more diligent regimen consists of a lengthy 17-step process that the clinician would routinely perform - and, despite being “less” diligent, the second regimen is a 9-step process, which still commits the clinician to a lengthy cleaning routine. "The difference in efficacy was statistically significant in the visually evident (chocolate-flavored enteral formula) residue, but not in the invisible (DAZO) residue. This suggests participants may not have cleaned as diligently when they did not see anything visible to clean compared to visible residue. The discrepancy highlights the importance of following the more diligent cleaning procedure regardless of the connector’s appearance.”
• Medela offers a Clean Connection Technique, which is a preventative approach to reducing the amount of overflow into the feeding tube moat. By training staff to approach enteral feeding preparation and management with a few key modifications, both the overflow and the clinician time dedicated to cleaning will be decreased.

2. Medication Accuracy

Address delivery of oral medication, including determining a need for oral adaptors paired with ENFit LDT syringes.

• Accurate delivery of medications in the NICU is essential. Small volume doses leave little room for error. The ENFit Low Dose Tip Syringe challenges oral delivery of medications. With exposed threading now present on the syringe tip, there is risk of injury to the oral mucosa in the NICU patient. The introduction of oral adaptors is in response to this risk; however, oral adaptors arguably add even more risk – the risk of inaccuracy. O’Mara, Gattoline, and Campbell (2019) state “LDT syringes with adapters essentially double the number of steps required for proper administration, creating opportunity for error with increased time and steps for completion.” They go on to say, “this study raises clinical concerns with the dosing accuracy of female low dose tip syringes and associated adapters. While is it beyond the scope of this study to fully elucidate the clinical impact of inaccurate small volume doses, clinicians whose patient populations include those receiving low volume oral medications should be aware of the potential impact on drug delivery.”
• Pharmacy oral tip syringes are validated to be accurate and are engineered incompatible with IV lines. ISMP recommends their use for delivery of safe and accurate oral medications.  Medela offers a unique solution that allows the pharmacy to continue using their oral tip syringes and not have to transition to ENFit for medication delivery. ENFit was designed for enteral feeding, not pharmacy. With our patented low dose technology, our Dual Cap offers a long term, house-wide solution for medication delivery. Not only does it allow for accurate delivery of medications, it is safe! One end features the ENFit design and the other is oral, allowing for ongoing compatibility. This is a safe, accurate, and convenient way for your pharmacy to continue the use of ISMP-recommended oral tip syringes while allowing the entire hospital to benefit from transitioning to ENFit enteral connectors.

3. Cost

Consider increased cost impact to you and your pharmacy with an ENFit conversion.

• Increased costs ensue due to the additional pieces necessary to manage medication preparation with the new ENFit design. These include ENFit-compatible adaptors for pharmacy to draw up medication, ENFit tamper evident caps, and practice change! What is now a slip action becomes a repetitive twisting motion for the technician. As I previously mentioned, the addition of oral adaptors may also be indicated in certain patient populations. The addition of these and other items may be difficult to quantify in the beginning of an ENFit conversion, but will quickly add up over the coming months following implementation.
• With the Medela’s Low Dose Dual Cap, no changes are necessary in the pharmacy. Current practices can remain exactly as is with medication preparation with oral tip syringes, allowing for no additional costs in the pharmacy. Clinical units would stock the Low Dose Dual Cap and only use when connecting the prepared oral tip syringes to an ENFit enteral device for delivery. Oral/PO administration can remain the same and does not require adaptors or special considerations, unlike the ENFit LDT syringe. The clinician maintains autonomy in determining the best route of administration without compromising accuracy. It’s the best of both worlds!

Remember, You Have a Choice!

Medela offers a full portfolio of ENFit products. So, if your hospital is making the move to ENFit, we are here to support you through the change. However, Medela also offers an alternative that provides unique flexibility to address specific NICU needs; this alternative is TwistLok. TwistLok is a safe and accurate long-term option that resolves many of the challenges noted with the use of ENFit:

• Resolves hub issues for feeding tubes
• Resolves most issues regarding delivery of oral medication
• No practice change necessary

While ENFit will be introduced for your adult and pediatric enteral feeding systems, Medela’s TwistLok is a great solution for your NICU. In conjunction with the Low Dose Dual Cap, delivery of safe and accurate medications in the most vulnerable of populations is preserved.

Why Medela?

In addition to our excellent, innovative neonatal-specific products, we also pride ourselves on excellent customer service. Should you choose to implement at your facilities, we will bring a team of Medela professionals, including our sales reps, clinicians, and enteral feeding specialists to help with your transition. We will be available on all units and at all facilities, both days and nights. In addition to on-site training, we have a multitude of resources on our website that can be used to review product training for new employees or those employees who may be unavailable for implementation. We also feature a Medela education section on our site that allows access to free education with the allotment of a promo code for your team members.

You will not be alone in the transition. Once you decide to move forward with Medela, we are committed to this relationship and will walk alongside you as a partner, providing the very best products and service to your tiniest, most fragile patients.

References

 O'Mara K., Gattoline SJ., & Campbell CT. (2019) Female low dose tip syringes-increased complexity of use may compromise dosing accuracy in paediatric patients. J Clin Pharm Ther, 44(3), 463-470. doi: 10.1111/jcpt.12810.

Abdelhadi, R., Lyman, B., Rahe, K., Keeler, D., & Sherman, A. (2021). Randomized Controlled Trial Assessing the Effectiveness of Two Cleaning Regimens for ENFit^® Connectors. MedSurg Nursing, 29(6), 401-406.