Cleaning the ENFit^® Hub: Recent Study Evaluates 17-Step Cleaning Process

In an effort to develop an international enteral feeding system that is for safer enteral feeding, an improvement that is safer than the legacy slip tip connector was born – the ENFit connector. This connector was designed to be compliant with the ISO Standard for enteral feeding connectors 80369-3 in the U.S. and Canada. The global design for the connector has a reverse gender connection with the male to female and a locking connector. This unique design is intended to eliminate or, at best, radically minimize the risk for enteral feeding tubing misconnections (the ability to connect to other small-bore connectors) and disconnections (slip out of the intended connection).

Important Considerations Around the ENFit Hub and Connector

However, an area of concern has been identified and it is a significant concern to consider when transitioning to the ENFit design. Since the new design has the male side of the connector on the feeding tube, this change allows for milk or medication to easily spill over into the wells of the moat and accumulate in the hub. When this occurs, it is a challenge to remove milk from the threads. The ENFit locking connector has a collar with threads for the locking system and, if not prevented or addressed fairly quickly, the milk or liquid medication can dry, adhere to the threads in the hub, and make it a challenge to clean.

Reversing the gender on a connector normally would not be a big deal. However, reversing the connector on the feeding tube hub has a significant impact on keeping the small crevasse (threads) within the hub from accumulating milk and/or medication build-up. There are enteral manufacturers that have developed a hub on the feeding tube with vents or holes in the moat and what clinicians have identified is that this is still not enough to prevent build-up of milk and to keep the  moat within the hub from retaining milk.

Reviewing the Recent ENFit Cleaning Study

In a recent study, Lyman and associates (2020),1 conducted a randomized control trial to evaluate the effectiveness of two cleaning regimens for ENFit connectors. The purpose of the study was to evaluate the effort required to clean the ENFit connector with dried residue in two ways, with visible residue and non-visible marker gel. In addition, the researchers wanted to compare the efficacy of an ENFit commercial cleaning brush specifically designed to clean ENFit connectors to a firm-bristled toothbrush.

The study design was comprised of two validated cleaning procedures; one more diligent, including a 17-step process and one that was less diligent, with a 9-step process, test soils and visual inspection. Both procedures included a brush, sterile water for cleaning, and flushing the moat. One major difference is the more diligent regimen included the use of a cotton-tip applicator and a method of flushing the hub in a pulse-flush fashion.

The results of their findings by conducting this study is not surprising. The more diligent cleaning regimen for the ENFit connectors were found to result in a greater percentage (30.7%) of feeding tubes with no residue left, compared to the connectors cleaned with the less diligent regimen (13.1%). And, they found minimal difference when using a commercial brush designed to clean ENFit or a firm-bristled toothbrush (26.2% vs. 16.7%).

In the conclusion of the study, investigators provide valuable recommendations. First, they suggested that nurses follow a thorough cleaning regimen and include pulse-flushes with water into the ENFit connector. When using a brush, they recommended using one with firm bristles and to wet bristles before cleaning. Education is essential and should include images and infographics that teach how to clean the ENFit connector hub and have it available for clinicians, as well as families for situations when a patient is going home with an enteral device.  

Finally, they emphasize education as an essential component with regards to changing clinical practice with the ENFit connector. The teaching should include how to prevent milk residue from accumulating in the moat and how to clean effectively.

The team conducting the study identified some challenges with consistency following the cleaning instructions. Also, they noted discrepancy with nurse participants scoring the cleaning regimen versus the investigators scoring. Their challenges reinforce the importance of implementing a cleaning process that can be followed with consistency and repeated as frequently as necessary. And, I personally really like the suggestion for having step-by-step images and graphics that teach how to clean.

As a side note, I sincerely appreciate the work of the study investigators and all of the nurses that participated in the research and collection of this data. Their efforts highlight the challenges and complexities involved with evaluating practice and conducting research at a large pediatric teaching hospital. The impact of this work will benefit others and will be significant and far-reaching.

Concluding Thoughts About the ENFit Hub and Cleaning Protocols

Although the ENFit connector design is safer than the legacy slip-tip connector, it is particularly  challenging to keep the moat clean for patients in the neonatal units for the following reasons:

• Feeding tube oral or nasogastric can dwell longer in neonatal patients. Depending on the material (polyurethane or silicone), they can stay up to 30 days.  Although the evidence does not support leaving it in for this length of time.
• Enteral feeding tubes are accessed many times during a day, including when checking tube placement, for delivery of enteral medication, and feeds; 16-20 times in 24 hours x 7 days equals over 100 times a week! The disconnection and reconnection can allow for milk and gastric content to flow up the tube and into the hub or for the contents of a syringe to overflow into the wells of the hub.
• The most vulnerable and fragile infants in the NICU have immature immune systems and it is unclear if exposure to milk that has dried and lingered in the hub for several days could aide bacterial growth.

For these reasons, NICUs across the country that have implemented ENFit or are considering transitioning will need to consider adopting a cleaning protocol that includes regular cleaning of the ENFit hub.

Frequency of repeating the cleaning protocol has not clearly been identified in the above study or in searches that I have conducted. If you are working in a Neonatal or Pediatric ICU that has developed a ENFit cleaning protocol, and if you would be willing to share the frequency in which you are conducting cleaning with your protocol, please let me know. I would be glad to post and share with other clinicians!

There are steps that can be taken to mitigate the accumulation of milk and medication (dried residue) in the moat of the ENFit hub. These steps have been reviewed in a previous blog article penned by my colleague, so I recommend taking a look when you have some time.

Finally, I also encourage you to see this additional helpful resource regarding ENFit cleaning procedures from stayconnected.org.

References

1. Randomized Controlled Trial Assessing the Effectiveness of Two Cleaning Regimens for ENFit^® Connectors. MEDSURG Nursing. Nov/Dec2020, Vol. 29 Issue 6, p401-406. 6p.