Conversion to ENFit Using the Dual Cap
Kathleen Quellen, RN, BSN / August 2021
Enteral Feeding Changes with New ENFit Design
Enteral feeding has changed in the last few years, with new safety features in the new design we call ENFit.
ENFit is an enteral feeding design with a goal of avoiding misconnections. The male/female hubs are switched, so the syringes are now female (with larger tips) and the tubing (extension sets, NGTs) are male ended. These two changes – first, the male/female switch and, secondly, the locking system are what’s considered to be the major design changes called ENFit. Color is not mandated. Slip tip syringes, such as pharmacy syringes for medications, will not fit into the ENFit end.
These changes can bring about practice change for the pharmacy and for clinicians, especially in the area of medication administration. What are these practice changes that impact clinical areas in the NICU/Pediatrics and Pharmacy? I've highlighted some below:
The major concern is the new female tip on the low dose syringes. The tip is much larger and many clinicians feel it is too large, accompanied by harsh edges, to put into a child’s mouth. Some ENFit tip pictures are shown below:
This large tip issue can sometimes be avoided by using adapters that have smoother tips for medication administration. But, these adaptors will increase the dead space and nurses must flush after administration. Studies have shown that these adapters can have accuracy issues with low dose medications because of the increased dead space and having to flush without a protocol. It is wise to ask your vendor about dead space, the need for flushing, and accuracy if using this product. Standard ISO accuracy is +/- 10% at 0.2ml.
Pharmacy also is directly impacted, since the NGT hub will no longer accommodate the slip tip syringe. The Pharmacy is also impacted with cost, as ENFit designs can be more expensive, current adapters all need to be changed out to fit ENFit, and technicians now must draw up meds with a twisting motion verses a slip tip (leading to a potential ergonomic issue for technicians). The low dose ENFit Pharmacy Syringe is designed to work within that +/-10% accuracy, are FDA-approved, and can work well if Pharmacy is aware of the issues and prepared. The larger hub on the ENFit syringe can also harbor additional medication if not properly drawn up and administered.
(Hub on ENFit Syringe)
ENFit works well for hospitals and provides safety, but it is a change in practice that requires proactive preparation and education. Another important part of preparing for this change is awareness, so you can help your facility be ready.
How Can Medela's Dual Cap Help?
A product is available that allows both nursing and pharmacy to avoid all these issues, including the large tip, cost, product changes, and technician impact. The Dual Cap is a product that was developed to specifically address the issues that impact NICU/Pediatrics and Pharmacy by allowing clinicians to control the method of administration.
The Dual Cap solution allows Pharmacy to continue purchasing their non-sterile, bulk-supplied PO syringes and not change to the ENFit low dose version, which has the large tip and threads. Pharmacy will draw up medications the same way they are doing today – with no new cost, adapters, or twisting motion needed. Medications will come to the nursing units in the PO syringe and nursing controls how to administer – if PO, the syringe can go directly into the infant’s mouth. If NG, the Dual Cap is put onto the end of the PO syringe and administered via the NGT. Also, the large hub on the ENFit syringe does not need to be addressed for accuracy and there is no need for a medication cap. This is a simple solution for all the issues of the new design when administering low dose medications. Here are some photos of the Dual Cap for reference:
Recommendations to move to ENFit are moving forward in 2021. In order to be prepared for this change, be aware of how this will specifically impact your NICU, Pediatric Units and Pharmacy. Product and education options are available to make it easier for whatever decision you make. After all, it’s all about safety and what works best for your facility’s needs.
About the Author
Kathleen 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 LLC since 2014. She covers hospitals all throughout the western United States.