ENFit Solutions for Pharmacy and NICU/Pediatric Clinicians

ENFit is moving forward across the United States. The NICU/pediatric and pharmacy areas will be impacted by the new design, including medication administration.

Undoubtedly, this makes clinicians concerned. But solutions are available.

These solutions will make everyone satisfied in all areas – including the NICU and their smallest of patients.

ENFit background

The ENFit connector design has three specifications to be aware of:

• Male/Female tips are switched
• It is a locking system
• Color is not mandated (orange or purple is fine)

The male/female switch has resulted in a larger opening on syringes. It equals larger dead space, which leads to the possibility of over/under dosing smaller patients in the NICU and pediatrics. This issue was solved by the Global Enteral Device Supplier Association (GEDSA) and enteral feeding manufacturers with an FDA approved “low dose syringe.”

ENFit low dose syringe

The ENFit low dose syringe allowed for accuracy of +/-10% at 0.2 mL.

Given the dosing accuracy resolution, it appeared the dosing issue had been resolved. But another concern arose: the low dose syringe had a much larger tip.

Many clinicians expressed concern over placing such a large tip into an infant’s mouth. In addition, if medication were drawn up from a cup, the moat-like area around the tip could trap medication.

That led to questions from pharmacy.

Pharmacists expressed concerns over the large tip, along with other issues unique to the pharmacy.

They typically use bulk-supplied, non-sterile syringes for PO administration. Those syringes are the ones nurses see when sent up to the units.

With that in mind, ENFit syringes could impact pharmacy in three ways:

• Cost – The new connector designs may increase costs.
• Products – The new designs resulted in new adaptors and caps that fit with ENFit, which was an issue for clinical areas also.
• Technician Impact – A Pharmacy Tech typically draws up medications from a slip tip, and it can be done rather quickly. With the new ENFit locking connectors, technicians would constantly be turning and twisting to draw up medications. That could lead to ergonomic issues for technicians. One publication, Advisor Live, pointed out that Children’s Hospital in Philadelphia drew up about 2,500 oral medications (per day!).1 That amount of twisting motion could impact efficiency and comfort for technicians.

Solutions for pharmacy, NICU, and pediatrics

There are solutions for the large-tipped low dose syringe to meet everyone’s need.

These solutions are in the form of oral adaptors for oral administration. One important thing to note before I list them: These will work but they add to the dead space and must be flushed for accurate administration.

3 ways to use ENFit low dose syringes:

1. The low dose syringe can be used as-is with the large tip. It’s a clinician concern, but the syringe can be used in this manner.
2. Straws for oral administration can be used to draw up medication from cups and avoid overfilling medication in the “moat” area of the tip. The straws must be readily available and used by everyone, for every medication, to be a successful solution.
3. Use a product called the Medela Dual Cap. The Dual Cap is a low dose cap (to maintain accuracy) that can be applied when needing to give medications enterally. It gives greater flexibility to meet the needs of different areas of the hospital.

How the dual cap works

The Dual Cap is used like this:

• Pharmacy continues to draw up in current PO syringes (the bulk supplied, non-sterile syringes and non-ENFit)
• The PO syringes are sent to the floor, as is currently done today.
• If the clinician wants to give the medication PO, then the large tip is avoided.
• If the clinician wants to give the medication enterally, then the Dual Cap is applied and makes the PO syringe an ENFit syringe. It is recommended to pull back for a small air flush of 0.3 mL.

The Dual Cap solution allows the pharmacy to avoid any changes to their current practice, eliminate cost increases, reduce the need for multiple new adaptors, and alleviate technician ergonomic impact.

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For clinicians on the units, the Dual Cap avoids having to put a large tip into an infant’s mouth (or use adaptors and straws).

Clinicians have many solutions to choose from. The big takeaway is to know that you have multiple options. Know the issues, evaluate options, ask to see manufacturer solutions, and be sure to include pharmacy in your decision process.

The switch to ENFit connectors is all about safety and avoiding misconnections, but all these areas must be closely considered. Look closely at the changes ENFit can bring. That will allow you to find what’s right for your institution, resulting in an easier and safe transition.

 

REFERENCES

1. Advisor Live^® Transitioning to ENFit Connectors: A Safer Enteral Feeding System. July 14, 2016 (Simmons, Hancock, Cohen, Pugliese)