Enteral Feeding: Clinical Units and the Pharmacy

Enteral feeding choices in the NICU are normally decisions made by clinicians in the NICU, based on nursing preference, and with possibly a bit of purchasing guidance for some of the financial pieces.

Pharmacy has always had a small part in enteral feeding, as they send up enteral syringes for both PO and enteral administration. No one ever considered calling the pharmacy to ask what NGT or extension set the NICU or Pediatric Unit should be using. We, the nurses, picked what we liked and they, the pharmacy, sent up syringes of medication that we used. This was a harmonious process for years, and worked very well.

Now several changes have entered by the way of regulating agencies and new products that are forcing some collaboration between pharmacy and the clinical areas when working with enteral feeding disposable products: NGT’s, extension sets, syringes, bags, and anything that works within the enteral arena.

GEDSA, The Global Enteral Device Supplier Association, has created enteral connectors based on AAMI and ISO recommendations that have been embraced by the global medical community, regulating bodies in the US, and other countries. GEDSA named these enteral connectors ENFit connectors. The recommended enteral connector changes are:

• All male/female connectors are to be switched
• Enteral connectors must be locking
• Color is not mandated (can be orange or purple)

Pharmacy is now involved because those PO/enteral syringes that were sent up to the units have to fit with the new enteral connector design. In fact, it was pharmacy leadership (via ISMP Newsletter April, 2015) that alerted GEDSA and the clinical community last year that the new female designed syringes had too much dead space for our NICU/Pediatric and some adult units.

The female design on ENFit syringes made doses under 2 mL less accurate than +/-10% (and more like +/- up to 40%) and that was an issue. Cries of “no way” and “we can’t use these” went out from clinicians everywhere. These were heard loud and clear by the regulating agencies and vendors, and changes were quickly made. New ENFit syringes (called low dose syringes) have been designed and are now cleared for use by the FDA.

Pharmacy became involved at a critical time and they have remained involved in this process. It’s no longer a unilateral NICU/Peds unit-based decision when moving to ENFit products. Pharmacy needs to be involved as pharmacy vendors supplying bulk, non-sterile syringes to the Pharmacy now need to be moving to ENFit products along with clinical units.

Not all pharmacy vendors are ready or will move to ENFit. Pharmacy and clinical units now need to look at 2 choices: 1) acceptable products for work flow and 2) products that work well between clinical units.

ENFit changes are not just coming – they are already here. Discussions need to begin to make changes that are all about avoiding misconnections and making patient care safer. With that said, knowing how to avoid some of the pitfalls – like not involving pharmacy in the decision-making process – can help make the transition easier.

If your unit moves to ENFit, and Pharmacy does not switch vendors or switch to the correct ENFit design, then enteral medications will have dosage issues. Also, if an infant comes in from another hospital or goes to a home care facility that does not have ENFit, how are you going to address giving feedings and meds? This can happen in reverse if your hospital is the one without ENFit and gets the ENFit patient.

Hospitals across the country have begun moving to ENFit. Pharmacy is aware this can happen, and they are asking for solutions along with clinicians because they need to administer mediations via these products.

Manufacturers have worked on solutions to these issues. Medela does currently offer two solutions:

1) A Dual Cap that enables the pharmacy to keep using their current non-ENFit PO/enteral syringes, but allows the clinician freedom to switch to ENFit.

2) A Transition Cap that can make ENFit designs compatible with non-ENFit designs.

The important thing is to get everyone involved: clinicians and pharmacy, when planning for these enteral feeding connector changes in your hospital. It will give the entire extended team a chance to make this process of change work for them, especially at the right time.

I also recommend looking at GEDSA.org as they provide so much information and guidance for all departments in this process. As always, some simple planning will allow the process of moving to ENFit much easier. That helps everyone who needs to be involved be satisfied with decisions made.