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ENFit Safe Enteral Connections Transition: Don't panic!

(Note: This is a cross-post, written on behalf of the Feeding Tube Awareness Foundation.)

In case you have not heard yet, change is coming to enteral feeding (aka tube feeding). It is a HUGE deal, and although I am no expert on the subject, we (Feeding Tube Awareness Foundation) have been in close communication with the Global Enteral Device Supplier Association (GEDSA), which is the organization responsible for facilitating the changes. We are doing our best to educate ourselves and stay apprised of what is coming in 2015-2016 and share that information with others. I do not claim to know everything, but I do want to share some of what I have learned in hopes of helping other people to not panic. Because let's face it, other people making changes to the way we feed our tube fed children = cause for panic. But don't panic, everything will be okay!

WHY:
First, let's go over why the changes are being made. One only need glance through this article about horrifying real-life examples of medical devices being connected to the wrong tubing in order to understand why change to medical connections is a good thing. The examples given in that article are incredibly disturbing. While it is hard to believe that medical professionals with any level of competency could make some of those mistakes, others are not so difficult to believe and illustrate the need for incompatibility between devices that are not meant to be connected to each other, such as IV tubing and feeding pumps, or trachs and feeding pumps. (and the one about the NG tube being connected to the Foley catheter is just gross.) Bottom line: enteral devices need to be compatible ONLY with enteral devices to avoid harmful and potentially fatal misconnections.

WHAT:
Beginning in Q1 2015, a transition to the new ENFit connections will begin to roll out in phases. It will be a slow process, which will help keep things running smoothly. There have already been many changes made to the timeline, which I feel is an indicator that the process is being done carefully so that the transition will be a smooth one.

(*Note: I am using the terminology used by GEDSA at www.stayconnected2014.org)

The first phase of the transition will include the administration sets changing from the current Christmas tree plugs to the new ENFit connectors. These are some of the current connections that we are all familiar with:
L: Kangaroo Joey administration set with MIC-KEY single port extension
R: MOOG EnteraLite Infinity administration set with AMT Y port extension


In place of the purple and red administration set connectors in the above picture will be the new ENFit administration connector. This is a generic example of what the new ENFit administration connector will look like:

In the first phase of the transition, administration sets (i.e. feeding pump bag plugs) will be changed to the new ENFit connector, like the above picture, and will include an adapter. The adapter will twist onto the ENFit administration set and will be a temporary feature that will only be included until the final phase of the transition. At that time, the adapters won't be necessary anymore.
This is a generic example of what the first phase (new ENFit pump bag plug + adapter) will look like:

Many people have expressed concern that the transition will make their current supplies unusable and we want to reassure everyone that this is not the case. The adapter piece will make it possible to use new ENFit administration sets with any extension sets you already have on hand. Here's what that will look like:
(wow, I need some lotion)
Here is how it would look connected to a Corpak NG tube:

Having said all that, these adapters will only be a temporary item. During the transition period, each administration set will come with an adapter. Once the final phase of the transition is complete, adapters will not be issued along with the administration sets anymore. {Reading between the lines, if you have a stockpile of the current extension tubes and are concerned that you won't use all of them before the final transition takes place, it wouldn't be a bad idea to save a few of the adapters so that your supplies don't go to waste.} If you do have a large stockpile, it's time to start moving through it, whether that means using the supplies yourself or sharing them with other people through non-profits and supply exchanges.

In the next phase of the transition, new ENFit syringes will be introduced. During the transition phase, syringes will also have adapters so that they can continue to be used with the current feeding tube connectors. I don't have any samples of ENFit syringes so there are no pictures, but they will come in a variety of sizes just like the syringes that are currently available. Be aware that once the transition is complete, cath tip, oral/slip tip, and Luer tip syringes will NOT be compatible with the new ENFit connections so you will not be able to use them. (believe me, I have tried and they don't fit)

The final phase of the transition will be when the feeding tube connectors change to ENFit connectors. At that point, the temporary adapters will be discontinued. This is a generic example of what the ENFit feeding tube connectors will look like:

This is what the inside of it looks like:

And here are both ends of the new ENFit connections side by side, with the feeding tube end on the left and the administration set end on the right:

The two pieces twist snugly together, and this is what they look like when they are connected:

Our friends at Nestle' were kind enough to show us some prototypes of their new ENFit feeding tubes. The top one is an NG tube and the bottom one is a PEG-type G tube:
Over the years, we have had problems with things like NG tube ports stretching and caps not staying closed, med ports popping open overnight and feeding the bed, leaking from extension tubes without caps, feed sets disconnecting from extensions or NG tubes during feeds, and syringes popping out of extension tubes during bolus feeds. No product is perfect and I imagine that over time, those of us who use these products daily will find their flaws, but overall I think the new connections are going to eliminate a lot of the common problems we currently have with feeding tube connections.

GEDSA has been very receptive throughout the process to concerns and questions from consumers. One of those concerns is whether or not the use of blenderized diet will still be possible due to the sizes of the openings in the new connectors. You can see here that the inner diameter of the new connection is the same size as the inner diameter of both the Infinity and the Joey connectors:
GEDSA's website does say that the use of an adapter with a syringe during the transition phase could result in a slightly smaller hole, but that as long as the hole in the extension tube is the smallest hole, the flow of formula should not be impacted. Keep in mind that the size of the hole in the actual feeding tube (G, GJ, J, and NG) will not change, nor will the size of the connector that connects the extension tube to the button for low-profile tubes, so if it works now, it will still work with the new connectors. The same goes for venting with the new ENFit syringes. The principle will still be the same: pull the plunger out of the syringe, connect to an extension tube, connect the extension tube to the button, and vent. The only difference will be the way the extension tube and syringe fit together.

HOW DO WE PREPARE:
These are the recommendations from GEDSA:
1. Learn about the products that are changing
2. Understand the transition to the new connectors
3. Have the right products on hand
     -Use up existing products and do not buy more than you need
     -Transition as soon as possible
     -Use the products only as directed
(Source: Transition Checklist for Patients and Caregivers)

TIMELINE:
The current timeline for the transition is this:
Q1 2015: ENFit administration sets with adapter available
Q2 2015: ENFit syringes available
Q3 2015: ENFit feeding tubes available
Q1 2016: Transition to ENFit connectors will be complete

This timeline could change, but this is what we should be expecting to see. Now is the time to start talking to your supplier about the changes, take inventory of the supplies you have on hand, and think about letting some of them go if you have a large stockpile.

CONCLUSION:
Yes, there will be changes. Yes, there will be some adjustment required of all of us, and yes, there will probably be some aches and pains associated as we all adapt to our new supplies. However, the transition process has been planned carefully and we all need to try to embrace these changes and be optimistic! DON'T PANIC! Remember that the final objective is to make all of these products safer by eliminating the possibility of accidental misconnections that could seriously injure or kill our loved ones who depend on medical devices.

For more information:
GEDSA's website has a wealth of information about the ENFit connections transition process. Here is a list of helpful links and resources that I strongly recommend looking at, starting with this video:


GEDSA's Stay Connected website: stayconnected2014.org
Timeline for ENFit Transition:  http://www.stayconnected2014.org/index.html#year2015
Patient/caregiver checklist: stayconnected2014.org/media/pdfs/Checklist-PatientCaregiver.pdf
FAQs about ENFit: http://www.stayconnected2014.org/media/pdfs/GEDSA-enteral-FAQ.pdf
FAQs for Blenderized Diet: stayconnected2014.org/media/pdfs/GEDSA-blenderized-FAQ.pdf
Article on Blenderized Diet and ENFit: http://www.oley.org/lifeline/TubetalkJA2014.html
Feeding Tube Awareness Foundation on facebook: https://www.facebook.com/FeedingTubeAwareness

Comments

  1. We use the corisafe to keep the kid from disconnecting his overnight feeds and feeding the bed all night… It looks like it won't fit the new connectors, but will the new connectors be stable enough to stay connected overnight?

    ReplyDelete
    Replies
    1. Judging by the sample I was given that you see in the pictures, it seems to me that the connections will twist together tightly enough to stay connected. It's hard to say for sure until we actually get the new products and start using them but if they are like the sample, they will stay connected better than what we currently have.

      Delete
  2. they addressed that? My meds come with a cap that the oral syringes fit nicely in, so I can turn them upside down to fill syringes. It makes it much easier to accurately dose (and if you're only giving .33 ml, accuracy is critical!). The way I see it, the new syringes won't fit those, and it will get the meds all over the connection part if you're dipping into a bottle. Any ideas on how they're working on that?

    ReplyDelete
    Replies
    1. The details on specific products haven't been made as widely available but manufacturers are starting to release information. The process for getting new products developed to standard and approved for use takes time so a lot of the specific details just aren't known yet but that doesn't mean the issues aren't being dealt with. I did come across an article from the Institute for Safe Medication Practices this morning that shows that the industry is aware of the need for bottle cap adapters that are compatible with ENFit syringes. Here's a link to that article: https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=86
      There may not be solutions for some of those things yet but know that they will come. In the transition period, there will be adapters for syringes so that they can still be used with bottle cap adapters for slip tip syringes. You can see examples of those here: http://www.amtinnovation.com/pdf/ENFit_WebVersion_2.pdf

      Delete
  3. I won't lie, I'm still really nervous from the BD standpoint. All the reassurances I've seen, including your point above, assume we are feeding BD using a delivery set. We use cath tip syringes and fat extensions. I know the button hole itself is small, but having a bottleneck from the start just makes me nervous. I assume there will be 60 mL syringes with the new connection tip, and that's what we will have to use, but I can't even picture how we'll draw up her food via that tiny little hole. And in our case, insurance/medicaid doesn't cover syringes, and we had to buy ours from a vet supply to get enough of a good quality kind. That is the heart of my, and many others, concerns about BD, since clearly the vet supplies are not changing to these connections. So for now, I'm stockpiling buttons, extensions and syringes and hope to be able to use these for a good long time.

    ReplyDelete
    Replies
    1. *sigh* I know. That's what everybody is worried about and believe me, I get that. I wish we had more answers but the products are still being developed and/or manufacturers haven't shared specifics for everything yet. Would you feel better if I told you that AMT will have an adapter you can use with the ENFit extensions that will make it like the current bolus extensions (i.e. compatible with cath tip syringes)? It's on the second page of the brochure: http://www.amtinnovation.com/pdf/ENFit_WebVersion_2.pdf

      Delete
    2. Yes!! That's exactly what we will need, but I didn't think there would be a piece like that! Thank you!

      Delete

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