• Article
  • March 8, 2017

Solving the Problem of Incompatible Tubing Connections

Children's hospitals face challenges in the transition to ENFit enteral devices. Here's how one hospital is tackling the serious problem.

Two years ago, The Joint Commission (TJC) issued a Sentinel Event Alert urging vigilance among health care organizations regarding the transition to globally-accepted standards for tubing connections. The compatibility of different types of tubing connections has presented potential danger to patients, including severe injury and death. 

The ENFit transition is aimed at reducing or eliminating adverse events associated with tubing misconnections. But the transition has also created a different set of challenges and concerns. 

A team of clinicians from Children's Mercy Hospital in Kansas City, Missouri, established a series of guidelines to work through this transition and recently published an article in the American Journal of Health-System Pharmacy detailing those practices. But first, some background on the issue. 

The state of misconnection errors

According to TJC's Alert, "Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected using Luer connectors, or connections can be 'rigged' (constructed) using adapters, tubing or catheters." The alert cited more than 100 errors resulting in 21 deaths  due to misconnections involving enteral feeding tubes and IV lines alone.

In one such case, a fetus and expectant mother were killed when a feeding tube was accidentally connected to the mother’s IV line. "The risk for tubing misconnection is high, considering that almost all patients admitted to the hospital are likely to receive an IV," according to TJC's Alert, warning that adverse events due to tube misconnection errors were likely underreported. 

The Global Enteral Device Supplier Association (GEDSA) is a collaboration of product manufacturers working to develop a tubing system for enteral feeding and medications—the ENFit system—that is incompatible with the traditional Luer lock system. The connections prevent linking of an ENFit syringe to non-ENFit products, such as IV and respiratory tubing to prevent an adverse event. But with this solution comes other challenges.

"Dead space" concerns

One concern with the ENFit system was how to deal with "dead space." Dead space refers to the volume of liquid left in the tip of the syringe not delivered to the patient when the gradient marking is at zero. ENFit syringes have a dead space of 0.15 mL to 0.20 mL, which can lead to a dosage reduction within that range. In the case of pediatric patients, that can be medically significant. At Children's Mercy Hospital, for example, roughly 30 percent of pharmacy-prepared oral doses are less than 1 mL. With a dead space volume of 0.15 mL, that could mean a dose discrepancy of anywhere from 10 percent to more than 100 percent.

Many manufacturers involved in the ENFit initiative have addressed this dead-space concern with syringe redesigns. Though effective for the enteral route, the range of solutions can create confusion for health care providers, patients and families as well as increased costs.

Children's Mercy's approach 

The team at Children's Mercy began tackling this challenge by assessing their enteral feeding and medication practices. The team determined which patient groups would be most affected by focusing on inpatient and ambulatory high risk areas.  In this manner, the team was able to make product implementation decisions. 

One particular concern: patients who require enteral treatments at home. Not only will the transition to ENFit present an added layer of complexity and confusion for patients and families, but the transition will complicate their ability to locate and acquire necessary supplies. Those concerns are highlighted in the results of a 2015-2016 survey conducted by Children's Mercy. The hospital canvassed several outpatient pharmacies in the area and found most were unaware of the ENFit transition with no plans to stock any ENFit supplies.

Communication, education are key elements

The team at Children's Mercy says communication and education, inside and outside the institution, are vital to navigating this complicated transition to ENFit enteral devices.

Here are the steps the team at Children's Mercy is taking:

  • Sent a letter to patients, families and caregivers to announce and explain the changes
  •  Developed a detailed informational pamphlet to share with patients and families on discharge
  • Formed a committee with representation from all levels of patient care to develop guidelines and processes to ensure patient safety through the transition to ENFit enteral devices
  • Established new processes for the ordering and administration of medications for patients impacted by the transition, aiming for uniformity in dosage and route communications
  • Organized a community-wide collaborative designed to open the lines of communication within the local provider community

Here's more information on this topic, including an opportunity to share information with other children’s hospitals via CHA’s Value Analysis program.