Transcript Breakout Session: Preventing Enteral Misconnections

Breakout Session:
Preventing Enteral Misconnections
Michelle Kozeniecki, MS, RD, CNSC
Clinical Dietitian, Froedtert Hospital
WiSPEN 2014 Fall Symposium
September 18, 2014
Objectives
• Identify and prioritize devices and practices
vulnerable to tubing misconnections
• Establish processes and device selection
guidelines to help safeguard against enteral
device misconnections
What is an Enteral Misconnection?
Definition: “An inadvertent connection between
an enteral feeding system and a non-enteral
system such as an intravascular line,
peritoneal dialysis catheter, tracheostomy,
medical gas tubing, etc.”
The Joint Commission Journal on Quality and Patient Safety 2008; 34(5): 285-292.
How Can Enteral Misconnections
Happen?
Contributing Factors
• Compatible tubing between unlike systems
(universal design)
• Use of IV syringes for oral medications
• Universal Spike for bags
Devices Vulnerable to Tubing
Misconnections
• Small-bore connectors (SBC): The Luer connector is a
classic type of SBC that allows direct or functional
connection between unrelated delivery systems
(e.g. vascular,
enteral,
respiratory,
epidural, and
intrathecal medical
devices,
components and
accessories)
http://www.fda.gov/MedicalDevices/Safety/MedSunMedicalProductSafetyNetwork/ucm127745.htm
Why is this Important?
• Case Report: A 24-year-old woman was 35
weeks pregnant and hospitalized for vomiting
and dehydration. A bag of ready-to-hang EN
was brought to the floor and the nurse
erroneously gave the EN through her IV line,
assuming it was PN. The fetus and mother
died after several hours of excruciating pain
• An overall 33% rate of permanent patient
harm or death has been reported.
The Joint Commission Journal on Quality and Patient Safety 2008; 34(5): 285-292.
Call for Design Changes
• All product manufacturers were urged to
implement “incompatibility by design” features
to prevent inappropriate connections when
attempted1.
• The new design was a group effort
– An international group of clinicians, practice experts,
manufacturers, and regulators
– International Organization of Standardization (ISO)
– Association for the Advancement of Medical
Instrumentation (AAMI)
1The
Joint Sentinel Event Alert. Tubing Misconnections – A Persistent and Potentially
Deadly Occurrence. March 27, 2006.
Nutrition End Connection
• ISO standard connectors
were universally adopted
on the nutrition end of
feeding/administration
sets in 2012
• Purpose: To prevent the
inadvertent use of IV
tubing as an enteral
administration set.
Patient-Access End Connection
(ENFit connector)
• Addresses “patient side” connections between
feeding tubes and administration sets,
medication, flush and bolus feeding syringes,
and other enteral devices
• Purpose: To help reduce the risk of enteral
tube feeding misconnections and improve
patient safety
Patient-Access End Connection
(ENFit connector)
• Unique design
– Does not allow connectivity with any other
connector for any other clinical use
– Provides a locking feature that signals the
appropriate connection and stays in place
• One-year transition timeline
Patient-Access End Connection:
Administration Sets
• Administration sets will be available starting
October-December 2014*
• Administration sets will have a transition
adapter to facilitate
compatibility between
the new and existing
designs, until new
enteral tubes are available
*All dates are projected estimates and subject to change
Patient-Access End Connection:
Enteral Syringes
• Enteral-specific syringes will be introduced
December 2014-March 2015*
• To be used for medications, flushes, and bolus
feeding
• Oral-tipped and
Luer-tipped
syringes will
not fit the new
ENFit
Connector
*All dates are projected estimates and subject to change
Medication Administration:
Best Practices
Review current systems and practices:
• Communicating the order/route (prescribers)
– In one study, 574 of 601 medications (96%) that
were ordered as “PO” were administered by
feeding tube
• Preparing and labeling syringes (pharmacists)
– Ready-to-administer enteral drug products
• Preparing and administering enteral meds
(nurses)
Patient-Access End Connection:
Enteral Tubes
• New enteral feeding
tubes with ISO standard
connectors will be
available starting April
2015*
*All dates are projected estimates and subject to change
“What can I do?”
• Look for education opportunities (see next
slides)
• Identify a champion or leader
• Make sure all stakeholders are aware and
involved
• Review protocols on feeding tube placement,
EN, and medication delivery for any needed
revisions
• Revise patient education materials
Resources
Timeline and FAQs:
www.StayConnected2014.org*
www.gedsa.org
EN Safety Toolkit:
www.nutritioncare.org/Guidelines_and_Clinical
_Practice/Toolkits/Enteral_Nutrition_Safety_T
oolkit/
*Stay Connected
Stay Connected is a program designed to facilitate
the transition from medical device applications
that allow connection between unrelated
delivery systems to new, safer connectors that
ensure compatibility and consistency while
reducing the likelihood of tubing
misconnections.
Stay Connected is organized by the Global Enteral
Device Supplier Association (GEDSA) in
partnership with leading industry organizations.
Stay Connected
www.StayConnected2014.org
• Sign up for the latest updates!
– Email notifications when new tools and
information is added
• Coming soon:
– Set of checklists for clinicians, manufacturers,
supply chain managers, etc.
– Short (5 min) video with connector animation
– In-service tool that can be used at your facility