GUIDANCE FOR THE PRESCRIBING AND ORDERING OF STOMA ... · Stoma Bags and Pouches ... Guidance on recommended quantities of stoma appliances is included within this document. ... discard

GUIDANCE FOR THE PRESCRIBING AND ORDERING OF STOMA APPLIANCES AND ADDITIONAL PRODUCTS Updated: January 2018 Review: January 2020

NHS FIFE Guidance for the Prescribing of Stoma Appliances and Additional Products 2017

CONTENTS PAGE INTRODUCTION.............................................................................................................................................................................3 ORDERING OF APPLIANCES.......................................................................................................................................................3 NEW PATIENTS..............................................................................................................................................................................4 REQUESTING PRESCRIPTIONS...................................................................................................................................................4 ISSUING PRESCRIPTIONS............................................................................................................................................................5 DISPENSING PRESCRIPTIONS.....................................................................................................................................................6 SUMMARY OF KEY POINTS..........................................................................................................................................................7 STOMA PRODUCTS PRESCRIBING AND QUANTITY GUIDE Stoma Bags and Pouches.............................................................................................................................................................9 Additional Products........................................................................................................................................................................................10 ADDITIONAL PRODUCTS FORMULARY Adhesive Removers.....................................................................................................................................................................14 Barrier Products...........................................................................................................................................................................15 Solidifying Agents........................................................................................................................................................................15 USE OF MEDICINES IN STOMA MANAGEMENT Medicines to use with care or avoid .........................................................................................................................................17 Antidiarrhoeals............................................................................................................................................................................18 ACKNOWLEDGEMENTS/REFERENCES.....................................................................................................................................20 APPENDIX – Overuse of Stoma Products..................................................................................................................................21

2 Author: W.McFarlane Colorectal Specialist Nurse Date: January 2018 K.Whatton Senior Prescribing Support Nurse Review: January 2020


INTRODUCTION

NHS Fife’s annual spend on stoma and associated additional products exceeded £2million in 2016. The specific needs of this patient group and the plethora of appliances and additional products result in primary care prescribers feeling ill equipped to modify or properly review a patient’s prescription. This guidance aims to provide basic information on appropriate and cost-effective stoma care prescribing.

ORDERING OF APPLIANCES • It is essential for patients to carry adequate stock of stoma appliances and be able to order additional supplies in plenty of

time.

• Poorly controlled prescribing can be wasteful and expensive. Over prescribing and over ordering of stoma appliances are frequently identified as significant areas of wasteful / unnecessary prescribing.

• As a general rule, no patient should be ordering in excess of TWO month’s supply at any one time.

• It should be recognised that, on occasion, patients may require larger quantities than normal.

• If patients are identified as routinely over ordering, it would be appropriate to discuss this with the patient and, if necessary,

ask them to contact / refer them to CSCNS (Colorectal/Stoma Clinical Nurse Specialist) for review.

• In exceptional circumstances, where the patient is unable to order their appliance, for example a patient with cognitive impairment with no carer who can order for them, it is acceptable for a DAC (Dispensing Appliance Contractor) or Community Pharmacist to telephone the patient to initiate the order as long as the time between contacting the patient and submitting the order to the GP is no longer than 7-10 days (with leeway for weekends and holidays). DACS must inform the GP practice when they are ordering appliances on behalf of a patient.



NEW PATIENTS • All new patients discharged from hospital with a stoma, will be given the choice of having prescriptions for stoma appliances

supplied by either a Dispensing Appliance Contractor (DAC), from a local Community Pharmacy or a dispensing doctor practice. New patients will have the process for ordering prescriptions and choices for having them dispensed explained to them by a CSCNS.

• On discharge, all patients should be supplied with a minimum of 7 day’s supply of stoma appliances. • On discharge, the CSCNS will provide the patient’s GP practice with a list of products being used, using the IDL (Immediate

Discharge Letter).

• Where patients choose to have their products supplied by a Community Pharmacy or DAC, the CSCNS, with the patient’s consent, will also provide the Pharmacy/DAC with a list of products.

• The product information to be provided will include: o Name and type of product o Manufacturer o Product code / product order number o Pack size o Frequency of use o Suggested number of packs required each month

• GP practices should use the list provided by the CSCNS to generate an initial repeat prescription list for patients to request

prescriptions.

• There may be some occasions e.g. when the condition of a stoma changes, when a patient will require products quickly. In such emergency circumstances a retrospective prescription may be required but this will only be arranged with prior permission from the prescriber. When these emergency circumstances have resolved prescriptions should then be issued before dispensing occurs.



REQUESTING PRESCRIPTIONS • Patients or their carers (including care home staff), should ensure that only products which are actually required are ordered,

in order to reduce wastage.

• Patients or their carers should usually only order items which are on their current repeat prescription list. • If a patient wishes to order additional / alternative items to those usually requested, they should first contact a CSCNS for

advice. • Following a review with a CSCNS, any changes made to a patient’s products will also be notified to the patient’s GP practice

in writing in order to ensure prescriptions are accurate. A copy of this form may also be sent to the relevant DAC or Community Pharmacy contractor, but only with the patient’s consent to do so.

• Any review with a patient should be used as an opportunity to ensure patients are ordering appropriate products, and in

quantities appropriate to their needs.

ISSUING PRESCRIPTIONS • The procedure for obtaining stoma appliances is for the patient or carer to request a prescription from the patient’s GP for

items listed on the patient’s current repeat prescription list. Once the prescription has been generated, it can either be dispensed by a DAC, Community Pharmacy or Dispensing Doctor Practice.

• Prescriptions should only be generated at the request of a patient, patient’s carer or CSCNS.

• Practices should ensure there is as little delay as possible in issuing prescriptions to reduce any delay patients experience in receiving stock. The Scottish Government recommends gold standard of 5 working days from request for prescription to patient receiving supplies.

• Prescriptions should be checked to ensure that products and quantities requested are appropriate to the needs of the patient

and not excessive, to prevent waste.(See Stoma Products Prescribing guide page 8) 5

Author: W.McFarlane Colorectal Specialist Nurse Date: January 2018 K.Whatton Senior Prescribing Support Nurse Review: January 2020


• No appliances should be supplied to a patient prior to a prescription being issued. Retrospective prescriptions should not be

issued except in emergency situations and only at the request of a patient, patient’s carer or CSCNS.

• It may be useful to have a system to ensure that named staff deal with requests from appliance contractors. DISPENSING PRESCRIPTIONS It is imperative that patients are made aware that they have the choice as to where their prescriptions may be dispensed. • It is helpful for practices to retain a note of patients’ dispensing preferences to aid communication

• DACs or Community Pharmacies must not dispense stoma appliances before being in receipt of a valid prescription, except in

the dispensing of urgent supplies. • In exceptional circumstances, urgent supplies may be dispensed by a contractor before receiving a prescription but only at the

request of a prescriber or CSCNS and with the prior permission of the prescriber. In such circumstances the prescriber must undertake to provide a prescription to the contractor within 72 hours.

• If urgent supplies are made on the request of a CSCNS, the CSCNS will arrange for a prescription to be issued and provided

to the contractor. • Alternatively, in urgent situations, the DAC, Community Pharmacy or Dispensing Doctor must contact a prescriber and request

their permission to supply the stoma appliance in advance of receiving a prescription.



SUMMARY OF KEY POINTS • Patients should be encouraged take responsibility for ordering their own supplies where possible.

• Patients must request a prescription before placing an order for any stoma appliances.

• Patients should only order items on their current repeat prescription list.

• If a patient wishes to order additional/alternative items, they should be encouraged to contact a Colorectal/Stoma Clinical

Nurse Specialist for advice first. • Following a patient review, the Colorectal/Stoma Clinical Nurse Specialist will inform the patient’s GP of any changes to

stoma appliances. Practices should update the patient’s repeat prescription list with this information. • Prescriptions for stoma appliances can be dispensed by either: a community pharmacy contractor, a dispensing doctor or a

dispensing appliance contractor. It is the patient’s choice which dispenser to use. • No stoma appliances should be supplied before the dispenser is in receipt of a valid prescription. Retrospective

prescriptions will only be issued in an emergency.

• Practices should ensure there is as little delay as possible in issuing prescriptions to reduce any delay patients experience in receiving stock

• Guidance on recommended quantities of stoma appliances is included within this document.

• Practices and patients can contact the Colorectal/Stoma Clinical Nurse Specialist for further advice either by telephone on

01592 643355 Ext 21062 or 21051. 24 hour patient helpline (answer phone) Ext 28800. NB Messages from Helpline are picked up Monday – Friday 0730-1530)



Stoma Products Prescribing and Quantity Guide

The recommended quantities stated on the following pages are those considered reasonable the majority of patients for One month’s supply.

N.B CSCNS – Colorectal/Stoma Clinical Nurse Specialist



STOMA BAGS AND POUCHES N.B New requests for Convex bags should be referred to the CNCSN Appliance Usual Quantity Guide

(monthly unless stated) Prescription directions

Notes

Colostomy bags - one piece systems

30 -90 bags Flat bags (1-3 boxes of 30) Convex bags (6-9 boxes of 10)

Remove and discard after use.

Bags are not drainable/ reusable. Usual use: 1-3 bags per day. Flushable bags only to be used on advice of CSCNS.

Colostomy bags – two piece systems

30-90 bags - (1-3 boxes of 30) PLUS 15 -20 Flanges/Base Plates – (3-4 boxes of 5)

Bag – remove and discard after use. Flange/Base Plate – change every 2-3 days.

The flange (base plate for 2 piece system) is not usually changed at every bag change. Items ordered separately. Usual use: 1-3 bags per day, 3-4 flanges/base plates per week.

Ileostomy bags – one piece systems

15-30 bags Flat bags (0.5 -1 box of 30) Convex bags (1-3 boxes of 10)

Drain as required throughout the day.

Usual use: Use a new bag every 1-3 days. Bags are drainable.

Ileostomy bags – two piece systems

15-30 bags PLUS 15 -20 Flanges/Base Plates – (3-4 boxes of 5)

Bag – change every 1-3 days Flange – change every 2-3 days

The flange (base plate for 2 piece system) is not usually changed at every bag change. Items ordered separately. Usual use: 1-3 bags per day, 3-4 flanges per week.

Urostomy bags – one piece systems

10-20 bags Flat bags (1-3 boxes of 30) Convex bags (6-9 boxes of 10)

Drain as required throughout the day

Bags are drainable. Usual use: new bag every 1-3 days.

Urostomy bags – two piece systems

10-20 bags PLUS 15 -20 Flanges/Base Plates – (3-4 boxes of 5)

Bag – change every 2 days Flange – change every 2-3 days

Renewed at every bag change. Items ordered separately. Flange not normally changed at every bag change.



Night drainage bags for urostomy patients

4 bags (1 box of 10 bags every 2-3 months)

Use a new bag every 7 days.

Bags are drainable

Flange extenders (for one and two-piece systems)

3 packs per month

Change every time bag is changed. May Require 2-3 for each bag change.

Often required for extra security if the patient has a hernia or skin creases as it increases adhesive area. If there is leakage around the stoma – refer for review.

Belts (for convex pouches)

3 per year 1 to wear, 1 in the wash, 1 for spare.

Washable and re-usable.

Support Belts/Underwear

3belts per year 6 pairs briefs/boxers per year

1 to wear, 1 in the wash, 1 for spare.

For patients with manual jobs / hernia – require heavy duty belt. Must be measured – refer to CSCNS. For sports – use light weight belt. To aid prevention of hernias and offer abdominal muscle support. Class 1 support underwear not recommended for prescribing in Fife. Patients are advised to purchase their own if required via high street shops or internet.

Adhesive removers

See Formulary pg 14

Lubricating deodorant gels

Not Recommended for Prescribing in Fife

Can be useful for ‘pancaking’(when faeces remain stuck around stoma instead of dropping into bag) A few drops of baby oil or olive oil can be used as an alternative.

Appliance Usual Quantity Guide (monthly unless stated)

Prescription Notes




Prescription directions

Notes

Bag Covers Not recommended for prescribing in Fife unless patient receiving: SALTS Koenig Rutzen –All Rubber Back Screw Outlet bags

Washable and reusable

Reduce bag noise. Are washable. With many newer products being opaque less need for covers. Available for patients to buy though internet or through Stoma Companies.

Deodorants Not recommended for prescribing in Fife

Ordinary household air freshener is recommended or patients may purchase stoma deodorant directly from Stoma Company.

Filters and Bridges Removable filters becoming obsolete but still used with some older products. All new products have built in filters. Limited role for bridges, only used on CSCNS advice.

Irrigation/Wash out Appliances/Stoma Caps

1 set every 6 months 30 caps per month

Single Use only Only suitable for patients with an end colostomy. Only undertaken on advice of CSCNS. Used to wash out faecal matter from the colon. As a result patients can wear a stoma cap, plug or dressing during the day and maintain some control over stoma.

Protective Shields 1-2 per year Limited need for these products. Patients receiving shields may require review from CSCNS. Can be used for sporting activities.

Barrier Products

See formulary pg 15



Not routinely recommended


Prescription directions

Notes

Discharge Solidifying Agents

See Formulary pg 15

Pastes, Seals and Washers

Use each time the bag is changed

Used if stoma is recessed or there are creases, folds etc.



ADDITIONAL PRODUCTS FORMULARY Many available additional products are not regularly required. However, prescriptions for these products may be requested by patients. In general, stoma additional products should only be prescribed on the advice of an NHS Colorectal/Stoma Clinical Nurse Specialist. Costs shown are taken from Scottish Drug Tariff November 2017



ADHESIVE REMOVER Used to remove excess ‘sticky’ adhesive from skin and reduce skin stripping.

Type Brand Code Quantity per box

Cost indication

Guidance

Adhesive remover wipes

1st choice: Salts Healthcare WipeAway wipes

WA1

30

30p/wipe £8.99 per

box

1 wipe per bag change

Only for exceptional circumstances when WipeAway is unsuitable 2nd choice: Opus Healthcare Lift Adhesive Remover

5500

30

30p/wipe £9.11 per

box


Adhesive remover spray

1st choice: Lift

5501

100ml

£6.42

1-3 cans per month (depending on frequency of bag changes). Use each time stoma bag is changed

Only for exceptional circumstances when Lift

spray is unsuitable 2nd choice: Salts Healthcare WipeAway Plus Remover Spray

WAP

50ml

£6.50

1-3 cans per month (depending on frequency of bag changes). Use each time stoma bag is changed



BARRIER PRODUCTS Only use barrier products if the skin surrounding the stoma is irritated. Most patients do not require long term. Please check before prescribing. Barrier creams are NOT recommended as they reduce adhesiveness of bags. Wipes are the preferred formulation. If patient using for more than 3 months, discuss with patient the need to contact CSCNS for review

Type Brand Code Quantity Per box

Cost indication*

Guidance

Barrier film wipes

1st choice: Smith & Nephew Secura Barrier Wipes

66800712

50

39p/wipe

£19.41 per box


Only for exceptional circumstances when Secura is unsuitable 2nd Choice: Salts Peri-Prep Sensitive No Sting Wipes

PPS1

30

51p/wipe

£15.47 per box


DISCHARGE SOLIDIFYING AGENT Binds loose stool and urine into a gel to reduce leakage and odours. MAY CAUSE BLOCKAGE OF THROAT AND AIRWAY IF SWALLOWED. CARE SHOULD BE TAKEN WHEN PRESCRIBING FOR VULNERABLE PATIENTS. (1)

Type Brand Code Quantity Per tub

Cost indication

Guidance

Discharge Solidifying Agent

1st choice: Peak Medical Ltd Gellymate Absorption Tablets

GD140

140

£14.85

Insert one to two sachets/capsules into every new bag. 15-30 sachets/capsules per

month Only for exceptional circumstances when

Gellymates are unsuitable 2nd Choice: Oakmed Ltd Gel X tablets

No code

140

£15.08

Insert one to two sachets/capsules into every new bag. 15-30 sachets/capsules per

month 15

Author: W.McFarlane Colorectal Specialist Nurse Date: January 2018 K.Whatton Senior Prescribing Support Nurse Review: January 2020


USE OF MEDICINES IN STOMA MANAGEMENT



Several medicines should be used with caution or avoided in patients with stoma

Medicines to use with care or avoid in stoma management. Drug Reason ANTACIDS Magnesium salts may cause diarrhoea.

Aluminium salts may cause constipation. ANTIBIOTICS Caution as may cause diarrhoea. DIGOXIN Stoma patients susceptible to hypokalaemia – monitor

closely, consider supplements or potassium sparing diuretics.

DIURETICS Patients may become dehydrated. Use with caution in ilesostomy patients – may become potassium depleted.

ENTERIC-COATED AND MODIFIED-RELEASE PREPARATIONS

Unsuitable, particularly in ileostomy patients, as there may not be sufficient release of the active ingredient. Consider non-EC/MR preparations first choice

IRON e.g. ferrous sulphate May cause loose stools and sore

skin in these patients May cause diarrhoea – ileostomy or constipation – colostomy. Stools may be black – important to reassure/warn patients.

LAXATIVE ENEMAS AND WASHOUTS Avoid in ileostomy patients – may cause rapid and severe loss of water/electrolytes.



Prescribing medicines for patients with stoma calls for special care

1. Some ileostomy patients can experience occasional problematic, high-volume liquid stoma output, which can cause dehydration, potential renal impairment, body image problems and increased product usage. Anti-motility agents (loperamide or codeine), can be used to treat this. They slow down gastrointestinal transit time, allowing more water to be absorbed thus thickening and decreasing the stoma output.

• Loperamide is preferred as it is not sedative and not addictive/open to abuse.

• Patients are usually able to self manage ad hoc dosing according to requirements

• Longer-term use with higher doses may be necessary if patients have a ‘short-bowel syndrome’

• Loperamide should be taken half an hour before food for maximum effect.

Medicines to use with care or avoid in stoma management cont. Drug Reason NICORANDIL (2) Anal and peristomal ulceration- related to inflammatory disease OPIOID ANALGESICS Caution as may cause constipation PROTON PUMP INHIBITORS May cause diarrhoea



2. Some patients experience constipation. With the exception of ileostomy patients, an increase in fluid intake or dietary fibre (wherever possible) should be tried first before initiating bulk forming or osmotic laxatives.

ROUTES OF ADMINISTRATION –Points of Note

• Please be aware that it may not be appropriate to use PR route for stoma patients, please check clinical records.

• Medication cannot be administered via the stoma.

Antidiarrhoeal (anti-motility) medicines used in stoma management. Drug Dose LOPERAMIDE 2MG CAPSULES 2mg up to 4mg four times a day as required

(Max 16mg daily) CODEINE PHOSPHATE 15MG AND 30MG TABLETS

15mg to 30mg four times a day (Max 240mg daily)



Acknowledgements Claire Fernie, Chairperson, Fife Branch - Ileostomy and Internal Pouch Association NHS PresQIPP: Continence and Stoma Toolkit V2.0 September 2015 Guideline first devised by NHS Fife Stoma Care Forum May 2013 References

(1) National Services Scotland (2017) SAN(SC)17/03 – Risk of Death and Severe Harm From Ingestion of Superabsorbent Polymer Gel Granules. Available at www.hfs.scot.nhs.uk/publications/1503321589-SAN(SC)1703.pdf

(2) Fake J, Skellet A, Skipper G A. Patient with Nicorandil-Induced Peristomal Ulceration, Gastrointestinal Nursing (2008); 5 (6): 19-23.

Useful Contacts NHS FIFE COLORECTAL NURSING TEAM Answer Phone Service (Checked Mon to Friday) 01592 643355 Ext 28800 FIFE OSTOMY SUPPORT GROUP – Meets once a month Sept to June – Ishbel Barr (Secretary) 01592 772200 NATIONAL KEY SCHEME (RADAR) – Giving access to 5,600 toilets in UK – Available from Disabilities Fife 01592 203993 ILEOSTOMY ASSOCIATION AND INTERNAL POUCH HELPLINE 0800 0184 724 or www.iasupport.org Local Branch: Betty McNeil (Secretary) 01383 416320 LIVING WITH A STOMA- information on lifestyle issues www.living-with-a-stoma.co.uk STOMAWISE – support network for people who have undergone stoma surgery - www.stomawise.co.uk GAY OSTOMATES – http://glo-uoaa.org/


http://www.hfs.scot.nhs.uk/publications/1503321589-SAN(SC)1703.pdf

http://www.living-with-a-stoma.co.uk/

http://www.stomawise.co.uk/

http://glo-uoaa.org/


APPENDIX 1: OVERUSE OF STOMA PRODUCTS COLOSTOMY -

Closed Pouches Usually changed 1-3 x daily

ILEOSTOMY Open ended Drainable

UROSTOMY – Pouches with tap

Does your patient use more than 30-90 pouches per month? (1 piece) OR Does your patient use more than 15 base plates and 30-90 pouches per month? (2 piece)

Does your patient use more than 30 pouches per month? (1 piece) OR Does your patient use more than 15 base plates and 30 pouches per month? (2 piece)

Patient may be experiencing problems. Discuss with patient and, if appropriate, referred to CSCNS for reassessment

Does your patient use more than 2 additional stoma products?

No action required Patient may be experiencing problems. Discuss with patient and, if appropriate, referred to CSCNS for reassessment.

No No

Yes Yes

No Yes


Documents

GUIDANCE FOR THE PRESCRIBING AND ORDERING OF STOMA ... · Stoma Bags and Pouches ... Guidance on recommended quantities of stoma appliances is included within this document. ... discard