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

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

2 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

3 INTRODUCTION NHS Fife s annual spend on stoma and associated additional products exceeded 2million in 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. 3

4 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. 4

5 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

6 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. 6

7 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 Ext or hour patient helpline (answer phone) Ext NB Messages from Helpline are picked up Monday Friday ) 7

8 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 8

9 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 Colostomy bags two piece systems bags Flat bags (1-3 boxes of 30) Convex bags (6-9 boxes of 10) bags - (1-3 boxes of 30) PLUS Flanges/Base Plates (3-4 boxes of 5) Remove and discard after use. Bag remove and discard after use. Flange/Base Plate change every 2-3 days. Bags are not drainable/ reusable. Usual use: 1-3 bags per day. Flushable bags only to be used on advice of CSCNS. 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 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 bags PLUS 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 Urostomy bags two piece systems bags Flat bags (1-3 boxes of 30) Convex bags (6-9 boxes of 10) bags PLUS Flanges/Base Plates (3-4 boxes of 5) Drain as required throughout the day Bag change every 2 days Flange change every 2-3 days Bags are drainable. Usual use: new bag every 1-3 days. Renewed at every bag change. Items ordered separately. Flange not normally changed at every bag change. 9

10 Appliance Night drainage bags for urostomy patients Usual Quantity Guide (monthly unless stated) 4 bags (1 box of 10 bags every 2-3 months) Prescription Use a new bag every 7 days. Notes Bags are drainable Flange extenders (for one and two-piece systems) Belts (for convex pouches) 3 packs per month Change every time bag is changed. May Require 2-3 for each bag change. 3 per year 1 to wear, 1 in the wash, 1 for spare. 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. Washable and re-usable. Support Belts/Underwear Adhesive removers 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. 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. 10

11 Appliance Bag Covers Deodorants Usual Quantity Guide (monthly unless stated) Not recommended for prescribing in Fife unless patient receiving: SALTS Koenig Rutzen All Rubber Back Screw Outlet bags Not recommended for prescribing in Fife Prescription directions Washable and reusable Notes 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. 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 11

12 Appliance Discharge Solidifying Agents Usual Quantity Guide (monthly unless stated) Prescription directions Notes 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. Not routinely recommended 12

13 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

14 ADHESIVE REMOVER Used to remove excess sticky adhesive from skin and reduce skin stripping. Type Brand Code Quantity per box Adhesive remover wipes Cost indication 1 st choice: Salts Healthcare WipeAway wipes WA p/wipe 8.99 per box Guidance 1 wipe per bag change Only for exceptional circumstances when WipeAway is unsuitable 2 nd choice: Opus Healthcare Lift Adhesive Remover p/wipe 9.11 per box 1 wipe per bag change Adhesive remover spray 1 st choice: Lift ml 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 2 nd choice: Salts Healthcare WipeAway Plus Remover Spray WAP 50ml cans per month (depending on frequency of bag changes). Use each time stoma bag is changed 14

15 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 Barrier film 1 st choice: Smith & Nephew Secura Barrier wipes Wipes Cost indication* 50 39p/wipe per box Guidance 1 wipe per bag change Only for exceptional circumstances when Secura is unsuitable 2 nd Choice: Salts Peri-Prep Sensitive No Sting Wipes PPS p/wipe per box 1 wipe per bag change 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 Discharge Solidifying Agent 1 st choice: Peak Medical Ltd Gellymate Absorption Tablets Only for exceptional circumstances when Gellymates are unsuitable 2 nd Choice: Oakmed Ltd Gel X tablets Cost indication GD No code Guidance Insert one to two sachets/capsules into every new bag sachets/capsules per month Insert one to two sachets/capsules into every new bag sachets/capsules per month 15

16 USE OF MEDICINES IN STOMA MANAGEMENT 16

17 Several medicines should be used with caution or avoided in patients with stoma Medicines to use with care or avoid in stoma management. Drug ANTACIDS ANTIBIOTICS DIGOXIN DIURETICS ENTERIC-COATED AND MODIFIED-RELEASE PREPARATIONS Reason Magnesium salts may cause diarrhoea. Aluminium salts may cause constipation. Caution as may cause diarrhoea. Stoma patients susceptible to hypokalaemia monitor closely, consider supplements or potassium sparing diuretics. Patients may become dehydrated. Use with caution in ilesostomy patients may become potassium depleted. 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 LAXATIVE ENEMAS AND WASHOUTS 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. Avoid in ileostomy patients may cause rapid and severe loss of water/electrolytes. 17

18 Medicines to use with care or avoid in stoma management cont. Drug NICORANDIL (2) OPIOID ANALGESICS PROTON PUMP INHIBITORS Reason Anal and peristomal ulceration- related to inflammatory disease Caution as may cause constipation May cause diarrhoea 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. 18

19 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) 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. 19

20 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 (2) Fake J, Skellet A, Skipper G A. Patient with Nicorandil-Induced Peristomal Ulceration, Gastrointestinal Nursing (2008); 5 (6): Useful Contacts NHS FIFE COLORECTAL NURSING TEAM Answer Phone Service (Checked Mon to Friday) Ext FIFE OSTOMY SUPPORT GROUP Meets once a month Sept to June Ishbel Barr (Secretary) NATIONAL KEY SCHEME (RADAR) Giving access to 5,600 toilets in UK Available from Disabilities Fife ILEOSTOMY ASSOCIATION AND INTERNAL POUCH HELPLINE or Local Branch: Betty McNeil (Secretary) LIVING WITH A STOMA- information on lifestyle issues STOMAWISE support network for people who have undergone stoma surgery - GAY OSTOMATES 20

21 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 pouches per month? (1 piece) OR Does your patient use more than 15 base plates and pouches per month? (2 piece) Yes 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) Yes No Patient may be experiencing problems. Discuss with patient and, if appropriate, referred to CSCNS for reassessment No Does your patient use more than 2 additional stoma products? No Patient may be experiencing No action required problems. Discuss with patient and, if appropriate, referred to CSCNS for reassessment. 21 Yes

STOMA GUIDANCE. Aims of this document. Version 3: April 2014

STOMA GUIDANCE. Aims of this document. Version 3: April 2014 STOMA GUIDANCE Version 3: April 2014 Acknowledgements Samantha Woodcock Medicines Management Pharmacy Technician ESCCG Rachel Lewis Medicines Management Practice Pharmacist ESCCG Catherine Atkinson Securicare