Prescribing Policy for Adult Stoma products and Appliances - Referral Support
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East Kent Prescribing Group
Prescribing Policy for Adult Stoma products and
Appliances
Recommendation
This policy is intended to provide community based prescribers with prescribing policy to enable
responsible issue of prescriptions for items that are supplied to people living with stomas.
The policy outlines the responsibilities of registered prescriber, NHS stoma nurses, dispensing
appliance contractor (DAC) and patient/carers or relatives.
Approved by: East Kent Prescribing Group (Representing Ashford CCG, Canterbury and Coastal CCG,
South Kent Coast CCG and Thanet CCG)
Date: July 2015
Address: c/o Canterbury and Coastal CCG, Ground Floor, Council Offices, Military Road, Canterbury,
Kent,CT1 1YW
Contact: T: 01227 791267 | E: accg.eastkentprescribing@nhs.net
Page 1 of 1PRESCRIBING POLICY
FOR
ADULT STOMA PRODUCTS & APPLIANCES
Version 1
Ratified by: Surgical Services
Date Ratified: 15 April 2015
Name of originator/author: Alanda Tofte Senior Matron for Surgery &
Clinical Lead for Stoma
Director responsible for implementation: Heather Lucas
Prescribing Advisor,
NHS South Kent Coast Clinical
Commissioning Group
Date issued: 8 June 2015
Review date: 30 September 2016
Target audience: Stoma Nurses, GP, Registered Prescribers,
DACs, Pharmacists.
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 1 of 34Version Control Schedule
Version Date Author Status Comment
1 30.3.2015 Alanda Tofte Draft Approval to be gained at
commissioners drugs &
Therapeutic Committee
2 15.4.15 Alanda Tofte Final 5.22 named person changed from
receptionist to prescribing clerk
5.23 request change to initiation of
and changes of prescription
5.24 issue prescriptions change to
repeat prescriptions
Consultation and Ratification Schedule
Name and Title of Individual Date Consulted
Name of Committee Date Reviewed
15 April 2015
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 2 of 34Contents
Page
Introduction 5
1.
2. Purpose 5
5-6
3. Background
6
4. Scope
Duties 6
5.
5.1 Clinical Stoma Nurse 6-7
5.2 GP practice 7-8
5.3 Primary Care Prescribers 8
5.4 Patient / Carers 9
5.5 Dispensing Appliance Contractor (DAC) 9
10
6. Prescriptions
6.1 Dispensing of prescriptions 10
6.2 Retrospective prescriptions 10
6.3 Urgent Prescriptions 10
6.4 Request for barrier creams and spray deodorants 10
7. Emerging Issues 11
Appendix 1 East Kent Stoma Pathway 12
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 3 of 34Appendix 2 Stoma Supplies on Discharge from Acute Care 13
Appendix 3 Quantity prescribing guide for stoma appliances and 14
accessories
Appendix 4 Referral to Stoma Nurse 17
18
Appendix 5 Management of Sore Skin
Appendix 6 Management of Skin Dips and Creases 19
Appendix 7 Management of Hernia pouches – Leaks. Specialist 20
appliances on advice of patient’s stoma nurse
Appendix 8 Medicines to use with care or avoid in stoma patients 21
Appendix 9 Medicines required for stoma management 22
23
Appendix 10 DACs
Appendix 11 National Associations 24
Appendix 12 Manufacturing Companies. 25
Appendix 13 References 26
Appendix 14 Key Stakeholders 27
Review and Revision Arrangements
Dissemination and Implementation
Document Control including Archiving Arrangements
Monitoring Compliance
Appendix 15 Equality and Human Rights Analysis (EHRA) 28
Appendix 16 Authors checklist of compliance with the policy 31
Appendix 17 Plan for Dissemination of Policy to the Commissioning 33
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 4 of 34Care Groups – Prescribing Policy for Adult Stoma
Products & Appliances
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 5 of 341. Introduction
This policy is intended to provide community based prescribers with prescribing policy to enable
responsible issue of prescriptions for items that are supplied to people living with stomas.
The policy outlines the responsibilities of registered prescriber, NHS stoma nurses, dispensing
appliance contractor (DAC) and patient/carers or relatives.
2. Purpose.
2.11 To provide a policy for the prescribing of stoma products and appliances.
2.12 To ensure that stoma appliance are prescribed in accordance with quantities of use.
2.13 To eliminate retrospective prescriptions.
2.14 To reduce cost.
2.15 To reduce waste.
2.16 For patients to have appliances which enable them to lead independent lives.
3. Background
3.11 Having a stoma is not just a physical problem but can be a psychological one and it is
essential to ensure that each person living with a stoma has an appliance, that is secure and
discreet (Burch 2008) and that stoma care routines are kept as simple as possible to minimise
potential skin problems (Williams 2006).
3.12 Assessment of the patients’ needs by the Stoma Care Nurse (SCN) is extremely important
to prevent misuse and additional management problems (Williams 2006).
3.13 There are three main types of output stomas:
a. Colostomy – an opening into the large bowel (colon), usually sited on the lower left side of
the abdomen; a transverse colostomy, which is sited above the waist, can be on the left or
right side
b. Ileostomy – an opening into the ileum (small intestine), usually sited on the right lower side
of the abdomen
c. Urostomy – an opening into the urinary tract and usually sited on the right lower side of the
abdomen.
3.14 The Department of Health (DH) reviewed the arrangements for issuing prescriptions for
dispensing of incontinence and stoma appliance and issued the NHS (pharmaceutical services)
(appliance) (amendment) regulations 2009, amended 2010.
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 6 of 343.15 The cost of stoma appliance and products are rising. During financial year 2013/14 Heather
Lucas to input xxxxx Clinical Commissioning Group spent xxxxxx on stoma appliances and
associated accessories in primary care.
4. Scope
This policy applies to the following within East Kent
Stoma Nurse Specialists (Hospital, Community and Company)
GPs
Prescribing clerks
Dispensing Appliance Contractors (DACs)
Pharmacy Contractors
District Nurses
Practice Nurses
Patients , Patients Carers and Relatives
5. Duties
The healthcare professional who prescribes the treatment legally assumes clinical responsibility for
the treatment.
5.1 NHS Stoma Care Nurse
5.11 Select and initiate the most appropriate product for treatment /management without pressure
from any pharmaceutical company or dispensing appliance contractor arrangement.
5.12 To discharge patients with newly formed stomas, from hospital with a 2 week supply with no
accessories (unless deemed clinically essential). This period may be extended if the stoma nurse
and patient have difficulty in finding an appliance which meets the patient’s clinical need.
(Appendix 2)
5.13 Educate the patient regarding their role in product management, storage and repeat
prescriptions ensuring that the patient fully understands their treatment plan
5.14 To undertake clinical product reviews at every touch point in the East Kent Stoma Care
Pathway (Appendix 1) and when patients / carers / district nurses/ or primary care prescribers
seek advice or raise concerns.
5.15 Only initiate stoma products listed in part IXA and IXC of the Drug Tariff.
5.16 Provide the GP with the following
New patients
Plan of care and follow up arrangements
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 7 of 34 Product initiation/ change details (including product codes),
Expected monthly usage,
Expected duration of treatment or if long term the date of next review.
Expected cost and identifies savings
Stoma Nurse Contact details
5.17 Monitor response to treatment and advise GPs of any changes to prescriptions.
5.18 Monitor closely those patients with high output stomas, titrating the use of medicines to
maintain independence and avoid unintended admissions.
5.19 Ensure clear arrangements for back up advice and support for patients and prescribers.
5.2 GP practice s
5.21 Know who their locality NHS stoma Nurse is.
5.22 Have a named person responsible for stoma prescriptions (one prescribing clerk and one
GP)
5.23 Only accept request for prescriptions including initiation of and changes to prescription,
5.24 from an NHS Stoma Care Nurse.
5.25 Issue repeat prescriptions at the request of Patient or carer.
5.26 To be aware of normal usage rate (Appendix 3).
5.27 Check the prescription request in accordance with the information in (Appendix 3) on the
quantities to be issued.
5.28 Flag irregularities with the GP / Patient and Carer
5.29 Understand which situations must be referred to the NHS Stoma Care Nurse (Appendix 5)
5.210 Only release prescriptions for one month.
5.211 Alerts the lead provider for stoma care if and when retrospective prescriptions are
requested.
5.212 Alert the NHS Stoma Care Nurse / District Nurse patients who have difficulty in managing
their repeat prescriptions.
5.213 Ensure that Review copies of Appliance Use Review (AUR) are stored in the patient’s
medical records.
5.214 Understand the ordering process.
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 8 of 345.215 Understand that more than the recommended amounts may be ordered under some
circumstances e.g. suffering with gastro-intestinal symptoms, dietary problems or skin issues i.e.
ulceration or undergoing chemotherapy.
5.216 Understand that some people living with stomas will need more ileostomy bags if they prefer
to use midi bags during the day and maxi bags at night (mainly younger persons for body image)
5.217 Does not enter into any arrangements for pharmaceutical company led reviews unless this
is authorised by lead provider for stoma care before commencement.
5.218 Inform Stoma Nurse / DAC / Pharmacy contractor when a patient with a stoma dies.
5.3 Primary Care Prescribers
5.31 Know the normal usage rate by the patient and flag irregularities to the NHS Stoma Care
Nurse. (Appendix no 3)
5.32 Know which medications may affect the use of stoma appliances ( Appendix 8)
5.33 Seek advice from the NHS Stoma Care Nurse when aspect of patient care and treatment
may affect stoma management or may cause a clinical concern.
5.34 Stop or adjust treatment/management on the advice of the Stoma Nurse.
5.35 NOT accept patient requests for new products without referring to the NHS Stoma Care
Nurse Treatment plan.
5.36 NOT issue retrospective prescriptions
5.37 Comply with the process for issuing urgent supplies
5.38 Generate a prescription for patient/ carer (or send to contractor) within the agreed
turnaround time and by the agreed method of dispatch.
5.39 Initiate a system for supply and then continue prescribing, adjusting prescriptions for
products as advised by the NHS specialist stoma nurse.
5.310 Document any communication from a Stoma Nurse / DAC/ Pharmacy contractor in the
patient’s clinical record.
5.311 Only issue prescriptions at the request of patient / carer/ stoma nurse
5.312 Ensure that patient understands treatment.
5.313 Support the education of patients and carers together with the Stoma Nurse.
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 9 of 345.4 Patient / Carers
5.41 The patient/carer should be educated to only order products which are actually required to
reduce stock piling and waste.
5.42 The patient /carer will ensure that the prescription for the stoma appliance is sent/ taken to
the pharmacist / DAC of their choice for dispensing.
5.43 The patient /carer should inform the prescriber if needs / circumstances change which might
impact on supplies.
5.5 Dispensing Appliance Contractors
5.51 Comply with each GP practice protocol
5.52 Provide each GP practice with details of patient’s authorisation for the DAC to supply items
on the patient’s behalf.
5.53 Provide a designated named contact for stoma coordination.
5.54 Request and Receive Prescription PRIOR to delivery of items.
5.55 Will NOT request RETROSPECTIVE PRESCRIPTIONS to cover items “already in the post”.
In these cases GPs will be entitled to refuse to supply a prescription.
5.56 DAC or pharmacy contractors must not supply stoma appliance before receiving a valid
prescription except in the dispensing of urgent supplies ( see section )
5.57 Agree frequency of supply and turnaround times form request of prescription to dispensing
with the lead provider for stoma care
5.58 Agree a method of receipt of prescription with each GP surgery ( FAX , email or post)
5.59 Will contact the prescriber to request permission to supply the stoma appliance be in
advance of the receipt of the prescription.
5.510 Will provide a reasonable supply of disposable wipes and bags as specified in the Drug
Tariff.
5.511 Will use packaging for deliveries without any markings which could indicate the contents.
5.512 Will notify the GP when a patient dies that prescription (including repeat dispensing
prescriptions which have not been sent have been destroyed.
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 10 of 346. Prescriptions
a. Where there are sudden changes or irregularities to a person’s request for prescription a
referral to a stoma nurse is be required.
b. Where the changes are initiated by the Stoma Nurse these changes will be communicated
to the named person for the GP practice named person (appendix ) within 4 days of change
c. Changes to prescriptions will not be made without consultation with a stoma nurse
specialist.
6.1 Dispensing of prescriptions
a. It is important that people living with stomas are aware they have a choice as to which
dispensing appliance contractor (DAC) or community pharmacy dispenses their stoma
prescription and that they can change their choice at any time.
b. This choice will be discussed with each person prior to discharge from acute care. Consent
will be obtained to pass person information details onto any DAC
6.2 Retrospective prescriptions
• Prescribers will NOT issue retrospective prescriptions
6.3 Urgent Prescriptions
In the case of urgency, the DAC or pharmacy contractor may supply an appliance only at the
request of a prescriber.
The prescriber should undertake to give the DAC or pharmacist a non-electronic prescription form
or non-electronic repeatable prescription in respect of the appliance requested within 72 hours.
Alternatively, the prescriber must transmit to the EPS service an electronic prescription within 72
hours.
6.4 Request for barrier creams and spray deodorants
These will not be prescribed unless in the rare situations that it is recommended by the stoma
nurse. Barrier creams reduce adhesion and deodorants are no different to household air
fresheners. If odour is present at times other than changing or emptying please refer patient to their
stoma nurse.
Any patients that have been on a barrier cream or deodorant for a long period of time must be
referred to the stoma nurses for review.
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 11 of 347. Emerging Issues
If problems in the provision of stoma appliances emerge that are not addressed in this
policy then please contact:-
East Kent Stoma Support Services
Direct Dial 01233 616614
Monday to Friday 8am – 6 pm
Or
ekh-tr.stomasupport@nhs.net
Emails will be responded to by members of the teams throughout the day with weekend
emails responded to on Mondays
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 12 of 34Appendix 1
EAST KENT Stoma Pathway
New Patient
Pre Surgical Counselling and Information
Elective MDM
Emergency OUTCOMES
Pre Surgical Patients
Preparation • Actively Involved in Service Development
Arrangements for Stoma Support and Advice
• Confident to return home after surgery
East • Support at home after hospital
Admission to Hospital / Home
• Access to a stoma nurse when worried
Hospital (day of • Health care professionals educated in stoma service
surgery) • Reduction in unplanned hospital admissions
ERP • Annual User Review (product and clinically)
Designated Staff to • CHOICE
Operation support emotionally
& and practically
In patient stay
Discharge from Pathway driven by evidence base
Daily Calls
Guidance to support
Hospital protocols
Clinical Advice and
Home Visits
independence
Integration of Health
Care Teams and Care Closer to Home / Impartial Advice
Tele Health
Support
Support Agencies Clinical, Dietary, Lifestyle and Product
Product Reviews &
clinical advice reviews at every touch point.
Home Visits Telephone Support 01233 616646 Mon- Fri
8-6pm
Embedding Email support ekht-tr.stomasupport@nhs.net
Lifestyle support
Observation and
Clinic Follow Up Independence
Preventing and
Proactively
East Kent Hospitals NHS Foundation Trust
Managing any
AUR Prescribing Policy for Stoma Appliance
Complications February 2015
Page 13 of 34Appendix 2
Stoma Supplies on Discharge from Acute Care
Skin Fillers, Thickening Agents, Lubricating drops, flange extenders
According to patient specific clinical need and with a timescale for use
Deodorisers, Barrier Creams, Non-Woven Swabs, Bag covers
Product use will be monitored, evaluated and changed by the Stoma Nurse through Tele Health
and Home visits during the first two weeks after discharge and then on at each touch point in
the patient pathway
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 14 of 34Appendix 3
Quantity prescribing guide for stoma appliances and accessories
Appliance Usual Monthly Prescription directions Notes
quantity
Colostomy bags 30-90 bags Remove and discard after use Discharge home on closed system / if loose stools can use
(one piece systems) solidifying agents on a case by case basis
Bags are not drainable. Usual use: 1-3 bags per day.
Flushable bags only to be used on advice of bowel/stoma
nurse.
Colostomy bags 30-90 bags + Bag – remove and discard after use The flange (base plate for 2 piece systems) is not
(two piece systems) 15 Flanges use 1-3 bags per day usually changed at every bag change. Items ordered
separately
Flange – change every 2-3 days
Irrigation 2 kit / year / To wash out colostomy See information re regarding irrigation
Irrigation sleeves 30/month Use once every 1-2 days Self-adhesive disposable sleeves
Stoma caps 30 For use on mucous fistulae or This may be in addition to original stoma bag
colostomy if irrigating
Ileostomy bags 15-30 bags Drain as required throughout the Bags are drainable
day.
Use a new bag every 1-3 days
Ileostomy bags 15-30 bags + Bag – change very 1-3 days The flange (base plate for 2 piece systems) is not
15 flanges Flange – change every 2-3 days usually changed at every bag change. Items ordered
separately
Urostomy Bags 10-20 bags Drain as required throughout the Bags are drainable
(one piece systems) day.
Generally replace bag every 2 days
Urostomy bags 10-20 bags + 15 Bag – change every 2 days The flange (base place for 2 piece systems) is not
(two piece systems) flanges Flange – change every 2-3 days usually changed at every bag change. Items ordered
separately
Urostomy Night 4 bags (1 box of 10 Use a new bag every 7 days Bags are drainable
drainage bags bags
every 2-3 months)
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 15 of 34Appendix 3
Quantity prescribing guide for stoma appliances and accessories (continued)
Accessory Usual quantity Prescription directions Notes
Flange extenders 3 packs per month Change every time bag is Often required for extra security if the
(for one and two-piece changed. May require 2-3 patient has a hernia or skin creases as it
systems) for each bag change increased adhesive area. If used as
there is leakage around the stoma
Belts (for convex 3 per year 1 to wear, 1 in the wash, 1 for Washable and re-usable
pouches) spare
Support belts 3 per year 1 to wear, 1 in the wash, 1 for For patients with manual jobs / hernia –
spare require heavy duty belt. Must be
measured – refer.
For sport – use light weight belt
Adhesive removers 1-3 cans (depending on Use each time stoma bag is Sprays are more cost effective than
frequency of bag changes) changed wipes.
‘Non-sting’, silicone based products are
recommended.
Deodorants Household air freshener is Use as needed when If correctly fitted, no odour should be
sufficient in most cases changing stoma bag apparent except when bag is emptied or
changed. Household air freshener is
sufficient in most cases. If odour
present at times other than changing or
emptying – refer for stoma nurse review.
Lubricating deodorant Not routinely required. A Put one squirt into stoma Only recommended if patients have
gels few drops of baby oil or bag before use difficulty with ‘pan caking’.
olive oil can be used as an Bottles are more cost effective than
alternative. If required 1-2 sachets. A few drops of baby oil or olive
bottles per month oil can be used as an alternative.
Skin fillers Follow directions of Change each time bag is Filler pastes/washers are used to fill
bowel / stoma nurse changed creases or dips in the skin to ensure a
seal. Alcohol containing products may
sting.
Skin protective Follow directions of Apply when bag is changed SHORT TERM USE ONLY (acute
(wipes, films, pastes and bowel / stoma nurse as directed prescription): may be used on skin that is
powders) broken, sore or weepy to promote
healing.
If used for >3 months, refer. Barrier
creams are NOT
Recommended as they reduce
adhesiveness of bags/flanges
Thickeners for ileostomy 2 boxes/tubs per month Use one with every new bag Useful for Crohn’s disease patients,
useful for loose watery output. 1-2
sachets/strips to be used each time
appliance is emptied.
Acute sports shield 1-2 / year Use for sporting activities
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 16 of 34Appendix 3
Other accessories used ( continued )
Other What does it do How long should Number of items on Acute or
accessories used it be used for average repeat
Drainable bag Soft ties or As long as the Number of Clipless (soft) REPEAT
fasteners plastic clips older type of ties should be equivalent to
used for the pouch is used number of pouches
older types of Hard plastic clips: 10 every
pouch 6 months
ACUTE
Discharge Used in patients High output Stoma (see
solidifying This is a sachet with a high EKHUFT high output
agents placed in the output stoma or stomas guideline or contact
pouch to change to thicken up stoma nurse) – quantities
the consistency output if it as advised by the stoma
of the stool becomes watery nurse.
without the need
for medication Ileostomies: rarely used,
only on stoma nurse advice
- 1 box should last at least
a year unless patient has
diarrhoea or specialist
circumstance such as
chemotherapy.
Flange extenders Used to extend Maybe needed Equivalent to 1-3 per pouch REPEAT
the flange long-term depending on need.
Irregular or sudden
increase should trigger
stoma nurse referral
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 17 of 34Appendix 4
Referral to Stoma Nurse
People living with stomas who order more than recommended usage ( Appendix 3)
Requests for barrier creams and deodorants
Long term use > 3 months of skin protective products (wipes/films/paste/powders)
Current use of pressure plates or shields- patient may benefit from the use of newer
products with built in convexity
Old style re-usable bags
Patients that are experiencing leakage
Patients that have developed hernias.
Patients experiencing dietary problems
Addition of medication by primary care prescriber which is likely to affect the function of
the stoma ( appendix ) must be communicated to the Stoma Nurse specialist
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 18 of 34Appendix 5
Sore Skin: Causes of sore skin include: leakage, trauma on removal of pouch, aperture cut incorrectly, too-frequent removal of
pouch or reaction to pouch adhesive Accessories used:
What does it do How long should it be used Number of items on average Acute or repeat
Accessories used for
Pushes the stoma outwards, Should be regularly reviewed As advised by the stoma nurse
Convex products reducing the risk of leaks by stoma nurse can cause
ulceration
(appliances)
Used to protect the skin, fill in Used at each pouch change
Mouldable Seals creases or dips around the stoma As advised by the stoma
and can be used to increase wear nurse
time of the pouch.
Used to “dry” weepy or wet skin – 1 powder tube
Powder most effective if minimally used (fine Short-term monthly review
coating)
Review monthly by
For peristomal skin which is broken Wipes: one wipe per flange stoma nurse
Non-sting barrier sore or weepy Short-term monthly review Spray:
Colostomies: 1-3 spray bottles per
wipes/films/sprays 30 pouches
Ileostomy & urostomy:1-3 units
per 60 pouches
Form a barrier between pouch and Rings: one ring per flange
Protective skin Short-term monthly review Wafers: as per stoma nurse
recommendation
Wafers/rings
Allow easy removal of the pouch Wipes: 1 wipe per pouch change
Adhesive remover without causing trauma to the skin Spray: 2-3 spray bottles per
Caution as some contain alcohol month
wipes/sprays which can sting broken skin. NOTE: Adhesive remover sprays
are more cost-effective than
wipes
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 19 of 34Appendix. 6
Dips / creases / skin folds / retracted stomas
Accessories used: What does it do How long should it be Number of items on Acute or repeat
used for average
Pushes the stoma Should be regularly As advised by the stoma Review monthly by stoma
Convexity outwards if it is retracted reviewed by stoma nurse nurse nurse
or flush can cause ulceration
Used to fill in skin Use cautiously & review Use varies approx. 1 tube Only for the period that
Pastes crevices around the by stoma nurse regularly per month stoma nurse advises or
stoma when patient – only occasionally until review
experiences difficulties in recommended by stoma
obtaining a seal due to nurses
creases or dips being
present
Designed to direct faecal For the period that stoma As advised by the stoma Review monthly by stoma
Collars matter into the appliance nurse advises or until nurse nurse
review
Fills in creases or dips For the period that stoma As advised by the stoma Review monthly by stoma
around the stoma nurse advises or until nurse nurse
review
Secures the stoma Maybe used long-term 2 – 3 belts per year ACUTE
Belts product to the skin, but only need 2-3 per These are washable and
however not all products year – therefore no need reusable
are compatible for repeat
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 20 of 34Appendix 7
Hernias Pouches may not mould around the abdomen, causing the adhesive to lift, thus causing leaks. Specialist appliances are
available on the advice of the patient’s stoma nurse.
Accessories used What does it do How long should it be Number of items on Acute or repeat
used for average
Retention strips/ Flange Flange extenders which Used at each pouch Equivalent to 1-3 per Only for the period that
extenders are tape used to provide change – only pouch depending on size stoma nurse advises or
extra adhesive aiding occasionally of hernia. If frequency of until review
better security recommended by stoma ordering suddenly
nurses increases, refer to stoma
nurse
Belts, girdles and Used for abdominal Stoma nurse 3-6 per year ACUTE
garments support if hernia is recommendation only. These are washable and
present reusable
East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 21 of 34Appendix 8
Medicines to use with care or avoid in stoma patients
Some medication can affect stoma effluent and the presence of a stoma can affect the absorption
and thus bioavailability of some medicines. In general:
Antacids Magnesium salts may cause diarrhoea.
Aluminium Salts may cause constipation
Antibiotics caution may cause diarrhoea
Digoxin Patients may be susceptible to hypokalaemia,
monitor as potassium supplements or a
potassium sparing diuretic maybe required
Diuretics Patients may become dehydrated and caution
in ileostomy patients as they may become
potassium depleted
Enteric-coated and modified-release may be unsuitable, particularly in ileostomy
preparations patients, as there may not be sufficient release
of the active ingredient
Iron – (Ferrous sulphate / Fumarate Ileostomy: may cause loose stools and sore
skin.
Colostomy: may cause constipation
Laxative enemas and washouts should be avoided in ileostomy patients –may
cause rapid and severe loss of
water/electrolytes
Nicorandil Anal and peristomal ulceration related to
inflammatory disease
Opioid analgesics may cause troublesome constipation
Proton Pump Inhibitors may cause diarrhoea
Medicines containing sorbitol should be avoided due to its laxative properties
Absorption of all medication should be checked with a pharmacist to ensure that the patient
receives the therapeutic dose of each medication this includes oral contraceptives.
Absorption of all medication should be checked with a pharmacist to ensure that the patient
receives the therapeutic dose of each medication this includes oral contraceptives.
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 22 of 34Appendix 9
Medicines required for stoma management
Ileostomy patients and High Out Put Stoma (HOS)
Some ileostomy patients can experience occasional problematic, high-volume liquid stomal output,
which can cause dehydration, potential renal impairment, body image problems and increased
product usage.
Anti-motility agents (Loperamide or equivalent or codeine phosphate), 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. (See EKHUFT Guidelines for Management of HOS)
Loperamide or equivalent is preferred as it is not sedative and not addictive/open to abuse. It
should be taken half an hour before meals.
Patient are usually able to self manage dosing according to requirements
Longer-term use with higher doses may be necessary if patients have ‘short-bowel syndrome’. (this
will be advised by Hospital consultant). Higher doses may be used when advised by hospital
consultants for high output stomas. See the link below for more information:
http://www.evidence.nhs.uk/search?q=%22Can+high+dose+loperamide+be+used+to+reduce+stom
a+output%22
If not effective initially i.e. patient still has high-volume output, Loperamide or equivalent capsules
can be opened and dissolved in squash / water before taking.
Constipation
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.
Medicines required for stoma management
Drug Dose
Loperamide 2mg capsules or Loperamide 2mg up to four times a day as required (max
(Imodium) Liquid 1mg/5ml 16mg daily).
Loperamide orodispersible tabs NB: higher doses may be used(unlicensed) by
hospital consultants for reducing stoma in
resistant case
1st line: Caps/Tabs
2nd line (if absorption issues): liquid.
3rd line ( if high doses still needed) :
Loperamide or dispersible tabs
Codeine Phosphate 15mg and 30mg tablets 15mg to 30mg four times a day (max 240mg
daily)
Laxido (macrogol 3350) 1–3 sachets daily in divided doses usually for
up to 2 weeks; maintenance, 1–2 sachets daily
Ispaghula sachets 1 sachet or 2 level 5-mL spoonful’s
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 23 of 34Appendix 10
DACs
• Fittleworth Medical Ltd: (0800 378 846) www.fittleworth.com
• Amcare (ConvaTec Stoma Care): (0800 282 254) www.amcaredelivery.co.uk
• Charter Healthcare: (0800 132 787) www.charterhealthcare.co.uk
• Emerald Prescription Service: (0800 526 116) www.bbraun-emerald.co.uk
• OakMed Gold: (0800592 786) www.oakmed.co.uk/oakmedgold.asp
• Pelican Home Delivery Service: (0800 318 282) www.pelicanhealthcare.co.uk
• Responder Home Delivery Service: (0800 220 300) www.ostomart.co.uk/home-delivery
• Salts Medilink (Salts Healthcare): (01213332000) www.salts.co.uk
• SecuriCare Medical Home Delivery Service: (0800 585125) www.securicaremedical.co.uk
• SureCalm Health care Ltd: (01256 300 150) www.surecalm.com
• Wilkinson Healthcare: (0115 9854011) www.aah.co.uk/content/wilkinson-healthcare
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 24 of 34Appendix 11
National Associations
• Colostomy Association: (0118 9391537) colostomyassociation.org.uk
• Ileostomy Association: (0800 0184724) www.the-ia.org.uk
• Urostomy Association: (08707707931) www.uagbi.org
• Gay Ostomates Association: (0151 7269010) www.gayostomates.org
• RADAR (disabled toilet key): (02072503222) www.radar-shop.org.uk
• Macmillan Association: (0845 601161) www.macmillan.org.uk
• Ostomy Lifestyle Centre: (0800 731 4264) www.lifestylecareline.com
• Sexual Dysfunction Helpline: (0807742571) www.sda.uk.net
• National Advisory Service for children with stomas: (01560 3222024)
• Cancer Bacup: (09098001234) www.cancerbacup.org
• Ostomy support: www.ostomysupport.info
• Bowel surgery: www.allaboutbowelsurgery.com www.meetanostomate.com
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 25 of 34Appendix 12
Manufacturing Companies
Dansac (0800 581117) www.dansac.co.uk
Coloplast (0800 220622) www.coloplast.co.uk
Hollister (0800 521377) www.hollister.co.uk
Convatec: (0800 282254) www.convatec.co.uk
Pelican : (0800 0527471) www.pelicanhealthcare.co.uk
Oakmed:(0800 592786) www.oakmed.co.uk
Salts: (0800 626388) www.salts.co.uk
B-Braun: (0800 163007) www.bbraun.co.uk
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 26 of 34Appendix 13
References
(Pharmaceutical Services) (Appliances) (Amendment) Regulations 2009, amended in April 2010.
www.legislation.gov.uk/uksi/2009/3340/contents/made?view=plan
An overview of the new arrangements under part IX of the drug tariff for the provision of stoma and
urology appliances – and related services in primary care (DH April 2010)
www.dh.gov.uk/en/Publicationandstatistics/Publication/PublicationsPolicyAndGuidance/DH110492
Black P (2009) Managing physical postoperative skin complications. British Journal of Nursing;
18: 17: S4-S10
Burch J; Sica J; Appliances in Stoma Care. West Sussex: Wiley Blackwell.
2008
Burch J (2011) Essential Care for patients with stomas. Nursing Times; 107:45, 12-14
Holmes S: How to assist in the care of stoma patients. Clinical Pharmacist 4: 327-329.
Lee J (2001) Common Stoma Problems: a brief guide for community nurses.
British Journal of Community Nursing. 6 (8): 407-413
Lyon C; Smith A (2010) Abdominal Stomas and their skin disorders London Informa Healthcare
Williams J(2006) Stoma Care Part 2: choosing appliance accessories. Gastrointestinal Nursing;
September 2006; 4 (7) 16-19.
PrescQIPP: Continence and Stoma toolkit v 2.0 available through the PrescQIPP website
(restricted access)
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 27 of 34Appendix 14
A) Key Stakeholders, Consultation, Approval and Ratification Process.
This policy has been circulated to the Surgical Division and to CCG prescribing Lead
For Information to Drugs & therapeutics Committees as this directs prescribing in the
community as opposed to prescribing in hospital
B) Review and Revision Arrangements.
This policy will be reviewed annually, jointly by the EKHUFT Clinically Lead for Stoma services
and The Commissioning Care Group Prescribing Lead. The policy will be amended where
necessary according to changes in legislation or organisational update and relevant Equity
Impact Assessment updates.
C) Dissemination and Implementation.
The Policy will be available on EKHIFT SharePoint and disseminate to GP practices by the
Commissioning Care Group Prescribing lead.
D) Document Control including Archiving Arrangements.
The Policy and future versions will be saved on the medicines Management shared share point
in accordance with the trust policy for the development and management of organisation wide
policies and other procedural documents. Updated versions will be circulated to the
Commissioning Care Groups accordingly
E) Monitoring Compliance.
Prospective Annual Audit
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 28 of 34Appendix 15
Equality and Human Rights Analysis (EHRA)
This Equality Analysis should be attached to any policy, strategy or business case for
decision.
Name of the policy, strategy PRESCRIBING POLICY FOR ADULT STOMA PRODUCTS &
or business case: APPLIANCES
Details of person completing the Analysis
Name Alanda Tofte
Job Title Senior Matron & Clinical Lead for Stoma Services
Division/Directorate Surgical Services Division
Telephone Number Mob 07920 503039 / Direct Dial 01843 234213
What are the main aims,
purpose and outcomes of the To standardise the process for prescribing stoma products and
policy, strategy or business appliance
case?
Does it relate to our role as a
service provider and/or an Yes
employer?
Information and research:
• Outline the information
and research that has
PrescQIPP: Continence and Stoma toolkit v 2.0 available
informed the decision.
through the PrescQIPP website (restricted access)
• Include sources and key
findings.
Include information on how
the decision will affect people
with different protected
characteristics.
Consultation:
• Has there been specific
consultation on this
decision?
• What were the results of
the consultation?
• Did the consultation
analysis reveal any Yes
difference in views
across the protected
characteristics?
Can any conclusions be
drawn from the analysis on
how the decision will affect
people with different
protected characteristics?
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 29 of 34Is the policy, strategy or business case relevant to the aims of the equality duty?
Guidance on the aims can be found in the EHRC’s PSED Technical Guidance.
Aim Yes/No
Eliminate discrimination, harassment and victimisation Yes
Advance equality of opportunity between persons who share
a relevant protected characteristic and persons who do not Yes
share it
Foster good relations between persons who share a relevant
Yes
protected characteristic and persons who do not share it
Assess the relevance of the decision to people with different protected characteristics and
assess the impact of the decision on people with different protected characteristics.
When assessing relevance and impact, make it clear who the assessment applies to within the
protected characteristic category. For example, a decision may have high relevance for young
people but low relevance for older people; it may have a positive impact on women but a neutral
impact on men.
Protected characteristic Relevance to decision Impact of decision
High/Medium/Low/None Positive/Neutral/Negative
Age High Positive
Disability High Positive
Gender reassignment High Positive
Marriage and civil High Positive
partnership
Pregnancy and maternity High Positive
Race High Positive
Religion or belief High Positive
Sex High Positive
Sexual orientation High Positive
Mitigating negative impact:
Where any negative impact
has been identified, outline
the measures taken to
mitigate against it.
Conclusion: This policy applies to all adult patients living with a stoma
• Consider how due regard
has been had to the
equality duty, from start
to finish.
• There should be no
unlawful discrimination
arising from the decision
(see PSED Technical
Guidance).
Advise on the overall equality
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 30 of 34implications that should be
taken into account in the final
decision, considering
relevance and impact.
Signature of person completing the Analysis
Name Alanda Tofte
Signed
Date 30.3.2015
Approval and sign-off Head of Department/Director
Name Click here to enter text.
Signed Click here to enter text.
Date Click here to enter text.
Chair of decision making Board/Group/Committee approval and sign-off
Name Click here to enter text.
Signed Click here to enter text.
Date Click here to enter text.
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 31 of 34Appendix 16
Author’s Checklist of compliance with the policy for the Development and
Management of Organisation Wide Policies and Other Procedural Documents.
Policy: PRESCRIBING POLICY FOR STOMA PRODUCTS & APPLIANCES
To be completed and attached to any policy when submitted to the appropriate committee for
consideration and approval.
Compliant
Requirement: Yes/No/ Comments
Unsure
1. Style and format Yes
An explanation of any terms used in Yes
2.
documents developed
Yes
3. Consultation process
Yes
4. Ratification process
Yes
5. Review arrangements
Yes
Control of documents, including
6.
archiving arrangements
Yes
7. Associated documents
Yes
8. Supporting references
Yes
Relevant NHSLA criterion specific
9.
requirements
Yes
Any other requirements of external
10.
bodies
Yes
The process for monitoring compliance
11. with NHSLA and any other external
and/or internal requirements
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 32 of 34Appendix 17
Plan for Dissemination of Policy to the Commissioning Care Groups of the
PRESCRIBING POLICY FOR ADULT STOMA PRODUCTS & APPLIANCES
To be completed and attached to any policy when submitted to the appropriate committee for
consideration and approval.
Acknowledgement: University Hospitals of Leicester NHS Trust (Amended)
Title of document: Prescribing Guidelines for Stoma Products & Appliances
Version Number: 1.
Approval Date: 15.4.15 Dissemination lead: Alanda Tofte EKHUFT
Previous document NA Heather Lucas CCGs
already being used? heatherlucas@nhs.net
If yes, in what format
(paper / electronic) Available on Share Point for EKHUFT & NHS Net to commissioners
and where (e.g.
Directorate / Trust Paper copies in Circulation
wide)?
Proposed New Policy
instructions
regarding previous
document:
To be disseminated How will it be Format (i.e. Comments:
to: disseminated, who will paper
do it and when? or
electronic)
Commission Care By CCG prescribing lead Electronic
groups By Senior Matron &
Clinical Lead for Stoma
Stoma Nurses Services
Community Drugs & Prescribing Lead Presentation
therapeutics Senior Matron & Clinical
Committees Lead for Stoma Services
General Practitioners Electronic &
and Prescribing Clerks paper
Author’s Dissemination Record - to be Used Once Document is Approved – to be kept with
the master document
Date document TBC Date TBC
forwarded to be document put
put on the Trust’s on Directorate
central register / in register (if
Sharepoint: appropriate) /
on Directorate
webpage (if
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
Page 33 of 34applicable)
Disseminated to: By Whom? Format (i.e. paper Date Disseminated:
(either directly or or electronic)
via meetings, etc.)
Acute Services Alanda Tofte Paper / Electronic
Surgical; Division
Consultant
Colorectal
Surgeons/ GM Heather Lucas
Commissioning Care heatherlucas@nh
groups Via s.net
Prescribing Lead
. East Kent Hospitals NHS Foundation Trust
Prescribing Policy for Stoma Appliance
February 2015
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