PRESCRIBING STOMA APPLIANCES The specialist nature of stoma care may hinder primary care prescribers from making modifications to patients’ therapy in order to avoid waste. This document outlines useful points to consider when producing prescriptions for stoma appliances. Practices are encouraged to use this document and other supporting guidance to identify where there is overuse or unexpected use of stoma appliances and as support to trigger review of therapy in order to bring about a change in practice. INTRODUCTION There are three main types of stoma: colostomy, ileostomy and urostomy. There are three types of stoma appliances: closed, drainable and urostomy bags. For colostomies, on most occasions, bags should not be reused and should be discarded once filled. A reusable, drainable bag may be required for patients with certain types of colostomies or for those requiring flexibility e.g. during travel or when experiencing stomach upset. For ileostomies and urostomies, drainable bags should be used. These bags should be drained when full. For each type of appliance there are one- or two- piece systems available. A one-piece system incorporates the seal and the bag in one item and the bag is attached directly to the patient’s skin and it is not necessary to supply a flange. A two-piece system consists of a bag and a flange or base plate. The flange is attached to the skin of the patient and the bag is then attached to the flange. The bag may be removed leaving the flange in situ; another bag may then be attached to the same flange. When prescribing, please remember: Bags and flanges are considered to be the basic necessary appliances for stoma care. Patients who have particular problems with their stoma may require additional accessories which should normally not be used routinely in the long term except under the advice of a stoma nurse specialist (see table 2 below for further details). Preferably, these should be processed as acute prescriptions. Prescriptions should accurately state the manufacturer’s name, size and type of bag and quantity to be supplied. Including drug tariff code numbers on the prescription is very useful. For most patients one or two months’ supply on a single prescription will be sufficient to meet normal requirements. It is ultimately for patients to decide how often they change their bags but Table 1 below gives an idea of how often different bags are changed and, therefore, approximate monthly quantities to be prescribed. The initial prescription for appliances should be for a small quantity until the type and size are finally determined. The stoma can shrink over the first few months, therefore the size of the aperture can change). Batch prescriptions are not recommended. Only appliances listed in Part IXC of the Drug Tariff may be prescribed under the NHS. When products are changed, ensure old products are deleted from the patient’s repeat orders. Patients must be informed that they have a choice as to whether a community pharmacy or dispensing appliance contractor (DAC) or a dispensing doctor dispenses their prescription. Prescriptions should only be issued at the request of the patient / patient’s carer / healthcare professional such as stoma specialist nurse / district nurse. Retrospective prescriptions should not be issued by the prescriber except in an emergency situation. USEFUL CONTACTS : Stoma Specialist Nurse teams at Medway Hospital Telephone: 01634 830000 ext 3636 ; bleep 738 Fiona Anscomb: [email protected] Julie Oxenham: [email protected] Caroline Read: [email protected] Ratified by: Medway CCG Clinical Advisory Group rd Date approved: 3 September 2013 Review date: September 2015

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Table 1: Average monthly stoma appliance usage. STOMA Colostomy

Ileostomy

Urostomy

APPLIANCE TYPE One-piece

AVERAGE MAXIMUM MONTHLY QUANTITY 90 bags (3 boxes of 30 bags)

1-3 bags per day

Two-piece

90 bags (3 boxes of 30 bags)

1-3 bags per day

10 – 15 flanges (for use with two piece colostomy bags)

One flange is usually left in Inform patients to change place for 2-4 days. one flange every 2-4 days.

30 bags (1 box of 30 bags) 30 bags (1 box of 30 bags)

Patients may wish to use Drainable bags. Inform one daily but one bag can patients to drain as required be used for up to 2-3 days throughout the day. before changing.

15 flanges (for use with two piece ileostomy bags)

One flange is usually left in Inform patients to change place for 2-3 days. one flange every 2-3 days.

10 – 30 bags (1 -3 boxes of 10 bags) 10 – 30 bags (1 -3 boxes of 10 bags)

Usually one bag is used for Drainable bags. Inform up to 2 days but bags may patients to drain as required be changed every 1-3 days. throughout the day.

One-piece Two-piece

One-piece Two-piece

DURATION

NOTES Bags are not normally drainable or reusable. Inform patients to remove and discard after use. Some patients may use drainable bags where they require flexibility e.g. travel.

15 flanges (for use with two One flange usually left in Inform patients to change piece urostomy bags) place for 2-3 days. one flange every 2-3 days. Night bags 4 bags (preferable to supply A new bag can be used for Drainable bags. one complete box of 10 on a up to a week unless they Can be used for one piece prescription so a box should begin to smell or become and two piece urostomy last 2-3 months). discoloured. systems. Convex appliances should generally only be recommended by a stoma specialist nurse after thorough assessment of the individual patient. Patients using stoma appliances for other indications such as fistula management, high output stoma management should be referred to the stoma specialist nurses. Notes 1. DACs and pharmacy contractors must also provide free of charge, where necessary, a reasonable supply of wipes and disposal bags for those items specified in the Drug Tariff. These should not be prescribed separately. 2. DACs can also cut bags to size if requested which may be useful for elderly patients and those who have difficulties manipulating scissors.

Ratified by: Medway CCG Clinical Advisory Group rd Date approved: 3 September 2013 Review date: September 2015

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ACCESSORIES Patients who have particular problems with their stoma may require additional accessories but these should normally not be used routinely in the long term. Recommendations on the routine use of accessories should only be made by stoma specialist nurses on an individual need basis. Accessories should preferably be prescribed as an acute prescription. In order for accessories to be prescribed appropriately, patients should be encouraged to discuss their needs with the prescriber prior to ordering additional accessories on the NHS. See table 2 below for further details on accessories that may be prescribed under the NHS. Some accessories can also be bought by the patient from manufacturers, DACs or community pharmacies.

Ratified by: Medway CCG Clinical Advisory Group rd Date approved: 3 September 2013 Review date: September 2015

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Table 2: Expected use of accessories in stoma care. PRODUCT Adhesives

TYPE Discs Rings Pads Plasters Flange extenders Sprays Solutions

FUNCTION

Adhesive removers

Sprays Liquids Wipes

Used to remove firmly stuck Not routinely required except the patient is appliances, clear residual experiencing soreness. adhesive and prevent skin Sprays are more suitable for general use and are damage. more cost effective however wipes may be useful for patients with reduced or limited dexterity. Silicone-based removers are a ‘non-sting’ product and as such are recommended for use.

Bag closures

Plastic clips Wire ties

Used to close drainable bags.

Bag covers

Belts

EXPECTED USE Limited role for use of these products if up to Used to maintain contact of date stoma products are prescribed. flanges with the skin and Certain stomas may require routine use of these prevent pouches from shifting. products. Seek advice from the stoma specialist nurse. Not recommended for use. Newer, more suitable products are available.

Use should be decreasing due to the availability of newer products with integral fastenings. Plastic clips are usually cleaned and re-used while soft wire ties are disposable.

Reduces bag irritation and With many of the newer products being opaque, discomfort resulting from the the requirement for bag covers is reducing. feel of the bag on the skin and bag noise. May assist with psychological adjustment. Belts Girdles Support belts and garments

Belts are used to secure the stoma product to the skin. Girdles, support belts and garments provide abdominal support for hernias.

For Hernia support appliances e.g. belts, knickers, pants: 3 appliances per year (1 to wear, 1 in the wash, 1 for spare).

Deodorants

Used to mask odour. Can assist with psychological adjustment.

If a product is required, prescribers are encouraged to prescribe the most cost effective product available.

Discharge solidifying agents

Used to change consistency of Use under the advice of a stoma specialist nurse. stool without drugs. Patients may also require additional treatment such as electrolytes.

Ratified by: Medway CCG Clinical Advisory Group rd Date approved: 3 September 2013 Review date: September 2015

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PRODUCT Filters / Bridges

TYPE

FUNCTION EXPECTED USE Filters control the release of Filters are becoming obsolete. All new pouches wind therefore preventing the will already have built in filters. bag from inflating or Limited role for bridges and there may also be ballooning. difficulties in obtaining supplies. Bridges help the motion to drop to the bottom of the pouch therefore helping prevent ‘pancaking’. Irrigation / washUsed to manage stoma output. Irrigation is only suitable for patients with an end out appliances colostomy and should only be undertaken under advice from stoma nurse specialists. Pressure Plates Forms convexity with retracted Limited need for use of these products. or Shields stomas which in turn cuts Patients currently receiving prescriptions for down on leakage. these products may require review and look to current systems being replaced with an alternative product with built in convexity. Skin fillers & Skin filler Used to fill skin crevices, Do not add on repeat. Use should be limited and protectives pastes creating a more even surface only under the advice of a stoma specialist nurse. Washers/Seals for the appliance to adhere to. Skin fillers & Pastes Protect and heal broken, Do not add on repeat. Use should be limited and protectives (protectives), weepy skin without affecting only under the advice of a stoma specialist nurse. Skin protectors Powders, adherence. Use under the advice of a stoma specialist nurse. Wipes, Films, Barrier Creams Wafers, Designed to cover and protect washers/seals skin, allowing healing of sore skin. Stoma Caps / Can be used to cover a stoma Maximum of one cap per stoma bag but likely to Dressings during bathing, showering or be less. swimming or after the stoma irrigation. Generally, water is sufficient to clean the stoma. Soaps, disinfectants, antiseptics cause dryness and irritation and should not be used routinely. REFERENCES 1. Bwalya C, Sica J, 2010. Supplying stoma products and services. Pharmaceutical Journal, 20th November. 2. Drug Tariff, May 2013 edition. Drug Tariff

Ratified by: Medway CCG Clinical Advisory Group rd Date approved: 3 September 2013 Review date: September 2015

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