Medicines Management Team – Prescribing Review Protocol
Stoma Care Appliances in Primary Care Applies to Pharmacist, medicines management technician (teams should be consistent and variation should be evaluated across the MMT) Rationale (a) While it is essential for the patient to carry adequate stocks of their stoma appliances and to be able to order additional supplies in plenty of time, this must be balanced against patient tendencies to over-order. (b) Poorly controlled repeat prescribing can be a wasteful and costly business. Over prescribing and over ordering of stoma appliances are frequently identified in general practice as important causes of wasteful prescribing. (c) Repeat ordering systems operated by some appliance contractors and pharmacies may contribute to the problem by inadvertently ordering excessive amounts or obsolete items (d) The guidelines in this protocol are designed to assist in decision making around rational and cost effective prescribing in stoma care and provide a framework for repeat prescribing of stoma appliances. (e) Quantities quoted are a guideline and it should be recognised that on occasion some patients may legitimately require larger quantities than those outlined. If patients are identified as routinely over ordering stoma care appliances it may be appropriate to contact local Stoma Care services (contact details provided at Appendix One) to arrange for the individual to be reviewed (f) Patients would normally be expected to order just one months’ supply, and as a general rule no patient should be ordering in excess of TWO months’ supply at any one time (g) Some patients are supplied with stoma products through Dispensing Appliance Contractors and it should be noted that Practices should not issues prescriptions retrospectively to these contractors. This protocol has been prepared to promote cost effective stoma care prescribing, using guidelines produced and agreed by the following trusts: Scarborough & York, Harrogate, Northallerton, and Leeds. Method There are many factors that need to be considered when reviewing the choice of a stoma product, and the guidelines provided by this protocol focus only on the range and quantity of items being prescribed for individual patients. Product choice is a specialised area, and changes of product type should not be made without referral back to GP and/or the Stoma Nurse 1. 2. 3. 4.
Check the practice has agreed to the protocol and a signed copy is in place Notify local pharmacies/dispensary of work being undertaken and inform any relevant practice staff e.g. dispensary staff. Run a computer search to identify patients who are currently receiving prescriptions for stoma items Use the data collection form (Appendix 1) and the medical records to record the following:
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
YHCS MMT V1.00 Author: SNL
- Identify items to exclude, e.g. wipes, deodorants and other accessories which should only be commissioned following advice from a clinical nurse specialist - Identify any stoma items where the quantity prescribed is outside the recommended guidelines (Appendix 2) - Any patients who have not been reviewed in the last 12 months (this includes an AUR from a Community Pharmacy). These patients should be referred to the stoma nurse for an AUR. 5. Agree with the Clinical Lead how the prescribing for such identified patients will be reviewed. A suggested approach is: a. Arrange a patient review with a GP or Specialist Nurse to discuss any unusually high level of ordering of stoma products b. Adjust the patient’s repeat medication screen in line with the recommendations of the Data Group such that it prevents any ordering above a set limit without specific prescriber authorisation 6. Send a letter to the patient advising them of the change. Liaise with practice staff to organise mail merge of letters and posting. At the end of the session, for all those changes that have been completed, a letter must be ready to send to the patient for information. 7. Add a READ code for all patients reviewed, indicating whether changes have been suggested or not. 8. Inform relevant practice staff. 9. Record the numbers/patients whose prescribing quantities have been changed using an ‘activity log’ (Appendix 3) 10. Use the activity log to review all changes made and to measure the effectiveness of the switch. Estimate cost savings made and present results back to the practice and organisation 11. Continue to monitor the long term outcomes of the switch e.g. cost savings via PPD data, complaints, problems encountered etc.
Exclusions 1. 2. 3. 4.
Patients whose stoma needs are currently being actively reviewed/ changed by a specialist nurse Any stoma patient identified by a specialist nurse as being unsuitable for review at this time Patients whose order quantities have been confirmed as necessarily above-average by a specialist nurse and/or GP Patients with high output stomas due to short bowel syndrome, jejunostomy and enterocutaneous fistulae may have special management requirements as these patients are more prone to leakage problems and sore skin.
To flag up for special consideration by GP 1. 2.
Any patient that you are concerned may benefit from a review of product choice, or other prescribing issue that you are concerned about. Palliative care patients
Points to discuss with practice 1. 2. 3. 4.
Who is the contact in the practice for the project? Agree content of patient letter – a possible form of words is attached below Agree the number of repeats to issue for patients who are switched. Any practice additions, deletions or amendments to the protocol.
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
YHCS MMT V1.00 Author: SNL
References 1. Guidelines for the Prescribing of Stoma Care Appliances in Primary Care – York Teaching Hospital Foundation Trust (Apr15 -WAITING FOR CONFIRMATION OF AGREED GUIDELINES ) Agreement to protocol Please detail any amendments to the protocol here/or attach a copy of agreed changes:
Signed on behalf of the practice:
………..………………………………………………….
Practice name:
….………………………………………………………..
Date:
...........................………………….
Possible letter Dear ~[Title/Initial/Surname] Review of stoma prescribing Scarborough & Ryedale Clinical Commissioning Group (SRCCG) are currently reviewing prescribing quantities of stoma products and related items in line with recent guidance from the stoma departments at local hospitals. The aim of the review is to promote optimum patient stock levels of stoma items. This has the advantage that whilst patients should not be in danger of running out of stocks, quantities are kept to a reasonable level to reduce storage issues and potential waste if items are changed. As a result the following changes have been made to your future prescriptions: For example: - SenSura ® 1-piece Uro drainable bag – reorder quantity changed to 2 boxes of 10 bags per month - Limone 50ml ® aerosol spray – this item is not included in the new guidelines and has therefore been removed If you have any queries regarding this letter please contact the surgery. If for some reason you feel this letter is inappropriate please accept our apologies and please let us know so we can amend your records. All medicines should be safely stored out of the reach of children. Yours sincerely [Usual GP/Registered GP/GP Prescribing Lead/Other]
__________________________________________________________________
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
YHCS MMT V1.00 Author: SNL
Agreement to letter Please detail any amendments to the letter here/or attach a copy of agreed changes:
Signed on behalf of the practice:
………..…………………………………………………
Practice name:
….……………………………………………………….
Date:
...........................……………………………….
Signed on behalf of MMT:
……………………………………………………………
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
YHCS MMT V1.00 Author: SNL
Appendix 1: Data Collection Form: Stoma Review Patient identifier
Product
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
Target Monthly order
Actual Average Monthly order
YHCS MMT V1.00 Author: SNL
Unexplained apparent excess?
Is product ordered by home delivery company? (if yes, please state which one)
Date of last stoma review
Referred to GP or stoma nurse? Y/ N
Repeat Screen amended? Y/ N
Appendix 2: Prescribing Guidelines for Stoma Products SRCCG (January 2014) SUMMARY TABL Type of Stoma Colostomy Large bowel stoma. Usually formed stool
Ileostomy Small bowel stoma. Semi-formed or loose output. Average volume 500-800mls
Urostomy
Type of Appliance One piece closed appliance
Frequency of Appliance change Changed 1-3 times a day
Anticipated usage per Month 3 x 30 Pouches
Two piece closed appliance
Flange – changed 2-3 times a week
3 x 5 Flanges
Pouch – changed 1-3 times a day
3 x 30 pouches
Drainable pouch
Changed every 1-2 days
15 - 30 pouches : Usually packed in boxes of 10 or 30
Bags are drainable
One piece drainable appliance
Changed every 1-2 days
15 - 30 pouches : Usually packed in boxes of 10 or 30
Drain as required throughout the day
Two piece drainable appliance
Flange - changed 2-3 times a week
3 x 5 flanges : Usually packed in boxes of 5 or 10
Pouch - changed every 1-2 days
15 - 30 pouches : Usually packed in boxes of 10 or 30
Urostomy all in one bag
Usually 1 bag every 1-2 days
20 - 30 bags (2- 3 boxes of 10 bags)
Urostomy flange bag
Usually 1 bag every 2 days
10-20 bags (1-2 boxes of 10 bags)
Urostomy flange (for use with flange bag)
Usually remains in situ for approximately 2 days - change every 2 days
Urostomy night drainage bag
Use a new bag every 7 days
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
YHCS MMT V1.00 Author: SNL
10 bags every 2 months
Notes Bags are not drainable / reusable
Bags are drainable
Type of Stoma
Adhesive remover Barrier creams
Frequency of Appliance change
Quantity prescribed per month
Used each time stoma appliance changed
1-2 cans per month
Apply when bag is changed as directed
1 tube alternate months
Barrier creams are not usually recommended as they reduce adhesion of bags/flanges
2 per year
Usually worn with a convex appliance. Washable and reusable. One should ordered first to ensure patient can manage before requesting another
Belts
N/A
Deodorants
Not routinely required
Not routinely required
Used each time stoma appliance changed
1 powder tube alternate months
Each time appliance changed
As per appliance
Protective wafers
Short term use only
As per appliance
Skin fillers (pastes)
Used each time stoma appliance changed
1-2 tubes per month
Powders Protective rings
Skin protective wipes
Notes
Apply when bag is changed as directed
Support garments should not be prescribed, unless a patient develops a parastomal hernia and/or has been advised to wear ‘support garments’ by the stoma nurse Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
N/A
YHCS MMT V1.00 Author: SNL
1 box every 1-2 months If stoma nurse requested a reasonable quantity to order initially would be a maximum of 3 girdles per year.
To aid removal of appliance
Should not be required. If pouch is correctly fitted, no odour should be apparent except when bag is emptied or changed. Household air freshener is sufficient in most cases Used for protection of excoriated/bleeding skin FOR SHORT TERM USE ONLY Used for skin protection and useful to fill skin creases. To be used under advice of stoma care nurse only Short term use only Used to fill skin creases. Not usually for long term use Short term use only (acute prescription): May be used on skin that is irritated/inflamed to promote healing. If used for > 3 months, refer patient to stoma nurse One should ordered first to ensure patient can manage before requesting another
Stoma underwear Stoma underwear should not be prescribed, unless a patient develops a parastomal hernia and/or has been advised to wear ‘support underwear’ by the stoma nurse
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
N/A
YHCS MMT V1.00 Author: SNL
If stoma nurse requested, a reasonable quantity to order would be 3 light support underwear per year.
Activity Log: Review of Stoma Care Practice:
Date Completed:
Work agreed on behalf of practice by:
Reason for undertaking work e.g. cost/safety:
Number of Patients Identified Number of Patients switched Number of Patients excluded
Savings made (approx.) Approx. time taken
Summary of findings
Difficulties encountered
Pharmacies Contacted
Points for discussion with Practice
Completed By:
Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
YHCS MMT V1.00 Author: SNL
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Protocol Title: Stoma Care Review Date of production: Feb 2015 Review date: Feb 2018
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YHCS MMT V1.00 Author: SNL