Stoma accessories formulary (Formularies)

• It is essential for patients to carry adequate stock of stoma appliances and to be able to order additional supplies in plenty of time. This must be balanced against over ordering.
• 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 ONE month’s supply at any one time.
• It should be recognised that, on occasion, patients may require larger quantities than normal, or an acceptable timetable can be agreed for those permanent ostomists who prefer less frequent ordering.
• If patients are identified as routinely over ordering, it would be appropriate to refer the patient to a CSCNS for review.

• All new patients with a stoma discharged from hospital, will be given the choice of having prescriptions for stoma appliances supplied by either a dispensing appliance contractor, or from a local community pharmacy contractor or dispensing Doctor practice.
• On discharge, all patients should be supplied with a minimum of 7 days 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, the CSCNS will also provide the Pharmacy with a list of products.
• Product type may change over the first 4 to 6 weeks post discharge. The CSCNS will inform the GP practice of any changes.
• The product information to be provided will include:
  • Name and type of product
  • Manufacturer
  • Product code/product order number
  • Pack size
  • Frequency of use
  • Suggested number of packs required each month.
• GP practices should use the list provided the CSCNS to generate a repeat prescription list for patients to request prescriptions.

• Patients or their carers (including care home staff), should ensure that only products required are ordered, in order to reduce wastage.
• Patients or their carers should 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 review with a CSCNS, any changes made to a patient’s product usage 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 dispensing appliance contractor 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.
• GPs or other practice staff can also obtain advice from the CSCNS by telephone on 01463 704522 or by email to: nhsh.colorectalstoma@nhs.scot.

• 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 Community Pharmacy, a Dispensing Doctor Practice or a Dispensing Appliance Contractor.
• Prescriptions should only be generated at the request of a patient, patient’s carer or CSCNS.
• 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.
• No appliances should be supplied to a patient prior to a prescription being issued. Retrospective prescriptions will not be issued except in emergency situations and only at the request of a patient, patient’s carer or CSCNS.
• There may be some occasions when a patient who is newly discharged from hospital with a stoma will require products quickly and may need frequent product changes until the stoma stabilises. If such patients opt to use a dispensing appliance contractor, the CSCNS will arrange for a supply of products to be delivered to them. A retrospective prescription may be required but this will only be arranged with prior permission from the prescriber. After these initial supplies, prescriptions should then be issued before dispensing occurs.
• There may be some occasions eg 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.
• Prescriptions for stoma appliances should be issued on separate prescription forms to other items requested by a patient eg medication. This will avoid problems if the patient chooses to use a dispensing appliance contractor for stoma appliances, and not a community pharmacy contractor/dispensing doctor practice.

Patients requiring stoma appliances can have these items dispensed by either:

• A community pharmacy contractor
• A dispensing doctor practice
• A dispensing appliance contractor.

It is imperative that patients are made aware that they have the choice as to where their prescriptions may be dispensed.

• Dispensing appliance contractors or community pharmacy contractors 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 of stoma appliances 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, they will arrange for a prescription to be issued and provided to the contactor.
• Alternatively, in urgent situations, the dispensing appliance contractor or community pharmacy contractor must contact a prescriber and request their permission to supply the stoma appliance in advance of receiving a prescription.

New patients will have the process for ordering prescriptions and choices for having them dispensed explained to them by a CSCNS.

On discharge, the CSCNS will provide the patient’s GP practice with a list of products being used, using IDL.

The CSCNS will also provide an updated product list when, following review, any changes are made to the requirements for an existing patient.

Patients already being prescribed stoma appliances will receive a letter from their general practice informing them that (other than in emergency circumstances) a prescription must have been issued by a prescriber (normally their GP) before any product can be dispensed for them by either a community pharmacy contractor, a dispensing doctor practice or a dispensing appliance contractor.

GPs will be advised that, if they identify a patient routinely over ordering products, they should refer the patient to a CSCNS for review.

All dispensing appliance contractors have been informed that no stoma appliances should be dispensed to a patient prior to a prescription being issued. The exception to this will be requests directly from a prescriber or a CSCNS to supply a product in advance of a prescription.

The recommended quantities stated below are those considered reasonable for a ONE MONTH supply.

All pouches should be delivered with complementary wipes and disposal bags.

One Piece Closed Pouches

• Most products come in boxes of 30 pouches.
• Most require to be changed 3 to 4 times daily.
• 30 pouches should last 7 to 10 days.
• Up to 120 pouches/month would be a reasonable quantity to order.

One Piece Drainable Bags

• Includes urostomy bags.
• These bags can be changed every 1 to 3 days.
• Most come in boxes of 30.
• Up to 30 bags/month would be a reasonable quantity to order.

Two Piece Closed Systems (involving a base plate/flange and pouch)

• Most base plates/flanges come in boxes of 5 or 10.
• Each base plate/flange is usually left in place for a period of 2 to 4 days.
• The pouches are usually in boxes of 30 and should be changed 2 to 4 times per day.
• Up to 15 base plates and 90 pouches would be a reasonable quantity to order.

Two Piece Drainable System (involving a base plate/flange and bag)

• Includes urostomy bags.
• Most base plates/flanges come in boxes of 5 or 10.
• Each base plate/flange is usually left in place for a period of 2 to 4 days.
• Drainable bags are usually supplied in boxes of 10 to 30, and changed every 1 to 3 days.
• Up to 15 base plates would be a reasonable quantity to order.
• Up to 30 drainable bags would be a reasonable quantity to order.

Night Bags

• These are for both one and two piece urostomy systems.
• Single use, new bag each night.
• Usually supplied in packs of 10.
• Up to 30 bags would be a reasonable quantity to order.

General Notes

• Use of accessories will be advised by the CSCNS on an individual patient basis.
• Barrier wipes/powders should be regarded as ‘one-off’ prescription and not be provided on a repeat basis, unless specified by CSCNS.
• NHS Highland do not recommend routine prescription of deodorant sprays.
• Dispensing appliance contractors may offer patients free samples. CSCNS review is required before any product is prescribed.

Adhesives (Discs/Washers, Pastes, Sprays or Solutions)

• These products should only be used following advice from CSCNS.

Adhesive Removers

• Adhesive removers are available as sprays, liquids and wipes.
• There may be a role for these products to prevent skin damage.
• These products should only be used on the advice of a CSCNS.

Bag Closures

• Used on older drainable pouches, to seal the end of the pouch, and being replaced by integral fastenings.
• There are two types; plastic clips and wire ties.
• Plastic clips are usually cleaned and re-used whereas wire ties are disposable.
• Some drainable pouches include closures in the box - check before ordering separately.

Bag Covers

• Wide range available.
• Help reduce bag irritation and discomfort resulting from the feel of the bag on the skin and also bag noise.
• Pouch covers are washable.
• The requirement for bag covers is reducing, with improving technology. 

Belts

• Ostomy/stoma belts are used to secure the stoma product to the skin.
• They are usually 30mm wide, adjustable and made of stretch elastic. They can be ordered in standard or large size.
• The advice of a CSCNS should be sought regarding their use as not all stoma products can have a belt fitted to them.

Deodorants (sprays and sachets)

• NHS Highland do not recommend routine prescription of deodorants.
• Patients can purchase small ostomy deodorant sprays via Dispensing Appliance Contractor/Online, if desired, but an ordinary household deodorant is generally suitable.

Filters/Bridges

• Removable filters are becoming obsolete but are still used with some older products.
• All new pouches have built-in filters which allow the dispersal of flatus from the pouch via a charcoal pad which absorbs any odour.
• Drainable bags can also have filters which can be fitted by the patient.
• There is a very limited role for bridges and there may be difficulties in obtaining supplies.
• These products should only be used on the advice of a CSCNS.

Irrigation/Wash-out Appliances

• Irrigation is only suitable for patients with an end colostomy and should only be undertaken on the advice of a CSCNS.
• The process involves introducing water into the stoma via a cone and irrigation set in order to wash out faecal matter from the colon. As a result patients can wear a stoma cap, plug or dressing during the day and have some control over the function of their stoma.
• Sleeves are for once only use.

Protective Shields

• There is limited need for these products and they should only be used on the advice of a CSCNS

Skin Protectives

• These are available as pastes, powders, wipes/films and creams.
• These products should only be used on the advice of a CSCNS.

Stoma Caps/Dressings

• Used to cover the stoma but have no actual capacity.
• Used by patients with mucous fistula.
• There are also products available for urostomists, but these have limited capacity.
• They can be used on a colostomy during the day when the stoma is 'quiet' or 'inactive'.
• Patients who irrigate their stoma often find these useful.
• They should not be used with an ileostomy due to the high activity of this type of stoma.
• Up to 30 caps a month would be a reasonable quantity to order.

This Formulary should be read in conjunction with the NHS Highland Policy for the Prescribing of Stoma Appliances on the Intranet. Most available accessories are not normally required however prescriptions for these products may be requested by patients. In general, stoma accessories should only be prescribed on the advice of an NHS CSCNS, who will make a decision on an individual patient basis. 

Points to note:

• Do not prescribe deodorants; patients should purchase an ordinary household deodorant/air freshener if required for when changing bags.
• Adhesive removers should only be prescribed following the advice of a CSCNS.
• Discharge solidifying agents are not usually needed, unless on the recommendation of a CSCNS.

*Cost: Prices from ISD Scotland stoma appliances list (Drug Tariff), January 2023.

Additional information on stoma prescribing guidelines can be found on appendix 4 of the National Stoma Quality Improvement SLWM (NSQIG) Final Report (November 2019).