Catheter - NHS West Suffolk Clinical Commissioning Group



Catheter Appliances Request FormAll requests to General Practice must be made via this form. GPs may refuse to prescribe unless ALL the relevant sections of theform have been completed and it has been received by the practice. Please refer to the Continence Ostomy and skin care formulary if further items are required.Please return completed form to the patient’s GP surgery – All requests are based on one month’s supply and can be placed on repeatPatient name:Date of Birth:GP:Date of request:NHS number (optional):Address:Requesting Nurse/Carer: Primary diagnosis: retention, incontinence…Relevant past medical conditions: Is the patient currently under an urologist if known? Additional comments:Any contra-indications or known allergies…When the patient was last reviewed? (if known): First line choice for catheters and accessoriesFor product codes and price please see the latest updated version of drug tariffType of ApplianceFORMULARY LIST(Tick box for relevant product & size)QUANTITY PER MONTHProduct codeCOMMENTSThe Product Size/tubeAll Silicone Female indwelling catheter□ BrillantAquaflate All-silicone with prefilled syringe12ch 14ch 16ch 1 catheterDA210112DA210114DA210116*Caution – Female catheterisation only*Please note 2nd line formulary option is LINC all-silicone catheter with lidocaine gel All Silicone Male/standard indwelling catheter □ BrillantAquaflate All-silicone with prefilled syringe 12ch 14ch 16ch 18ch 1 catheterDA310112DA310114DA310116DA3101181 catheter every 4-12 weeks Latex Female Indwelling catheter □ Sympacath AquaFlate Hydrogel Coated Latex with prefilled syringe12ch14ch16ch18ch 1 catheterDH210112DH210114DH210116DH2101181 catheter every 4-12 weeks depending on frequency of changes*Contains LATEX**Caution – Female catheterisation only*Latex Male Indwelling catheter □ Sympacath AquaFlate Hydrogel Coated Latex with prefilled syringe12ch14ch16ch18ch 1 catheterDH310112DH310114DH310116DH3101181 catheter every 4-12 weeks depending on frequency of changes*Contains LATEX*Single-use Intermittent Catheters Teleflex Flocath QuickFemale (sizes 8-14)81012141618 *male only120 catheters (4 packs of 30)851241Integral saline solution and Protective sleeve. Smaller in size/more compact.Approx. use in normal circumstances 4-5 catheters per day / 4-5 packs per monthMale(sizes 8-18)851221Single-use Intermittent CathetersTeleflexLiquick BaseFemale(sizes 6-14)6810121416 *male only120 catheters (2 packs of 60)630010-630016For patients requiring a more flexible catheter and these are longer.Approx. use 4-5 catheters per day / 2-3 packs per monthMale(sizes 10-16)630106-630114Please note** There are other types of catheters on formulary so refer to this if the above products are not suitable. First line recommendations are as above **Intermittent catheterisation allows patients to empty their bladder when the normal functioning of the bladder is impaired. A single use catheter is inserted into the bladder by the patient to drain and is then removed. Patients may be assessed and commenced on intermittent catheterisation if they have been reviewed by an appropriate specialist, please see the formulary for further information. Catheter Bags and AccessoriesLINC Medical Systems LINC Flo Leg Bag350ml day bagT tap onlyDirect inlet10 cm tube1 box of 10 LM350SDT LM350MDT1 box approx every 2-3 months. Bag to be changed every 5-7 days.LINC Medical Systems LINC Flo Leg Bag500ml Lever TapLooser tap for poor dexterity Direct10cm30cm1 box of 10 LM500SDL LM500MDL LM500LDL1 box approx every 2-3 months. Bag to be changed every 5-7 days.500ml T Tap LM500SDT LM500MDT LM500LDTLINC Medical Systems LINC Flo Leg Bag750ml day bagT Tap only Direct10cm30cm 1 box of 10 LM750SDT LM750MDT LM750LDT1 box approx every 2-3 months. Bag to be changed every 5-7 days.Linc-Flo Non-sterile Single use bags NIGHT BAG2 litre night bag100cm tube3 bags of 10 per month LM2LNSFirst choice single use Twist off tapLinc-Flo drainage bag with tap outlet Use for 5-7 days2 litre drainable night bagT tapLever tap 120cm tube 1 box of 10 SLC13 SLC13-L1 box every 2-3 months*If patient using bags more frequently – consider daily single use bags as alternativeCatheter lubricating gelTeleflex Cathejel LidocainFemale 8.5g Male 12.5g 2CJLL08501 CJLL1250For catheter insertion: Contains Lidocaine*Not required for LINC catheters that include Lidocaine gelCatheter valves L.I.are Flo catheter valveLever tap1 box of five CF1Alternative to leg bag*Assessment of bladder function is necessary before using this product*Holders/support strapsClinisuppliesProsys Retainer G-StrapAdult size not abdominal for leg bags. 1 pack of 4. PCS50PRN use Approx. every 4-6 monthsThese are washableProsys sleevesSmallMedium Large Box of 10. PLS3881 PLS3904 PLS3928Incontinence Sheaths and AccessoriesIncontinence SheathsProsys Flofit Self Adhesive SiliconeStandard 24mm28mm31mm35mm40mm1 Box of 30PSS24STD/B – PSS40STD/BUse 1 sheath per 24 hours*Ensure patient is correctly measured prior to use*1 pack per monthPop onPSS24POPON/B- PSS40POPON/BWide-BandPSS24WIDEBD/BPSS40WIDEBD/BBarrier Film WipesColoplast Conveen Prep Wipes (Contains Alcohol)Sheath prep wipesStandard size1 Box of 54620421 wipe used at each sheath change Approx. every 24 hoursOne box per monthAdhesive Remover SprayGreat BearGB Aerosol Spray50ml1 can10380ATo aid sheath removal when requiredPlease note Catheter maintenance solutions are not included on this form as they require a clinical reason for use. Usually not on repeat unless requiring regular bladder wash outs following assessment and recommendation by a specialist.The catheter passport is has been developed collaboratively with national experts to support providers in delivering consistent evidence based catheter care. It will ensure healthcare Professionals have the right information to for each patient. Please refer to this tool. Other requests – please provide rationale for thisProduct nameProduct sizeFrequency, duration and quantityReason for request (must be completed or theproduct cannot be supplied)Please refer to IESCCG & WSCCG Catheter, Stoma and Skincare formulary for other products. For any queries regarding this order form contact: denise.hutchinson4@ Medicines management appliance nurse5289550-622300Flow chart for continence appliancescenter6197603078184787850039338255668305These items can be placed on repeat but review date should be set.400000These items can be placed on repeat but review date should be set.5015557505373838874703696190Check the items ordered on the form are within the quantity guidance. The amounts shown are recommended for one month. 400000Check the items ordered on the form are within the quantity guidance. The amounts shown are recommended for one month. 5031721339041000401068623886810042456102913380Formulary Items00Formulary Items920750239651500-3238502900806Non formulary Items00Non formulary Items305435339532600-5653393646522Contact requesting clinician or care home to inform non-formulary.Signpost to Suffolk continence formulary. Can an alternative be used instead?400000Contact requesting clinician or care home to inform non-formulary.Signpost to Suffolk continence formulary. Can an alternative be used instead?-5651505335497If no alternative available and a rationale has been given: Produce/process prescription as normal but advice can be sought from the East and West Suffolk Medicines Management Appliance Nurse for continenceDenise.hutchinson4@ Some patients under Urology or specialist services may require alternative products so seek confirmation from those involved. 00If no alternative available and a rationale has been given: Produce/process prescription as normal but advice can be sought from the East and West Suffolk Medicines Management Appliance Nurse for continenceDenise.hutchinson4@ Some patients under Urology or specialist services may require alternative products so seek confirmation from those involved. center12700Request received for continence appliances. 4000020000Request received for continence appliances. 1729105916305All district nurse and care homes requests should be made via the East and West Suffolk CCG order form (1 per patient). Ask for completion before accepting. This can then be placed on repeat and reviewed accordingly.00All district nurse and care homes requests should be made via the East and West Suffolk CCG order form (1 per patient). Ask for completion before accepting. This can then be placed on repeat and reviewed accordingly. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download