Information for patients who've been advised to take phosphate binders.
Why do I need to take phosphate binders?
Phosphate binders are tablets to help keep the phosphate level in your blood within the normal range. You may not have any symptoms of a high phosphate but taking your phosphate binders may prevent problems with your bones, blood vessels and heart. The normal range for blood phosphate is between 0.8mmol/l and 1.5mmol/l.
How do phosphate binders work?
They work by binding to the phosphate in your food, allowing it to pass out in your stool. You may also be advised to reduce your intake of phosphate containing foods. Your renal dietitian can provide you with information if this is needed.
How do I take my phosphate binders?
To work properly phosphate binders will either need to be chewed or swallowed whole either before, during or immediately after any meals, snacks or drinks containing phosphate. Your renal dietitian can guide you based on the phosphate binders you have been prescribed by the doctor. See the information below. Take your prescribed dose daily and spread your tablets throughout the day when you eat. Your renal dietitian can guide you on how to take these tablets with your usual meal pattern and food choices. See the information on page 4. You do not need to take your phosphate binders if you miss a meal. If you forget to take your binders with a meal try to remember to take the next dose at your following meal.
Practical tips
Keep a container of binders in each of the places you eat.
Keep a container of binders in your bag/pocket/in the car ready for when you eat out.
Set an alert on your mobile phone to remind you to take your binders when you eat.
Phosphate binders and other medication
Phosphate binders and some tablets should not be taken at the same time. Some tablets will need to be taken 1 to 3 hours before or after taking your phosphate binders. Check the patient information leaflet provided with your phosphate binders for information. You can also ask your pharmacist or doctor or dietitian.
You or your health care professional can complete the following pages to remind you when and how to take your phosphate binders. Follow the advice of your pharmacist, doctor or dietitian.
Things you should write down:
The name and daily dose of your phosphate binder.
When to take your phosphate binders: meals/snacks, the binder, and the recommended dose.
The timing of your phosphate binders with meals/snacks: before, during, or after.
How to take your phosphate binders: chew well or swallow whole.
Managing your fluid intake is an important part of your treatment
Drinking less can:
Help you breathe more easily.
Prevent your ankles swelling.
Help you keep your blood pressure stable.
Help prevent faintness or cramp on dialysis.
It is also very difficult to control your fluid intake if you eat a lot of salt. Try not to add salt to cooking or at the table. Speak to your dietitian for more information on how to eat less salt. Your doctor nurse or dietitian can advise you how much fluid to have.
Write down the amount of fluid you have been advised to have.
Useful measurements
Standard cup = 150ml.
Standard mug = 250ml.
Standard tumbler = 250ml.
Standard wine glass = 125ml.
Other helpful amounts
600ml = 1 pint.
1000ml = 1 3/4 pints.
Remember liquid foods could as part of your food allowance
Some typical servings
Item
Quantity
ml
Custard/jelly/yoghurt
1 typical pot
100
Ice cream
1 typical scoop
50
Milk pudding
1 serving
200
Ice cube
1 standard
30
Soup
1 serving (1/2 can)
200
Milk on cereal
1 serving
125
If you are feeling thirsty, try one of these first
Slice of lemon or orange.
Frozen grapes or pineapple cubes.
Boiled sweets or sugar free mints.
Chewing gum.
Try this to help space your drinks through the day
Pour water into a jug in the morning that is the same as the amount of fluid you can have daily.
Every time you have a drink such as squash, tea, coffee, milk, pour away the same amount of water from the jug.
This will help you keep track of the amount you are drinking and how much fluid you have left in your allowance for that day.
Helpful tips
Use a small cup or glass for drinks. This should be about 150mls (5½fl.oz).
Keep a record of your fluid intake to help you see how much you are consuming.
Spread your fluids through the day and have smaller drinks.
Remember spicy foods can make you feel thirsty. Try to reduce these foods.
Use plastic ice cubes in drinks to save on fluid.
Brushing your teeth or rinsing your mouth with water or mouthwash can help to freshen your mouth.
If you have a dry mouth, artificial saliva sprays such as Glandosane (available on prescription) can help.
Try swallowing tablets with food instead of fluid.
If you drink less on one day, save some of your fluid allowance for the next day.
You can drink sociably, but choose smaller drinks and try to drink less before or afterwards.
Modern slavery is the removal of personal freedoms in order to exploit human beings for financial or personal gains. It can take many forms including forced labour, human trafficking and sexual exploitation. It is a complex issue with a global reach. There were an estimated 50 million people in modern slavery in 20211 and these numbers are increasing. We recognise that modern slavery will exist in our supply chain, and we are committed to do all we can to identify and manage the risks that our business and purchasing activities pose.
Our Statement
This Modern Slavery and Human Trafficking statement is for the financial year ending 31 March 2023. It outlines the shared commitment and actions that have been carried out by Bristol and Weston NHS Purchasing Consortium (B&WPC), North Bristol NHS Trust (NBT) and University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) over this time period. In the statement, terms such as ‘our’ and ‘we’ refer to all three organisations. This is the first modern slavery statement that we have produced. It covers the following areas of our business activities;
The recruitment of both temporary and permanent employees.
The working conditions and practices for our employees.
The procurement of goods and services.
Organisation Structure and Supply Chains
Bristol and Weston Purchasing Consortium B&WPC provide a comprehensive range of purchasing services to support local Trust and Healthcare Providers.
B&WPC staff are NHS employees, hosted by North Bristol NHS Trust and the services provided include all aspects of clinical and non-clinical purchasing and supply chain management. B&WPC’s main clients include both NBT and UHBW and cover an annual spend of approximately £750m. B&WPC work closely with both Trusts to support compliance with all purchase-to-pay procedures and deliver improved efficiencies.
North Bristol NHS Trust
NBT has over 12,000 staff delivering healthcare across main sites at Southmead Hospital Bristol, Cossham Hospital and Bristol Centre for Enablement and within the local community of Bristol, North Somerset and South Gloucestershire. NBT is a regional centre for neurosciences, plastics, burns, orthopaedics and renal services. NBT’s aim is to deliver an outstanding patient experience and its values of caring, ambitious, respectful and supportive underpin everything that we do.
University Hospitals Bristol and Weston NHS Foundation Trust
UHBW has a workforce of over 13,000 staff, delivering over 100 different clinical services across 10 different sites serving a core population of more than 500,000 people locally and from across the southwest.
With services from the neonatal intensive care unit to care of the elderly, UHBW provides care to the people of Bristol, Weston and the southwest from the very beginning of life to its later stages.
Our Supply Chain
Our supply chain is large, multi-tiered, global and complex. We procure a wide range of clinical and non-clinical goods, services and works. This includes medical equipment, personal protective equipment and uniforms, dressings, mattresses and bed linen, laptops, software, furniture and mechanical and electrical services to name but a few.
Many of our purchases are from sectors that are known to be high risk for modern slavery. Our approach to identifying and managing modern slavery risks must be embedded into any new procurement activity and within our existing contracts to be effective.
We let contracts over a range of timescales from medium to long term relationships to oneoff purchases. As part of our procurement policy, we actively seek to utilise frameworks provided by public sector organisations such as NHS Supply Chain and Crown Commercial Services. We have over 2,500 tier 1 suppliers and over 1,000 active contracts in place.
Policies in relation to slavery and human trafficking A number of national regulations and mandates have been set over the past 12 months that allow for modern slavery to be prioritised as a topic for consideration in the purchases that we make.
The Health and Care Act 2022 allow for regulations to be set to eradicate modern slavery and human trafficking in NHS supply chains. NHS England has also adopted the mandatory inclusion of Net Zero and Social Value criteria in the evaluation of all tenders. This is also mandated for all NHS Trust procurements. Modern slavery can be a topic addressed under social value where it is proportionate and relevant to the contract.
We have created two policies that build on this national level focus to address to this issue. The B&WPC procurement strategy 2022-25 is published online and is publicly available having been signed off and approved by the Trust Boards of both NBT and UHBW.
B&WPC Procurement Strategy 2022-25. This document sets out our values and outlines the areas of focus for B&WPC to ensure that we are maximising the value obtained from our external spend. There are 4 objectives within the strategy. The Anchor in the Community objective includes a clear commitment to remove modern slavery for our supply chain and to use our market leverage to drive an ethical supply chain. The aim is to ensure that our supply chains and procurement processes are ethical, free from worker abuse and exploitation and provide safe working conditions. An away day was held with all B&WPC staff to engage with and explore the strategy and what its aims mean in the short, medium and long term to the team.
Joint Ethical Procurement Strategy. This document will reflect our joint vision and aims to support the delivery of exceptional healthcare services in a sustainable manner. Included within the definition of ‘sustainable’ is ethical conduct and social value. We will document a specific commitment to ensure that our supply chain and procurement processes are ethical, free from worker abuse and exploitation and provide safe working conditions. This policy will be approved and be available publicly during 23/24.
Our existing recruitment policies set out the processes that cover the recruitment of both our temporary and permanent employees. The overall approach is governed by compliance with legislative and regulatory requirements and the maintenance and development of good practice in the fields of employment.
Our recruitment processes are robust and adhere to safe recruitment principles. We have a range of policies and procedures to protect staff from poor treatment and/or exploitation which comply with all respective laws and regulations. This includes policies on recruitment, pay and equality, diversity and inclusion.
In addition to this, we have clear systems and polices in place to encourage the reporting of concerns, speaking up and the protection of whistleblowers Our policies such as Safeguarding Adults and Children, Dignity at Work, Grievance procedure and Freedom to Speak Up policy provide additional platforms for our employees to raise concerns about poor and inappropriate working practices. We have a number of dedicated Freedom to Speak Up Guardians and Executive and Non-Executive Director leads for Freedom to Speak Up. Whilst these are not exclusively for the purpose of raising concerns for modern slavery and human trafficking, their remit covers any issues linked to this.
Risk Assessment and Management
A category level environmental, social and governance risk assessment has been carried out for our spend profile. This assessment included the identification of modern slavery risks across the lifecycle of goods and services purchased on criteria including the risk of forced labour, child labour, working conditions and discrimination. The following purchasing categories were identified as high risk:
Construction.
Information Technology (IT).
Food and Catering.
Medical Equipment.
Textiles (clothing, bed linen etc).
Waste Management.
Temporary Staff and Recruitment Services.
Due Diligence Process
Our robust recruitment processes are in line with relevant employment legislation and adhere to safe recruitment principles. We follow strict pre-employment checks on all directly employed staff, Bank Workers and others undertaking work within our organisation. These include identification, right to work, qualification, registration and reference checks. Our pre- employment checks are in line with the NHS employment check standards and our Resourcing functions oversee fair and equitable recruitment and selection practices.
We align to nationally negotiated NHS pay rates and terms and conditions of employment. We consult and negotiate with recognised Trade Unions on proposed changes to working arrangements, policies and contractual terms and conditions.
Only approved frameworks are used for the recruitment of temporary agency staff. All providers are audited to provide assurance that pre-employment clearance has been obtained in line with the NHS Employment Check Standards.
We also provide access to learning and development opportunities and provide a comprehensive staff benefits and health and wellbeing offer.
As part of our standard checks within our procurement process, bidders are checked (where relevant) for their compliance with the Modern Slavery Act (2015).
We have been engaging with our category leads and main suppliers within our IT category to raise awareness and understand the maturity levels of work across the sector in this area. We aim to replicate this approach for other high-risk categories.
We will use this to inform the due diligence processes we need to implement. We recognise that our current due diligence processes are not adjusted to reflect the risk associated with the purchase involved. We will develop our process over the coming year to ensure that our due diligence processes are proportionate to the risk posed by the purchase in question.
KPIs to measure effectiveness of steps being taken
We have a robust governance mechanism for monitoring the delivery of the commitments set out in our policies. The Sustainable Procurement Workstream as part of the ICS Green Plan Implementation Group is made up of representatives from all three organisations. It is responsible for driving the delivery of the commitments and reporting on their progress to the Green Plan Steering Group that sits above this and feeds into Executive and Board level activities at each organisation.
Training on Modern Slavery and Human Trafficking
We provide advice, training and support about modern slavery and human trafficking to all staff through our safeguarding children and adults mandatory training, our safeguarding policies and procedures and our safeguarding teams.
We also ensure that all staff receive a comprehensive induction programme which includes information on, and guidance regarding modern slavery and human trafficking.
Specifically within our procurement function, B&WPC has been developing a capability framework for all procurement job roles. This framework will be completed in the next financial year and will include modern slavery and social value.
A list of available training resources, including those on modern slavery, has been complied and is available for B&WPC staff to access.
UHBW and NBT plan to develop education resources and make them available to their staff and, over the coming year, map the key stakeholders who are involved in the procurement and contract management process to focus engagement efforts and further drive our shared commitment to eradicate modern slavery and human trafficking from our supply chains.
Information for patients who have been advised to have a CT scan.
Introduction
You have been advised by your doctor to have a Computerised Tomography investigation which is more commonly referred to as a CT scan. This leaflet will explain what CT is, the benefits and risks, as well as what the examination involves. If you have any further questions please speak to your doctor, nurse or radiographer looking after you.
CT scans take place in the Imaging department which can also be known as the Radiology or X-ray department. This is the facility within a hospital that carries out radiological examinations such as X-rays, CT scans, Magnetic Resonance Imaging (MRI) scans, Ultrasound scans along with other types of radiological investigations.
Radiologists are doctors specially trained to interpret the images and carry out more complex examinations. They are supported by highly trained operators, known as radiographers, that carry out X-rays and other imaging procedures.
What is a CT scan?
A Computerised Tomography (CT) scanner is a machine that uses ionising radiation (X-rays) and a computer to produce very detailed cross-sectional images of any part of the body. The information is then built up into a series of pictures for the radiologist to view.
What are the risks and benefits of having a CT scan?
A CT scan involves the use of ionising radiation (X-rays); we are all exposed to natural background radiation every day from radioactivity in the air, food that we eat and even from space. Exposure to ionising radiation from a CT scan carries a small risk, however, the main benefit of having the scan is to get an accurate diagnosis so that you can get the right treatment for you. A specialist will have agreed that the benefit of the scan outweighs the risk of the ionising radiation, and we can assure you that all safeguarding to minimise ionising radiation exposure is taken.
If you are between the age of 12 and 55 years of age and there is any chance that you could be pregnant then please contact the Imaging department before you attend for your appointment. The contact details will be on your appointment letter.
Patients should ideally be scanned within the first 10 days of their menstrual cycle. If you are between the age of 12 and 55 and your appointment does not lie within this timeframe, or you are or may be pregnant please contact the Imaging department before you attend. The contact details can be found on your appointment letter.
Some patients will require an injection of contrast medium, also described as X-ray dye, for their scan which increases the amount of information seen on the scan. There is a small chance of an allergic reaction to the injection of contrast medium, however, the Imaging team are trained to deal with any complication, and the risk is very small.
The Imaging team will make sure you are feeling alright and have recovered before letting you leave the department.
Is there anything I need to do before my CT scan?
Please read your appointment letter as this will give you specific details of how to prepare before your CT scan.
If your appointment letter asks you to drink water before your scan please do so, slowly, over one hour prior to your appointment time. This will keep you hydrated and will also highlight the bowel if we are imaging your abdomen and pelvis. You do not require a full bladder for your CT scan.
If you are taking any medication prescribed from your doctor, please continue to take these as normal, unless told otherwise by your doctor.
If you are asthmatic please bring your inhaler with you to your appointment.
It is recommended that you attend your appointment in clothing that doesn’t contain any metal fastenings, zips or decoration as they show up on the CT scan. If this is not possible, we may require you to change into a hospital gown which will be provided.
Please be punctual to your appointment time. We are a busy department and if you are late for your appointment, we may not be able to fit you in. If you are running late on the day of your appointment, then please let us know by contacting our booking office on 0117 414 8989. If we know you may be delayed, then we may be able to rearrange things to fit you in.
What happens during my CT scan?
From the reception waiting area you will be escorted through to the CT waiting area. From this point onwards you will be cared for by a small team of radiographers, image support workers and possibly a radiologist. The radiographer will be the professional carrying out your CT scan.
In the CT waiting area a member of the CT team will begin to get you ready for your scan. If necessary, you will be asked to change into a hospital gown or to remove any metallic items from the area being scanned.
The radiographer will take you through to the CT scan room and, if necessary, assist you onto the CT scan couch. The radiographer will then raise the couch up and move it into the CT scanner until the part of the body we need to scan is in the centre of the hole in the middle of the CT scanner.
Once you are in the correct position the radiographer will leave the room to perform your scan in an adjacent room. The radiographers can always see and hear you throughout your CT scan and can communicate with you through an intercom if required.
You will be required to keep still throughout your CT scan to avoid blurry images being produced. You might also be asked to follow breathing instructions given by the CT scanner which the radiographer will explain to you before they leave the scan room.
If an injection of contrast medium or X-ray dye is required, a cannula will be placed into a vein in your arm. The radiographer will connect this to a machine called an injector pump that will administer the dye during the scan. When the contrast is injected, it is common for some patients to feel a sensation of warmth around their body, a metallic taste in the mouth or throat and the sensation of peeing. These feelings are normal and are just sensations, they usually pass within the first 30 seconds. Please be assured that the feeling of peeing is just a feeling and not actually happening. Not all patients will experience these feelings.
How long will my CT scan take?
If you have been given an injection of contrast media as part of your CT scan, then you will be required to stay in the department for an extra 15 minutes after your scan has finished. This is so that we can ensure that you have not had an allergic reaction.
If you have not received an injection of contrast media, then in most cases, you will be able to leave the department immediately after your CT scan has been completed. You can eat and drink as normal after your scan.
If you experience any problems after your CT scan, then please contact your GP or 111.
How will I get the results of my CT scan?
After your appointment, your CT scan images will be reviewed by a radiologist. The radiologist will write a report which is then sent to the doctor who requested a scan for you. The doctor who requested your scan will inform you of the results.
This page is for patients whose doctor has requested you have a kidney (renal) biopsy. We hope the following information will answer some of the questions you may have about this procedure.
What is a kidney biopsy?
A kidney biopsy is a medical test, where a small sample of tissue is removed from your kidney with a needle. The sample is then sent to the pathology department where it is examined under a microscope.
Why do I need to have a kidney biopsy?
A kidney biopsy helps to assess and diagnose the problem, if any, in your kidney. Kidney biopsies are usually done for one of three reasons.
To find out why a kidney is not functioning properly.
To get a sample of a mass on a kidney.
To assess a kidney before a kidney transplant.
The importance of a kidney biopsy is that it allows for the kidney cells to be assessed by a pathologist to help make a correct diagnosis and plan any necessary treatment.
Are there any alternatives to a kidney biopsy?
There is no other procedure that will give your doctor the same information as a kidney biopsy.
What are the risks associated with kidney biopsies?
A kidney biopsy is usually a safe procedure. Potential complications are uncommon and include:
Some people experience pain, which is usually not severe and can be controlled with simple painkillers.
Bleeding or bruising around the puncture site which should settle down by itself.
There is a small risk of minor internal bleeding after the biopsy. The risk is around 1 in 20 and will usually settle down by itself. The nurse will monitor your blood pressure and pulse during and after the procedure and you will stay in hospital for up to five hours after the procedure so that we can monitor you.
Some people pass blood in their urine after a biopsy. This will usually settle on its own within a few days. If you continue to pass blood for more than 1 week or if you pass a lot of blood, then contact the Imaging department to ask for assessment and advice. If you become unwell out of working hours, then attend A&E. The number for the Imaging department can be found on your appointment letter.
Occasionally people will have a significant bleed, in which case it may be necessary to do a further procedure to try to stop the bleeding. This will occur in approximately 1 in 50 people.
There is a very small risk of death. This risk is less than 1 in 1000.
What happens before the procedure?
You will need to have a blood test a few days before the procedure to check that you are not at increased risk of bleeding and that it will be safe to take the biopsy. This may be arranged to take place at your GP surgery.
You can continue taking your normal medication. If you are on any medication that thins the blood we ask you to call the Imaging department using the number on your appointment letter. We may need to adjust your medication before undergoing this procedure. These may need to be stopped to keep the risk of bleeding to a minimum. This medication includes but is not limited to; aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran and apixaban.
Please arrange for someone to collect you from the hospital and take you home by car, as we advise you not to use public transport. You are not permitted to drive for 24 hours post-procedure and we would like someone to stay with you at home in the first 24 hours. Please inform the department if this is not possible, as we will need to identify alternative arrangements.
On the day of the procedure:
You should eat nothing for six hours before your appointment. You may drink water until the time of your appointment.
You will arrive at Gate 19 and be accompanied into our day case area.
You may take your normal medication unless instructed otherwise. It would be useful to bring a list of your usual medications.
Please inform us if you are allergic to anything. n You will be asked to change into a hospital gown and a small plastic tube (cannula) may be put into your arm.
A radiologist (x-ray doctor) will discuss the procedure with you. You will be given an opportunity to ask questions. If you want to go ahead with the procedure you will be asked to sign a consent form.
Once all the checks have been performed and consent signed, you will be taken to the procedure room on the trolley. There will be a nurse and a radiologist with you throughout the procedure.
The radiologist will use an ultrasound machine to look at your kidney to find the correct area to take the biopsy from.
Your skin will be cleaned with an antiseptic solution and covered with sterile drapes.
The radiologist will then inject a local anaesthetic into the area selected for biopsy, which will briefly sting and then go numb. Most people will feel a pushing sensation, but the biopsy is not usually painful. A special needle is used to remove a small piece of kidney tissue. Occasionally it is necessary to take more than one sample.
Once the radiologist has taken the sample, the needle will be removed, and the radiologist will apply a dressing.
What happens after the procedure?
You will be taken back to the day case area so that the nursing staff may monitor you closely.
If you are in pain tell the nursing staff so you can be given appropriate painkillers.
You will be required to stay flat for one hour and then sit up for a further two hours. Then walk around for half an hour.
You will be able to eat and drink as normal.
If everything is satisfactory, you will be free to go home. Please arrange for someone to collect you on discharge rather than drive yourself. n Have someone stay with you overnight.
You should rest for the remainder of that day and the following day, avoiding any strenuous activities for 36 hours.
Keep a regular check on the biopsy site. The dressing can be removed after 24 hours.
If you have any discomfort, take your usual pain relief as prescribed. But, if the pain is severe please contact the Imaging department using the number on your appointment letter.
Some people pass blood in their urine after a biopsy. This will usually settle on its own within a few days. If you continue to pass blood for more than 1 week or if you pass a lot of blood, then contact the Imaging department to ask for assessment and advice. If you become unwell out of working hours, then attend A&E.
What happens next?
The results of the biopsy will be sent to the consultant who referred you, who in turn will either contact you or write to your GP with the results.
If you experience any symptoms you are concerned about, please contact the Imaging department directly on the number on your appointment letter or contact your GP or the emergency department.
Finally, we hope this information is helpful. If you have any questions either before or after the procedure the staff in the Imaging department will be happy to answer them.
References
North Bristol NHS Trust (2022) “Ultrasound Guided Liver Biopsy”
North Bristol NHS Trust (2022) “Kidney Biopsy Information for Patients”
Halimi, J., Gatault, P., Louguet, H., Barbet, C., Bisson, A., Sautenet, B., Herbert, J., Buchler, M., Grammatico-Guillon, L. & Fauchier, L. Clinical Journal of the American Society of Nephrology (2020) “Major Bleeding and Risk of Death after Percutaneous Native Kidney Biopsies”
What is a Fractional Exhaled Nitric Oxide (FeNO) test?
This is a quick and easy way to measure inflammation (irritation) in the lungs.
The test may be done in the diagnosis of asthma, to evaluate a chronic cough, or to see how well treatment is working in a patient who has already been diagnosed with asthma.
What does the test involve?
You should not smoke on the day of the test.
You should avoid eating nitrate rich foods (such as leafy green vegetables and beetroot) on the day of the test.
You will be asked to sit in a chair for testing
You will be asked to take a deep breath in as fully as possible and blow out at a steady pace for about ten seconds.
The test takes about five minutes to complete.
What happens after the test?
The results will be sent to the healthcare professional that requested the test and they will discuss the results with you at your next appointment.
Reference
ATS/ERS Recommendations for standardized procedures for the measurement of exhaled nitric oxide 2005 (Joint statement).
An exercise assessment, also called cardiopulmonary exercise test, involves performing an increasing level of activity so that your heart and lungs can be monitored to assess your level of fitness.
Why do I need to have this test?
These tests will help us understand what may be causing any limitation to the amount of activity you can undertake. This will help to give you the most appropriate treatment or advice.
Who will perform my test?
The test will be performed by two respiratory physiologists. Respiratory physiologists are staff who have extensive training and knowledge in respiratory physiology and performing lung function tests.
What will happen during the test?
Before the test begins the physiologist will explain the test to you in detail and answer any questions that you have.
To begin with you will be asked to perform some breathing tests through a mouthpiece. You will then have some electrodes attached to your chest so we can monitor your heart and be fitted with a facemask so we can monitor your breathing.
The exercise is usually performed on a bicycle. Every minute the workload will increase until you feel you can no longer continue.
Important information
Please avoid vigorous exercise on the day of your appointment.
Please take all medication as normal and please bring a list of all medication with you.
Please do not smoke, consume alcohol or eat a heavy meal within four hours of the test.
Please wear loose clothing and shoes suitable for exercise.
Do not wear lipstick or nail varnish/false nails.
Please do not wear any body lotion.
Thank you for your co-operation. This will assist us in obtaining accurate information and enable us to provide you with the most appropriate treatment.
Frequently asked questions
Will there be any discomfort or side effects of this test?
This is a maximal test so you will feel short of breath and fatigued at the end but this will resolve once the test has ended. Your breathing and heart rhythm are monitored continuously during the test. At any time either you or the physiologist can stop the test.
Is there a different test I could have?
There is no other test that would give us all this information about your exercise tolerance and limitations.
When will I be told the results of my test?
The results will be sent to the professional that requested the test. They will discuss the results with you at your next appointment.
Further information
If you have any questions regarding your appointment please call us on 0117 414 9939.
A hypoxic challenge test is a procedure performed to give us information about what might happen to your blood oxygen levels if you travel in an aeroplane.
Why do I need to have this test?
In an aircraft there is less oxygen available in the air. For people with a respiratory problem this can cause their oxygen levels to drop too low. This test will determine whether you need additional oxygen when you are in an aircraft.
What happens during the test?
Before the test begins the Physiologist will explain the test to you in detail and will answer any questions that you may have.
For the duration of the hypoxic challenge test you will be seated. A probe will be put on your finger. This will provide us with information about your blood oxygen levels.
As part of the test it is also necessary to take several pinpricks of blood from your earlobe to provide further information about your blood oxygen levels.
The test may take up to 90 minutes to complete. The length of the test may vary depending on your blood oxygen level.
Important information
Please continue to take all medications as normal.
Please do not wear nail varnish to your appointment.
You are advised not to book or pay for any flights until you have had the results of this test.
It is very dangerous to go on a flight if you have been advised against this or to travel without oxygen if you have been advised to use it. You could experience serious breathing difficulties.
Thank you for your co-operation. This will assist us in obtaining accurate information and enable us to provide you with the most appropriate treatment.
Frequently asked questions
Will I experience any discomfort or side effects?
The only discomfort you may experience is a slight scratch on your ear when a pinprick of blood is taken. There are no known side effects associated with this test.
Is there a different test I could have?
There is no other test that would give us this information about your blood oxygen levels in a flight environment.
When will I be told the results of my test?
The Physiologist will provide information about the outcome of the test at your appointment. The report will be sent to the professional requesting the test. If you require paperwork to be completed for the airline this will need to be completed either by your Consultant or GP. If you require oxygen it will be your responsibility to organise this with the airline that you are travelling with.
What should I wear when I attend for my test?
You should wear normal comfortable clothing.
Reference
British Thoracic Society Standards of Care Committee (2011) BTS Clinical Statement on air travel for passengers with respiratory disease. London: British Thoracic Society.
This page is for patients whose doctor has requested that you have a coronary angiogram. The following information will answer some of the questions you may have about this procedure.
What is a coronary angiogram?
A coronary angiogram (sometimes called ‘cardiac catheterisation’) is an X-ray study which takes pictures of the blood flowing through the coronary arteries which supply the heart with blood. It can highlight narrowings or blockages in these arteries caused by fatty calcified deposits – coronary artery disease.
Why do I need to have an angiogram?
The angiogram gives a detailed assessment of the arteries to give doctors extra information to help them decide on the appropriate treatment. If you have a narrowing coronary (heart) artery, that can be treated with ‘balloon coronary angioplasty and stent’ (PCI). This can be done in the same procedure or sometimes separately at a later date.
What is an angioplasty/PCI?
Coronary angioplasty, often called PCI (Percutaneous Coronary Intervention), is a procedure where a balloon is used to open a blockage in a coronary artery. It is very similar to an angiogram procedure and is performed in the same room, under the same conditions, and the recovery is similar. The main difference is that an angiogram only collects information (pictures), whereas an angioplasty performs a treatment (inserting a stent).
An angioplasty/PCI takes approximately 1-2 hours to perform. The length of time will vary from person to person depending on the complexity of the coronary artery disease. A balloon is used to stretch the artery and a stent (wire mesh tube) is then put in the narrowed artery and acts as internal scaffolding, keeping the artery open.
What are the risks?
Generally it is a very safe procedure. Potential complications are uncommon but include:
Damage to the blood vessels in the leg or arm. Bleeding or haematoma (a lump/bruise under the skin) around the puncture site.
A small risk of stroke.
A small risk of heart attack.
A small risk of emergency cardiac surgery.
A small risk of death.
Very rarely an allergic reaction to the injected substance.
X-ray is used in this procedure but with modern equipment the risk from the X-ray is very low.
What happens before the procedure?
Pre-assessment
You will be invited to attend pre-assessment clinic/ telephone consultation, where we will explain the procedure to you and collect information. If you need an interpreter, please let us know as soon as possible. An ECG will be performed and you might be asked for a blood sample.
You will need someone to take you to and from the procedure and who will stay with you at home overnight. If this is not possible, let us know in advance and we will arrange an overnight bed. They will not be able to stay with you on the day of the procedure.
Please let us know if you might be pregnant. Also, let us know of any allergies, and bring a list of your current medication.
Medication guidelines
If you take diuretics (water tablets), do not take them on the morning of your procedure as you may find it inconvenient.
If you are taking metformin (glucophage), ideally it should be stopped 48 hours prior and not re-started until 48 hours after your procedure.
If you take warfarin, stop taking it 4 days prior to the procedure.
If you take any other anticoagulant (blood thinner, e.g. rivabaxan, dabigatran, apixaban, edoxaban) stop taking it 2 days prior to the procedure.
It is now very common to have combined ‘angiogram and angioplasty (PCI)’ and it is very important that you take dual anti-platelet medication leading up to, and on, the morning of the procedure. This is usually a combination of aspirin and clopidogrel, or aspirin and ticagrelor. This will be discussed in pre-assessment, and prescribed if necessary. These medications are vital for the procedure to go ahead as they prevent blood clotting in the stent.
Preparation for the procedure checklist
Have nothing to eat after 6:30am if your procedure is in the morning.
Have nothing to eat after 10:30 am if your procedure is in the afternoon.
You can drink water up until the procedure.
Bring all your usual medication in with you on the day of the procedure.
Your wedding ring can be taped to your finger but please leave other valuables at home. Please remove all nail varnish.
Bring a newspaper or a book with you so that you will have something to do when the procedure is over.
Bring slippers and a dressing gown, but as few other possessions as possible.
Take/stop taking medication as instructed. You should take your usual regular medication unless instructed otherwise.
On the day of the procedure
When you arrive
You will arrive at the Imaging Department (Gate 19) and be accompanied into our day case area. A cardiologist will explain the procedure to you, and the benefits and potential risks. You will have an opportunity to ask questions. If you choose to go ahead with the procedure you will need to sign a consent form, which may be done during your pre-assessment visit. Please let us know of any allergies too. From there, you will be asked to change into a hospital gown and paper pants and a nurse will go through the procedure checklist and place a small plastic tube called a cannula, in a vein in your forearm to allow medications to be given if necessary during the procedure.
During the procedure
You will be taken to the Cardiac Catheterisation Laboratory (Cath Lab). You will be asked to lie down flat on the X-ray table with a pillow for the procedure. There will be a small team of nurses, doctors, cardiac physiologists and radiographers with you throughout.
If you are feeling anxious, you will be offered sedation but will stay awake. The nurse will then cover you with a drape and clean the area at the top of your leg or wrist with antiseptic solution. Then the doctor will inject local anaesthetic into your wrist (if radial) or the area at the top of your leg (if femoral) which will briefly sting and then go numb.
After this, you may just feel a pushing sensation when a small plastic tube (sheath) is inserted into your femoral or radial artery. A catheter is passed though the sheath and up inside the artery to the heart. Once the catheter reaches your coronary (heart) arteries, contrast liquid is injected into the bloodstream and X-ray images are taken.
The X-ray machine will move around you, but will not touch you. It is important that you stay still throughout to take the clearest pictures possible. Once the doctor has acquired enough images, the X-ray machine will be removed.
If the doctor used the wrist artery (radial), a pressure device called a TR band will be placed on your wrist and inflated. This will be deflated gradually until it can be removed. Alternatively, if the doctor used the leg artery (femoral), a seal may be used to plug the artery or pressure will be applied either with a pressure device or manual pressure.
What happens after the procedure?
You will be taken back to recovery/day case area initially, so that nursing staff can monitor your observations and the wound site very closely. Relax as much as you can and tell the nurse straight away if you experience any discomfort, notice any swelling or bleeding at the wound site, numbness in the leg/arm, or you feel unwell. You will be able to eat and drink as normal. Please make sure you drink plenty of fluids after this procedure which will help pass the contrast liquid out in the urine.
How long will I have to stay in recovery?
Recovery time after an angiogram is usually around 3 hours, but can sometimes be longer.
Recovery time after an angiogram is usually around 3 hours, but can sometimes be longer. If you have an angioplasty (PCI), your recovery time will be longer (about 6 hours) or you may require an overnight stay in hospital. This will be discussed in your pre-assessment appointment.
If the doctor used the wrist radial artery:
The band around your wrist will be slowly deflated over 2-3 hours and then removed. This will be longer, usually 3-5 hours, for an angioplasty/PCI.
The band will then be removed and replaced with a small dressing.
Try not to move your wrist much while your artery is healing.
If the doctor used the leg femoral artery:
If a pressure device or manual pressure was used to stop the bleeding you will need to stay flat for 1 hour and bed rest for a total of 3 hours.
If you have had a seal you can sit up straight away if there is no bleeding, and move around after 2 hours. This may be longer if bleeding occurs. require an overnight stay in hospital. This will be discussed in your pre-assessment appointment.
What happens next?
Before you are discharged
Before you are discharged, the doctor will discuss the results with you. If you have coronary artery disease that requires further treatment, the doctor will explain the options and there may be a meeting. This may be cardiac surgery (coronary artery bypass grafts – CABG), coronary angioplasty/PCI or drug therapy. You will then be given a discharge letter.
Discharge advice
Do not do any heavy lifting or strenuous exercise, like weight lifting or cycling, for 4-5 days. Do not drive 48 hours after an angiogram and 1 week after an angioplasty/PCI (DVLA advice). Drink lots of water (2L) in the following 24 hours. If you were sedated, don’t sign any legal documentation for 48 hours.
Radial (wrist) puncture:
Rest the arm for 2-3 days.
Avoid flexing/ bending the wrist, lifting and putting weight through the arm.
Avoid bathing and washing up for 48 hours after. You may shower the following day, but avoid scrubbing the wound. If wet, replace the dressing with a plaster.
Femoral (groin) puncture:
Avoid bending from the hip for 2-3 days or anything that strains stomach muscles.
Avoid straining when going to the toilet.
Apply light pressure over the puncture site, when coughing, sneezing, or laughing.
Avoid bathing for 48 hours post procedure. You may shower the following day, but avoid scrubbing the wound, and pat dry thoroughly.
Any problems
Complications are rare but can happen, particularly in the first 24 hours, so make sure you have a responsible adult with you. If the wound starts to bleed or swell suddenly, apply firm pressure to the puncture site for 10-20 minutes. If the wound is in the groin, lie flat while pressure is applied for you. If the bleeding stops, seek medical advice. If you are unable to stop the bleeding, call 999 immediately.
A bruise around the site is common but should fade after 2-3 weeks. If it becomes swollen, or you develop persistent pain/ tenderness, contact your GP. If you get any chest discomfort after discharge that does not resolve 5-10 minutes after using your GTN spray, call 999.
Information for kidney patients who need to lower the phosphate levels in their blood.
Eating less phosphate from additives can help this.
Phosphate is often added to food by manufacturers as additives. This phosphate from additives gets into your blood stream more easily than the phosphate found naturally in foods. Phosphate additives can make your blood phosphate levels too high.
This information explains which foods have these additives and how you can avoid them, and which foods you can eat that don’t have phosphate additives.
Some foods are naturally high in phosphate (also known as phosphorous). You could eat less of these too. Ask your dietitian for advice about this.
How can I reduce phosphate additives?
To reduce the amount of phosphate additives you eat:
Eat freshly cooked, unprocessed food more often.
Check ingredient labels and limit foods with phosphate additives.
Swap to brands without phosphate additives.
Why do I need to reduce the phosphate level in my blood?
When the kidneys are not working properly, the level of phosphate in the blood often rises too high. The normal range for blood phosphate is between 0.8mmol/l and 1.5mmol/l.
High levels of phosphate can cause:
Hardening of blood vessels.
Damage to your heart.
Weak bones.
Aching joints.
Itchy skin.
How do I eat less phosphate additives?
If a food contains phosphate additives, you will see the name or E number on the ingredient label. Additives with “phos” in their name contain phosphate. You may be able to swap to a different brand without phosphate additives.
Check ingredient labels and try to avoid these additives:
E number
Name
Where found
E338
Phosphoric acid
Processed meats, sweets. cakes, chocolate, cola drinks.
Processed meats and cheeses, sports drinks, dried milk powder.
E341
Calcium phosphates
Shop-bought desserts and powder dessert mixes, instant pasta mixes.
E343
Magnesium phosphates
Bakery products, liquid egg, salt, substitutes.
E450
Diphosphates
Bakery products, processed meat and cheeses, soups and sauces.
E451
Triphosphates
Processed cheese, icing sugar, flavoured syrups.
E452
Polyphosphates
Processed potato products.
To help you avoid phosphate additives, here are some examples of food labels. They show how phosphate additives are listed on the packaging.
Sausages
Cake
If food contains phosphate additives try checking similar options to find one without.
What foods can I eat?
By choosing fresh, unprocessed foods where possible, you can reduce the phosphate additives you are eating. This will help to you lower your blood phosphate levels.
Here are some suggestions for swaps:
Foods commonly containing phosphate additives
Suitable swaps - but always check labels
Ham. chicken, or turkey slices.
Home cooked cold meat, chicken, or turkey. Or brands without phosphate additives.
Processed cheese spreads or dips.
Flavoured or plain cream or cottage cheese.
Processed cheese slices, cheese triangles.
Cheddar cheese or another hard cheese.
Naan bread, crumpets.
Tortilla wraps, pitta bread, bread or English muffins.
Muffins, scones, sponge cakes.
Fresh fruit, iced buns, fruit teacakes, hot cross buns, jam tarts, meringues, croissants, shortbread, digestive, and rich tea biscuits.
Cola drinks.
Water, fruit squash, flavoured water, lemon or orangeade, non-alcoholic ginger beer.
It can be difficult to find processed meat without phosphate additives. Your dietitian can guide you on processed meats without additives available where you normally shop.
Eating less red and processed meat is recommended for us all as they are linked with causing bowel cancer. They are also high in fat and salt. For healthier, lower phosphate options, see the NHS websites on the next page.
How can I eat more sustainably?
Many people want to eat food that is more environmentally friendly. These are good ideas for the planet and for you too:
Limit red and processed meats. Try some plant food sources of protein such as beans, lentils, soya mince, Quorn, and tofu instead.
Moderate the amount of dairy foods you eat and consider a plant-based milk.
Eat less processed food that is high in fat, sugar, and salt.
Summary
This page has shown you ways you can eat less phosphate from food additives by:
Eating freshly cooked, unprocessed food more often.
Checking labels for phosphate additives, and limiting foods with phosphate additives.
Swapping brands to avoid phosphate additives.
Useful webpages:
For guidance on healthy amounts of meat to help reduce your risk of bowel cancer:
