Pharmaceutical Services DivisionMinistry of Health Malaysia

PROTOCOLMEDICATION THERAPY ADHERENCE CLINIC, WARD & HMR: NEUROLOGY (STROKE)

Pharmaceutical Services DivisionMinistry of Health Malaysia

Lot 36, Jalan Universiti46350 Petaling Jaya, Selangor.

Tel. : 03-78413320/3200 Faks : 03-79682222

www.pharmacy.gov.my

MEDICATION THERAPY ADHERENCE CLINIC,

WARD & HMR: NEUROLOGY (STROKE)

First Edition2013

Pharmaceutical Services DivisionMinistry of Health Malaysia

PROTOCOL

First Edition, 2013

Pharmaceutical Services Division

Ministry of Health, Malaysia

ALL RIGHTS RESERVED

No part of this publication may be reproduced, stored or transmitted in any form or by any means whether electronic, mechanical, photocopying, tape recording or

others without prior written permission from the Senior Director of Pharmaceutical Services, Ministry of Health, Malaysia.

Perpustakaan Negara Malaysia Cataloguing-in-Publication Data

ISBN: 978-967-5570-47-6

[ i ]

PREFACE

Stroke is a global health problem and is the second commonest cause of death. In Malaysia, it is the third largest cause of death after heart diseases and cancer. It

is considered to be the single most common cause of severe disability. The risk of having recurrent stroke is very high throughout the year if patient are not provided with a proper management. Hence, pharmacists play an important role in improving patient care, with regards to medication adherence, education and awareness of quality of life in order to convey

the best management to the patient.

This protocol is meant for pharmacists in Ministry of Health (MOH), who are involved in providing intensive stroke management. This protocol will ensure the standardisation of practice on the activity and documentations of practice and continuity of care towards stroke patients from ward, to medication therapy adherence clinic and home medication review.

I would like to thank the Neurology Task Force Group, Pharmaceutical Services Division, MOH for their contribution and commitment to the publication of this protocol.

DR. SALMAH BINTI BAHRIDIRECTOR OF PHARMACY PRACTICE AND DEVELOPMENTPHARMACEUTICAL SERVICES DIVISIONMINISTRY OF HEALTH, MALAYSIA

[ ii ]

ADVISORSDr. Salmah binti Bahri

Director of Pharmacy Practice DevelopmentPharmaceutical Services Division, MOH

EDITORSRosminah binti Mohd Din, Pharmaceutical Services Division, MOHNoraini binti Mohamad, Pharmaceutical Services Division, MOH

Eezmalina Sazza binti Shaharuzzaman, Pharmaceutical Services Division, MOH

EXTERNAL REVIEWERSDato’ Dr Hj. Md Hanip bin Rafia

Consultant Neurologist and Head of Department of NeurologyHospital Kuala Lumpur

Dr. Zariah binti Abdul AzizConsultant Neurologist

Hospital Sultanah Nur ZahirahDr. Looi Irene

Consultant NeurologistHospital Seberang JayaDr. Nor Aida binti MusaRehabilitation Physician

Hospital Sultanah Nur Zahirah

CONTRIBUTORSNorsima Nazifah binti Sidek

Hospital Sultanah Nur ZahirahCik Khor Seau Ting

Hospital Sultanah Bahiyah‘Arafah Nur Na’im binti Hamzah

Hospital Rehabilitasi Cheras

ACKNOWLEDGEMENTPharmaceutical Services Division would like to thank all who have in one way or

another supported and/or contributed towards the development of the protocol.

TABLE OF CONTENTS PAGE NUMBER

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TABLE OF CONTENTS PAGE NUMBERA. Stroke Medication Therapy Adherence Clinic

(SMTAC) Protocol 1 • Introduction 1• Objectives 1• Scope Of Service 2• Location / Setting 2• Man Power Requirement 2• Appointment 2• Procedures 2• Others 5

B. Stroke Protocol for Ward Pharmacist 6• Introduction 6• Location / Setting 7

C. Home Medication Review (HMR) 8• Introduction 8• Scope Of Service 8• Man Power Requirement 8• Appointment 8• Procedures 10

References 10

Appendices • Appendix 1 : Stroke MTAC Pharmacy Workflow 12• Appendix 2 : Patient Consent Form 13• Appendix 3 : Patient Assessment Form 14• Appendix 4 : Patient’s Visit Form 15• Appendix 5 : Modified Morisky Medication Adherence Scale Guide 21• Appendix 6 : Education Outline for Stroke Patient 23• Appendix 7 : Stroke Ward Pharmacy Workflow 24• Appendix 8 : Stroke Management Checklist 25• Appendix 9 : Stroke Education Checklist 26• Appendix 10 : Home Medication Review (HMR) Workflow 28

[ 1 ]

A. STROKE MEDICATION THERAPY ADHERENCE CLINIC (SMTAC)

INTRODUCTION

Stroke represents a major health concern for Malaysians, ranking as one of the top 10 reasons for hospitalisation and the third largest cause of death in Malaysia. It is considered to be the single most common cause of severe disability and an estimated 40,000 people in Malaysia suffer from stroke every year. The number of Malaysians suffering from stroke is increasing rapidly while most of the cases were preventable.

The morbidity burden for patients, families, and society is ponderous. Seventy percent of stroke patients who recovered keep themselves away from social activities and nearly 30% of survivors suffer permanent disabilities and needed assistance in coping with their daily activities. Stroke hits the health budget in the form of long and costly rehabilitation process.

Stroke is the most preventable of all life-threatening health problems. Modifying certain behaviors has been shown to decrease stroke incidence. Awareness of the risk factors of stroke and the ways to control them; recognizing the signs and symptoms of strokes which are necessity for prompt emergency stroke care can minimize the chance of getting stroke as well as the level of disability it cause.

Pharmacists as an integral part of the health care team can play a significant role in improving patient’s awareness and knowledge and are in a key position to track adherence to drug therapy. Pharmacist involvement can improve disease and disability prevention, leading to fewer physician visits, decrease the need for medical treatment, lower heath care costs and most important, improve patient’s quality of life.

Stroke Medication Therapy Adherence Clinic (SMTAC) is an ambulatory care service conducted by pharmacist in collaboration with physicians and other health care providers with the aim in improving patient’s compliance and knowledge with therapy.

OBJECTIVE

1. To maximize the benefits of medication and minimise the adverse effect and complications resulting from the medication.

2. To improve patient’s adherence towards medication and post stroke management.

[ 2 ]

3. To increase patient’s understanding towards their illness and medication through education, monitoring, and close follow up.

4. To enhance awareness on risk factors and prevention of recurrent stroke through education on healthy lifestyle and risk factor management by collaborating with other MTAC programs and other facilities .

5. To work together with neurologist, physicians and other healthcare providers in patient’s pharmacotherapy management.

SCOPE OF SERVICE

Patients who are managed in the Neurology/Stroke/Medical Clinic/Rehabilitation Clinic who are referred to SMTAC by health care professionals.

LOCATION / SETTING

The SMTAC service should operate in the clinic area during clinic days.

MAN POWER REQUIREMENT

At least 2 pharmacists should be assigned to SMTAC.

APPOINTMENT

Appointment should be scheduled by pharmacist. Number and frequency of visits for patients under SMTAC will be determined by the pharmacist conducting the MTAC and patient’s/caregiver’s capabilities. For continuity of service, patient shall be referred to HMR team or pharmacist at other MOH facility by using the CP4 form.

PROCEDURES

The procedures for SMTAC workflow and documentation are shown in Appendix 1, 2, 3, 4 and 5.

1. SELECTION OF PATIENT

1.1 Patient who has been diagnosed with stroke with the following criteria:

a. Newly diagnosed with stroke and initiated with medication.

b. Patient suspected of having non-adherence towards their medication.

[ 3 ]

c. Patient who have drug related problems and suspected adverse drug reactions.

d. Patient referred by healthcare providers, i.e. specialist, medical officers, pharmacist, speech therapist.

A consent form must be obtained from the patient as an agreement to enroll in SMTAC.

2. MISSED APPOINTMENT

Patient/caregiver will be contacted by phone for appointment to be rescheduled.

3. MODULE

3.1 FIRST VISIT

At the initial visit, the pharmacist will perform an initial assessment of the patient/caregiver. The initial assessment will entail:

3.1.1 Review of patient medical/medication history3.1.1.1 List of medication3.1.1.2 Method of administration

3.1.2 Conduct a baseline assessment3.1.2.1 Past medical/medication history3.1.2.2 Social/family history3.1.2.3 Diet/lifestyle3.1.2.4 Allergies (drug and food etc)3.1.2.5 Medication knowledge3.1.2.6 Medication adherence3.1.2.7 Any other drugs/supplement/herb intake

3.1.3 Determination of any medication related problem and issues3.1.3.1 Untreated conditions3.1.3.2 Drug use without indication3.1.3.3 Improper drug selection3.1.3.4 Sub therapeutic dosage3.1.3.5 Over dosage3.1.3.6 Adverse drug reactions (ADRs)3.1.3.7 Drug interactions3.1.3.8 Failure to receive medication

[ 4 ]

3.1.4 Pharmacist recommendation3.1.4.1 Discussion with neurologist or physician regarding patient’s

pharmacotherapy management or if any pharmaceutical care issue identified.

3.1.4.2 Proposed action plan or ultimate outcome as agreed by patient/caregiver.

3.1.4.3 Discussion with patient/caregiver on the pharmaceutical care plan based on the laboratory parameters.

3.1.5 Patient’s counseling and education• Stroke symptoms• Secondary prevention of stroke

o Stroke risk factoro Medication

Importance of drug adherence Indication of each drug

o Diet controlo Exerciseo Smoking cessation

• Target for BP, Glucose level, LDL and other related parameter• Medication indication, administration, storage, common side

effects etc• Rehabilitation intervention

o Promote stroke recoveryo Prevention of complications

3.2 FOLLOW UP

3.2.1 An appointment is given one to two months later to assess patient’s related issues (adherence, disease control, drug’s side effect and efficacy).

3.2.2 Scheduled appointments based on patients/caregiver timing preferences.

3.2.3 Pharmacotherapy management advice and stroke education provided and referral made to physician for any drug related issues.

[ 5 ]

4. OTHERS

4.1. SCOPE OF FUNCTION AND RESPONSIBILITIES OF PHARMACIST

4.1.1 Monitoring and Evaluation.

4.1.2 Pharmacotherapy management consultation.

4.1.3 Patient Education – refer Appendix 6.

4.1.4 Medication Dispensing• Medications shall be dispensed to the patient/caregiver

during part supply medication collection or during scheduled appointment.

4.1.5 Documentation• All relevant data to be recorded using the designated forms as

follows and kept in the patient’s profile. The documentation will contain the followings:o Patient demographic and medical/medication history.o Assessment of patient’s medication knowledge and

adherence (Modified Morisky Medication Adherence Score).

o List of patient’s current medication.o Pharmaceutical care issues and pharmacist’s plans.

During each visit, patient’s status will be updated in patient’s file such as any medication changed or added, medication adherence progress, any drug related issues, patient’s complaint, any intervention and action plan for each medical condition addressed.

4.2. QUALITY ASSURANCE/OUTCOME

4.2.1 This service shall be continuously assessed to ensure that patients are receiving optimal care.

4.2.2 Outcomes of SMTAC will include improvement in patient medication knowledge, controlled risk factor and reduce hospitalisation.

[ 6 ]

B. STROKE PROTOCOL FOR WARD PHARMACIST

INTRODUCTION

The pharmacist is involve in the care of acute stroke patient by collaborating with multidisciplinary team (Neurologist/Physician, Rehab Physician, Staff Nurse, Occupational Therapist, Physiotherapist, Speech Therapist, Dietician and Social Worker) in the management of patient, focusing on medication therapy.

The procedures for stroke protocol for ward pharmacist workflow are shown in Appendix 7.

In the ward, pharmacist should perform the following functions:

1. Involve in stroke round.

2. Patient medication history taking (CP1 and National Stroke Registry form).

3. Review patient‘s medication management and progress.

4. Assist in managing stroke patient in accordance with the following guidelines:

- To fill up Stroke Management Checklist (Refer Appendix 8).

Acute management

• Thrombolytic therapy for patient arriving within 4.5 hour for ischemic stroke.

• Antiplatelet within 48 hours of admission for ischemic stroke and Transient Ischemic Attack (TIA).

• Deep Vein Thrombosis (DVT) prophylaxis for patient with leg power of <3/5 (for ischemic stroke, to start immediately and for hemorrhagic stroke, after 72 hours of event).

• Hypertension management (refer to CPG Management of Ischemic Stroke 2012).

• Hyperglycemia management (refer to CPG Management of Ischemic Stroke 2012).

• Infection management (refer to CPG Management of Ischemic Stroke 2012).

[ 7 ]

Secondary prevention of stroke

• Antiplatelet upon discharge for ischemic stroke and TIA.

• Lipid lowering therapy upon discharge (for hemorrhagic stroke, must consider the risk of stroke recurrence).

• Anticoagulant for stroke patient with atrial fibrillation.

* Time of initiation will depend on the severity of the stroke.

• DVT prophylaxis for patient with leg power of <3/5 (if there is a need to continue).

• Risk factor control

* Hypertension (refer to CPG Management of Hypertension 3rd Edition 2008).

* Diabetes Mellitus (refer to CPG Management of Type 2 Diabetes Mellitus 4th Edition 2009).

* Atrial Fibrillation (refer to CPG on Management of Atrial Fibrillation 2012).

* Ischemic Heart Disease.

* Others.

5. Patient education (Refer Appendix 9)

• Stroke risk factor.

• Stroke symptoms.

• Secondary prevention of stroke.

• Medication.

* Importance of compliance.

* Indication and role of each drug.

• Diet control.

• Exercise.

• Smoking cessation.

• Target for BP, Glucose level, LDL and other related parameters.

LOCATION / SETTINGThis ward pharmacy service shall operate in the ward.

[ 8 ]

C. HOME MEDICATION REVIEW (HMR)

INTRODUCTION

HMR is a patient – focused process which advocates the optimal and quality of medication at the stroke patient’s home. It involves systematic assessment of the patient’s medication in order to identify and meet the medication - related needs as well as to identify, resolve and prevent drug related problems.

This service is a continuity of patient’s care from ward and MTAC to their home. It is a comprehensive activity which involves clarification of the indication for use and administration details of all prescription and non – prescription medicines, assessment of medication storage in the home and any drug related issues.

SCOPE OF SERVICES

This service is to be extended to stroke patient under Stroke Pharmacist Management. The stroke patient may be referred from hospital to nearest facility (i.e. health clinic) for this service by using CP4 form and Home Medication Review referral form (refer Home Medication Review Protocol 1st edition 2011).

MANPOWER REQUIREMENT

All HMR appointment should be conducted by a qualified pharmacist. The HMR pharmacist will accompany the multidisciplinary homecare team members (Homecare Nurses, Physiotherapist and Occupational Therapist) to conduct the HMR activity. However if the pharmacist are able to provide the service without a home care team, a minimum of two pharmacists are required.

APPOINTMENT

Appointments and frequency of visits for patients under the HMR program will be determined by the pharmacist who is conducting the HMR and in consultation with the referral pharmacist (if applicable).

PROCEDURES

The procedures for stroke HMR workflow and documentation are shown in Appendix 10.

[ 9 ]

1. SELECTION OF PATIENT

1.1 The criteria which may be used to determine the need of a patient’s recruitment to the Stroke HMR are as follows:

1.1.1 Refer by neurologist/physician, homecare nurse or selection by Ward/MTAC pharmacist.

1.1.2 Non or poor compliant patient.1.1.3 Geriatrics who are managing their own medication with no or

poor family support.1.1.4 Newly discharge patient with multiple concomitant problems.1.1.5 Patient on Nasogastric Tube.1.1.6 Patient suspected to have poor disease controlled such as poor

glucose control and poor blood pressure controlled despite on medication.

2. ACTIVITIES2.1 Assess patient and fill up the HMR form (refer to Home Medication

Review Protocol 1st edition 2011).2.2 Assess stroke management (Refer Appendix 9).

2.2.1 Aspirin and lipid lowering therapy.2.2.2 Indication to continue DVT prophylaxis (if applicable).2.2.3 Indication to start anti hypertension (if applicable).

2.3 Assess patient’s knowledge and compliance by using Modified Morisky Medication Adherence Scale.

2.4 Identify any pharmaceutical issues.2.4.1 Any drug related issues will be discussed with the neurologist/

physician during or after HMR.2.5 Check necessary parameters: Blood pressure, glucose level, INR (if

applicable).2.6 Any drug related issues will be discussed with physician during HMR or

after HMR.2.7 Assess storage of medication at home.2.8 Assure patient has the next appointment date with the doctor and

remind the patient to attend the clinic on the appointment date.2.9 Follow up visit will be held upon referring from stroke team or when

deemed appropriate by HMR pharmacist.

[ 10 ]

REFERENCES

1. CPG on the Management of Ischemic Stroke 2012.

2. Home Medication Review Protocol 1st edition 2011.

3. Venketasubramaniam N The epidemiology of stroke in ASEAN countries - A review. Neurol J SEA 1998; 3: 9-14.

4. Health Facts, 2009. Health Information Centre, Planning and Development Division, Ministry of Health.

5. S C Johnston, S Mendis, CD Mathers. Global variation in stroke burden and mortality: estimates from monitoring, surveillance and modeling. Lancet Neurol 2009; 8: 345-54.

APPENDICES

[ 12 ]

Appendix 1

STROKE MTAC PHARMACY WORKFLOW

Medical Assistant

Pharmacist

Neurologist/Physician

Pharmacist

Pharmacist

Pharmacist

Pharmacist

Registration

Vital sign and body weight check (if needed)

• Discuss on treatment optimization• Assess for any drug related issues if

patient is not seen earlier• Answer queries & provide information

• Explain regarding medication management changes (if any)

• Provide counseling and Education• Dispense medication

Pharmacist Assessment and Review

Review and Treatment

Screen prescription

Documentation

Yes

No

Patient comes for MTAC follow up and medication supply

Discuss with physician regarding the pharmaceutical

care issues identified

Problem or intervention

[ 13 ]

Appendix 2

PERAKUAN PENYERTAAN

Saya………………………………………………………………...(No.K/P: ....…………………………………….)

bersetuju menyertai program Stroke Medication Therapy Adherence Clinic (SMTAC)

atau Klinik Kepatuhan Terapi Ubat Strok yang dianjurkan oleh Jabatan Farmasi,

Hospital……………………………………………………………Saya juga berjanji akan memberikan

kerjasama sepenuhnya dengan menghadiri ke semua sesi kaunseling yang diadakan

oleh Pegawai Farmasi SMTAC dan aktiviti – aktiviti lain berkaitan dengannya yang

bertujuan membantu pengurusan penyakit strok saya/pesakit.

…....................................... (Tandatangan) Nama pesakit : No. K.P. :Tarikh :

Pegawai Farmasi yang bertugas,

…………………………………….(Tandatangan)Nama :Cop :Tarikh :

PATIENT CONSENT FORM

[ 14 ]

Appendix 3

Visit No: Date:

Patient Name:

NRIC: MRN:

Stroke Subtype:

Risk Factors:

Evaluation/Problem(s) & Action(s) Taken

No Issues (raised by patient/observed by pharmacist)

Action/Counseling

Pharmacist Signature & Stamp

PATIENT ASSESSMENT FORM

[ 15 ]

Appendix 4

PATIENT ID:NEUROLOGY (STROKE)

MEDICATION THERAPY ADHERENCE CLINIC (MTAC) PHARMACY DEPARTMENT,

.………………………………………………………………………………

Patient Name: Contact No.:

NRIC: Marital Status:

Address:Sex:

Male

Female

Caregiver’s Name: Relationship: Contact No.:

Social/Family History: Smoking Alcohol

Drug Abuse Pregnant

Stroke Subtype:

Concomitant Diseases:

Past Medication History:

No. Name of Drug(s) Date start Date stop

PATIENT’S VISIT FORM

[ 16 ]

LABORATORY PARAMATERS

Normal ValueDate

VITAL SIGNS

BP (mmHg)

PR 60-100 p/min

RR 12-18 b/min

CARDIAC ENZYMES

CK 24-195 u/l

LDH <247 u/l

AST <45 u/l

LIPID PROFILE

T. Chol <5.2 mmol/L

TG (mmol/L) 0.6 -2.3 mmol/L

LDL (mmol/L) <1.8 mmol/L

HDL (mmol/L) >1.7 mmol/L

RENAL PROFILE

Na 133-145 mmol/L

K 3.3-5.1 mmol/L

SrCreatinine 45-84 umol/L

CrCl 105-150 ml/min

[ 17 ]

LIVER PROFILE

Albumin 35-50mg/dL

ALP 30-120 u/l

ALT <34 u/l

COAGULATION PROFILE

PT 10.6-15.0 sec

APTT 26-42 sec

INR

OTHERS:

RBS 6-8 mmol/l

FBS 4-6mmol/L

HbA1c <6.5%

Uric Acid 180-420 µmol/L

[ 18 ]

Date / Visit Pharm Care Issues Pharmacist intervention Outcome Pharmacist’s sign

& stamp

[ 19 ]

ASSESSMENT ON PATIENT’S/CAREGIVER’S MEDICATION KNOWLEDGE

Date Medication Visit 1 Visit 2 Visit 3 Visit 4

D F I T D F I T D F I T D F I T

Score (%)

[ 20 ]

Date Medication Visit 5 Visit 6 Visit 7 Visit 8

D F I T D F I T D F I T D F I T

Score (%)

[ 21 ]

Appendix 5

MODIFIED MORISKY MEDICATION ADHERENCE SCALE GUIDE

1 Do you sometimes forget to take your medicine? No=1 Yes=02 Thinking over the past two weeks, were there any days

when you did not take your medicine?No=1 Yes=0

3 Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?

No=1 Yes=0

4 When you travel or leave home, do you sometimes forget to bring along your medication?

No=1 Yes=0

5 Did you take your medicine yesterday No=0 Yes=16 When you feel like your disease is under control, do you

sometimes stop taking your medicine?No=1 Yes=0

7 Do you ever feel hassled about sticking to your treatment plan?

No=1 Yes=0

8 How often do you have difficulty remembering to take all your medications?

Never/Rarely 0Once in a while 1Sometimes 2Usually 3All the time 4

CODING For item no.8For Item 8:If Item8=0 Score: 1 If Item8=1 Score: 0.75 If Item8=2 Score: 0.5 If Item8=3 Score: 0.25 If Item8=4 Score: 0

Interpretation:

Adherence Level Score

Low Adherence < 6

Medium Adherence 6 to <8

High Adherence 8

[ 22 ]

Modified Morisky Medication Adherence Scale Visit 1 Visit 2 Visit 3 Visit 4

1. Do you sometimes forget to take your medicine?

2. Thinking over the past two weeks, were there any days when you did not take your medicine?

3. Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?

4. When you travel or leave home, do you sometimes forget to bring along your medication?

5. Did you take your medicine yesterday?

6. When you feel like your disease is under control, do you sometimes stop taking your medicine?

7. Do you ever feel hassled about sticking to your treatment plan?

8. How often do you have difficulty remembering to take all your medications?

a) Never/ rarely (0 marks)

b) Once in a while (1 mark)

c) Sometimes (2 marks)

d) Usually (3 marks)

e) All the time (4 marks)

SCORE

Modified Morisky Medication Adherence Scale Visit 5 Visit 6 Visit 7 Visit 8

1. Do you sometimes forget to take your medicine?

2. Thinking over the past two weeks, were there any days when you did not take your medicine?

3. Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?

4. When you travel or leave home, do you sometimes forget to bring along your medication?

5. Did you take your medicine yesterday?

6. When you feel like your disease is under control, do you sometimes stop taking your medicine?

7. Do you ever feel hassled about sticking to your treatment plan?

8. How often do you have difficulty remembering to take all your medications?

a) Never/ rarely (0 marks)

b) Once in a while (1 mark)

c) Sometimes (2 marks)

d) Usually (3 marks)

e) All the time (4 marks)

SCORE

Notes on Compliance:

[ 23 ]

Appendix 6

EDUCATION OUTLINE FOR STROKE PATIENTFirst visit:

• Brief overview about stroke and stroke subtypes.

• Stroke risk factors.

• Stroke symptoms.

• Specific discussion on drugs as secondary prevention of stroke – indication, role of each drug and adverse effects.

* For ischemic stroke and transient ischemic attack (TIA) –anti platelet

* Lipid lowering therapy.

* Antihypertensive drug.

* Anticoagulant for cardio embolic stroke.

• Therapeutic goal for main parameter : blood pressure, glucose level, LDL and INR.

Second visit

• Education on risk factor (hypertension , diabetes mellitus, atrial fibrillation, ischemic heart disease, hyperlipidemia, smoking cessation (if applicable), alcohol consumption (if applicable) and etc.

Third visit

• Stroke complication and prevention.

Fourth visit

• Benefit of exercise.

• Basic nutrition and diet control.

Subsequent Visit

• How to maintain the therapeutic goal and long term plan.

• Revision on treatment goals.

• Specific drug counseling.

[ 24 ]

Appendix 7

STROKE WARD PHARMACY WORKFLOW

Stroke Round

End

Check case notes and complete patient medication history taking (CP1)

Review patient‘s medication management and progress (Appendix 8)

Patient education and bedside counseling (Appendix 9)

Follow up patient and review medication therapy

Discharge Counseling

Refer HMR teamHome Medication Review

Upon discharge

YES

NO

[ 25 ]

Appendix 8

STROKE MANAGEMENT CHECKLIST

Patient Name:MRN:

Please Tick During Admission

• Thrombolytic therapy for patient arrived within 4.5 hour for ischemic stroke

Antiplatelet within 48 hours of admission for ischemic stroke and TIA

In Ward

• Deep vein thrombosis (DVT) prophylaxis for patient with leg power of <3/5 (for ischemic stroke start immediately, for hemorrhagic stroke, after 72 hours of event)

• Lipid lowering therapy Stroke education checklist (refer appendix 8)

During Discharge

• Antiplatelet upon discharge for ischemic stroke and TIA• Lipid lowering therapy upon discharge (for hemorrhagic stroke, must

consider the risk of stroke recurrence)• Anticoagulant for stroke patient with atrial fibrillation

Time of initiation will depend on the severity of the stroke • DVT prophylaxis for patient with leg power of <3/5 (if there is a need

to continue)• ACEI for hypertension and stroke prevention

[ 26 ]

Appendix 9

STROKE EDUCATION CHECKLIST

Patient Name:MRN:

Stroke Please Tick

• What is Stroke• Stroke subtypes• Pathophysiology • Symptoms of stroke• Stroke risk factors

Secondary prevention

Medication

• Indication, role, dosage, administration, frequency, possible and common side effects, drug interaction (if applicable)

• Anti-platelet (for ischemic stroke and TIA) – GI upset, to take after meal

• Cholesterol-lowering agent, muscle pain (rhabdomyolysis)

o Must be taken before sleep

• ACEs inhibitor/ARBo Will be started after two week of stroke (for ischemic stroke).o Must go to nearest clinic for BP monitoring and drug initiation/

optimization.o ACE- cough.

• DVT prophylaxis (if applicable).

• Anti coagulant (if applicable).

• Importance of drug compliance.

Risk factor controlled – HPT, DM , Hyperlipidemia, AF, IHD etc

[ 27 ]

Monitoring parameter and target for all the parameter

• Blood pressure• Glucose level • LDL level • Other parameters related to risk factors

Life style modification

• Diet control• Smoking cessation• Stress management• Regular exercise

Rehabilitation

• Importance of adherence to rehabilitation plan• Stroke complication and prevention

o Aspiration Pneumoniao Urinary Tract Infectiono Bed Soreo Upper Gastro Intestinal Bleedingo Depressiono Recurrent Stroke

Closing

• Assess patient’s/caregiver’s understanding towards the disease and medication

• Provide patient with stroke booklet or relevant pamphlet• Provide contact information for any enquiries

[ 28 ]

Appendix 10

HOME MEDICATION REVIEW (HMR) WORKFLOW

Referred case or selection by pharmacist

Documentation

Visit Patient’s Home

Assess medication adherence and storage at home

Assess any pharmaceutical care issues

Discussion with physician

Discuss with caregiver on the management plan changes via

MTAC visit

CounselingUnsatisfied

Satisfied

YES

NO