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Wednesday 23 January 2019
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The pharmacist's role in a stroke unit

Policy & practice: Stroke units

Derek Taylor
MSc MRPharmS
Hospital Pharmacy Manager
Royal Liverpool & Broadgreen Hospitals
Liverpool
UK
E:Derek.Taylor@rlbuht.nhs.uk

The word stroke refers to a clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death. It occurs in a quarter of the population over the age of 45 and accounts for 11% of all deaths in England and Wales. The risk of recurrent stroke within five years of a first stroke is 30–43%.

The multidisciplinary nature of a stroke unit
Over recent years, there has been considerable improvement in the active care of stroke patients within a specialist unit, which in turn has led to less deaths and less disability for patients who survive. A key change in stroke care is the fact that patient management has become a multidisciplinary team effort. This team should consist of the following healthcare professionals, each of whom should have a specialist expertise in stroke and rehabilitation:

  • Consultant physician.
  • Nurses.
  • Speech and language therapist.
  • Physiotherapist.
  • Occupational therapist.
  • Dietitian.
  • Pharmacist.
  • Clinical psychologist.
  • Social worker.

Other requirements for an effective stroke unit include knowledgeable staff and informed patients (through continuing education programmes for staff, patients and carers), access to brain and vascular imaging services, agreed protocols for common problems and clearly defined, shared decision-making processes between the patient, their family and carers, and healthcare professionals.

Stroke care pathways
Stroke units are increasingly using care pathway documents in both the acute and the rehabilitation phases. The advantage of a detailed care pathway, started for every patient on admission, is that it specifies the level of multidisciplinary care that a patient should receive. These pathways usually contain sections that cover the standard of care while in the  accident and emergency department, the acute stroke unit and the rehabilitation unit. The rehabilitation goals and overall discharge plan are also detailed in this document. Management plans for the common complications of stroke are then fed into this individualised plan, which is also an auditable record of the standard of care that every patient has received.

The role of the pharmacist
Pharmaceutical expertise is of value at many points in this stroke care process, and this may be documented in the stroke care pathway. Examples of this input are detailed below.

Management of dysphagia
Oropharyngeal dysphagia is common in patients with stroke (incidence of 64–90%), with aspiration rates of 22–42%. Therefore, a patient's swallow reflex should be determined after liaison with the speech therapist. If the patient is on an enteral feeding regimen or a texture-modified diet, the pharmacist should ensure selection of the most appropriate medicine formulation (for example, the use of commercially available solutions or thickening agents). Advice on the correct timings of prescribed medication and on appropriate administration and flushing techniques is also important, especially if an enteral feeding tube is in place. Examples of medication where this advice is particularly important include phenytoin, due to its interaction with enteral feeds, and carbamazepine, due to its possible interaction with the feeding tube.

Compliance with evidence-based medicine guidelines
The pharmacist should promote adherence to local and national prescribing guidelines. In recent years, the publication of the results of several large trials (for example, Heart Outcomes Prevention Evaluation [HOPE], Perindopril pRotection aGainst REcurrent Stroke Study [PROGRESS], Heart Protection Study [HPS], Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events [CAPRIE] and European Stroke Prevention Study [ESPS-2]) have demonstrated the benefit of prescribing antihypertensives, statin therapy and antiplatelet agents for the secondary prevention of further thromboembolic events.

Monitoring of newly prescribed and existing drug therapies
The pharmacist should monitor all prescribed medication for effectiveness and adverse effects. Examples of this monitoring include attainment of target blood pressure levels (in the rehabilitation phase), monitoring for gastric irritation with antiplatelet therapy, avoidance of aggravating therapy, such as centrally acting suppressants, and monitoring of other parameters such as urea, electrolytes, blood glucose and temperature.

Advice on correct management of stroke complications
Although there should be documented treatment plans (in the stroke care pathway) for all significant complications, the pharmacist can provide more detailed advice on prescribing for these complications – such as hemiplegic pain, agitation, cerebral and pulmonary oedema, deep vein thrombosis and depression.

Counselling
Each patient should receive both verbal advice and written medication information, in the form of patient information leaflets and a medication reminder chart. The latter should include information about the reason for the medication, how and when to take it, and any possible common adverse effects. The importance of long-term prophylactic treatment, such as antiplatelet, antihypertensive and cholesterol- lowering therapy, should be stressed to the patient.

Assessment of potential compliance and concordance problems
After a stroke, patients may experience difficulty in taking their prescribed secondary prevention medication. These compliance or concordance issues may arise from any impairment in manual dexterity or cognitive function resulting from the stroke. The use of any compliance aids should be with the consent of the patient.

Liaison with general practitioners and community pharmacists on discharge
There should be documented procedures to ensure that an individual's general practitioner and community pharmacist receive written pharmaceutical discharge information. This should include changes to medication, alternative formulations of medicines, nutritional products and details of any compliance aids provided. Patients and their families should be made aware of this process.

Liaison with patient support groups
All patients should be given contact information for local groups and national organisations that provide support and information to both patients and carers.

Conclusions
Through a variety of interventions and monitoring, the pharmacist can make a significant contribution, both in the acute and in the rehabilitation phases, to the care of the stroke patient and the multidisciplinary stroke team. However, the success of this input is dependent upon building effective communication channels with the different healthcare professionals involved in the stroke team.

Further reading
Intercollegiate Working Party for Stroke. National
clinical guidelines for stroke (2nd ed). London (UK): Royal College of Physicians; 2004.

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