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Summary What is known and objective Good communication between hospital and primary care physicians (PCPs) is important for the continuity of patient care in the transition phase following hospital treatment. Drug-related problems and medication errors may occur at that interface. Discharge letters often lack a structured medication report at the end and therefore may not provide the reasons for medication changes, resulting in low adherence rates. The objectives were to develop a structured medication report as part of the discharge letter, to evaluate the impact of the medication report in ischaemic stroke patients and to identify the most important issues in the transitional care process of stroke patients. Methods First, a structured medication report was developed. Thereafter, the impact of this new medication report on clinical practice was evaluated with an open, prospective, interventional two-phase study conducted at the Klinikum Fulda gAG (Germany), which included patients with ischaemic stroke and >2 drugs in the discharge medication. In the control group (CG), the neurologist included the current medication in the discharge letter. In the intervention group (IG), the clinical pharmacist added the detailed information to a medication report. To evaluate adherence to discharge medication, the PCP was interviewed 3 months after hospital discharge about the medication. Adherence was measured with respect to the entire medication regimen, antithrombotic and cholesterol-lowering drugs and discontinued medication. The most important issues in the transitional care for patients with ischaemic stroke were identified on the basis of the secondary stroke prevention and cardiovascular risk factors. Results and discussion Overall, 312 patients were enrolled in the study with 156 patients in each group. By providing detailed information in the newly developed discharge letter, adherence increased significantly from 83·3% (CG) to 90·9% (IG; P = 0·01). Significant differences between the CG and IG were found with regard to adherence to both antithrombotic drugs [83·8% CG vs. 91·9% IG (P = 0·033)] and statin therapy [69·8% CG vs. 87·7% IG (P

Background and Purpose— Communication between hospitals and primary care physicians is essential for the continuity of care for patients being transferred from hospital to ambulatory care. Patients are often discharged from hospital on medication regimes different from those used before hospital admission. The aim of the study was to evaluate the adherence to hospital discharge medication in patients with ischemic stroke before and after implementing a systematic approach provided by a clinical pharmacist. Methods— Patients with transient ischemic attack/ischemic stroke taking ≥ 2 drugs during hospital stay and at discharge were prospectively recruited. In the control group, the neurologist included the medication list in the discharge letter as before. In the intervention group, the clinical pharmacist listed the medication on admission and at discharge next to each other and gave detailed information for all medication changes during hospital stay. Results— Overall, 312 patients were enrolled in the study with 156 patients in each group. Significant differences between the control group and intervention group were ascertained with regard to adherence to both antithrombotic drugs (83.8% control group versus 91.9% intervention group [ P =0.033]) and to statin therapy (69.8% control group versus 87.7% intervention group [ P Conclusions— Providing detailed information on medication changes can lead to substantially improved adherence to discharge medication, probably resulting in better secondary stroke prevention.

Surgical site infections (SSIs) are associated with a high morbidity, mortality and healthcare costs. The prevention of SSIs is based on a combination of preoperative preparation, surgical techniques, perioperative antibiotic prophylaxis (PAP) and postoperative wound care. Despite an abundance of evidence demonstrating the effectiveness of antimicrobials to prevent SSIs, the use of antimicrobial prophylaxis in this clinical setting is associated with inappropriate timing and selection and excessive duration of administration. To date, pharmacy interns (PIs) have not been involved in this process. The aim of this study was to evaluate feasibility of involving PIs in monitoring adherence to the guidelines for antibiotic prophylaxis in surgery patients.The study was conducted in seven hospitals in Germany within the framework of the project "Pharmacy interns on the ward" (P-STAT2). Twenty-seven PIs participated, either from either May to October 2008 or from November 2008 to April 2009. Each patient admitted to the participating wards was consecutively monitored. PIs documented the antibiotic prophylaxis and checked the adherence with the hospital ward's PAP guidelines taking both the choice of antibiotic drug and the duration of PAP into account. The costs of antibiotics, personnel and material were calculated in cases of non-adherence with guidelines.This is the first time that PIs were involved in monitoring antibiotic prophylaxis guidelines. A total of 6,167 patients were enrolled (mean age 58.3 ± 19.6 years; 47.1% male); of these, 5,064 patients underwent surgery and were ultimately available for evaluation. Guidelines for antibiotic prophylaxis were followed in 70.7% of the cases.The study revealed that many patients do not receive the appropriate antibiotic prophylaxis despite the fact that guidelines are in place. Based on these results, we conclude that PIs may play an important role in antibiotic prophylaxis management.

Objectives To improve patients health-related quality of life (HQL) after transient ischemic attack (TIA) or ischemic stroke; to guarantee an effective secondary prevention; to increase the patient’s satisfaction with recommendations regarding their medication by pharmacists. Setting Stroke Unit, neurological ward at the Klinikum Fulda, rehabilitation hospitals and community-based pharmacies in the region of Fulda, Germany. Method Patients with TIA or ischemic stroke were included. The patients were assigned to an intervention group (IG) or a control group (CG). The individual assignment of patients to IG or CG was based on the type of the local pharmacy to which patients belong. Community-based pharmacies either delivered standard care (CG) or provided additional intensified pharmaceutical care (PC; IG). Pharmacies delivering PC belong to a pre-existing “Quality Assurance Working Group” (QAWG). To evaluate the patient’s HQL, the Short Form-36 (SF-36) was used at study entry in hospital and at 12 months. The secondary prevention was documented at study entry in hospital and at 12 months. The patients’ satisfaction was measured by a questionnaire at the end of the study. Main outcome measures Patients’ HQL; secondary prevention; patients’ satisfaction with recommendations of the pharmacists with regards to their medication. Results Out of 1316 patients screened for participation in this study, 255 were recruited with 90/255 patients assigned to the IG and 165/255 patients assigned to the CG. During the study, the HQL of the patients in the IG did not change significantly. A significant decrease in the HQL was observed for the CG in 7/8 subscales and in both summary measures of the SF-36. After 12 months, 85.3% of the patients in the IG and 86.3% of the patients in the CG were treated with antiplatelet drugs or oral anticoagulants in accordance to treatment guidelines. Patients in the IG were significantly more satisfied with the individualized recommendations of the pharmacists than patients in the CG. Conclusion Our findings indicate that an intensified PC of patients after ischemic stroke by dedicated pharmacists may have a positive impact on HQL and patients’ satisfaction. PC in this study had no impact on adherence to secondary prevention medication.

A 61-year-old patient with a sudden numbness of the right arm and hand and signs of amnestic aphasia is admitted to the stroke unit with the diagnosis of an acute ischemic stroke for systemic thrombolysis. Based on a case-report, drug-related problems are discussed according to the SOAP scheme. Aspects of pharmaceutical care such as counselling by a pharmacist about secondary prevention, discharge information and a pharmaceutical care plan in the community pharmacy are described.

Background Health-related quality of life (HRQoL) after stroke is an important healthcare measure. Pharmaceutical Care (PC) is an evolving concept to optimize drug-therapy, minimize drug-related problems, and improve HRQoL of patients. The purpose of this study was to evaluate the impact of PC on HRQoL, as determined by Short Form 36 (SF-36) among patients after TIA or ischemic stroke one-year following their initial entry in hospital. Methods Patients were assigned to either an intervention (IG) or a control group (CG). The individual assignment of the patient to IG or CG depended on the community pharmacy to which the patients were assigned for care. Community pharmacies either delivered standard care (CG) or provided intensified PC (IG). Pharmacists who are members of the "Quality Assurance Working Group" (QAWG) provided PC for patients in IG. Results 255 patients were recruited (IG: n = 90; CG: n = 165) between 06/2004 to 01/2007. During the study, the HRQoL of the patients in IG did not change significantly. In the CG, a significant decrease in the HRQoL was observed in 7/8 subscales and in both summary measures of SF-36. Conclusions This is the first follow-up study in Germany involving a major community hospital, rehabilitation hospitals, community pharmacies and general practitioners investigating the impact of PC on HRQoL of patients after ischemic stroke. Our findings indicate that an intensified education and care of patients after ischemic stroke by dedicated pharmacists based on a concept of PC may maintain the HRQoL of IG patients.