HOME MEDICATION REVIEW PROTOCOL - pharmacy...i Second Edition, 2019 Pharmaceutical Services Programme Ministry of Health Malaysia Lot 36, Jalan Universiti, 46200 Petaling Jaya, Selangor,

HOME CARE

PHARMACY SERVICES

PROTOCOL

2nd Edition 2019

PHARMACY PRACTICE & DEVELOPMENT DIVISION

MINISTRY OF HEALTH MALAYSIA

i

Second Edition, 2019

Pharmaceutical Services Programme Ministry of Health Malaysia

Lot 36, Jalan Universiti, 46200 Petaling Jaya, Selangor, Malaysia

Tel: 603 – 7841 3200 Fax: 603 – 7968 2222

Website: www.pharmacy.gov.my

© ALL RIGHTS RESERVED

This is a publication of the Pharmaceutical Services Program, Ministry of Health Malaysia. Enquiries

are to be directed to the address below. Permission is hereby granted to reproduce information

contained herein provided that such reproduction be given due acknowledgement and shall not

modify the text.

http://www.pharmacy.gov.my/

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PREFACE

Monitoring of medication use and medication review at patients’ home has been done through provision of Home Medication Review

(HMR) by pharmacists for patients treated at Malaysia Ministry of

Health (MOH) facilities. First Edition HMR Protocol was published in

2011 focusing more on geriatric, psychiatric and stroke patients. Since

then, a lot of patients have benefited from the service as visits to a

patient's home allows for real-time patient assessment and the

patient's concerns about medications are further identified.

However, finding from National Survey on the Use of Medicines (NSUM) by

Malaysian Consumers 2015 and the huge cost of medication return by patients are cues

that this service need to reach more groups of patients and the scope need to be widened.

Thus this Home Care Pharmacy Services (HCPS) Protocols are developed to incorporate

and update HMR protocol as well as other pharmaceutical services done at patient’s

home which targeting at wider groups of patients living at different types of residential

settings. It outlines the procedures and documentations during Home Care Pharmacy

Services sessions and serve as a guide to enable standardization of practice and

establishment of service throughout MOH’s facilities.

I would like to congratulate the Home Care Pharmacy Services Protocol Task

Force, Pharmacy Practice & Development Division, MOH for their contributions and

commitment to the publication of this protocol.

Thank you

DR. ROSHAYATI BINTI MOHAMAD SANI

Director

Pharmacy Practice & Development Division

Ministry Of Health Malaysia

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MEMBERS OF PANEL

ADVISORS

Dr Roshayati binti Mohamad Sani

Director of Pharmacy Practice and Development Division, Ministry of Health

EDITORS

Rozita binti Mohamad

Pharmacy Practice and Development Division, Ministry of Health

Nor Hasni binti Haron


Amalina binti Amri


CONTRIBUTORS

Jurisma binti Che Lah

Hospital Tuanku Fauziah

Shamini a/p Rama

Hospital Bahagia Ulu Kinta

Noor Haslina binti Othman

Hospital Raja Perempuan Zainab II

Dr Hadijah binti Mohd Taib

Hospital Kuala Lumpur

Ammar bin Kamar

Hospital Kuala Lumpur

Larry Lee Lian Seng

Hospital Tengku Ampuan Rahimah

Lim Si Wei

Klinik Kesihatan Kajang

Mohd Syafiq bin Yusof

Bahagian Perkhidmatan Farmasi JKN

Terengganu

EXTERNAL REVIEWER

Munira binti Muhammad


ACKNOWLEDEGEMENTS

This Division would also like to thank those who were involved directly or indirectly in

preparing this 2nd Edition of Home Care Pharmacy Services Protocol.

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TABLE OF CONTENT

Definitions ………………………………………………………………………………………………………………………………....1

A. Introduction ..................................................................................................................................................................... 3

B. Objectives .......................................................................................................................................................................... 4

C. Scope Of Service ............................................................................................................................................................. 4

D. Manpower Requirement ............................................................................................................................................. 4

E. Frequency of Sessions .................................................................................................................................................. 5

F. Patient Selection…….………………………………………………………………………………………………………..…...5

G. Patient Criteria………………………………………………………………………………………………………………………........5

H. Administrative Requirement…………………………………………………………………………………………………..…...6

I. Patient Consent & Risk Assessment………………………………………………………………………………….……….....6

J. Activities during Home Care Pharmacy Session…………………………………………………………………………....7

K. Documentation…………………………………………………………………………………………………………………………...8

L. Procedures………………………………………………………………………………………………………………………......9

1. Patients Enrollment ........................................................................................................................................................ 9

2. Preparation Prior Visit .................................................................................................................................................. 9

3. Conducting Home Visit .................................................................................................................................................. 9

4. Post Visit……………………………………………………………………………………………………………………………10

M. Workflow………………………………………………………………………………………………………………………………….11

N. Things to do when conducting Home Care Pharmacy Services……………………………………………..12

O. References ....................................................................................................................................................... 13

List of Appendix

Appendix 1: Guide to Medication Review and Reconciliation Pathway………………………………………………15

Appendix 2: Nota Rujukan Pesakit……………………………………………………….…………………………..…….………..16

Appendix 3: Surat Rujukan Perkhidmatan Farmasi Home Care ……………………….....…….……………………….17

Appendix 4: Kebenaran Keluar Untuk Menjalankan Perkhidmatan Farmasi Home Care……….…….............18

Appendix 5: Borang Persetujuan Pesakit/ Penjaga Perkhidmatan Farmasi Home Care…………………….....19

Appendix 6: Home/ Residential Care Facility Visit Risk Assessment Form ........................................................ 20

Appendix 7: Home Care Pharmacy Services Report Form……………………………………………………….………..21

Appendix 8: Home Care Pharmacy Services Information Gathering Form (1st Session) .............................. 23

Appendix 9: Home Care Pharmacy Services Information Gathering Form (Subsequent Sessions) .......... 27

file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075026file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075031file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075033file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075037

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Appendix 10a: Medication Identification Chart (English) ............................................................................................ 28

Appendix 10b: Medication Identification Chart (Bahasa Malayu) ............................................................................. 29

Appendix 10c: Medication Identification Chart (Bahasa Cina) ................................................................................... 30

Appendix 10d: Medication Identification Chart (Bahasa Tamil) ................................................................................ 31

Appendix 11: Home Care Pharmacy Services Patient Registry ................................................................................ 32

Appendix 12: Home Care Pharmacy Services Visit Record……………………………………………………………….33

Appendix 13: Senarai Semak Kesan Sampingan Ubat-Ubatan Psikotropik………………………………………...34

Appendix 14: Assessment of drug side effects (Antipsychotic Side Effect Checklist (ASC))………………..35

Appendix 15: Toronto Side Effect Scale (TSES)………………………………………………..……………………………...36

Appendix 16: Screening Tools: Medication / Medical Related Issues……….........................................................37

Appendix 17: Medication Appropriateness Index (MAI) ………………………………………………………………....38

Appendix 18: Guide to Drug Therapy in Patients with Enteral Feeding Tubes…………………………………..39

file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075041file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075044file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075045file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075047file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075038file:///C:/Users/amalina/Documents/Klinikal/HMR/combined%20hmr%20protocol%2023218.doc%23_Toc4075039

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DEFINITIONS

Home Care Pharmacy

Services (HCPS) /

Perkhidmatan Farmasi Home

Care (PFHC)

: Pharmaceutical care services provided at patient’s home/

residential care facilities.

Home Medication Review

(HMR)

: Comprehensive clinical review of a patient's medications

in their home / residential care facilities by a fully

registered pharmacist.

Drug Reconciliation : A process of creating the most accurate list possible of all

medications a patient is taking including drug name,

dosage, frequency, and route and comparing that list

against the physician admission, transfer and/or discharge

orders, with the goal of providing correct medications to

the patient at all transition points by addressing

discrepancies including duplications, omissions, and

interactions.

Medication Review : A structured, critical examination of a patient’s

medications with the objective of reaching an agreement

with the patient about treatment, optimizing the impact of

medications, minimizing the number of medication related

problems and reducing waste.

Pharmacist : Fully registered pharmacist working at government health

facilities.

Duta Kenali Ubat Anda (Duta

KUA)

: Community representatives who have gone through a

structured training and actively involved in delivering basic

information related to medications.

Medication Therapy

Adherence Clinic (MTAC)

: An ambulatory care service conducted by pharmacists in

collaboration with physicians to help patients improve their

medication adherence level and disease control.

Home Care Pharmacy

Services Session

: Sessions of Home Care Pharmacy Services conducted for

one particular patient.

Home Care Pharmacy

Services Visit

: Visit for a purpose of conducting Home Care Pharmacy

Services for houses/ residential care facilities, which might

consist of more than one patient in a visit.

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Multidisciplinary Team : Home Care Pharmacy Services conducted by a group of

health care workers who are members of different

disciplines (doctor, pharmacist, nurse, occupational

therapist etc.) with each providing specific services to the

patient.

Pharmacy-Only Team

: Home Care Pharmacy Services conducted by pharmacy

staff which may involve pharmacist and assistant

pharmacist and may involve KYM ambassador.

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A. INTRODUCTION

Home Care Pharmacy Services (HCPS) formerly known as Home

Medication Review (HMR) is one of pharmaceutical care services to ensure

continuity of patient’s care at home after returning from health facilities i.e.

outpatient or inpatient setting with the aim to advocate optimal and quality use of

medications. The whole process involves comprehensive and systematic activities

that include drug reconciliation and medication review for all prescription and non-

prescription medications including nutritional supplements, vitamins, herbal/

complementary medication and other remedies, resolving pharmaceutical care

issues including adverse reactions, patient’s adherence as well as medication

storage at patient’s home and referring patients to the next of care if necessary.

Home medication review (HMR) programme is implemented by Ministry of

Health Malaysia in 2004 and the first edition of HMR protocol is published in 2011.

Pharmacists were recruited to join the HMR team and since then play a proactive

role in ensuring medication adherence of all patients under the home care team.

World Health Organization (WHO) and the European Council (Council of Europe

CoM) have stressed the importance of including pharmacists as an active member

of the multidisciplinary HMR team with the aim of benefiting patients’ health, 1, 2

The positive impact of involvement of pharmacist in HMR service on outcome

for specific diseases has been demonstrated, such as hypertension,

anticoagulation therapy and heart failure.3 Literatures have shown the benefit of a

home visit by HMR team after hospital discharge on patients’ quality of life and

outcomes such as unplanned readmissions, and out of-hospital deaths.4,5 Study

on impact of HMR in psychiatry patients also showed improvement in adherence

and knowledge towards medication and also their quality of life.6 HMR found to be

beneficial to patients whom quality use of medicines can be an issue and patients

who are at risk of medication misadventures especially those with co-morbidities,

age or social circumstances due to characteristics or complexity of their

medications. Currently, HMR service in Malaysia healthcare facilities has been

focusing on patients with special needs from three disciplines, which are

psychiatry, geriatric and neurology (stroke), and also for other patients with chronic

illnesses and multiple medications at patients’ home as well as residential care

facilities.

Provision of Home Care Pharmacy Services may fill the gap hindering the

effectiveness of care provided at health facilities where home visits can help the

patients by educating them on proper management of medication supply and

improving patient understanding and subsequently adherence to the treatment.

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B. OBJECTIVES

1. Primary Objective

The main objective of Home Care Pharmacy Services is to provide seamless

care to improve health outcomes and quality of life of patients by emphasizing

the quality use of medicines, through appropriate, safe, judicious and proper

use of medication in the home or residential setting. The pharmacist works

with the patient, caregivers, doctors and other health care providers in

evaluating medication-related information, identifying and preventing side

effects and adverse drug reactions as well as optimizing health outcomes.

2. Secondary Objectives

a. To reconcile patient’s medication in order to avoid unnecessary and/or

potentially inappropriate medications that may lead to adverse drug

reaction.

b. To identify and manage possible medication-related issues such as

adverse drug reactions and possible drug interactions related to

prescribed medications, Over-The-Counter (OTC) medications, traditional

medications and health supplements

c. To counsel patients and their caregiver(s) in order to improve their insight

and knowledge towards their medications and overall well-being.

d. To educate patients and caregivers on the importance of adherence

towards medications.

e. To monitor and ensure proper storage of medications at patient’s home or

residential care facilities.

f. To educate and empower patient’s or caregiver(s) in managing patient’s

illness and medications.

g. To identify other psychosocioeconomic issues that affect medication-

taking behaviour.

C. SCOPE OF SERVICE

The Home Care Pharmacy Services is to be extended to patients at home or

residential care facilities who are currently seeking treatment at Ministry of Health

facilities.

D. MANPOWER REQUIREMENT

The Home Care Pharmacy Services should be provided based on agreement with

management of the health facilities or doctor in-charge. The pharmacist

conducting the activity should be aware of the risks involved and shall not conduct

the activity alone.

A minimum of two personnel are required and may be conducted as part of:

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i. Multidisciplinary Team, or

ii. Pharmacy-Only Team, with or without Duta KUA

E. FREQUENCY OF SESSIONS

The Home Care pharmacists or Multidisciplinary Team will determine the

frequency of Home Care Pharmacy Services sessions required for the patients.

Subsequent sessions are strongly encouraged to ensure continuity of healthcare.

Eligible patients may also be referred to other services which is beneficial to them

such as Medication Therapy Adherence Clinic (MTAC) or outpatient medication

counselling.

F. PATIENT SELECTION

Eligible patients may be enrolled into Home Care Pharmacy Services by:

i. Selection by Home Care pharmacist or Multidisciplinary Team

ii. Referral from other pharmacists / doctors / other healthcare providers / Duta

KUA

iii. Request from patients / caregivers / residential care facilities

G. PATIENT CRITERIA

1. Eligibility Criteria

Patients who are eligible for Home Care Pharmacy Services are those who

have poor adherence towards medications or have difficulties in medication

management with at least one of the following criteria:

i. Taking medications for chronic diseases.

ii. Taking medications that require close monitoring (e.g. warfarin,

dabigatran, and insulin).

iii. Taking medications with medical devices such as insulin pen and inhaler.

iv. Newly discharged patient with significant change in medications for

chronic illnesses.

Other considerations include:

i. Bedridden patient.

ii. Taking medications with narrow therapeutic index requiring therapeutic

drug monitoring (e.g. lithium, sodium valproate, carbamazepine,

phenytoin etc.).

iii. Managing own medications with no or poor family support and at risk of

medication errors due to mental or physical disabilities.

iv. Patients who have defaulted treatment or failed to refill medications for

chronic illnesses.

v. Patient with suspected of or predispose to unsafe use of medications.

vi. Referred case from doctors/ pharmacists/ other healthcare professionals/

Duta KUA requiring pharmaceutical intervention.

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2. Exclusion Criteria

i. Patients who are not under MOH follow-up.

ii. Patients who are homeless or do not have a proper place to stay.

iii. Patients with high-risk behaviors.

iv. Foreign workers or non-permanent residents.

v. Patients or caregivers who do not consent for Home Care Pharmacy visit.

3. Discharge Criteria

Patients can be discharged from the Home Care Pharmacy Services when

all pharmaceutical issues have been resolved and no further monitoring is

needed.

H. ADMINISTRATIVE REQUIREMENT

Home Care pharmacists involved need to obtain written approval from Director or

Head of Department (Refer Appendix 4). The approval stays valid until the

pharmacist who has been given approval ends his/her service in Home Care

Pharmacy Services or when there is a change of the Director or Head of

Department.

I. PATIENT CONSENT AND RISK ASSESSMENT

1. Pharmacy-Only Team

Pharmacist must obtained patient or caregiver consent and perform risk

assessment prior to visit.

2. Multidisciplinary Team

Case manager or other healthcare provider can obtain patient or caregiver

consent and perform risk assessment prior to visit.

Personnel involved should take safety measures during home visit such as by

giving notification to supervisor of visit arrival/departure times, wearing uniform/

working pass. Wearing safety jacket when crossing the river to go to patient’s

residence is necessary and personnel should constantly be aware of the

surrounding. Personnel are advised to have insurance protection.

The involvement of Duta KUA is helpful in assessing security aspects of selected

patient’s home prior visit.

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J. ACTIVITIES DURING HOME CARE PHARMACY SESSION

Generally, pharmacist will perform the following technical and clinical activities

during Home Care Pharmacy sessions:

i. Reconcile all prescribed and non-prescribed medications and supplements.

(refer appendix 1)

ii. Assess the balance and storage condition of the medications.

iii. Assess on handling of medication (e.g. Ryle’s tube medication administration).

iv. Assess the level of patient's or caregiver’s understanding and adherence

towards medications.

v. Identify issues related to medications.

vi. Counselling on disease and medications as needed to the patients.

Other additional specific activities as below may be done according to disciplines

as below:

Discipline / Therapy Activities

Psychiatry Assessment of side effects of antipsychotic and

antidepressants (appendix 13, 14, & 15).

Geriatric

Identification of medical and pharmaceutical care

issues in older persons & assessment of

appropriateness and handling of medications

(appendix 16, 17 & 18).

Neurology (Stroke)

Assessment of suitability and appropriateness of

medication & handling of medication according to

patient’s swallowing function (appendix 18).

Paediatric Administration of medications.

Anticoagulant INR monitoring and dose adjustment of warfarin.

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K. DOCUMENTATION

The following are the forms required for Home Care Pharmacy Services:

No. Form Name Form No. Form Usage

1. Nota Rujukan Farmasi CP4 For pharmacist to refer patient for

1. Home Care Pharmacy Services

(for Pharmacy-Only Team).

2. Subsequent care following Home

Care Pharmacy visit

2 Surat Rujukan

Perkhidmatan Farmasi

Home Care

HCPS1 For doctors / other Health Care

Professionals / Duta KUA to refer

patient for Home Care Pharmacy

Services (for Pharmacy-Only Team)

3. Kebenaran Keluar Untuk

Menjalankan Perkhidmatan

Farmasi Home Care

HCPS2 To obtain permission from Director or

Head of Department to leave office in

order to conduct Home Care Pharmacy

Services

4. Borang Persetujuan

Pesakit/ Penjaga

Perkhidmatan Farmasi

Home Care

HCPS3

To obtain written consent from patient/

caregiver to receive Home Care

Pharmacy Services

5. Home/ Residential Care

Facility Visit Risk

Assessment Form

HCPS4 To assess risk and hazard prior visit to

home or residential care facility. (for

Pharmacy-Only Team)

6. Home Care Pharmacy

Services Report Form

HCPS5 To summarize activities done during

Home Care Pharmacy visit


Services Information

Gathering Form (1st

Session)

HCPS6 To document patient information and

finding during first Home Care

Pharmacy session


Services Information

Gathering Form

(Subsequent Sessions)

HCPS7 To document patient information and

finding during subsequent Home Care

Pharmacy sessions

10. Medication Identification

Chart (English, Malay,

Chinese & Tamil version)

HCPS8 To list current medications for patient’s

reference. (Optional: e.g. patient with

low educational level/ language

barrier)


Services Registry

HCPS9 A master list of patients enrolled in

Home Care Pharmacy Services


Services Visit Record

HCPS10 To record yearly sessions of Home

Care Pharmacy Services Session

performed

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L. PROCEDURE

Implementation and provision of Home Care Pharmacy Services will depend on

the creativity and suitability at the respective states and facilities setting. The

following is the procedure for conducting the Home Care Pharmacy Services:

1. Patient Enrolment

a. Identification & Referral for Home Care Pharmacy Services

Multidisciplinary Team

The team will identify eligible patient requiring Home Care Pharmacy

Services.

Pharmacy-Only Team

Pharmacists will identify eligible patient requiring Home Care Pharmacy

Services and make referral to Home Care Pharmacist by using Nota

Rujukan Pesakit (CP4) while doctors, Duta KUA and other healthcare

professionals will make referral using Surat Rujukan Perkhidmatan

Farmasi Home Care (HCPS1).

b. For Pharmacy–Only Team, Home Care Pharmacist will

i. Obtain consent from patient/ caregiver by filling in Borang Persetujuan

Pesakit/ Penjaga Perkhidmatan Farmasi Home Care (HCPS3).

ii. Perform Risk Assessment prior visit by using Home/ Residential Care

Facility Visit Risk Assessment Form (HCPS4).

2. Preparation Prior Visit

a. Date and time of visit will be arranged together with members of

multidisciplinary team and patient/ caregiver. As for Pharmacy-Only Team

that involving different health facilities, date and time of visit will be arranged

by coordinating officer.

b. Patient’s file will be prepared and updated and items needed (equipments

and medication refill tools etc.) during visit will be prepared.

3. Conducting Home Visit

a. Pharmacist will introduce him/herself and explain the purpose of Home

Care Pharmacy Services to the patient/ caregiver.

b. Pharmacist will conduct patient assessment and document it in Home Care

Pharmacy Services Information Gathering Form (1st Session) (HCPS6)

or Home Care Pharmacy Services Information Gathering Form

(Subsequent Sessions) (HCPS7).

c. Pharmacist will evaluate medication adherence and medication storage

and perform pharmacotherapy review as below:

10

Identify pharmaceutical care issues.

Carry out interventions to address all the identified drug-related

problems.

Communicate with Multidisciplinary Team on suggested

recommendations and interventions.

For Pharmacist-Only Team, write referral note if required (referral to

doctors at health clinic / MTAC pharmacist / medication counselling) by

using Nota Rujukan Pesakit (CP4).

Counsel and educate patient/caregiver on medication taking and

advise/provide appropriate aids for compliance, equipment for

administration or monitoring. Check the use and maintenance of

equipment such as glucometer, nebuliser etc. Provide medication

information pamphlets when necessary.

Fill in Medication Identification Chart (HCPS8) based on current

medication list.

Remind patient/ caregiver to bring their remaining balance medications

on their next appointment

Determine if patient require subsequent sessions and arrange

date/time of visit accordingly.

4. Post Visit

a. Post visit should be carried out based on patient’s need.

b. Record patient’s particulars in Home Care Pharmacy Services Registry

(HCPS9) and Home Care Pharmacy Services Visit Record (HCPS910).

c. Proper completion of Home Care Pharmacy Services Report Form

(HCPS5).

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M. WORKFLOW

Workflow

*for Multidisciplinary Team, risk assessment and patient’s / caregiver’s consent will be performed and

obtained by case manager / other healthcare provider

Multidisciplinary Team

identify patient for Home

Care Pharmacy Service

Pharmacist/ Doctor/ other

health professional/ Duta KUA

identify & refer patient for

Home Care Pharmacy Service

*Perform risk assessment

*Obtain patient’s / caregiver’s

consent

Arrange date and time for Home Care Pharmacy Services visit

Prepare for Home Care Pharmacy Services visit

Subsequent

session required?

Discharge patient

Conduct Home Care Pharmacy Services sessions

Document Home Care Pharmacy Services sessions

End

Start Start

Multidisciplinary Team Pharmacy-Only Team

Yes

No

Responsibility

Multidisciplinary team/

referring personnel

Home Care Pharmacist


Multidisciplinary team /






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N. THINGS TO DO WHEN CONDUCTING HOME CARE PHARMACY SERVICES

The following is a guide to things to do for pharmacist when conducting Home

Care Pharmacy Services:

Pre Visit

i. Prepare or update patient’s folder

• Patient consent & risk assessment form (Pharmacy-Only

Team)

• Home Care Pharmacy Services Information Gathering

Form 1st session or subsequent sessions

• Patient’s health record

ii. Prepare equipment for Home Care Pharmacy Services visit

• Device for medical check-up (e.g. electronic blood pressure

monitor, glucometer and test strips, weighing scale, alcohol

swab and blood lancets)

• Device for medication checking (e.g. tablet counting tray &

spatula)

• Medication supply (mobile floor stock of medications,

medication envelope/ bottle, medication refill (if applicable).

• Medication aid (e.g. medication identification chart, pill box)

• Medication counseling tools (flip chart, demonstration set

(e.g. inhaler, insulin) and medication information

pamphlets)

iii. Phone call to remind patient/caregiver & inform details of visit

During

Visit

i. Introduce yourself and explain objectives of Home Care

Pharmacy Services

ii. Gather patient’s information (demography, medical status and

issues that may influence medication administration).

iii. Perform the following:

• Medication reconciliation (all medications including OTCs,

traditional medication and health supplements)

• Assessment of medication storage

• Assessment of knowledge and adherence towards

medications

• Identification & intervention on Pharmaceutical Care Issues

(PCIs)

• Medication counselling as needed

• Prepare Medication Identification Chart

• Provide medication aid (e.g. pill box) when applicable

• Referral note to doctors or for MTAC service or outpatient

pharmacy counselling if required

• Arrangement for subsequent sessions if necessary

Post Visit i. Complete all documentations

ii. Update Home Care Pharmacy Services registry & visit record

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REFERENCES

1. World Health Organization. The role of the pharmacist in the health care system. World Health Organization, Geneva, Switzertland, 1994 [Online]. Available via http://apps.who.int/medicinedocs/pdf/h2995e/ h2995e.pdf (Accessed 20 November 2019).

2. Council of Europe CoM. Resolution ResAP (2001) 2 concerning the

pharmacist's role in the framework of health security. Council of Europe, Strasbourg, 2001 [Online]. Available via https://wcd.coe.int/ViewDoc. jsp?id=193721&Site=CM (Accessed 20 November 2019).

3. Beny J, Bero LA, Bond C. Expending role of outpatient pharmacist: effect on

health services utilization, cost and patient outcomes (Cochrane Review). In: The Cochrane Library, Issue 3, 2000. Oxford, UK

4. Stewart S PS, Luke CG, Horowitz JD. Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths. J Am Geriatr Soc. 1998;46(2):174-80.

5. A Nor Elina MCS, PA Ball. The impact of home medication review in patients

with type 2 diabetes mellitus living in rural areas of Kuantan, Malaysia. Journal of The International Society for Pharmacoeconomics and Outcomes Research. 2014 May;17(3): A127

6. Tan YM, Chong CP, Cheah YC. Impact of hospital pharmacist-led home medication review program for people with schizophrenia: A prospective study from Malaysia. J Appl Pharm Sci, 2019; 9(07):034–041

7. Domiciliary Medication Management Review – Guidelines for Pharmacists.

Pharmaceutical Society of Australia. December 2009.

8. Holland, R., Lenaghan,E. , Smith,R. Lipp, A., Christou, M., Evans,D. & Harvey,I. Delivering a home-based medication review, process measures from the HOMER randomized controlled trial. The International Journal of Pharmacy Practice. 2006. 14:71-79.

9. National Health and Morbidity Survey. 2006.

10. National Survey on the Use of Medications (NSUM) by Malaysian Consumers 2015.

11. Home Medication Review Protocol. Pharmaceutical Services Division, Ministry of Health Malaysia. 1st Edition. 2011.

12. Yee MT, Chee PP & Yee CC. Impact of hospital pharmacist-led home medication review program for people with schizophrenia: A prospective study from Malaysia. Journal of Applied Pharmaceutical Science.2019; Vol 0(00), pp 001-008.

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13. The Society of Hospital Pharmacists of Australia (SHPA) in focus Background

Material - Medication reconciliation – November 2012. Retrieved from https://www.shpa.org.au/sites/default/files/uploaded-content/website-content/Fact-sheets-position statements/final_medrecbackground28nov2012_0.pdf

14. Rebecca, W. & Vicky, B. (2015). Handbook of Drug Administration via Enteral Feeding Tubes Third Edition, London, Pharmaceutical Press.

15. Administering Drug Via Enteral Feeding Tubes. A Practical Guide. Retrieved from https://www.bapen.org.uk/pdfs/d_and_e/de_pract_guide.pdf

16.Peter, J. G. A Guide to Enteral Drug Administration in Palliative Care, BPharm,

Dip Hosp Clin Pharm Pract Vol. 17 No. 3 March 1999 Journal of Pain and Symptom Management.

https://www.bapen.org.uk/pdfs/d_and_e/de_pract_guide.pdf

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APPENDIX 1

Guide to Medication Review and Reconciliation Pathway

Adapted from SHPA in focus Background Material - Medication reconciliation – November 2012

Dicharge Home Care Pharmacy Services / Subsequent sessions

Supply verified information for ongoing care

Supply all information about the patient's medicines to all involved in the patient's care

Reconcile the history with the precribed medicines

e.g. Reconcile the patient's own medications with discharge medication orders

Confirm the accuracy of the medication history

- Confirm using a second source (precription/ discharge note/ referral note etc.).

- Update the medication history if new information becomes available.

Obtain the best-possible medication history

- Review background information.

- Conduct a patient/ carer interview.

Home Care Pharmacists meet patient / caregiver at patient's home / residential care facility

16

APPENDIX 2

CP4

17

APPENDIX 3

HCPS1

...........................................................

(Tandatangan)

Nama :

Cop :

Tarikh :

SURAT RUJUKAN

PERKHIDMATAN FARMASI HOME CARE

Maklumat Pesakit:

Nama :

MRN/ No. K/P :

Umur :

No. Telefon :

Alamat :

Sebab-sebab Rujukan:

18

APPENDIX 4

HCPS2

KEBENARAN KELUAR UNTUK MENJALANKAN

PERKHIDMATAN FARMASI HOME CARE

Sukacita dimaklumkan bahawa Pegawai Farmasi ini:

Encik / Cik / Puan : __________________________

No. Kad Pengenalan: __________________________

Adalah anggota farmasi Hospital/ Klinik Kesihatan ________________________

yang telah diberi kebenaran untuk melawat pesakit di rumah/pusat jagaan untuk

menjalankan Perkhidmatan Farmasi Home Care.

Sekian, terima kasih. Saya yang menjalankan amanah, …………………………………………………………. (Tandatangan & Cop) Nama: Ketua Jabatan/Unit:

19

APPENDIX 5 HCPS3

Borang Persetujuan Pesakit/ Penjaga

Perkhidmatan Farmasi Home Care

Saya, ............................................ Nombor Kad Pengenalan (K/P).............................. (nama penuh seperti dalam K/P) bersetuju untuk menyertai Perkhidmatan Farmasi Home Care yang akan dijalankan

oleh Pegawai Farmasi Hospital/Klinik Kesihatan .................................................. .

Saya telah diberi penerangan berkaitan perkhidmatan ini. Saya memahami dan

bersetuju untuk membenarkan Pegawai Farmasi yang terlibat menjalankan aktiviti

lawatan ke rumah saya/ Pusat Jagaan, mengadakan sesi temu bual, mengambil dan

berkongsi gambar ubat-ubatan (sekiranya perlu) bagi tujuan pendidikan dan

kesedaran pengguna.

.................................................... .....................................................

(Tandatangan) (Tandatangan)

Nama : ........................................ Nama Penjaga: .................................

No. K/P: ....................................... No. K/P : .................................

Tarikh : ........................................ Tarikh : .................................

Pegawai Farmasi Yang Bertanggungjawab,

...........................................................

(Tandatangan)

Nama :

Cop :

Tarikh :

(Salinan asal - disimpan oleh Pegawai Farmasi, salinan pendua - diserah kepada pesakit)

20

APPENDIX 6

HCPS4

Home/ Residential Care Facility Visit Risk Assessment

Name:

R/N:

Age:

Phone:

Address:

(A) ACCOMODATION – tick type, Indicate floor level

House

Residential Care Facility

Flat / Unit

Public Housing

Commercial Premises

Other details (e.g. Level)

…………………………………………

Yes No Unknown Remarks

(B) OCCUPANTS

Are other people likely to be present during

the visit?

If yes, list other:

Will these people have an effect on our safety

or patient treatment?

Are there any indicators of risk to staff from

the patient? (i.e. PSY history/ drug abuse)

(can be asked directly or gleaned from

medical history)

(C) ACCESS TO PREMISE

Is it difficult to see the number of the house

from the street?

Is there difficulty accessing or parking near

the property? (i.e. specific instruction/

comments about entering/ exiting the

property)

If yes, comment:

(D) ANIMALS

Are there any animals inside or outside the

premise that need to be isolated prior to visit?

(E) OTHER

Are there any potential hazards?

Notes:

1 – 3 of YES : Proceed to visit

4 – 6 of YES : Proceed to visit with companion

7 of YES : Not to Visit

_________________________ ___________________

Signature & Stamp Date

21

APPENDIX 7

HCPS5

HOME CARE PHARMACY SERVICES REPORT FORM

Pharmacy Department, Hospital/ Health Clinic: _________________________________________

A. Home Care Pharmacy Service Visit

Date : Start Time : End Time :

Home Care

Pharmacist : Full Time/Part Time

Location : Patient’s homes/Residential care

Discipline : Psychiatry/Geriatric/Stroke/

Others _____________

Home Care Pharmacy

Team

: Multidisciplinary/Pharmacy-Only

team

Personnel (Name & Post):

1.

2.

3.

4.

5.

No. of

- Patient’s Homes

- Residential Care

:

:

No. of Patients :

No. of 1st Session :

No. of Subs. Sessions :

B. INTERVENTIONS & REQUEST ENCOUNTERED INTERVENT

ION

DESCRIPTION NO. OF

INTERVE

NTION

ACCEPT

ED

REQUEST /

INFORMATION

PROVIDED

NUMBER TOTAL

(1)

Incomplete

prescription

1. Patient Data Drug toxicity

2. Drug Dose / Administration

3. Dose Side effects

4. Frequency Drug indication

5. Duration Drug interaction

6. Dr’s chop & Sign Contraindication

(2) Incorrect/

Inappropriate

/Inadequate

regimen

1. Drug Pharmacokinetic

2. Dose TPN

3. Frequency Pharmaceutical availability

4. Duration Pharmaceutical

compatibility

5. Wrong patient Pharmaceutical

Identification

6. Polypharmacy General Product

Information

7. Contraindication Others

8. Drug interaction

9. Incompatibility Total Information

Provided

(3) Miscella-

neous

1. Medication not in the list

2. Wrong administration

3. Unclear handwriting

4. Authenticity OTHERS NO. OF ACTIVITY

5. Lab monitoring Counselling

6. TDM Dispensing

7. TPN Referral after session(CP4)

Total Intervention Total ADR Report

22

C. DESCRIPTION OF REQUEST / INTERVENTION ENCOUNTERED

D. FOLLOW UP REQUIRED

No. Follow Up Checklist Sign

_________________________

Pharmacist’s Sign & Stamp

Date:

23

APPENDIX 8

HCPS6

HOME CARE PHARMACY SERVICES INFORMATION GATHERING FORM (1ST SESSION)


A. Demoghraphic Data

Name : MRN/IC : Age : Gender : M / F Race : M / C / I / Others

Ht / Wt / BMI: Contact No. : Location : Patient’s home/ Residential Care

Living Alone : Yes /No Address:

B. Medical Status

Past Medical / Surgical History:

Last diagnosis from last hospital discharge/ clinic visit:

Allergies : Yes/No

Details and reaction:

Smoking:

□ Yes

□ No

□ Former Smoker**

□ Passive Smoker***

Alcohol:

□ Yes

□ No

□ Has Stopped

Drug Abuse:

□ Yes

□ No

□ Has Stopped

Pregnant / Breastfeeding:

□ Yes

□ No

□ Not applicable

* If available, ** Not smoking for 6 months or more, *** living with smokers

C. Issues influencing medication use and effectiveness

Vision

(Can patient read label?)

□ Good □ Poor □ Others __________

Language and/or

literacy problems

□ Yes □ No

Hearing □ Good □ Poor □ With aids

Swallowing □ Good □ Poor

Speech □ Clear □ Not clear □ No speech

Cognition (memory &

comprehension)

□ Good □ Poor

Mobility

(e.g. walking stick,

wheelchair, amputee)

□ ADL independent □ ADL dependant,

specify ___________

Insight

(patient’s belief about

prescribed medication)

□ Good □ Poor

Administration of medication

Medication

administered by

□ Self-administered □ Partner/ Carer,

specify __________

Method of

administration

□ Swallowing □ Tablet crushing □ Nasogastric tube □ PEG tube □ others_________

Devices/ Aids □ Inhaler □ Insulin pen □ Nebuliser

□ Spacer □ Blood glucose

monitoring set

□ Blood pressure monitoring

□ Other __________

Dose Administration

Aid (DAA)

□ Dosette box/ Pill box □ Alarm

□ Medication schedule □ Special packaging

□ Others □ None

24

D. Medication Assessment (Including prescribed & non-prescribed medications, herbals, supplement & traditional medicine)

Medication

[Name (generic & brand),

Strength]

Prescribed dose &

frequency

Date of

supply

Quantity

Supply

Total

balance Compliance*

Actual

Consumption Pharmacist’s Note

D F I T

Total DFIT Score (%)

*Compliance score = No. of tablet dispensed – No. of tablets not taken x 100% Correct no. of tablets should be taken Compliant (80 – 100%), Partial Compliant (20 – 79%), Non-compliant (0 – 19%)

25

Pharmacist’s Sign & Stamp: Date:

E. Pharmaceutical Care Issues

Issues Pharmacist’s Recommendation /

Intervention / Solution

Reasons Outcome

F. Information Provided

G. Home Care Pharmacy Care Plan

This patient require the following:

□ Subsequent session; Date: _________________

□ Follow-up counselling*

□ Referral to Medical Officer*

□ Referral to MTAC*

□ Discharge

*CP4 form has been given to patient on ____________ (date)

26

Laboratory Values

Visit

Date

BP (mmHg)

PR (bpm) 60-100

RR (bpm) 12-18

Lipid Profile

T. Chol (mmol/l)

27

APPENDIX 9

HCPS7

HOME CARE PHARMACY SERVICES INFORMATION GATHERING FORM (SUBSEQUENT SESSIONS)


Date: ________ Session No: ________

A. Demographic Data

Name : MRN/IC : Age : Gender : M / F Race : M / C / I / Others

Ht / Wt / BMI : Diagnosis:

B. Medication Assessment

Medication

[Name (generic &

brand), Strength]

Prescribed

dose &

frequency

Date of

supply

Quantity

supply

Total

balance

Compliance

*

Actual

Consumption

D F I T

Total DFIT Score (%)

Pharmacist’s Note:

*Compliant (80 – 100%), Partial Compliant (20 – 79%), Non-compliant (0 – 19%)

Pharmacist’s Sign & Stamp:

C. Pharmaceutical Care Issues

Issues Pharmacist’s Recommendation /

Intervention / Solution

Reasons Outcome

D. Information Provided

E. Home Care Pharmacy Care Plan

This patient require the following:

□ Subsequent session; Date: ________

□ Follow-up counselling*

□ Referral to Medical Officer*

□ Referral to MTAC*

□ Discharge

*CP4 form has been given to patient on __________(date)

28

APPENDIX 10a

HCPS8a

MEDICATION IDENTIFICATION CHART

Date:___________________

NO NAME & STRENGTH

(affix actual drug if necessary) INDICATION

TO BE TAKEN BEFORE/ AFTER FOOD

AMOUNT/ TIME OF ADMINISTRATION

OTHER SPECIAL INSTRUCTIONS

MORNING ( )am

☼ AFTERNOON

( )pm

EVENING ( )pm

NIGHT

( )pm

29

APPENDIX 10b

HCPS8b

CARTA PERUBATAN

Tarikh:___________________

Bil. NAMA UBAT & KEKUATAN

(lekat ubat sebenar jika perlu) KEGUNAAN

SEBELUM / SELEPAS MAKAN

KUANTITI & MASA AMBIL UBAT

LAIN-LAIN ARAHAN

PENGGUNAAN

PAGI ( )am

☼ T/HARI ( )pm

PETANG ( )pm

MALAM ( )pm

30

APPENDIX 10c

HCPS8c

服药图

日期：___________________

编号药名和份量

(如有需要，附上实药) 用途饭前 / 饭后

吃药时间和数量

特别指示早上

( )am

☼ 中午

( )pm

下午

( )pm

晚上

( )pm

31

APPENDIX 10d

HCPS8d

மருந்து அடையாள விளக்கப்பைம் Date:___________________

எண்

மருந்தின் பபயர் &

மருந்தளவு

(உண்டமயான

மருந்டத

காண்பிக்கவும்)

பயன்பாடு உணவுக்கு

முன் / பின்)

அளவு/ மருந்து சாப்பிடும் நநரம்

மற்ற

பயன்பாடட்ு

வழிமுறறகள்

காடை ( )am

☼ நண்பகை்

( )pm

மாடை ( )pm

இரவு

( )pm

பின்னர ்

32

APPENDIX 11

HCPS9

HOME CARE PHARMACY SERVICES REGISTRY


No. Rn /

I.C No Name Diagnosis

Date

Tel No. Address Notes

Enrolment Discharge

33

APPENDIX 12

HCPS10

HOME CARE PHARMACY SERVICES VISIT RECORD


Year: _________

NO. NAME RN / I.C No DATE OF SESSION (PLEASE STATE IF DISCHARGED)

JAN FEB MAC APR MAY JUNE JULY AUG SEPT OCT NOV DEC

34

APPENDIX 13

Senarai Semak Kesan Sampingan Ubat-Ubatan Psikotropik

Bil. Sila tandakan (√) jika jawapan ‘ya’ Ja

n

Fe

b

Ma

c

Ap

r

Me

i

Ju

n

Ju

l

Og

os

Se

p

Okt

No

v

Dis

1. Pengetahuan ubat yang diambil

1.1 Adakah pesakit mengambil ubat seperti yang diarahkan?

1.2 Adakah pesakit tahu berapa jenis ubat yang perlu

diambil?

1.3 Adakah pesakit tahu berapa kali dia perlu ambil ubat

dalam satu hari?

1.4 Adakah pesakit tahu berapa biji ubat yang perlu diambil

pada setiap hari?

1.5 Adakah pesakit tahu nama ubat yang diambil?

2. Senarai semak kesan sampingan ubat

2.1 Kering mulut

2.2 *Meleleh air liur

2.3 *Pergerakan mulut / lidah tidak terkawal

2.4 *Ruam kulit

2.5 Kulit mudah peka pada cahaya matahari

2.6 *Badan menggeletar / menggigil

2.7 *Ketegangan Otot (Dystonia)

2.8 *Pergerakan kaki tidak terkawal (Tardive dyskinesia)

2.9 *Mata terbeliak / terbalik ke atas

2.10 *Ketegangan leher

2.11 *Berjalan seperti robot

2.12 Pening

2.13 *Rasa mengantuk

2.14 *Rasa gelisah dan tidak boleh duduk diam (Akathisia)

2.15 *Pergerakan yang perlahan (Bradykinesia)

2.16 *Perubahan fungsi seksual termasuk nafsu seks susah

mencapai kemuncak

2.17 *Kabur penglihatan

2.18 Sembelit

2.19 Susah buang air kecil

Bil. Tindakan yang diambil (Sila tandakan (√) jika jawapan ‘ya’)

Ja

n

Fe

b

Ma

c

Ap

r

Me

i

Ju

n

Ju

l

Og

os

Se

p

Okt

Nov

Dis

1.1 Tiada tindakan jika tiada kesan sampingan

1.2 Memerlukan penilaian yang lebih kerap

1.3 Kesan sampingan yang bertanda (*) memerlukan rujukan

kepada Pegawa Perubatan / FMS / Pakar Psikiatri untuk

tindakan selanjutnya

35

APPENDIX 14

Assessment of Drug Side Effects (Antipsychotic Side Effect Checklist (ASC))

No. Problem Yes No Comment(s)

1. Loss of energy and drive:

Have you had trouble moving, getting going, or stating things? Do you feel slowed

down?

2. Feeling unmotivated or numb:

Have you had trouble getting motivated or wanting to do things you used to?

(Sometimes people describe this as “Feeling like a zombie”.

3. Daytime sedation or drowsiness:

Are you tired or sleepy during the day? Feelings of tiredness can happen throughout

the day or only at certain times.

4. Sleeping too much:

Do you sleep too much? Do you feel you sleep for too long? Do you have a problem

getting out of bed in the morning, or do you need to go back to sleep for a large part of

the day?

5. Muscle being too tense or stiff:

Do your muscles feel stiff or rigid? Do you feel cramps or muscle pains in the arms,

legs, or neck?

6. Muscles trembling or shaking:

Have you had any shaking or muscle trembling?

7. Feeling restless or jitter:

Have you had any feelings of restlessness? Do you ever feel like you want to “jump out

of your skin”?

8. Need to move around and pace; can’t stay still:

Do you often need to get up and pace around? Do you have trouble sitting still? Do you

still rock from one leg to the other?

9. Trouble getting to sleep or staying asleep (insomnia):

Do you have trouble falling asleep or getting to sleep when you want to? Do you wake

up during the night, or wake up too early in the morning?

10. Blurry vision:

Do you have blurry vision? Things may seem out of focus. People with blurred vision

may have trouble with reading printed words in newspapers.

11. Dry mouth:

Is your mouth too dry? Does it feel like you have cotton in your mouth? Does it seem

like your tongue sticks to the top of your mouth?

12. Drooling:

Do you have too much saliva (spit)? Is your pillow wet when you wake up?

13. Memory and concentration:

Do you have any memory problems? Are you more forgetful? Is it hard to concentrate?

Do you find it hard to follow conversations, watch programs on TV, or read?

14. Constipation:

Do you have problems with constipation?

15. Weight change:

Have you had any changes in weight? Do you feel that you are overweight? Do you

gain weight quickly, or cannot seem to go on diet? Are your clothes getting too big or

too small for you?

16. Changes in sexual functioning:

Do you have any sexual problems or difficulties? Sometimes people say they have

problems with low sex drive. Some men say they have difficulties with erections or

ejaculation, and some women say they have difficulty achieving orgasm.

17. Menstrual or breast problem:

If you have regular menstrual periods, have you had any menstrual problems lately?

Sometimes women stop having their normal periods, or have irregular periods. Have

you had this problem recently? Sometimes they maybe milk leakage from the breasts.

36

APPENDIX 15

Toronto Side Effect Scale (TSES)

Within the last two weeks, have you experienced any of the following symptoms?

How much trouble did this side effect cause you?

(Physician: rate frequency and severity of the symptoms)

Frequency Severity

Never Some

times

About

half

the

time

Often Every

day

No

trouble

Extreme

trouble

1. Nervousness 1 2 3 4 5 1 2 3 4 5

2. Agitation 1 2 3 4 5 1 2 3 4 5

3. Tremor 1 2 3 4 5 1 2 3 4 5

4. Twitching/myoclonus

(muscle contraction)

1 2 3 4 5 1 2 3 4 5

5. Abdominal pain 1 2 3 4 5 1 2 3 4 5

6. Dyspepsia (stomach

upset)

1 2 3 4 5 1 2 3 4 5

7. Nausea 1 2 3 4 5 1 2 3 4 5

8. Diarrhoea 1 2 3 4 5 1 2 3 4 5

9. Constipation 1 2 3 4 5 1 2 3 4 5

10. Decreased appetite 1 2 3 4 5 1 2 3 4 5

11. Increased appetite 1 2 3 4 5 1 2 3 4 5

12. Weakness or fatigue 1 2 3 4 5 1 2 3 4 5

13. Dizziness 1 2 3 4 5 1 2 3 4 5

14. Postural

hypotension (dizzy

when getting up)

1 2 3 4 5 1 2 3 4 5

15. Drowsiness/daytime

somnolence

1 2 3 4 5 1 2 3 4 5

16. Increased sleep 1 2 3 4 5 1 2 3 4 5

17. Decreased sleep 1 2 3 4 5 1 2 3 4 5

18. Sweating 1 2 3 4 5 1 2 3 4 5

19. Flushing 1 2 3 4 5 1 2 3 4 5

20. Edema (fluid

retention)

1 2 3 4 5 1 2 3 4 5

21. Headache 1 2 3 4 5 1 2 3 4 5

22. Blurred vision 1 2 3 4 5 1 2 3 4 5

23. Dry mouth 1 2 3 4 5 1 2 3 4 5

24. Anorgasmia/no

orgasm

1 2 3 4 5 1 2 3 4 5

25. Increased libido 1 2 3 4 5 1 2 3 4 5

26. Decreased libido 1 2 3 4 5 1 2 3 4 5

(Men only: item 27 – 29)

27. Premature

ejaculation

28. Delayed ejaculation

29. Erectile dysfunction

30. Other, specify:

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

5

5

5

5

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

5

5

5

5

None ≤2

lbs

≤4 lbs ≤6

lbs

≤7

lbs

No

trouble

Extreme

trouble

31. Weight gain 1 2 3 4 5 1 2 3 4 5

32. Weight loss 1 2 3 4 5 1 2 3 4 5

37

APPENDIX 16

Screening Tools: Medication / Medical Related Issues

Known kidney problem? Y N Unusual bleeding or bruising? Y N

Frequent urinary infections? Y N Anaemia? Y N

Difficulty in urination? Y N Sores/ulcers on leg or feet? Y N

Frequent urination at night? Y N Leg pain or swelling? Y N

Known liver problems/hepatitis Y N Thyroid problems? Y N

Trouble eating certain food? Y N Known hormone problems? Y N

Nausea or vomiting? Y N Arthritis or joint problems? Y N

Constipation? Y N Muscle cramps? Y N

Diarrhoea? Y N Muscle pain/aches if weakness? Y N

Bloody or black bowel movement? Y N Memory problems? Y N

Abdominal pain or cramps? Y N Dizziness? Y N

Frequent heartburn/indigestion? Y N Hearing or visual problems? Y N

Stomach ulcer in the past? Y N Frequent headaches? Y N

Shortness of breath? Y N Rash or hives? Y N

Coughing up phlegm or blood? Y N Change in appetite or taste? Y N

Chest pain or tightness? Y N Dry mouth? Y N

Fainting spells or passing out? Y N Walking or balance problems? Y N

Thumping or racing heart? Y N Other problem? (details) Y N

Other problems: If yes, please specified:

1.

2.

3.

4.

38

APPENDIX 17

Medication Appropriateness Index (MAI)

To assess the appropriateness of the drug, please answer the following questions and circle the

applicable score:

1. Is there an indication for the drug? 1 2 3 9

Comments: Indicated Not Indicated DK*

2. Is there medication effective for the condition? 1 2 3 9

Comments Effective Ineffective DK

3. Is the dosage correct? 1 2 3 9

Comments: Correct Incorrect

4. Are the directions correct? 1 2 3 9

Comments: Correct Incorrect DK

5. Are the directions practical? 1 2 3 9

Comments: Practical Impractical DK

6. Are there clinically significant drug-drug

interactions? 1 2 3 9

Comments: Insignificant Significant DK

7. Are there clinically significant drug-disease/

condition interactions? 1 2 3 9

Comments: Insignificant Significant DK

8. Is there unnecessary duplication with other

drug(s) 1 2 3 9

Comments: Necessary Unnecessary DK

9. Is the duration of therapy acceptable? 1 2 3 9

Comments: Acceptable Unacceptable DK

10. Is the drug the least expensive alternative

compared to others of equal utility? 1 2 3 9

Comments: Least

expensive Most expensive DK

Total

*DK: Don’t Know

39

APPENDIX 18

Guide to Drug Therapy in Patients with Enteral Feeding Tubes

A. Consideration in medication administration via enteral feeding:

• Suitability of dosage form, availability of alternative drugs/form or can the

physical form be altered

• Physical and chemical compatibility with enteral feed

• Complicating factors that may affect the absorption or clearance of the drug

B. Recommendation for enteral drug administration:

1. Is an alternative route of drug administration available? Would this be more

appropriate?

2. Select the most applicable dosage form for administration via the enteral

feeding tube.

3. Is there a more suitable dosage form available in an alternative drug?

4. Simplify the medication regimen.

5. Prepare the selected dosage form for administration

6. Confirm compatibility with the enteral formula before administering

medications via the feeding tube. Never add medications directly to the enteral

formula.

40

7. Choose an appropriate method of drug administration for patients prescribed

continuous feeding

• For medication presumed compatible: Cease the enteral feed, thoroughly

flush the tube, then administer the medication. Before recommencing the

feed, flush the tube again.

• For medications requiring administration on an empty stomach: Cease

feeding 30 minutes before drug administration. Allow a further 30 minutes

after administration to permit drug absorption.

• For documented drug/enteral formula incompatibilities:

- Single daily dose, stop feeding 2 hours prior to drug administration

and recommence 2 hours later.

- More than once daily administration, allow one hour either side of the

administration time.

C. Choice of drug formulation

Preferred formulations

Liquids or soluble tablets are the preferred formulations to be administered

via a feeding tube.

Some injections can be given enterally.

Crushing tablets or opening capsules should be considered as a last

resort

Medicines that should not be crushed

× Enteric Coated (EC): The coating is designed to resist gastric acid to

protect the drug and/or reduce gastric side effects.

× Modified/Slow Release (MR, SR, LA, XL): These are tablets or capsules

that are specifically designed to release the drug over a long period of

time. Crushing these will cause all the drug to be released at once and

may cause toxic side effects.

× Cytotoxic & Hormones: These should not be crushed due to the risks to

staff from exposure to the powdered drug.

**For further reading, refer to the individual monographs and Handbook of Drug Administration via Enteral Feeding

Tubes, Rebecca White & Vicky Bradnam