18.6 Quality Improvement, Practice Standards & Interprofessional Collaboration (Protocols, Teamwork & Debriefing)

18.6 Quality Improvement, Practice Standards & Interprofessional Collaboration (Protocols, Teamwork & Debriefing)

Quality Improvement Frameworks

The Donabedian Model

Quality is measured through structure (resources and organization, such as pharmacist coverage hours), process (what is done, such as time from triage to antibiotic) and outcome (results for patients, such as sepsis mortality).

The IHI Model for Improvement

The Institute for Healthcare Improvement model asks three questions:

1. What are we trying to accomplish? Write a specific, measurable, time-bound aim. Example: "Increase the share of patients with septic shock who receive antibiotics within 60 minutes of triage from 55% to 80% by June."
2. How will we know that a change is an improvement? Choose measures.
3. What change can we make that will result in improvement? Choose change ideas.

Changes are tested with small Plan-Do-Study-Act (PDSA) cycles: one shift, one nurse or five patients at first, then larger tests, and then implementation and spread.

Types of Measures

Lean and Six Sigma

• Lean removes waste (waiting, motion, overprocessing, defects, excess inventory) using value-stream mapping and standard work. Example: redesign the path from order to administration of a time-critical antibiotic.
• Six Sigma reduces variation using DMAIC: Define, Measure, Analyze, Improve, Control. Six Sigma performance equals 3.4 defects per million opportunities.

Displaying Data Over Time

Run charts plot data over time against the median. Signals of nonrandom change include:

• A shift: 6 or more consecutive points all above or all below the median
• A trend: 5 or more consecutive points all going up or all going down
• Too many or too few runs, or one point far outside the rest

Statistical process control charts add control limits, usually 3 standard deviations from the mean. They separate common-cause variation (built into the process; fixing it requires redesigning the process) from special-cause variation (a specific cause to find and address).

QI vs. Research

QI projects that improve local care usually do not need IRB review. Projects designed to produce generalizable knowledge, or that randomize patients or add risk, may be research and need review (Section 15.3). Ask the IRB when unsure, especially if the results will be published.

Medication Use Evaluation (MUE)

An MUE assesses how a drug is used against criteria approved in advance (indication, dose, monitoring, outcomes). It can be prospective (before dispensing), concurrent (during therapy) or retrospective. In the ED, MUEs commonly target thrombolytic dosing, 4F-PCC use, sugammadex, antimicrobial choices and high-cost antidotes. The findings drive order set changes, education and formulary decisions, and the measurement should be repeated after changes.

Professional Practice Standards and Guidelines

• The Pharmacists' Patient Care Process (JCPP, 2014): Collect, Assess, Plan, Implement, and Follow-up: Monitor and Evaluate, with collaboration, communication and documentation throughout. It gives ED interventions a consistent structure.
• ASHP Guidelines on Emergency Medicine Pharmacist Services (2021) describe the core responsibilities of the EM pharmacist:
  • Bedside care, including resuscitation
  • Prospective medication order review
  • Medication histories and transitions of care
  • Antimicrobial stewardship and culture follow-up
  • Toxicology consultation
  • Medication safety and emergency preparedness
  • Education and scholarship
• Credentialing and privileging: board certification (BCEMP), PGY2 emergency medicine residency and hospital privileges for collaborative practice agreements (for example, pharmacist-managed culture callbacks or medication protocols) define the pharmacist's scope locally, within state pharmacy law.

Developing Protocols and Policies

1. Identify the problem with data (MUE, error reports, delays).
2. Review the evidence and guidelines, and grade their strength (Section 15.3).
3. Write the protocol with all stakeholders: physicians, nursing, pharmacy, informatics and sometimes EMS.
4. Get approval through P&T, the relevant medical staff committees and nursing leadership.
5. Build it into the EHR (order sets, CDS) and smart pump libraries, and educate staff.
6. Measure, audit and revise.

Practice Advancement, Committees and Education

The 2024 outline tasks include advancing EM pharmacy practice, advocacy and committee work. Practical examples:

• Documenting interventions and cost avoidance to justify pharmacist positions and extended coverage hours.
• Serving on P&T, sepsis, stroke, trauma and resuscitation committees.
• Precepting students and residents.
• Teaching nurses and physicians.
• Keeping the BCEMP credential through continuing education (Section 1.1).

Interprofessional Collaboration

Communication During Resuscitation

• Closed-loop communication: the team leader gives a clear order to a named person, the receiver repeats it back, and the leader confirms. This is essential for weight-based or unfamiliar doses.
• TeamSTEPPS (AHRQ) builds four teamwork skills: communication, team leadership, situation monitoring and mutual support. Its tools include briefs, huddles, debriefs, call-outs and check-backs.
• CUS ("I am Concerned, I am Uncomfortable, this is a Safety issue") and the two-challenge rule let any team member, including the pharmacist, stop a dangerous action. If a concern is raised twice and ignored, escalate up the chain of command.

The pharmacist's role in a code: prepare drugs and check doses, keep time for epinephrine and other repeat doses, anticipate the next drugs (antiarrhythmics, electrolytes, post-ROSC infusions), help with documentation, and act as the team's drug information source.

Debriefing

Debriefing after a resuscitation improves team performance and is supported by AHA resuscitation guidelines.

Psychological safety, a Just Culture approach to errors (Section 14.1) and second-victim support for staff after bad outcomes are essential. Debriefs often reveal medication system problems: missing drugs in kits, look-alike products and confusing concentrations. Feed these into the QI and formulary processes above.