Loop closure is the final step in the trauma performance improvement process, but it also be the aspect of PI that can cause the most trouble for trauma program leaders.
“Loop closure is the demonstration that an implemented corrective action effectively protects future similar patients from the impact of a past quality issue,” said Nancy Bartkowiak, BSN, RN. “It’s the last piece of your PI process, and this is the piece that commonly gets missed.”
Bartkowiak took a close look at several approaches to corrective action planning during her session at the 2024 Virtual Summit for Level III, IV & V Trauma Centers. Selecting the right approach is one key to creating a realistic action plan that works for your trauma center.
Develop a practice guideline or protocol
When a quality issue occurs, creating a new practice guideline or protocol can help establish safer processes. However, according to Bartkowiak, this approach should be used with caution.
“Guideline and protocol development is probably one of my least favorite options,” she said. “Blanketly putting out a policy and expecting everybody to follow it is not always the best approach.”
Even when a new guideline is needed, you do not always need to start from scratch. The most straightforward option is simply to revise one of your center’s current guidelines.
You can also use a practice guideline developed by a national trauma organization or another trauma center. However, it is important to review these guidelines carefully and adapt them to your hospital. In terms of the SMART goals model, the guideline or protocol must be attainable and realistic.
“The big thing is to make sure your goals match what you can achieve at your center,” Bartkowiak said. “If I’m having an issue with massive transfusion protocol, I can’t put in my policy that I’m going to do ROTEM if I don’t have ROTEM. If I steal a policy from somebody else, I need to read it to make sure it doesn’t have ROTEM in it because the state reviewer will catch that.”
Bartkowiak also recommends allowing ample time to disseminate a new policy before implementation. “Give yourself some time to educate the staff that you need to educate before you do your go live, because that’s when you’re going to really start tracking whether your action plan is working.”
Form an action-planning work group
When investigating quality issues, staff work groups are often better able to identify underlying issues than the TPM or PI coordinator. For example, Bartkowiak recently formed a work group to examine challenges around temperature regulation for trauma patients.
“I put a work group together to see what they could come up with, and they discovered that the temperature regulator on the wall of the trauma room actually regulated the temperature in two or three rooms,” she said. “So if we keep our trauma room really warm, it is going to be too warm for some of our other patients, like patients who maybe are septic.”
In this example, the work group quickly identified the facilities issue that was a key part of the corrective action plan. “In my experience, the staff that are actually working in a department may be able to come up with a better action plan or action items than you can,” Bartkowiak said.
While work groups should include all key stakeholders, she recommends keeping them as small as possible. In addition, every work group should include a champion to communicate findings to trauma leadership.
Provide team education
Education can be an excellent way to address quality issues that are driven by knowledge gaps. However, understaffing and budget constraints have made it harder for trauma program leaders to implement education-based action plans.
According to Bartkowiak, the solution is to focus on short educational interventions. Options include:
Storyboards. “Storyboards weren’t popular back when I first started, but now with so little time to do education, storyboards are actually a really good choice,” she said. Storyboards can focus on skills like chest tube insertion or how to use the rapid infuser. “You can make up a little two- or three-question quiz and have people slip their answers into a collection box. You have proof that they looked at the storyboard and read it because they answered the questions.”
Cafeteria mini-session. “I did a table in the cafeteria at lunchtime with the focus on tourniquet use,” she said. “I stopped everyone after they went through the cashier line and did a quick mini-session on applying a tourniquet, holding pressure, etc. Then I had them sign a roster.”
ED staff meetings. “This is one of my favorite things, because I can do a little five-minute presentation on a PI issue,” she said. “I do a different topic every month, and I pick something that we’re struggling with.”
Impromptu quizzes. “I sometimes play a trauma activation game with the staff,” she said. “I’ll just go through the ED, describe a patient scenario and then ask, Was this an activation or not?”
“It’s just thinking outside the box of what will work for your staff,” she said. “But the key is documentation. Remember — document, document, document.”
Provide one-on-one counseling
“The key with using counseling in your action plan, as with everything in loop closure, is to document, document, document,” she said.
Bartkowiak recommends following up all face-to-face counseling with an email to confirm the discussion. For example: “As a follow-up to the conversation we had today, we discussed that the motorcycle accident of (date) should have been called as a partial trauma activation,” she said. “I require that they respond — Okay, Got it, sorry, whatever — but I want you to acknowledge that you got my email and that you read it.”
She encourages PI leaders to provide counseling promptly. “Try not to delay it, but be as concurrent as you can with your PI,” she said. “And remember to communicate with staff about good things that went well, not just bad notes.”
Originally published in the Community & Rural Trauma Centers Special Report
This article was originally published in the Community & Rural Trauma Centers 2024 Special Report. This special issue highlights practical strategies for building high-performing trauma teams and ensuring quality care for trauma patients in every setting. To read the full issue, tap the cover image at right or click here.
