Loop closure is a key element of trauma performance improvement (PI). Failure to document it adequately results in one of the most frequent deficiencies issued by the American College of Surgeons (ACS). Based on my experience reviewing more than a hundred trauma centers, PI leaders struggle with one aspect of trauma loop closure more than any other. This mistake not only affects documentation, it points to larger problems with a PI program.

What is this mistake? It is labeling your corrective action plan as loop closure. The problem, of course, is that having a plan is not the same as “closing the loop.” Your plan is simply what you intend to do. During an ACS site visit, reviewers want to see what you have already done, not what you anticipate.

So how do you demonstrate to the ACS that you have performed loop closure and documented it adequately? In this article, I will share a simple approach that I recommend to all the trauma program leaders I work with. I will also walk through some examples of what does and does not constitute adequate loop closure. But first, let’s clarify what the ACS says about closing the loop in trauma PI.

What the Orange Book says about trauma loop closure

As described in Resources for the Optimal Care of the Injured Patient – Sixth Edition, trauma performance improvement is not only action-oriented, but forward-looking:

“When an opportunity for improvement is identified, appropriate corrective actions to mitigate or prevent similar future adverse events [emphasis added]must be developed, implemented, and clearly documented by the trauma PIPS program (CD 16–18).”

In other words, reacting to past problems is only one aspect of trauma PI. To truly close the loop on an improvement opportunity, program leaders must make changes that will prevent the same problem from happening again. How does the PI process prevent future adverse events?

“An effective performance improvement program demonstrates through clear documentation that identified opportunities for improvement lead to specific interventions that result in an alteration in conditions [emphasis added]such that similar adverse events are less likely to occur (CD 16–19).”

Again, the focus is on accomplishments, not plans. You have not achieved adequate loop closure until you can document that a safety-focused “alteration in conditions” has already occurred.

A documentation tool that helps drive trauma loop closure

There are several possible ways to document loop closure. However, I recommend that PI leaders adopt a simple tool. Buy a rubber stamp that reads: “Future similar patients are less likely to have this problem because [blank lines for entering explanation].” Here is what the stamp might look like:

An actual, physical rubber stamp? Yes, if at all possible. Alternatively, if your program’s PI documentation is completely electronic, build this statement into your PI template.

The main point is that the PI coordinator or trauma program manager should complete this sentence in the PI folder of every reviewed case. This helps ensure loop closure focuses on the ultimate goal: an alteration in conditions such that similar adverse events are less likely to occur.

When you fill out the statement, make sure you use perfect grammar. Why? Paying attention to grammar will force you to describe what has already been done (in the past tense), not what you plan to do. Imagine how silly it would sound to write, “Future similar patients are less likely to have this problem because Dr. TMD is planning to speak with Dr. Variance about the problem.”

Describing “that which has been done” is completely different from describing something planned for the future. Again, action-oriented loop closure is never a plan. It is a work product.

An example of inadequate trauma loop closure

Imagine that an adverse outcome occurred following an undertriage event. Just for the sake of discussion, let’s say an emergency department physician failed to activate the trauma team for a patient who was found down at the bottom of a full flight of stairs. This imaginary patient had a Glasgow Coma Scale score of 3 because he was completely unresponsive. The ED physician noted that the patient was found in a pool of blood and had a scalp laceration. However, instead of activating the trauma team, he ordered a CT scan, interpreted it to show a hemorrhagic contusion, and admitted the patient to the medical service.

The trauma program manager identified this event through an audit filter (“non-surgical admission with GCS < 8 and injury code”). He then wrote a brief summary and sent it to the trauma medical director for secondary review. The TMD felt this problem warranted committee discussion, so she wrote a secure email to the emergency physician asking why the trauma team was not activated. The ED physician created a thoughtful response and sent it by secure return email to the TPM, and the issue was presented by the TMD at the multidisciplinary trauma peer review committee meeting four weeks later.

The committee considered the event, reviewed the bi-directional email, discussed the details, and then adjudicated the issue by vote. Committee members believed that nearly all the ED physician’s peers would have activated the trauma team, and they felt that failure to activate contributed to the bad outcome. They determined that the care was “inappropriate,” and the TPM documented this very clearly in the minutes of the committee meeting.

Having found a problem, program leaders must now do something to discourage it from happening again. What are the options? Certainly, the TMD could call the ED physician and remind him that the activation criteria were not followed. The TMD could ask the trauma committee’s emergency medicine liaison to make the call. The TMD could write a polite “informational letter” reminding the ED physician about the need to activate appropriately.

If the process ended there, could you say that loop closure was achieved? To answer that question, let’s go back to our rubber stamp. Future similar patients are less likely to have this problem because…the TMD “will” speak with the ED physician or “will remind” the ED physician of the criteria? Clearly, the loop is not yet closed.

An example of strong trauma loop closure

Trauma PI leaders need to do something that will make the same problem less likely in the future. In the scenario described above, the committee should create an action plan commensurate with the risk to future patients.

If this was the ED physician’s first encounter with the committee, there may be a system problem. It may be that ED physicians are not aware of the activation criteria used at this individual hospital. More likely, however, this is an individual physician (peer review) issue, because an injured patient with a severely depressed GCS should be a highest-level activation according to ACS minimums for all verified trauma centers.

So let’s say that the physician had or should have had the criteria available, and that he failed to act appropriately. With future safety in mind, the committee has several viable options:

• Targeted education: One approach might be to require the ED physician to attest in writing that he conducted a literature review about triage accuracy and its implications for trauma care. The committee could also require the physician to speak to the trauma team about his findings in an educational forum.
• Additional training: If this is the physician’s second or third encounter with the trauma team on an activation issue, the committee could require him to take the Advanced Trauma Life Support (ATLS) course again.
• Focused review: If this physician is “notorious” for undertriage, a focused review might be an attractive option. The trauma program would review ALL the physician’s triage decisions for a period of time, as opposed to waiting for another audit filter to be tripped.
• Change in privileges: If the physician is a frequent offender but refuses to even respond to the committee, a de-credentialing recommendation may be in order.

Before the committee makes a decision, it often makes sense to get more data. The trauma program manager could use the registry to compare the physician’s triage decisions to patient ISS scores, in a manner similar to the “Cribari Method” for determining triage accuracy. It would then be easy to compare the physician’s undertriage rate with that of the overall department. This would help the trauma peer review committee make a data-driven decision.

How to impress reviewers

During an ACS site visit, the reviewers must make recommendations to the Verification Review Committee as to whether the trauma program meets several dozen PI criteria. It’s a complex process, and it often extends beyond the chart review, through the dinner, and into the hospital tour the following day. Strong documentation of loop closure facilitates the process for reviewers.

When a reviewer sees the PI folder for our example scenario — including the screening forms, the TPM initial review, the TMD secondary review, and the bi-directional communication — he or she will want to see the committee minutes. If the minutes say that Future similar patients are less likely to have this problem because the emergency physician was put on a six-month focused review, during which no further episodes of undertriage occurred, the reviewer will be impressed!

ACS reviewers need to leave your hospital convinced that your PI program protects future similar patients from whatever problems were identified. The rubber stamp method helps program leaders stay focused on forward-looking actions for ensuring future patient safety.

Marco Bonta, MD, FACS is the trauma medical director at Riverside Methodist Hospital in Columbus, Ohio. Dr. Bonta a former member of the Verification Review Committee of the ACS Committee on Trauma and a former ACS site reviewer. He frequently serves as a consultant to trauma centers preparing for verification. To find out more, visit www.traumaconsulting.com.