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evidence-based protocol, heat loss prevention, quality management process, quality management tool, trauma care



  1. Hayes, Janice S. PhD, RN
  2. Tyler-Ball, Suzette RN BHSA
  3. Cohen, Sharon S. RN, MSN, CEN, CCRN
  4. Eckes-Roper, Jeanne RN, BSPA-HCA
  5. Puente, Ivan MD, FACS


This article describes a quality management process used to develop an evidence-based protocol for heat loss prevention in trauma patients. The quality management tool applied was the ADDIE process (Assess the problem, Determine the root cause, Design a solution, Implement the solution, and Evaluate the outcome). Use of this process required multiple applications and resulted in the identification of a multifactorial root cause. Ongoing changes and additions to the action plans were implemented.