Quality Corner: Burton’s Rule for Quality Improvement Education

Determining the most common, most serious and most unusual is an excellent way to set immediate priorities for your QI education.


Toward the end of every year I start making the rounds, talking to our instruction staff and polling potential students to help decide what, if any, new or different training we should offer in the coming year. In the past some good ideas have surfaced, but this year’s suggestions seemed particularly unimaginative. After dutifully jotting down the few ideas offered, I conferred with our training center medical director, Dr. Barry Burton.

Dr. Burton listened to my plight, leaned back in his chair and said, “Most common, most serious and most unusual.” I instantly recognized the brilliance of his answer, even if I hadn’t fully comprehended the specifics.

“What’s your most common type of call?” he asked.

“Well, I’d have to look,” I replied tentatively.

“No, you don’t,” he said. “There’ll be plenty of opportunities to cover other topics. What would you say, off the top of your head, is one of the most common calls we get?”

“Probably motor vehicle crashes,” I said.

“There ya go!”

So what are some of the problems with how we’re handling those calls? Being the QI guy, I discovered plenty of issues—or opportunities for improvement. Of course, critical issues generate immediate provider feedback, and for other significant issues, which seem to occur more commonly, we typically send a CQI bulletin via e-mail.

The one issue that nags at me with motor vehicle crashes is often no vital signs are documented until a complete set with full BP and pulse oximetry is acquired, which is frequently not until several minutes after patient contact. An initial assessment is always done—I’ve seen providers routinely palpate a radial pulse as soon as they reach the patient—but it seems many providers don’t realize how to properly document the primary trauma assessment.

Most Common

Motor vehicle crashes, or MVCs, are a very common, if not the most common, type of call we encounter at Bucks County Rescue Squad. Most are minor but all have to be assessed, and it’s not always practical to drag a cardiac monitor or pulse ox into the street to an overturned car. So, included as part of our next trauma course is assessment of MVC patients, with an emphasis on performing and documenting the primary trauma assessment utilizing the most important and readily available assessment tools we carry—our own senses.

We set up scenarios and emphasized with students the organized process of observing and describing their assessment as they approach the patient. Beginning as we approach, the general appearance of the patient is noted. Is the patient conscious? Do they appear to be in distress? Is there any obvious external bleeding? As we reach the patient we feel for a radial pulse, while at the same time feeling and looking more closely at the skin color. Is their skin color good or are they pale or cyanotic? Is their skin dry or are they diaphoretic? Is the pulse palpable at the radial; is it weak or strong, slow or fast? An actual blood pressure should be acquired as soon as possible, but may quickly be approximated by the quality of the pulse.

As you may recall hearing or reading, a pulse that is palpable at the radial is typically within the range of at least 80–90 mmHg systolic. If not palpable at the radial you can check the carotid. For a pulse to be palpable at the carotid, it needs to be at least 60–70 systolic. Palpable pulses are, of course, not as accurate as a taking a full blood pressure, but it is an acceptable way to rapidly assess your patient, especially if the result fits with the rest of the clinical picture, e.g., skin color and capillary refill. Is the capillary refill quick, delayed or completely absent due to peripheral vasoconstriction?

Lastly, assess the patient’s mental status. Does the patient respond appropriately to questions like, “Are you hurt anywhere?”; “Did you lose consciousness?”; “Do you remember what happened?”; “What year and month is it?” There are several potential causes of altered mental status to be considered in the MVC patient, such as primary brain injury; cardiovascular compromise or shock; alcohol or other substance abuse; or hypoglycemia, just to name the most common.

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