Quality Corner: Burton’s Rule for Quality Improvement 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.
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.
Some of our most serious calls are for patients in respiratory distress. As a result, we re-emphasized respiratory assessment and treatment in our annual airway class. Some key points we highlighted were the routine use of pulse oximetry as one more important piece of the assessment puzzle for respiratory patients, as well as checking the accuracy of the patient’s SpO2 reading by evaluating the strength of the pleth wave. We emphasized the 2010 AHA guidelines, which state the ideal SpO2 should be between 94–99%. A patient in respiratory distress but maintaining good oxygen saturation is compensating and will still benefit from supplemental O2, while one with sats below 90% is hypoxic and may require more aggressive management. Constant reassessment will help determine how aggressive. Early ventilatory assist with CPAP or BVM for a patient fatiguing due to respiratory failure can be lifesaving.
We also reviewed the state-mandated use of continuous end tidal CO2 for all advanced airways, as well as considering its usage for the complicated respiratory distress patient, i.e., those patients who have both COPD and CHF where lung sounds are diminished, there are no clear cardiac symptoms and the history of present illness seems to be a tossup between COPD and CHF. A waveform resembling a shark fin, as opposed to the more typical square waveform, is indicative of at least some degree of the bronchospasm of asthma or COPD. This could tip the balance to begin initial treatment with beta agonists, such as albuterol, and constant reassessment. If the patient’s condition improves, continue with treatment; if not, reconsider your differential diagnosis of CHF.
Dr. Burton also made the case for early 12-lead ECG acquisition for any respiratory patient where the cause is not clearly respiratory in nature, e.g., asthma, COPD exacerbation or anaphylaxis. He emphasizes basic airway management before advanced, including positioning of the patient, early intervention with assisted ventilation in patients in respiratory failure and the fact that when ventilating a patient, air will go where plastic won’t. Therefore, all providers should be proficient with BVM ventilation and the use of basic airway adjuncts, such as oral and nasopharyngeal airways. Endotracheal intubation is still the gold standard of airway management, but as recent studies have indicated there is no dire need to insert then in the early stages of cardiac arrest or most cases of respiratory emergencies, unless basic airway interventions prove inadequate.
There are a few critical skills which are rarely required, but when they’re needed, they are lifesaving. Because they are so rare and critical, these interventions should be reviewed regularly—so when they are needed, the need is recognized and providers can approach the intervention with some degree of familiarity and confidence. For us, and probably most EMS agencies, pleural decompressions and cricothyrotomies are the two rarest interventions performed. These intervention are things we cover twice a year; once in our trauma class and again during skills verification for our medical command reauthorization.
Once providers are properly educated on any topic in emergency care, most will perform better as of the very next shift. Dr. Burton’s rule of the most common, most serious and most unusual is an excellent way to determine the immediate priorities for your quality improvement education.
Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at firstname.lastname@example.org.