Chronic Pediatric RMT
This section is oriented specifically for the pediatrician on call.
CPP RMT is part of the daily responsibilities of the inpatient peds provider. This is perhaps one of the most difficult aspects of providing care here and will take some time to learn how to do well. On a busy day you may receive as many as 30 RMT! Although urgent and emergency health aide calls can come at any time of the day or night, regular daily traffic is scheduled from 9:00 to 5:00PM Monday through Friday. Peds gets all RMT for both sick and well CPP visits. We also get all dental pre-op travel clearance authorization RMT. These are sent to us so that we can carefully screen the patients to make sure they are well enough for travel. YKHC dental rehabs can only be done if the patient has been well and has had no respiratory illness or runny nose in the past 4 weeks.
Health aides will send an RMT to chronic pediatric patient proxy box in message center prior to calling. It is almost always more efficient to read through that document and review the problem list prior to doing the RMT. Then you can then skip the verbal history and physical and move directly to any questions and decision-making when on the phone. When doing your RMT you read their encounter and then review their orders for the patient as well as the selected power plan. You then modify the message note with your plan and statement and send it back to the specific Health Aide.
If you need a medication sent from Bethel pharmacy – Order it from the blue Plus from the left side of the screen and select mail to patient when placing orders
How To Do RMT:
1. Go to Message Center
2. Go to Proxies tab on upper left– hit arrow – Select the appropriate RMT box: Yukon/Kusko/Emergency/CPP/Optometry/Dental
3. Select first document in the list appearing on the Right side and open it.
4. Read RMT- then to review orders
5. Locate patient’s name in right upper corner and select the downward arrow to open the patient’s chart within orders
6. Scroll on the Order’s View box (lite blue box on the left side) to see the village clinic powerplans located at the top.
7. Review the Village Powerplan selected in the right window.
- If no orders added, just close the chart.
- If you check additional order boxes, sign (NOT INITIATE)
- For orders not on the power plans, select ADD to PHASE. Then hit sign (NOT INITIATE)
8. Close the patient’s chart; MESSAGE CENTER should automatically becomes visible with the RMT document you were working on.
9. How to Modify and add addendum – right click within the body of the RMT document and choose modify
10. The curser will blink in the area for you to add the addendum will appear at the bottom of the RMT document.
11. Type in your comments.
12. Now at bottom of RMT document Hit Additional Forward Action box –
13. In the To: field - Select the Health aide who sent the RMT document to you (delete previous RMT health aide’s name).
14. Then Click OK and Close – (DO NOT HIT NEXT)
Trying to decide whom to send to Bethel becomes somewhat easier with experience. Remember that for many or most of our patients traveling to Bethel when they are sick is fairly routine and not the tremendous hardship it seems at first. On the flip side, it is always more efficient to treat uncomplicated patients in the village. This helps to decrease the burden of patients to be seen in the clinics and saves patients the cost, time, and hassle of a trip.
For example, a patient with known asthma and stable vitals who presents with an exacerbation may be started on steroids, nebs, etc and followed up the next day by the health aide. Do not be afraid to monitor the patient in the village for a few hours to see how the patient will respond to your treatment before making the decision to bring them in. Obviously the time of day will dictate whether or not this is feasible. If the last plane for the day is leaving in 30 minutes and you think the patient might need to come in by all means go ahead and have them come in. This is vastly cheaper than arranging a medevac later in the night.
It is important to be aware of the role weather can play in all of this. Not infrequently planes cannot fly because of the snow, fog, icy flooded runways, wind, or darkness (not all villages have runway lights). If bad weather is expected you may want to use a lower index of suspicion to have patients sent in to Bethel before they get stuck in the village. Coastal villages often get weathered in more frequently than non-coastal villages.
At times you will need to provide ongoing care for a patient in the village who is weathered in. For example, we not uncommonly give albuterol nebs every one to two hours and provide supplemental oxygen in the village for a weathered-out patient in respiratory distress. You may also need to cover patients with IM Rocephin if you suspect serious infection and are unable to bring them in. We often have to adapt the usual standards of care to fit our unique situation – creative thinking is helpful (can a midlevel from a nearby subregional clinic reach them by snow machine or boat?) and more experienced Bethel providers may be able to suggest fixes that have helped in the past.
Another specific condition that may present during RMT congenital adrenal hyperplasia, also referred to as CAH or AGS (an older term still frequently used here in the Delta). Patients with CAH require daily supplementation of both mineralocorticoids and glucocorticoids at baseline, and can’t produce an adequate adrenal response to stress. They need added supplementation during illnesses. In general, for mild infections without a fever, no change in the steroid dose is made. For severe infections and for all febrile illnesses, the usual dose of hydrocortisone is doubled for the duration of fever or acute illness and the parent is instructed to encourage po hydration. If the patient is having fever double or triple-dose the glucocorticoid. If the patient is vomiting and cannot keep medication down they need to come in to Bethel that same day for IV steroids.
Some conditions warrant an automatic trip to Bethel for evaluation, no matter how good the patients might look. These include all babies 12 weeks old or less with temperature of 100.4 or greater and infants less than 2 months (even if afebrile) who are felt to need antibiotics, OM, first seizure episodes etc. These RMT’s on non chronic peds patients should be routed through the FP’s but occasionally you will receive them by mistake so you should be aware of our guidelines.
RMT Helpful Hints
When you decide a patient needs to travel in to Bethel PLEASE triage the patients to the appropriate destination, and have the health aides make an appointment prior to patient arrival if indicated. Otherwise, a patient sick enough to be flown in from a village may end up as an overbook in a 20-minute slot; this doesn’t allow adequate time to take care of the patient. All febrile newborns requiring a full septic work up should be directed to the ER. Patients who will get to clinic after hours should also go straight to the ER, as should those too sick for clinic. REMEMBER, a little forethought/advance planning can cut HOURS from the patients wait time.
- Another way to help keep the system running as smooth as possible is to avoid sending patients to the ER unnecessarily. If you receive an RMT on a patient who needs to come in but who will end up arriving too late in the day to be seen in the clinic, consider bringing them in for a scheduled appointment the next morning. If their condition deteriorates, they will already be in Bethel and can be seen in the ER over- night. More stable patients can remain in the village and be sent in the following morning for a scheduled appointment; it depends on the urgency of the complaint (an eczema flare, for instance, could be brought in the next day and should NOT be sent to the ER!). Obviously you must use your best judgment as to which patients absolutely must come in that day.
- Often times you will have patients that you need to sign out to the on call pediatrician, such as patients being managed in the village. The patient can be placed on the pediatric alert list in RAVEN prior to sign out.
- If you are managing a complicated or sick patient, please be sure to document vitals, meds, and decision- making with TIMES on the RAVEN encounter– it will help facilitate ongoing patient care and will also protect you medico-legally in the event of a bad outcome.
- In addition to RMT you will also frequently receives calls from physicians from other facilities such as ANMC, Providence, or specialists that have seen one of our patients. It is critical that all discharge information and follow up instructions gets passed on to all other peds providers that might end up seeing this patient. The easiest way to do this is by clearly updating problem list plus an email or RAVEN communication to pediatric providers. Please have a chart created for the patient by alerting the pediatric case manager or case manager assigned to the village.
- At times you will receive RMT for non-chronic peds patients. This may be because a CHA wants a second opinion or feels a patient is sick enough to warrant a pediatrician’s involvement. It may also be an error. Talk to the health aide to find out for sure. If you have time, you may assist with any pediatric RMT, whether or not the patient is a chronic peds patient (CPP). It acceptable to redirect non-urgent, non-CPP patients to the appropriate family medicine provider.
- If you identify a patient who can be “graduated” from the CPP list via RMT (i.e. a patient who had frequent respiratory illnesses in his/her first few years of life but has had no problems in recent years) you can document this on the RMT and you need to change ‘CPP’ to “no longer CPP’ on the alert tab.
- Please update the problem list for as many RMT patients as you can.
- Health aides are now required to take and send telemed pictures for every RMT case involving a rash, skin infection or laceration. In these cases, the RMT note to provider will indicate that there is a telemedicine case for you to sign in and view. After you view the case, you will need to send back a comment indicating that you have reviewed the RMT and pictures and what your diagnosis and plan are. You then print out a copy of the billing sheet, write the diagnosis with date and signature, attach a copy of the RMT and turn it in for billing at the end of the day. Each one is worth over $400 so please remember to do the paperwork!
Subregional Clinics (SRC) often have midlevel staff and an expanded formulary. Please consider sending close by village patients to a SRC.
- SRCs can do plain film xrays when they have a technician.
- They can also do CBC, chemistries, blood gases and send out blood cultures/urine cultures.
- CHAs are only allowed to give rectal, po, and IM medications—no IV meds. They may have the ability to start an IV and give fluids on bigger children.
- CHAs can send in abscess and throat cultures. It is OK to send in a urine culture on older children, but if they are less than 5 years old they should come to Bethel for a possible UTI. Please no bag urine specimens, they are source of contamination. Do not try to obtain any other labs in villages, as everything that can go wrong will go wrong.
Telemedicine Billing Flow
1. CHAP in village sees patient – writes up RMT Takes pictures and create an AFHCAN case. Sends it to Family Medicine or chronic peds.
2. CHAP documents the regular history and physical on the RMT and also writes–“ See Telemedicine and (amount of) pictures sent.”
3. CHAP types in the comment section of the Telemedicine Case on AFHCAN.
4. Sends the Telemedicine case to AFCHAN
5. RMT provider gets the RMT– reads it.
6. RMT provider goes to the AFHCAN Website – finds the case - reviews it.
- The RMT provider types in Comments on RAVEN CHA encounter form Acknowledgement of the case—Example: I reviewed your pictures – 3 of the Left toe
- Comments on the case—Example The left toe looks like it has a long shallow ulcer that is has some fibrin on it.
- Types in the diagnosis and the treatment plan—Example would say this is a left toe diabetic ulcer and would recommend it be treated with dry dressings and sending it to wound care in Bethel tomorrow. Make an appointment
7. Sends the RMT back to the Health Aide and orders a charge for the AFCHAN case review.
Telemedicine Carts and Capability
All village clinics (and Bethel hallway clinics) have a telemedicine cart equipped with tools for recording and sending specialized forms of patient data between village clinics, YKHC and to specialists at ANMC when necessary.
- Each cart is equipped with a scanner, digital camera, EKG machine, otoscope, video capability and other attachments. (Video is used only rarely and can only be viewed in the main conference room of the hospital)
- Health aides are now required to take and send pictures for every RMT case involving a rash, skin infection, or laceration. In these cases, the faxed patient encounter form will indicate that photos accompany the case and you will need to log in to the telemedicine program online, view the photos, and reply to the health aide using both the online program and the faxed form. We are now able to charge for these consults if they meet required documentation requirements
- After viewing a telemed/AFCHAN case sent to the peds folder or to you, you must archive the case.
- You will be trained to access and use the telemed program during your orientation.