O2099: Implementation of Consistent Medical Direction Consults During Pediatric Critical Care Interhospital Transport

Purpose/Objectives: Johns Hopkins Pediatric Transport coordinates all incoming pediatric transfers to our quaternary center. Pediatric intensivists serve as medical control physicians (MCPs); nonetheless, there is significant heterogeneity within the medical direction process, with communication between transport team members and MCP occurring on an as-needed basis (without communication for some calls). We aimed to implement consistent transport medical direction via audio telecommunication systems for all incoming critical care transports (CCTs), provide appropriate documentation in the hospital’s electronic medical record (EMR), and facilitate billing for all direction provided. We hypothesized that: 1) this QI effort would lead to a more consistent, reliable, and comprehensive medical direction process; and that 2) timely access to medical direction during transport might improve quality metrics and, importantly, patient outcomes.

Design/Methods: The new process implemented on 8/1/2021 required the team to initiate a formal consult with the MCP after assuming care of the patient at the referring institution and, as needed, for additional medical direction before and during patient retrieval. Subsequently, the MCP would document in our institution’s EMR utilizing a prefilled note template and bill using the appropriate transport medical consult code(s) (99485 for acute patients ≤24 months old, first 30 minutes; 99486 add on for acute patients ≤24 months old, additional 30 minutes; 99288 for non-acute or patients >24 months). Pre-implementation, we provided training to the MCPs and transport personnel, including education on the new transport workflow and information regarding billing and transport medical control requirements. Subsequently, we performed a retrospective review of all pediatric CCTs performed six months pre- and six months post-intervention to assess compliance with the new medical direction process (including documentation and billing) and compare transport quality metrics.

Results: Our team performed 849 pediatric CCTs during the study period: 356 pre- and 493 post-intervention. Their characteristics are included in the Table. The post-intervention cohort was younger and included more patients triaged to the ICU, but transport logistics were not different between groups. Of the 493 post-intervention CCTs, 430 were inbound – thus eligible for medical direction consult – and of these, 377 (87.7%) consults were documented in the EMR. Their monthly distribution is included in the Figure. These 377 documented consults had 387 associated billing codes (99288: 218, 99485: 159, and 99486: 10), resulting in $38,700 in charges and $22,653 in payments. When compared to pre-intervention, the post-intervention CCTs had higher compliance with in-transport ETCO2 monitoring (97.6% vs. 89.7%), temperature monitoring (90% vs. 64.9%), glucose documentation (92.4% vs. 79.4%), and pain assessment (98.7% vs. 93.8%).

Conclusion/Discussion: Consistent transport medical consultation is feasible for pediatric critical care transports, impacts patient care en route, and generates revenue. QI efforts are ongoing, as our team strives for 100% compliance and further assessment of its impact on patient outcomes.