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Ballad Health Answering Questions

Ballad Health has announced important changes that will improve care for the most serious of injuries and the most fragile of newborns in our region. These changes in how we deliver care to patients affected by major traumatic injury and high-risk newborns will occur over the next year.

What exactly is happening?


Our region has three trauma centers today, and we will continue to have three trauma centers. In fact, including the population of NE Tennessee and SW Virginia, we will have nearly a quarter of all the trauma centers in the state of Tennessee right here in our region covering what is 14.5% of the total population. Trauma makes up a small portion of all visits to the emergency departments in our hospitals – it is only one percent of our total emergency room volume. Each hospital in the region will continue to offer full-service emergency care, which includes emergency treatment for heart attacks, strokes, and other injuries and illness. Because the evidence shows that the most severe trauma cases have better outcomes in higher volume trauma centers with the most consistent physician coverage, we are aligning our trauma system to ensure the highest severity cases are performed at the trauma center that performs the most cases, which is Johnson City Medical Center. This makes sense. Last year, between Holston Valley Medical Center and Johnson City Medical Center, only 380 cases were considered “major trauma”. Just under 40 percent, 150 of those cases, were at Holston Valley, while just over 60 percent were at Johnson City Medical Center. For the first time, our region will benefit from a new Pediatric Trauma Unit at Niswonger Children’s Hospital. Currently, there is only one emergency room in the region dedicated to children, and it is in Johnson City. Ballad Health will invest in new pediatric emergency departments in Kingsport and Bristol designed especially for children. Last year, there were 20,000 pediatric ER visits in Sullivan County. We will work over the next year with Emergency Medical Services throughout the region to develop a regional trauma and emergency transport system, with pre-hospital communications. This system will be designed to ensure patients are transported more quickly to the emergency room or trauma center that is best for the patient.


Virtually all the scientific evidence supports ensuring the highest risk newborns are cared for in regional centers supported by pediatric subspecialties. Not only does the evidence support it, it is also the law and policy of Tennessee. Therefore, the level III neonatal intensive care unit (NICU) for the region will be at Niswonger Children’s Hospital, while level I nurseries will continue to be provided in Kingsport, Bristol, Johnson City, Greeneville, Abingdon VA, and Wise County VA. Niswonger Children’s Hospital is one of only five state-designated perinatal centers in Tennessee, and also holds the highest level of certification for perinatal services from the nation’s most respected accreditation agency, The Joint Commission. This certification involves care components for both obstetrics care and newborn care.

What are the reasons behind these changes?

These decisions followed analysis by physicians and regional leaders who determined, based on the scientific evidence and recommendations from organizations like the American Academy of Pediatrics, state law and state policy, that high-risk deliveries of newborns should be done in hospitals that have immediate capability to provide pediatric subspecialty care. The evidence shows that delivering a high-risk baby in a hospital that does not have immediate availability of pediatric specialties like surgery, gastroenterology, neurology, and others, places the baby at risk when the baby has to be transferred. It also creates delays in care. Simply, our region already has a standard of care for many moms and babies that provides that level of care, and our board of directors believes there should not be two standards of care for newborns. All high-risk newborns should be in the presence of pediatric specialties as quickly as possible.

A similar decision was reached related to trauma care. More than

90 percent of trauma service is general surgery, orthopedic and neurosurgery. Those services are continuing at Holston Valley Medical Center, Bristol Regional Medical Center and Johnson City Medical Center. So, for the overwhelming majority of trauma services, people will not see a difference. Only major trauma cases will be directed to Johnson City Medical Center. Already, 60 percent of the major trauma cases are treated there. Last year, Holston Valley Medical Center served 150 major trauma cases – less than 10 percent of its total volume of trauma. The American College of Surgeons, which verifies the quality of trauma centers through their verification program, typically requires a volume of at least 250-300 major trauma cases each year. This is because the evidence shows better outcomes for major trauma at higher volume centers. Because Johnson City Medical Center currently treats 230 major trauma cases annually, and Holston Valley treats 150 major trauma cases annually, neither is likely to be verified by the American College of Surgeons as being at the highest level. With this change, we will seek American College of Surgeons verification, so our region will have independent verification that our trauma services are the highest quality available. Finally, we believe that rather than duplicating services which the evidence shows is not adding value, it is better to use the resources to create new services that are needed and not currently being provided. That is how we will be able to bring new Pediatric ERs to Kingsport and Bristol, which will benefit thousands of children and their families. And it is how we can invest in a new pediatric trauma unit. Currently, the closest pediatric trauma center is almost two hours away. And, it is how we will invest in new pediatric sub-specialties so families can get care here.

Were these decisions based on money?

No. To the contrary. We are spending money on new emergency rooms, new pediatric specialties, new adult specialists, new transport equipment, a medical call center, new protocols for the region for EMS and upgrades to surgical equipment. These decisions were made so that we can deliver better, higher quality care.

Are you closing any trauma centers?

No. There will be three trauma centers.

Will patients have to travel further for trauma care?

No. Most patients experiencing trauma will continue to go to the trauma center closest to them, as there will still be three trauma centers with the specialties that are most often utilized today. Only major cases will be transported to Johnson City. Also, all 20 Ballad Health ERs will continue to provide emergency care for patients experiencing health issues like heart attacks, strokes and injuries. If you have an emergency, you should go to your closest ER, or call 911, just as you do now. Our region does have unique challenges with EMS transport because of its geography. Currently, trauma transports may be delayed due to a variety of factors, including unavailability of transports or lack of coordination. This is why Ballad Health has proposed working with all the regional EMS offices to create a regional system of protocols, a pre-hospital communication system with connectivity to the trauma centers, and other improvements which will help create better, faster transport. Ballad Health cannot make these changes without a partnership with EMS, and we pledge to be active participants with the amazing people who provide our first response. Finally, it is important to point out that our region will have three trauma centers, including a level I center. We will have trauma resources far in excess of what other more populated and larger geographic regions have. For instance, Asheville, NC does not have a level I trauma center, with the closest one being more than an hour outside Asheville. Charlotte, NC, Nashville, Memphis, Chattanooga, Knoxville, Orlando, FL, Tampa, FL, Miami, FL – each have one level I trauma center These decisions were made after careful deliberation by a group of regional leaders and physicians, including physicians who perform trauma surgery, and were based on state law and policy, recommendations by the American Academy of Pediatricians, peer-reviewed research and best practices. The board of Ballad Health, each of whom lives here and is affected by these decisions, unanimously believes in providing a consistent and high standard of care for our patients, and that such decisions are based on the best evidence. Our region is blessed to have incredible hospitals with Holston Valley Medical Center, Johnson City Medical Center and Bristol Regional Medical Center as anchors to our regional network of health care. Ballad Health is committed to sustaining this quality and continuing to improve it each day. You can find the latest information at balladhealth.org/savinglives.

Why are you closing the neonatal intensive care unit at Holston Valley?

While the services that Holston Valley can provide are excellent, the availability of the full complement of pediatric specialties does not exist there. The overwhelming body of evidence, including recommendations from the American Academy of Pediatricians, National Institutes of Health studies, Tennessee law and Tennessee policy of the Department of Health, strongly supports “regionalization” of high-risk neonatal services. Tennessee law explicitly directs the Department of Health to establish a “regionalized system of care, including highly specialized personnel, equipment and techniques that will decrease the existing high mortality rate and the life-long disabilities that currently prevail in surviving newborn infants.” Accordingly, the Department of Health established five regional perinatal centers, of which Niswonger Children’s Hospital is the only one in the region. Niswonger Children’s Hospital is the only hospital in the region that holds the highest certification as a perinatal center by the independent accreditation agency for hospitals. This certification includes components of obstetric care and care for newborns. The certification comes as a result of an intensive independent review of the capabilities of Niswonger Children’s Hospital, and results, in part, from the fact that Niswonger has more than 25 pediatric specialties available. Pediatric surgical specialties do not exist at Holston Valley. Why are these specialties important? If an emergency occurs, and a specialist is not available, the baby will have to be transferred. Transferring a highly fragile newborn can have risk, according to the evidence. An Oxford University article stated, “transport in utero is a far safer option” for an infant, indicating that it is far better for a mom to deliver a high-risk newborn at the hospital where the newborn will receive care. Such hospitals should have a higher volume of NICU services and pediatric specialties to support the baby. A study in the New England Journal of Medicine stated, “Mortality among very-low-birthweight-infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients.” Virtually every study, and every body of evidence supports this assertion, which is why most states have requirements for regionalization of NICU services. The American Academy of Pediatricians has weighed in on this as well, stating, “because most infant deaths in the United States occur among the most immature infants in their first few days after birth, improvements in regionalized systems may reduce mortality among the most preterm newborn infants.” They go on to state, “designation of level III care should be based on clinical experience, as demonstrated by large patient volume, increasing complexity of care, and availability of pediatric medical subspecialties and pediatric surgical specialists.” Currently, Holston Valley Medical Center’s NICU has an average daily census of seven. Niswonger Children’s Hospital has an average daily census of 27. Holston Valley Medical Center does not have pediatric surgical subspecialties to support the NICU. Niswonger Children’s Hospital has more than 25 specialties. Ensuring these fragile infants are cared for at Niswonger Children’s Hospital is the right thing to do for these infants.

Could Holston Valley become a level II NICU?

While Holston Valley is licensed for level III NICU beds, the need for pediatric subspecialists required by the state for level III nurseries is not present at the facility. The volume of babies meeting the level II status is too low to maintain that level of service. Keeping the level II nursery would also fall outside of the American Academy of Pediatrics recommendation and the state of Tennessee regionalization guidelines to ensure that volumes are high enough to maintain quality service.

What happens if my baby is not high-risk? Can I deliver my baby at my local hospital?

Yes. Newborn services are continuing at our hospitals throughout the region, including level I nurseries. We have level I nurseries in Kingsport, Johnson City, Greeneville, Abingdon, VA, and Wise County, VA, which can provide basic care to neonates who are low risk. They can perform neonatal resuscitation at delivery, and they can care for pre-term infants at 35-37 weeks gestation who are stable. They can stabilize newborns who are less than 35 weeks gestation or who are ill until they can be transferred to Niswonger Children’s Hospital where the highest level of care for our region will exist.

Some have said my baby is at risk if we have to travel farther to Johnson City. Is that true?

This is absolutely not true. In fact, in the last two years, more than 500 high-risk infants from as far away as two hours have been treated at Niswonger. Hundreds of newborns from Hawkins and Hancock counties, Russell County, VA, Dickenson County, VA, Smyth County, VA, and even North Carolina, have been transferred to Niswonger Children’s Hospital. Niswonger Children’s Hospital has a transport team composed of highly skilled nursing and respiratory therapists who are trained in both ground and air transport. That Niswonger Children’s Hospital is the region’s perinatal center is not new, and many families from very far away have taken advantage of these services. The real question is, given the overwhelming evidence about the best chances for the survival of newborns, why would we want any high-risk infants to be treated in any environment that does not have pediatric specialists and higher volumes? We would not. And that is why we believe this is the right move for these moms and babies going forward.

Why are the baby volumes at Holston Valley so low?

Our region is facing a major challenge. In the last four years, the number of births in the region has declined by seven percent. Holston Valley Medical Center has seen a decline of 17.9 percent. This is a major concern for Ballad Health and should be a concern for the region. As birth volumes decline, it becomes even more important that we sustain the volume of services at Niswonger Children’s Hospital. Why? Because as volumes decline, it becomes more difficult to sustain specialties in pediatrics. By optimizing the use of our region’s only children’s hospital, it becomes a more appealing place for pediatric specialists to practice, and thus we are more likely to sustain the specialties. The economic issues surrounding these declining birth rates is another matter on which many in our region are focused. Ballad Health believes there is an urgency in the need for the region to work more closely together to grow our economy and invest in reversing the population trends we are seeing. If these trends continue, it will have a negative impact on our region’s hospitals and healthcare workforce. Given the culture, beauty and ethic of our region, we believe we are among the most attractive places in America to invest, grow a family and work. Ballad Health is proud that our regional approach to healthcare will make us even more appealing, given the broad and extensive services we can provide locally.

What about babies born with drug dependence? Isn’t this a problem, and will they all have to go to Niswonger Children’s Hospital?

Children born with neonatal abstinence syndrome do not have to be transferred to Niswonger Children’s Hospital, but we believe it is best they are in many cases. The care provided at Niswonger Children’s Hospital for moms suffering from addiction and babies withdrawing from drugs was recently recognized by the nations leading accreditation agency for hospitals – The Joint Commission – as a best practice. Niswonger Children’s Hospital recently constructed a new 17-bed special care unit which serves the special needs of these babies. This unit has private, quiet rooms and other resources which are necessary for helping these newborns. Because Niswonger is associated with Woodridge, and has significant subspecialties, there is also support for the mom and family related to drug treatment, if necessary.

Learn more at balladhealth.org/savinglives where we have created a special section devoted to answering your questions about the latest changes we are making to improve care for our community.

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