However, if history is any indicator, neither Ballad nor its predecessors Mountain States Health Alliance and Wellmont Health System have ever “lost” a baby during transport to Niswonger Children’s Hospital in Johnson City, according to a 20-page letter Ballad Health CEO Alan Levine wrote to the Tennessee Department of Health on Dec. 28.
Under the terms of the Certificate of Public Advantage governing the hospital merger, Ballad Health has to gain state approval before implementing its plan to downgrade Holston Valley’s NICU from a Level III to a Level I nursery.
Levine initially submitted a letter to the Department of Health on Nov. 12 that requested approval of the proposed changes to pediatric services, which also includes opening pediatric emergency rooms in Kingsport and Bristol and expanding telemedicine connectivity to Niswonger.
In a Dec. 13 response letter, Department of Health Commissioner Dr. John Dreyzehner said the state would need more information on 14 specific topics, including the estimated timeline for implementation and how Ballad will manage high-risk pregnancies in non-NICU facilities.
Under the proposed plan, Levine said the doctor in charge of a mother’s care will continue to determine the most appropriate place for deliveries based on the baby’s and mother’s needs.
“Ballad does not, and will not interfere with physician judgement regarding the most appropriate location for delivery,” Levine wrote.
To ensure there is adequate care for any potential high-risk delivery, Ballad also plans to form a Rapid Response Team consisting of respiratory therapists and nurses with advanced training in neonatal resuscitation and stabilization.
“It should be noted that all Ballad delivery hospitals except HVMC currently offer transport of high-risk pregnancies to (Johnson City Medical Center) if the infant is expected to need services at a level higher than that which would be provided at a Level I nursery,” the letter states.
“In addition, all Ballad hospitals except HVMC currently offer transport of newborns to Niswonger if the infant is determined to need NICU services after birth. The proposed plan will simply add HVMC to the other nine Ballad hospitals that offer transport of mothers and/or babies to Niswonger if a level of care higher than Level I Nursery is needed.”
Since Sullivan County is notorious for having one of the highest neonatal abstinence syndrome, or NAS, rates in the country, many have wondered how downgrading the county’s only Level III NICU would impact the babies born addicted to opioids.
According to Levine’s letter, “many babies suffering from NAS do not need NICU levels of care.”
“The provision of care for NAS infants is often confused with the need for NICU care. Certainly, some babies suffering from NAS do need NICU levels of care, but there are many babies suffering from NAS who do not need NICU levels of care,” Levine wrote.
“Using NICU resources for babies who do not actually need NICU levels of care is an inefficient use of resources and not medically appropriate.”
Describing the reasoning behind the decision, Levine said the Ballad Health Board of Directors were concerned that low patient volumes at Holston Valley’s NICU could create a “question of compliance with state standard for operation of a Level III NICU.”
Holston Valley currently has 15 licensed Level III NICU beds, but “does not meet the state guidelines to serve as a Level III NICU.
“The HVMC NICU is operating with an average daily census of eight, in our view, dangerously low by NICU standards. Maintaining a low volume NICU of any level can create safety and quality risks for the patients,” Levine’s letter stated.
The state’s NICU standards recommends an occupancy rate of 80 percent or greater to ensure optimal use of resources. Holston Valley’s NICU operates at a 53-percent capacity, while Niswonger’s NICU operates at 69 percent.
Because many infants can receive care at the hospital where they were born, Ballad said about 100 babies annually will be transported to Niswonger who would otherwise go to Holston Valley Medical Center for care.
Dreyzehner even directly asked Ballad if it had considered alternative models, such as downgrading Holston Valley’s NICU to a Level II instead of the proposed Level I, but Levine said a Level II would not solve the volume problem Holston Valley is facing.
Holston Valley’s NICU currently has an operating loss of about $1.5 million a year, representing roughly 10 percent of the hospital’s total annual net operating loss. With the savings gained from operating a Level I nursery, Levine said Ballad Health could invest roughly $456,840 into telemedicine equipment, provider fees, staff education and training and additional transport team costs.
He also noted that this proposed change would not result in any layoffs, as every Holston Valley NICU team member will be given an opportunity to transfer to Niswonger.
In his letter to Ballad Health, Dreyzehner said once the state receives all the information it deems necessary to process the request for changes to pediatric services, a 90-day approval period will begin.
Since Ballad announced the plan on Nov. 14, the Sullivan County Commission, the Church Hill Board of Mayor and Aldermen, the Scott County Board of Supervisors and the Hawkins County Commission have all passed resolutions opposing the hospital’s proposed changes.
To read Levine’s letter, go to www.tn.gov/content/dam/tn/health/documents/copa/20181228131010022.pdf.