What exactly is happening with the NICU service changes?

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 is the only hospital in the region with 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.

Why are you making these changes?

The improvements we are making to pediatric care reflect our systemwide mission to provide our region with more coordinated, easily accessible care. We hope that no family anticipating the birth of a child has to face the incredibly difficult situation of dealing with complications once the baby is born.

However, we know this happens, and we are committed to providing our families facing these challenges with the most advanced services, technology, and quick access to pediatric specialists right here in the Tri-Cities. By realigning our level III NICU services at Niswonger Children’s, we can improve the quality of care we provide to our region’s most delicate babies.

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 for 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.

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 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.

Why is Niswonger Children’s the right location to realign level III NICU services to?

Niswonger Children’s can provide high-risk babies with latest technology solutions such as nitric oxide administration and whole-body cooling for brain injuries as well as onsite access to pediatric specific specialists, including pediatric surgeons, neurologists, endocrinologists, hematologists/oncologists, orthopedic surgeons, child life specialists, and specially-trained neonatal nurse practitioners, none of which are available today at Holston Valley or any other Ballad Health hospital.

All of these services are critical when it comes to helping the most vulnerable babies in our region.

We are committed to expanding and investing in the services we provide today at Niswonger Children’s. We are actively recruiting for additional pediatric specialists including pediatric surgery, gastroenterology, pulmonology, neurology, ENT, urology, neurosurgery, ophthalmology, and child abuse.

Our goal is to save lives and improve quality of life for high-risk babies in our region. We have these excellent, advanced services right here in our region. Fortunately, there is no need for families to drive to Knoxville when already dealing with a stressful and overwhelming situation.

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 which 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.

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 nation’s 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.