The region is fortunate to have a state-designated perinatal center at Niswonger Children’s Hospital. In addition to launching our region’s first-ever pediatric trauma service at Niswonger, we are:

• Investing in new pediatric ERs in Kingsport and Bristol
• Investing in new pediatric subspecialties to serve our region, including: pediatric surgery, gastroenterology, pulmonology, neurology, ENT, urology, neurosurgery, ophthalmology, and child abuse
• Realigning our level III neonatal intensive care (NICU) services at Niswonger*
• Connecting all our hospitals to Niswonger through telemedicine, allowing access to pediatric sub-specialists at rural hospitals by mid-2019

*Read about the planned NICU improvements here.

Realignment of high-acuity services in Kingsport

Our excellent hospitals in Kingsport are only three miles apart. We will be focusing higher-acuity Kingsport services in one location to allow doctors and nurses to perform more of the same procedures – which research shows improves outcomes and reduces costs. We are:

• Locating interventional cardiology, orthopedics and neurosurgery in Kingsport at Holston Valley Medical Center
• Maintaining medical cardiology services at Indian Path Community Hospital

These improvements have been based on best practices and were designed in collaboration with local leadership, our physicians and other experts. The changes reflect the vision behind Ballad Health and our commitment to match the services we provide to the needs of our community.

Frequently-asked questions

General FAQs

Why are changes being made?

These improvements reflect Ballad Health’s commitment to creating a strong, single system that brings excellent care to the people of our region and that makes best use of our resources and our skilled physicians and employees. Matching our services to the needs of the people of the region is important.

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 Kingport 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.

Are you closing any trauma centers or emergency departments?

No. There will be three trauma centers.

Will we still have a safety net hospital?

Yes. Our region has benefitted from Johnson City Medical Center serving as the essential access safety net hospital. This designation brings additional resources to our region and ensures safety net services are provided. State rules require the hospital to maintain level I trauma and perinatology services in order to keep this designation.

Are these changes just about saving 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.

Will jobs be lost or created due to these changes?

We are not doing a workforce reduction. There will be impact on some people based on where they currently work, but we are not reducing our workforce. We will also be recruiting new pediatric specialists to serve our region, including these subspecialties: pediatric surgery, gastroenterology, pulmonology, neurology, ENT, urology, neurosurgery, ophthalmology, and child abuse.

With all these changes, is healthcare at Ballad Health going to cost me more?

To the contrary. Reducing unnecessary duplication of services, providing higher quality and coordinated care, should reduce the overall cost of care.

Why is the Holston Valley NICU being moved?

Niswonger Children’s Hospital is the region’s state-designated perinatal center. Realigning level III neonatal intensive care (NICU) services at Niswonger Children’s means the most high-risk babies born in our region will have access to everything they need in one place.

Read more about the planned NICU improvements.

Trauma-specific FAQs

What exactly is happening with trauma and emergency services?

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, or 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.

Why are you changing Ballad Health trauma services?

Our goal is to save lives and improve quality of life. The regional trauma and emergency system will better integrate our highly-skilled trauma experts in Kingsport, Bristol and Johnson City with EMS, helicopter transport and our other emergency rooms across the region. With new regional protocols developed with EMS and a new regional medical call center, we will ensure assessment and rapid ambulance and helicopter transport of patients to the center most appropriate for the patient’s needs.

What’s the difference between ER care and trauma care?

Hospital ERs treat patients with emergency illnesses and injuries, many of which are life-threatening. Examples are heart attacks, strokes, bone fractures, injuries sustained from automobile accidents, sports injuries and serious illness. All Ballad Health hospitals are equipped to treat such conditions. Trauma care requires advanced capabilities, which is why the assessments and coordinated approach by the medical call center are so important. A hospital with a trauma center typically can handle any emergency condition, plus the trauma unit has the capacity to treat more severe traumatic injuries related to everything from gunshot wounds to other traumatic injuries that may be life threatening.

Why does this lead to better outcomes?

Research shows that high-acuity trauma patients have greater inpatient survival when treated in coordinated, inclusive trauma systems. The new system will help us identify patient needs and more quickly coordinate transport to the appropriate center for care. Research also shows that patient outcomes improve when high-acuity trauma patients are served in one location. The benefit of our changes is that we will have three trauma centers, with one assigned to treat the most serious of cases. Similar to our regional stroke system, trauma care will be coordinated and integrated.

Will people have to travel farther 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.

Why did you choose Johnson City Medical Center as the level I trauma center?

There are several reasons for this. First, Johnson City Medical Center is already the busiest trauma center in the region and handles most of the “major” trauma service for the region. Second, its co-location with Niswonger Children’s Hospital allows us to offer pediatric trauma services thanks to cross coverage between physicians and professional staff who provide adult and pediatric trauma. Third, JCMC must have level I trauma to maintain safety net hospital designation in the region.

What are the differences between level I, level II and level III trauma centers?

Variation in trauma center levels relates primarily to the manner that physician coverage is provided.

Level I

• Provides the most advanced care for the smaller number of the most serious of injuries
• Must provide research and outreach
• Must provide onsite physician coverage 24/7 for a variety of surgical specialties

Level II

• Similar physician availability as level I centers, but surgeons and other specialists may be available through a call system, versus onsite 24/7

Level III

• Provides the same services as a level II center, but generally level III trauma centers are more focused on orthopedics (More than 65% of Ballad Health’s specialty consults for trauma cases across all three trauma centers are orthopedic)
• Nothing precludes a level III trauma center from providing additional specialty coverage based on patient need. Ballad Health will provide general surgical, orthopedic and neurosurgical coverage at all trauma centers, plus the additional specialties required for the smaller number of the most major cases at the level I center.

What services will the trauma centers at Bristol Regional and Holston Valley provide?

While major trauma cases will be transported to Johnson City Medical Center, the vast majority of trauma cases will continue to be treated in the trauma center closest to the patient. More than 65% of our specialty consults for trauma are orthopedic, and orthopedic and neurosurgical services will continue to be available at Holston Valley and Bristol Regional. Based on an assessment of patient need, patients will be transported to the closest trauma center appropriate for their needs.

How do I – or the EMTs – know where to go in a trauma situation?

If you feel you have a life-threatening condition, always call 911.

First responders will be equipped to provide immediate aid and get you to the fastest, most appropriate hospital treatment. We will work with emergency medical services (EMS) throughout the region to establish protocols for transport. Those protocols will be used with our new medical call center. That system will coordinate with ground transport and helicopter services to ensure timely transport to the most appropriate center based on that patient’s needs.

NICU-specific FAQs

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.

Have another question or comment?

Use the contact form here to reach out about the new Regional Trauma and Emergency System or other improvements.