Ballad Health’s plan to consolidate the region’s two level three neonatal intensive care services has faced pushback in large part due to the high rates of babies experiencing drug withdrawal symptoms from opioid exposure that may soon need to travel to Johnson City, instead of Kingsport, for higher level care.
Data from the Tennessee Department of Health shows Northeast Tennessee has the highest neonatal abstinence syndrome (NAS) rates in the state and even in the country.
When it comes to this public health epidemic, there’s growing evidence that what’s considered standard doesn’t always make the most sense, according to Dr. Shawn Hollinger, Niswonger Children’s Hospital NICU medical director.
“As we’ve seen more and more babies with NAS and learned more and more about the treatment of NAS, a lot of times the NICU may not be the best setting for that care,” he said.
Hollinger said NICUs can be too loud and too bright for these sensitive babies.
Niswonger’s CEO Lisa Carter said that some NAS babies will need NICU services but the “vast majority” are uncomplicated cases that can be cared for at community hospitals by staff in your average nursery.
“As long as you have physician support at those local hospitals it can absolutely be done,” she said.
Carter said many families stand to benefit.
For example, about a third of Holston Valley Medical Center’s NICU patients were NAS babies in fiscal year 2018. Of those, none of them were transferred back to lower level facilities for care.
In a recent letter to the Tennessee Department of Health, Ballad CEO Alan Levine described localizing care “a recognized opportunity for improvement.”
“It’ll keep families closer together. That’s always a win,” said Carter.
Carter also points out that it’ll cut down on transports and, therefore, the cost of travel for families during sometimes lengthy treatment periods.
In fact, she said physicians at Johnson Memorial Hospital in Abingdon have already taken this on. Levine said in his letter that it cut down on NICU transports from over 20 to just six in one year.
It isn’t just Ballad making this change.
Yale New Haven Children’s Hospital in Connecticut spearheaded a version of this approach in their region, and Dr. Matthew Grossman, Associate Professor of Pediatrics at Yale School of Medicine, was at the helm.
He said he knows of at least 30 other states that have implemented some version of his methodology.
“These babies don’t need intensive medical care,” Grossman said. “The better our results have been is the less we’ve done medically.”
Four years following implementation, he said they’ve dramatically decreased their average length of stay from more than three weeks to less than six days.
For comparison, Holston Valley Medical Center’s average length of stay is 12 days and Niswonger’s is fifteen. The national average for NAS babies is about three weeks.
In Connecticut, Grossman said their success wasn’t just related to a change in the treatment location. It was also a change in approach, where parental involvement is the first line of treatment.
“Instead of relying on medication, let’s try to rely on mom more and the results were really dramatic,” Grossman said.
NAS babies still widely receive morphine treatment. Dr. Hollinger said it’s one of the main reasons they’re often treated in a NICU setting.
“I think there has been a trend towards being more conservative with morphine treatment. We definitely have trended in that direction as well,” Hollinger said.
But Hollinger said they’re not considering phasing out morphine in the near future.
That’s one of the key differences between the model Ballad plans to roll out and the one that’s already been executed in Connecticut.
“Eat, sleep and console, that’s our model,” Grossman explained. “So if they’re not eating well, sleeping well, you can’t console them, then you increase treatment.”
For Grossman, “increase treatment” generally means more mom, not more medication. In other words, instead of giving babies doses of morphine when they’re distressed, mothers or volunteers simply hold them.
Grossman said they used to treat 98 percent of their NAS babies with morphine. Today, they use the drug under 10 percent of the time and they do so in single doses.
He said without widespread morphine treatment, the transition to community care was easy.
“There is no special skill. It’s just normal empathy, things that nurses are good at,” Grossman said.
Carter said, for Ballad, the next step will be to talk to community physicians about this change to see what their appetite is to take responsibility for local NAS care.
A nurse working at a Ballad Health hospital currently administering care to NAS babies, who spoke on the condition of anonymity, said she doesn’t believe staff received proper hands-on or classroom training to care for these babies.
She said this puts nurses at risk of losing their licenses.
The nurse said their staff is often stretched thin, which makes it difficult to provide the higher level of care NAS babies require. She believes this puts patients at risk.
Ballad issued this statement to News Channel 11:
For our program started at Johnston Memorial Hospital in 2017, nurses and physicians underwent extensive training prior to launching the local NAS unit. New nurses are assigned preceptors during their training period, and competencies specific to their individual job are verified annually.
Ballad Health has not made any changes to NAS care at Norton Community Hospital, which is now provided at the discretion of pediatricians. Standardizing best practices across our system is a key goal of the regionalization of NICU services.
Importantly, every nurse has a professional responsibility to inform their supervisor if at any time they feel they need additional knowledge or skills to perform their assigned duties.
If Ballad’s NICU consolidation plan is approved, they said they’ll start project meetings with local physicians within a month.