SKYLINE MEDICAL CENTER NASHVILLE, TENNESSEE

TRAUMA CENTER SITE VISIT REPORT APRIL 30, 2015

Introduction Skyline Medical Center was site visited on April 30, 2015. This hospital was designated as a provisional Level II Trauma Center in May of 2015. The site visit was conducted as required by the Board of Licensing Health Care Facilities as a performance based review using the Trauma Center rules 1200-08-12 (revised May 2013). Generation of this report was accomplished by: Interviews with key personnel (hospital administrators, the Trauma Medical Director, the Trauma Program Manager and other involved personnel), direct evaluation of care via review of individual medical records, analysis of trauma registry data and reports, review of the quality assurance program, and other supporting documents. Improvements and Accomplishments

1. The trauma surgeon call panel has stabilized with four surgeons dedicated to this trauma facility

2. There has been approval for two additional trauma surgeons 3. Two additional mid-level providers have been added 4. There is complete ophthalmology coverage 5. A second trauma QI nurse and registrar have been added 6. There is a new telemedicine psychiatry service 7. TEG assays have been implemented 8. Rural Trauma Team Development Course was offered in January 2015 9. A service line case manager has been added 10. There is approval for two additional registrars and one QI nurse 11. There has been expansion of sub-specialty service coverage

Trauma Injury and Payor Data Trauma service admissions have grown substantially since provisional designation was granted. May 19, 2014 through February 28, 2015 reveal the following breakdown: Total

Admits ISS 0-15

ISS 16-25

ISS 26-40

ISS 41+

Ave ISS

Ave RTS

RTS

Financial summary of patients over the past several years reveals the following Self-

Pay Commercial Medicare Medicaid Tenn

Care Work. Comp

2013 (partial year) 14% 32% 44% 2% 4% 4% 2014 19% 33% 34% 3% 7% 4% 2015 (partial year) 16% 34% 32% 5% 8% 5% These numbers have remained stable since 2013. Hospital Organization Primary Trauma Service Personnel

Position Name % Time Committed to Program

Trauma Medical Director Roger Nagy, M. D. 100% Trauma Program Director Sheryl Forman, R. N. 100% Surgical Critical Care Director

Roger Nagy, M. D.

Administrator for Trauma Jason Boyd 25% Trauma Registrars Paula Griner

Erin Svarda Kim Bartlett TBD funded, but not filled

100% 100% 100%

Trauma PI Coordinator/Injury Prevention

David Kerley 100%

Trauma Education/EMS Liaison

Howard Evans 100%

Trauma Mid-Level Providers Kendall McCarty, PA-C Adam Wilson, ACNP

100% 100%

Trauma Surgeons Roger Nagy, M. D. George Hart Tyson, M. D. Haile Mezghebe, M. D. Darrell Hunt, M. D.

100% 100% 100% 100%

Trauma Service/Activation Criteria/Response Times. There are currently four surgeons responsible for trauma call. All have added certification in surgical critical care. All trauma and acute care surgery cases/call are staffed by these fellowship trained trauma surgeons who take in-house call. All participants have current ATLS certification, appropriate continuing education credits in trauma annually, and appropriate participation in trauma service conferences and committees. Trauma Service organization includes two mid-level providers who are involved in the ongoing clinical care of trauma patients throughout their hospital stay. The mid-level providers participate in the quality improvement program and trauma case reviews. Written

graded activation criteria were presented to the site survey team and a check sheet for activation is available in the Emergency Department for all trauma encodes from EMS. There were no apparent problems with response times by the trauma physicians. The organizational chart for the institution was reviewed and interviews with administration, as well as other documentation, demonstrate support for the Trauma Program. An annual budget outlining salaries and positions specific to the trauma service were provided. Surgical Specialty Availability. Surgical specialty call schedules were reviewed and 24/7 coverage of all required specialties was documented. Review of records revealed problems with neurosurgical response times and timely interventions, generating concerns for adverse outcomes. Non-Surgical Specialty Availability. Non-Surgical specialty call schedules were reviewed and documented 24/7 coverage of all required specialties. Review of Trauma Performance Documents did not reveal any problems with Non-Surgical Specialty coverage or availability. Facility Resources and Capabilities

Emergency Department: Personnel/Qualifications/Equipment. The Emergency Department has a designated Physician Director, William Gibson, M. D. There are a total of 14 physician providers, all of which are either board certified or board eligible in emergency medicine. Nursing staff is available 24/7. Tour of the Emergency Department verifies that all essential equipment is available.

Intensive Care Unit for Trauma Patients:

Personnel/Qualifications/Equipment. Dr. Roger Nagy also serves as the Medical Director of the Trauma/Surgical Intensive Care Unit. This is a mixed medical, surgical, and trauma intensive care unit. Trauma patients are not in any specialized location and the nursing care spans the continuum from medicine to surgery to trauma care. Care report review indicates that this is problematic in that the special needs and issues of trauma patients are not always recognized and appropriately addressed. Nurse ratios are appropriate, and there is a plan to surge capacity as census rises. This institution often operates at 85% or greater capacity, which can pose a problem for coverage, however a staffing plan is in place to cover surges. All essential equipment is present on the unit.

Post-anesthetic Recovery Room. No deficiencies were documented.

Acute Hemodialysis. Hemodialysis is available 24/7. Continuous renal

replacement therapy (CRRT) is also available.

Organized Burn Care. Skyline does not have a burn center. Transfer Agreements with regional Burn Centers were provided to the site review team.

Radiological Special Capabilities. The site team toured the Radiology

Department. All required capabilities were noted to be present. Radiologist presence is not available at night, but there is capability within the system for diagnostic test reviews with the ability to speak directly to the radiologist as needed.

Organ Donation Protocols. Organ donor protocols were reviewed and

appropriate levels of notification were met. Operating Suite Special Requirements/Availability. There is an operating room available for the trauma service 24/7. One operating room is staffed throughout the night, and on the weekend. If in use, a call team is activated. Given the annual emergency Department visits and rising operative volume, there appears to be a need to expand this capability to ensure proper flow and availability of operating rooms and teams to accommodate emergencies and increased weekend load. Clinical Laboratory Services All essential Clinical Laboratory Services are available. Additionally, point-of-care (POC) testing is available in key areas: the operating room, emergency department, and Trauma ICU. There is a massive transfusion protocol in place, and undergoes evaluation with each use. Trauma Medical Director Roger Nagy, M. D. is the Trauma Director. He maintains appropriate certification, participates in call, and has the authority to manage all aspects of trauma care. He coordinates performance improvement and the peer review process, and with assistance of the hospital administrator, is involved in the budgetary process. He is current in ATLS and provides other trauma-related education within and without the institution. Attending General Surgeons on the Trauma Service One hundred percent of the call for trauma is done by the Trauma Medical Director and Trauma Service physicians. All are Board Certified in General Surgery with added qualifications in Surgical Critical Care. All have current ATLS certification and appropriate trauma specific CME.

Trauma Nurse Coordinator (TNC)/Trauma Program Manager (TPM) The full-time Trauma Program Director is Sheryl Forman, R. N. Ms. Forman has extensive experience in the trauma arena and provides the oversight of all activities of the service. A defined job description was presented to the site surveyors and is appropriate. Trauma Registry The trauma registry is staffed by 3 full-time registrars, each of which has completed four hours of education through the state in April 2015. An additional FTE has been approved, but not yet filled. Data is obtained from retrospective chart review for registry entry. All patients with ICD-9 discharge codes of 800-959.9 are placed in the registry with the following exclusions: 905-909.9 (late effects of injury), 910-924.9 (superficial injuries), and 930-939.0 (foreign bodies). Also excluded are hypo- and hyperthermia, barotrauma, and lightning. Strangulation, drowning, and electrocution are only included if there is an associated injury diagnosis. Trauma registry data is electronically submitted to the state database quarterly. Programs for Quality Assurance: Medical Care Education/Trauma Process Improvement/Operational Process Improvement (System Issues)

1. Trauma Peer Review Committee is a closed confidential meeting that meets monthly. 100% of admitted trauma patients are abstracted and undergo preliminary review for appropriateness of care by the Trauma Medical Director and Trauma PI Nurse. Cases that fall out are referred to the Trauma Peer Review Committee. In this meeting specific patient cases are reviewed, as well as quality metrics, performance and safety of the trauma program. Each case is discussed and recommendations are made regarding determinability preventability, and corrective actions. The core group includes all physician groups caring for the trauma patient, the PI coordinator, quality management director, and registrars. This group also develops and assesses evidence-based guidelines, pathways, and protocols.

2. Trauma Performance and Patient Safety (TPIPS) Committee meets monthly after the trauma peer review Committee. This is a multi-disciplinary committee and members are appointed by the Trauma Medical Director. Quality, safety, and effectiveness of care are discussed at this meeting. Committee members provide departmental updates and assist in the development of evidence-based guidelines and protocols. Reports from this committee are reported to the Medical Executive Committee.

3. Quarterly Trauma Morbidity and Mortality Conference. This is a conference that meets quarterly and serves as an educational forum in which patient care and outcomes are discussed.

4. Hospital Medical Quality Improvement Committee is made up of physician and administrative leadership of the hospital. It reviews all hospital QI efforts. Problems not solved through other mechanisms can go through this committee to the hospital administration or the Board.

There are many processes for review in place at this institution. Nonetheless, the site team determined that loop closure was inadequate. There must be clear documentation that loop closure occurred, tracking or trending of repeated issues performed, and that a plan for action is undertaken when performance issues are identified. The plan of action needs to be clearly documented and then reviewed until there is resolution of the issue. Chart Reviews of Medical Care All charts for review were available on computer and assistance for access obtained from Trauma Service personnel as per the request letter. Multiple TRISS plots were available for review. The data was divided based on blunt and penetrating trauma. Thirty-five to forty charts were reviewed for clinical care and all team members participated in the chart review. Although charts from all categories were reviewed, there was a concentration on the more severely injured patients. A number of deaths in the high probability of survival area of the TRISS plot occurred in patients with traumatic brain injury. From these charts it was not possible to determine neurosurgical consultation response times and in several instances, care appeared delayed. There were several instances of airway compromise or hemodynamic instability that did not appear adequately addressed by the PI process, particularly in terms of loop closure. Several unstable trauma patients and patients who were victims of penetrating trauma were also transported to this facility when destination guidelines would dictate a different level of care. Trauma Bypass Log A bypass memo was available and documents a diversion rate well below the 5% level for trauma. Outreach/Training/Public Education/Research Skyline offers a variety of in-house training events, as well as community training events. These include TNCC, disaster classes, trauma case reviews, skills fairs, and a variety of trauma-related lectures. There is a Trauma Education and Training Plan and area-specific clinical skills and competencies are identified and taught. Skyline also teaches the Rural Trauma Team Development Course. Skyline has several Injury Prevention endeavors including Battle of the Belt, lectures to area schools on binge drinking/distracted driving and craniofacial trauma/seatbelt use. They have programs geared towards seniors as well, including Senior Medical University 101 Presentation on SLIP, and a fall prevention program.

Trauma System Development Dr. Nagy is on the Trauma Care Advisory Council and the Tennessee Committee on Trauma. Mr. Steve Otto is the administrator liaison for the Trauma Care Advisory Council. Both attend meetings regularly and are involved with the activities of the council. CONCLUSIONS In the one year since provisional verification, Skyline has demonstrated ongoing support for the trauma program. An enormous amount of work and commitment is evident, and the volume of patients treated has exceeded original expectations. The trauma call panel has been stabilized and is now filled with dedicated local trauma surgeons. However, review of patient care did reveal several deficiencies. Given these deficiencies, a corrective action plan must be presented to the board within 60 days. The institution will remain on provisional status for one more year in order to correct these issues. DEFICIENCIES

1. Neurosurgical response times, immediate availability, and timely intervention could not be determined from the records.

2. Case reviews revealed lapses in recognition of patients in shock or airway compromise.

3. The events noted above, while recognized via the PI process, did not have appropriate loop closure. Loop closure must include an action plan for correction which is clearly delineated and documented, tracking and trending performed of recurring issues, and clear documentation of resolution of the problem.

AREAS OF IMPROVEMENT

1. There is not a dedicated critical care unit for patients with traumatic injuries. This complex care needs to be aggregated in a location that allows specialty nursing care to maximize efficiencies, patient safety, and outcomes.

2. Trauma patients not in the intensive care unit are scattered throughout the facility. Again, given the complexity and multi-disciplinary nature of this care, identifying a common unit to care for these patients enhances processes of care and patient safety.

3. There is difficulty following the hemodynamic status of patients given the current constraints of the electronic health record. It is advised that these measures be located in a continuous form in one location within the record to enhance tracking of these parameters to ensure appropriate and timely intervention.

EXIT INTERVIEW Following the site visit, the team held a meeting to evaluate the findings and make conclusions. An exit interview was then held and the conclusions and recommendations as stated in this report were presented to the hospital administrative, medical and nursing staff present.