NEWS

TriStar Skyline trauma center fails first-year test

Tom Wilemon
twilemon@tennessean.com

A new trauma unit at TriStar Skyline Medical Center failed to get past its one-year provisional status because of "several deficiencies" — including treating brain injuries.

The Tennessee Board of Licensing Health Care Facilities has given the hospital a second chance, extending the provisional status for a year. But the hospital must first submit a corrective action plan within two months of the board's May 6 decision.

State inspectors conducted a review of patient records and quality monitoring documents on April 30. The review found that a number of patients with traumatic brain injuries with a high probability for survival had died in Skyline's emergency room.

However, a majority of those patients had preexisting conditions and had even signed off on advanced directives with do not resuscitate orders, said Dr. Jeff Guy, chief medical officer for TriStar Health, a division of HCA.

He said the company stands by its trauma program and regularly "reviews trauma cases to make recommendations."

Guy noted that Skyline's trauma mortality rate is 2.87 percent, significantly better than the state rate of 4.3 percent and the national rate of 4.47 percent.

State inspectors also determined that Skyline had failed to adequately monitor its treatment responses.

"A number of deaths in the high probability of survival area in the TRISS (trauma injury severity score) plot occurred in patients with traumatic brain injury," the report stated. "From these charts it was not possible to determine neurosurgical response times and in several instances, care appeared delayed."

Unstable trauma patients, including people with penetrating wounds, were transported to Skyline "when destination guidelines would dictate a a different level of care," the report said.

Skyline operates a provisional Level II trauma center, the second highest designation, while Vanderbilt University Medical Center has Level I centers for adults and children.

"While we acknowledge that our documentation did not always reflect actual timeliness of our neurosurgical response in every case, we are confident that our emergent neurosurgeon response is timely, and we have taken steps to ensure that documentation clearly reflects that coverage," Guy said.

The Skyline trauma center also was cited for lapses in recognizing patients in shock, with compromised airways and experiencing severe low blood pressure. And its performance improvement process did not have appropriate closure to show clear documentation of problems being resolved.

Guy defended the performance of trauma center personnel, saying protocols were in place to ensure the highest standard of care.

"We stand behind the quality of our trauma program and the protocols that are in place to ensure the highest standard of care. All good clinical programs are constantly improving their processes," Guy said. "We have rigorous peer review that involves physicians from multiple specialties, nursing, administration, and other healthcare providers that comprehensively and regularly reviews trauma cases to make recommendations."

The trauma center admitted 1,602 patients between May 19, 2014 and Feb. 28, 2015. During that time, it often operated at 85 percent or greater capacity, the report noted.

But trauma patients were not separated from other emergency room patients — a situation characterized as "problematic in that the special needs and issues of trauma patients are not always recognized and appropriately addressed."

Reach Tom Wilemon at 615-726-5961 and on Twitter @TomWilemon.

TRAUMA CENTERS

Level I

A comprehensive regional resource, capable of providing complete care for every aspect of an injury.

Level II

Centers able to initiate definitive care for all injured patients.

Level III

Has a demonstrated ability to provide prompt assessment, resuscitation, surgery and stabilization of injured patients, among other care.

Level IV

Has the ability to provide advanced trauma life support prior to patients transferring to a higher level facility.

TRISTAR HEALTH RESPONDS

Dr. Jeff Guy, chief medical officer of TriStar Health, addressed point-by-point deficiencies cited in a state report that kept TriStar Skyline Medical Center's new trauma center on provisional status for another year.

Timeliness of response with neurosurgeon coverage

We have full 24/7 neurosurgeon coverage, in compliance with level II trauma center standards. While we acknowledge that our documentation did not always reflect actual timeliness of our neurosurgical response in every case, we are confident that our emergent neurosurgeon response is timely, and we have taken steps to ensure that documentation clearly reflects that coverage.

Instances of airway compromise and low blood pressure

We stand behind the quality of our trauma program and the protocols that are in place to ensure the highest standard of care. All good clinical programs are constantly improving their processes. We have rigorous peer review that involves physicians from multiple specialties, nursing, administration, and other health care providers that comprehensively and regularly reviews trauma cases to make recommendations.

Unexpected deaths of trauma patients according to survivability score

Overall, our trauma mortality rate is 2.87 percent, significantly better than the TN rate of 4.3 percent and the national rate of 4.47 (source: American College of Surgeons, National Trauma Data Bank.). Of the 1,602 trauma patients treated during the period under review, 26 patients were deemed unexpected mortalities based on TRISS (trauma injury severity score) scoring. The complexity of these patients' conditions when presenting at the hospital is not always sufficiently captured by the TRISS assessment, which captures only anatomical injury, vital signs and age, but does not consider a patient's preexisting medical conditions. In 62 percent of these 26 cases, advance directives (living will, do not resuscitate orders) were in place at the patients' requests, and they ultimately succumbed to the severity of their conditions.

Trauma patients not being transported for higher level of care

Destination guidelines are pursuant to the State of Tennessee's "2011 Guidelines for Field Triage of Injured Patients," and we are confident that local EMS responders act in the best interests of patients in the determination of where to take trauma cases.