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.

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

The trauma surgeon call panel has stabilized with four surgeons dedicated to this
trauma facility
There has been approval for two additional trauma surgeons
Two additional mid-level providers have been added
There is complete ophthalmology coverage
A second trauma QI nurse and registrar have been added
There is a new telemedicine psychiatry service
TEG assays have been implemented
Rural Trauma Team Development Course was offered in January 2015
A service line case manager has been added
There is approval for two additional registrars and one QI nurse
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:

2014/2015

Total
Admits
1602

ISS
0-15
1521
95%

ISS
16-25
62
3.8%

ISS
26-40
17
1%

ISS
41+
2
.1%

Ave
ISS
6.8

Ave
RTS
11.7

RTS
<10
117

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

2013 (partial year)

2014
2015 (partial year)

SelfPay
14%
19%
16%

Commercial

Medicare

Medicaid

32%
33%
34%

44%
34%
32%

2%
3%
5%

Tenn
Care
4%
7%
8%

Work.
Comp
4%
4%
5%

These numbers have remained stable since 2013.

Hospital Organization
Primary Trauma Service Personnel
Position

Trauma Medical Director

Trauma Program Director
Surgical Critical Care
Director
Administrator for Trauma
Trauma Registrars

Trauma PI Coordinator/Injury
Prevention
Trauma Education/EMS
Liaison
Trauma Mid-Level Providers
Trauma Surgeons

Name

Roger Nagy, M. D.
Sheryl Forman, R. N.
Roger Nagy, M. D.

% Time
Committed
to Program
100%
100%

Jason Boyd
Paula Griner
Erin Svarda
Kim Bartlett
TBD funded, but not filled
David Kerley

25%
100%
100%
100%

Howard Evans

100%

Kendall McCarty, PA-C

Adam Wilson, ACNP
Roger Nagy, M. D.
George Hart Tyson, M. D.
Haile Mezghebe, M. D.
Darrell Hunt, M. D.

100%
100%
100%
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.

2.

3.

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 evidencebased guidelines, pathways, and protocols.
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.
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.

2.

3.

Neurosurgical response times, immediate availability, and timely intervention

could not be determined from the records.
Case reviews revealed lapses in recognition of patients in shock or airway
compromise.
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.

2.

3.

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.
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.
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.