Keeping Pace

From the Fall 2019 edition of Vanderbilt Medicine Magazine

Illustration by Lucie Rice

Nashville, once a mid-size city with a Southern small-town feel, is experiencing explosive growth. It’s bursting at the seams with unparalleled new construction, exciting new employment opportunities and a bustling food and entertainment scene.

But along with Nashville’s rapid growth comes uncertainty and struggle — a need for affordable housing, better schools, mass transportation options to ease clogged roadways and easy access to health care, both in the city and in its surrounding metropolitan areas that are also rapidly growing.

Vanderbilt University Medical Center, one of the largest academic medical centers in the Southeast, managing nearly 2.5 million patient visits each year, is meeting the growth head-on, working to treat an influx of more patients where they live and work.

According to new population estimates from 2018, Metropolitan Nashville and its surrounding counties now have a population of 2,090,956, making it the 24th most populated city in the United States, according to the U.S. Census Bureau.

It’s estimated that about 81 people per day move to Nashville. Across the 10-county Cumberland Region around Nashville, the Metropolitan Planning Organization is forecasting close to another million people by the year 2035, making Nashville larger than the Denver region is today.

The city’s surrounding counties have absorbed most of the growth since 2015 with Rutherford County’s population increasing the most, followed by Williamson County, Davidson County and then by Wilson County.

VUMC has a presence in all of those counties, and continues to closely monitor growth, ready to adapt to the developing health care needs in and around Nashville.

There are multiple reasons for Nashville’s rapid evolution.

  • The city has granted large tax incentives to major corporations for relocation, and Tennessee remains without a state income tax.
  • Major businesses moving to Nashville are bringing an influx of new residents. Amazon.com Inc. is building an Operations Center of

Excellence in downtown Nashville, creating 5,000 high-paying corporate jobs. AllianceBernstein, a New York-based global investment management firm is moving its headquarters to Nashville and bringing 1,050 new jobs and a $70 million investment.

  • Nashville is receiving national publicity: It’s been called “Nowville” by GQ magazine and the “it city” by the New York Times.

VUMC is responding to the city’s development by expanding its capacity to care for as many patients as possible at VUMC and in the community, said Tom Nantais, MBA, VUMC’s executive vice president for Adult Ambulatory Operations.

“With the recent injection of AllianceBernstein personnel into Nashville, and Amazon following behind, that’s about 7,500 more people just for two employers coming in,” he said.

Tom Nantais, MBA, tracks Nashville’s increasing need for outpatient services. Photo by Joe Howell.

One of the first things those employees will need is primary care, and there’s a shortage of primary care physicians across the country, Nantais said. VUMC held a retreat in May to look at the need for primary care in Davidson County and how it can be best structured to accommodate the new companies and residents moving into the Nashville area.

Currently there are several options for seeking primary care through a VUMC provider, Nantais said. There are about 100 VUMC primary care physicians or nurse practitioners who see patients at 33 locations at VUMC and the surrounding areas. These include several walk-in clinics and locations within many Walgreens.

“Employing physicians can be expensive and acquiring practices can be costly. I think the future is embracing the physician and nurse practitioner team-based model,” Nantais said. “We have outstanding nurse practitioners and their partnership with our physicians is very important to us.”

Nantais said VUMC will be expanding walk-in clinics, which are especially popular with millennials, many of whom don’t have a primary care physician. “Millennials see primary care differently. It’s episodic in their eyes versus longitudinal. Our older patients want to maintain a relationship with their primary care doc. But in Nashville, where the average age is lower in the metropolitan area, they’re looking for different options to access health care. Our walk-in clinics give them instant access and connectivity back to VUMC specialists,” he said.

“Vanderbilt is known for its patient care, quality and stature in the health care community,” Nantais said. “It has that panache that attracts people to it. Our job is to make sure we can provide appropriate and timely access for the patients coming into the system.”

VUMC is also looking at telehealth options to remotely provide care when and where patients want to receive it, and in 2016 created a new patient care service, Vanderbilt Health OnCall, where patients can pay a set fee to have a nurse practitioner come to their residence or office to provide care.

“It’s just another way of accessing primary care,” Nantais said. “This service is growing. If you’re in a hurry and not feeling well, it’s

a great way to have a VUMC nurse practitioner come to you at your convenience.”

Access is something leaders at VUMC take seriously, Nantais said. “Our contact center fields about 4 million phone calls a year, probably two-thirds are related to visits, and the rest to prescriptions. We have 300 agents working tirelessly to make sure patients get to the right clinic.”

 

Trauma in an evolving city

VUMC’s Trauma Center, providing care for 65,000 square miles, handles about 5,800 acute traumas annually, with 4,706 patients admitted last year. It’s the only Level 1 Trauma Center in Middle Tennessee, providing the highest level of surgical care for trauma patients.

“We’ve seen about a 20% increase in volume over the past five years,” said Richard Miller, MD, chief of the Division of Trauma and Surgical Critical Care. Next year, the trauma center is expected to exceed 5,000 admissions, he added.

The Trauma Center has 14 trauma surgeons. When Miller arrived at Vanderbilt 17 years ago there were six.

Front and center in the Trauma Center’s success is the Vanderbilt LifeFlight program, the critical care air medical transport service of Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital at Vanderbilt since 1984.

LifeFlight has nine helicopters, one airplane and nine ground ambulances. One of the nine helicopters serves as a backup, and the remaining eight are strategically placed at bases to provide rapid access to VUMC Trauma for all of Middle Tennessee, parts of West and East Tennessee, Southern Kentucky and Northern Alabama.

“We have the busiest aeromedical helipad in the country,” Miller said. Half the transports are for trauma; half are for other critically ill patients.

Most of VUMC’s trauma patients fall into two categories: those with blunt injuries caused by motor vehicle accidents and those with penetrating injuries caused by gunshot and stab wounds. About 80% of VUMC trauma patients have blunt trauma. About half of the trauma patients seen at VUMC are from Davidson County and neighboring Williamson County.

“Last night we had four gunshot wounds and we average about two or three stab or gunshot wounds a day. That’s the nature of becoming a large city; you are going to have a large subset of the population involved in penetrating trauma,” Miller said.

“And as traffic patterns become more problematic in our city and surrounding highways, we are seeing more car accidents. That’s the nature of a growing town that unfortunately is not keeping up with the traffic structure.”

An increasing number of vehicle accidents are from distracted driving — people texting and using cellphones while driving, he said. Tennessee passed a hands-free cellphone law in July banning the use of handheld devices while driving.

As Nashville’s population and tourism increase, there’s also an increasing potential for a mass casualty event. The Trauma Center, led by Vanderbilt’s Emergency Preparedness program, continues to train for that possibility, one they hope never occurs.

“Our job is to anticipate and be ready for it, in hopes that it never happens. That’s our motto,” Miller said. “The key is to be ready for a plane crash, a mass shooting, an explosion. We can manage a large group of patients. We have an average of 20 patients admitted in a 24-hour period. We can manage that number. We do it every day. However, when there’s an incident like Las Vegas and you have more than 50 people killed and another 400 people shot or injured, it’s chaos, hopefully organized chaos, but it’s chaos nonetheless. That’s difficult to ever be prepared for. Not a single center in the country can manage that volume. You do the best you can with the resources you have, and you rally together with every single hospital in the area.”

 

Just another day in the ED

VUMC’s emergency visits have also increased. Vanderbilt’s emergency departments (the Adult Hospital and Monroe Carell Jr. Children’s Hospital at Vanderbilt) now see 70,000 adults and more than 50,000 children a year.

“The volume is up four to fivefold and the severity has gone up too,” said Corey Slovis, MD, chairman of Emergency Medicine. “Our ED had relatively slow growth until about five or six years ago. But the more people who arrived in Nashville and heard about Vanderbilt, the more patients wanted to come here.”

Corey Slovis, MD, left, and Richard Miller, MD, have seen an uptick in trauma injuries and ER visits in recent years. Photo by Daniel Dubois.

VUMC’s emergency department is the third highest acuity emergency department in the nation with an academic base.

“We see everything. I worked yesterday. I started my shift at 6 a.m. and by 7 we had delivered a baby in the parking lot outside the ED. During that day we saw two patients with LVADs (left ventricular assist devices for the heart), two patients had acute allergic reactions, a patient playing basketball badly dislocated his ankle, we had an acute myocardial infarction and two patients with acute heart rhythm disturbances. We also had usual abdominal pain, chest pain and fevers. An amazing day, but just another day here.”

The increasing number of patients means that VUMC will have a bigger emergency department. “Plans are in the works,” Slovis said.

Recent improvements to the Emergency Department include opening the C pod (one of three pods) for less acute patients and implementing a fast track that begins in the waiting room. “A physician is assigned to our waiting room 16 hours a day — he or she triages patients, begins the workup and gets lab work under way. All this is done before a room becomes available.

“It’s really changing the old concept of ‘you come in, you get checked in, you get triaged.’ Now we can start some things before you even see a physician, your X-rays and labs are done and a rapid disposition can then be made,” he said.

Slovis said Nashville’s reputation as a great city to live and work is also strengthening an already reputable Vanderbilt emergency medicine training program, bringing the best young emergency medicine resident physicians to Nashville.

“Our program already had a great reputation, but rather than being in a small little southern town off the beaten path, we are in one of the most exciting, vibrant cities in the nation. It’s a wonderful place to live and train.”

 

Sunburn, blisters, strokes

Nashville’s development may be best reflected in the influx of large events, and subsequently, the growth of Vanderbilt LifeFlight’s Event Medicine team.

The program began in 2008 when VUMC became the official health care provider of the NHL’s Nashville Predators. Vanderbilt LifeFlight Event Medicine provides advanced EMT and paramedic level EMS (emergency medical services) for team members and spectators at all home games for the beloved hockey team. Vanderbilt LifeFlight Event Medicine also provides EMS coverage (including ambulance standby) for all events at the Bridgestone Arena, Vanderbilt sports and many other venues, including some of Nashville’s largest outdoor events.

Michael Wallace atop the LifeFlight helipad. Photo by Anne Rayner.

“We take care of everything from providing Band-Aids for blisters, to handing out sunscreen or the most serious medical emergency you can imagine — trauma, heart attacks and strokes,” said Michael Wallace, director of Ground Transport, Event Medicine and Emergency Communications for Vanderbilt LifeFlight.

Event Medicine started with a few dedicated employees. Now there are more than 70 event medicine staff members. (The majority are EMTs and paramedics along with a few nurses and physicians.) For the largest events, the program draws qualified staff from all areas of LifeFlight and throughout the VUMC enterprise.

For Nashville’s 2018 Fourth of July event, the largest in the nation with more than 250,000 attending, Event Medicine staff set up numerous fixed tent stations throughout downtown Nashville, and multiple roaming teams carried backpacks of medical equipment. The program can’t operate without the expertise of an emergency communications hub coordinating response efforts, much like a 911 system, located in a mobile command center situated in the downtown area.

Patients can be quickly transported to Vanderbilt if needed, but of the thousands of patients treated at an event, the number who need to be taken to the hospital is low.

“That’s one of the amazing things about our event medicine program,” Wallace said. “You can have hundreds of thousands of people surging into the community, coming in from all over the world, stretching the capacity of the city beyond what it normally is. If everyone who needed treatment ended up going to a hospital or clinic, they would be quickly overloaded. That’s part of our strategy — if you can offer an onsite service, it eliminates the excessive burden on the hospitals.

“We’ve mushroomed from those early days of a couple hundred events a year to over 1,000 large-scale events a year,” Wallace said.