pediatric critical care experience at Naval Hospital Guam: Suggestions for critical care training during residency, The

Military Medicine, Jun 2000 by Poss, W Bradley

Objectives: To determine the critical care experience encountered by three recently graduated military pediatricians at an overseas military hospital and present one model of maximizing allowable critical care training time during residency.

Method: Retrospective reviews of all admissions to the special care nursery and intensive care unit at U.S. Naval Hospital Guam were performed for a 3-year and a 2-year period, respectively. Age, diagnosis, birth weight (if applicable), level of nursery care, invasive procedures performed in the nursery (endotracheal tube, umbilical artery, and umbilical venous catheter placement), patient outcome, and the need for medical transport were recorded. Results: During a 3-year period, there were 122 admissions to the special care nursery (7.1% of all deliveries). In addition, pediatricians performed a total of 53 invasive procedures on these patients, and 29 infants required medical transport to an off island neonatal intensive care unit for additional care. During a 2-year period, 70 pediatric patients were admitted to the adult intensive case unit, representing 10.296 of all intensive care unit admissions during this period. Fourteen of these patients required medical transport to an off-island referral hospital. Conclusion: Graduating military pediatric residents may be faced with caring for a wide range of critically ill neonatal and pediatric patients depending on their assignment. Residency training programs, with the recent increased emphasis on primary pediatric care, will need to streamline instruction in pediatric critical care to provide maximal benefit to the resident while maintaining compliance with Residency Review Committee guidelines.

Introduction

Guam is a relatively small tropical island with a population of approximately 150,000. U.S. Naval Hospital (USNH) Guam is one of two hospitals on the island, serving approximately 7,000 active duty military members and their dependents. In addition, members of the Guam National Guard, retirees and their beneficiaries, and civil service workers are eligible for care. The hospital is staffed by three Navy pediatricians, who provide care for approximately 5,500 outpatient visits, 150 inpatient admissions, and 500 births annually. Patients requiring specialized care are referred to either USNH Okinawa in Japan or Tripler Army Medical Center (TAMC) in Honolulu, Hawaii. Neonatal transport services are provided by U.S. Air Force neonatologists stationed at USNH Okinawa; however, the pediatricians on Guam also provide transport services to and from USNH Okinawa, TAMC, and Naval Medical Center San Diego (NMCSD). To analyze the critical care experiences of military pediatricians at USNH Guam, we reviewed the records of children requiring admission to either the special care nursery or the intensive care unit for a 3-year and a 2-year period, respectively.

Materials and Methods

A retrospective review of all admissions to the newborn nursery during the period from January 1, 1995, to January 1, 1998, was performed. Whenever appropriate, and when it can be performed safely, high-risk expectant mothers are transferred to USNH Okinawa. Records of these patients were not analyzed. The total number of live births was identified, and infants were classified by admission to the level I (basic or routine newborn care), level II (specialty newborn care), or level III (subspecialty newborn care) nursery.1 We identified the mode of delivery (vaginal or cesarean section), birth weight, and gestational age. Infants were then classified as low birth weight, very low birth weight, or extremely low birth weight based on a weight of less than 2,500 g, less than 1,500 g, or less than 1,000 g, respectively. We identified the diagnoses of neonates admitted to the special care nursery as well as any procedures performed and the disposition (discharge to home, transfer to another facility, or death).

In addition, we reviewed pediatric admissions to the intensive care unit (ICU) for the period January 1, 1996, to January 1, 1998. Admission data from 1995 were unavailable for review because of inadequate record keeping during this period. Information identified included the age of the patient, the diagnosis, and the disposition (discharge to home, transfer to the medical ward, transfer to another facility, or death).

Results

USNH Guam averaged 575 births annually during the period from January 1, 1995, to January 1, 1998 (Table I). Cesarean section, which has been associated with higher perinatal morbidity, was performed in 15% of all deliveries (273 of 1,725). Approximately 7% of all deliveries, or nearly 41 infants per year, were classified as level II and level III nursery admissions and thus required increased levels of care. In addition, 11.59% of all liveborn infants (200 of 1,725) were classified as premature, with a gestational age of less than 37 weeks. Finally, there were 7 extremely low birth weight or very low birth weight infants as well as 63 low birth weight infants delivered during the period reviewed.