Patient Characteristics and Procedural Volume at an Overseas Military Treatment Facility Emergency Department: Effects of the COVID-19 Pandemic and Implications on Clinical Skill Sustainment
Authors: Manoukian Martin A C , Maguire Connor E , Lopachin Tyler R , Benham Derek A , Singaraju Raj C 
Published: January 2025

ABSTRACT

Introduction
Future conflicts against near-peer competitors require proficient physicians to mitigate operational morbidity and mortality. Recent literature suggests that current patient demographics and staffing models may not sustain the combat care skills of military physicians. However, skill sustainment at overseas military treatment facilities located within foreign countries has not been examined. This article investigates patient characteristics and procedural performance rates within the U.S. Naval Hospital Okinawa Emergency Department (USNHO-ED), providing novel insight into the skill sustainment provided to U.S. Military physicians stationed in a foreign country.

Materials and Methods
An automated retrospective chart review of patients triaged within the USNHO-ED from January 2018 to June 2022 was performed. Patient census, emergency severity index (ESI) triage scores, patient disposition, and procedures of interest were recorded. Procedures of interest included: “endotracheal intubation,” “arterial line placement,” “central line placement,” “dislocation reduction,” “procedural sedation,” “cardioversion,” “thoracostomy,” “blood product transfusion,” “lumbar puncture,” “paracentesis,” “arthrocentesis,” and “joint injection.” Monthly procedure rates and procedure rates per 1,000 patients were calculated. Procedure rates for individual physicians with greater than 500 patient encounters were calculated. Variation in patient characteristics and procedural rates during the COVID-19 pandemic was investigated.

Results
The USNHO-ED triaged 128,696 patients and performed 865 procedures of interest during the study period. In total, 5,020 patients were triaged as ESI 1/2, 34,179 patients were triaged as ESI 3, and 89,499 patients were triaged as ESI 4/5. A total of 122,881 patients were discharged from the emergency department. The procedures performed most often were procedural sedation (4.02 per month, 2.06 per 1,000 patients), dislocation reduction (3.41 per month, 1.75 per 1,000 patients), lumbar puncture (1.94 per month, 0.99 per 1,000 patients), and endotracheal intubation (1.21 per month, 0.62 per 1,000 patients). All other procedures were performed less than once per month and 0.5 instances per 1,000 patients. Over half of physicians with at least 500 encounters did not perform a blood product transfusion, thoracostomy, central line placement, arterial line placement, cardioversion, or paracentesis. Rates for many procedures were lower than those seen at civilian institutions. During the COVID-19 pandemic, the daily census was lower, patients were more often triaged to higher ESI 1-3, and the admission rate was higher. Procedural sedations per month, as well as procedural sedations, dislocation reductions, and blood product transfusions per 1,000 patients, increased during the COVID-19 pandemic. No other temporal procedural variation occurred. Pediatric patients were more often triaged to ESI 4/5, more likely to be discharged, more likely to undergo procedural sedation, and less likely to undergo endotracheal intubation, blood product transfusion, thoracostomy, central line placement, cardioversion, or joint invasive procedures.

Conclusions
This study demonstrates a low patient volume, patient acuity, and procedural performance rate for physicians at USNHO-ED. The inability of military physicians stationed in foreign locations to leverage the local civilian market further reduces their ability to maintain operational readiness. In combination, these hindrances degrade physician readiness, creating significant risk in the ability to support warfighters engaged in combat operations. Unique staffing models and partnerships must be developed to maintain the proficiency of overseas military physicians.