The assessment of Puerto Rico's emergency care environment uses a similar methodology to that applied to the 50 states and the District of Columbia. As such, the data presented for Puerto Rico are from the same sources as that presented for the states, with very few exceptions (noted in the appendices). Since much of the data collected for the states did not include Puerto Rico, a true comparison is not possible and a grade was not calculated.
Puerto Rico faces many of the same challenges that greatly affect the overall emergency care environment in numerous states, such as health care workforce shortages, long emergency department (ED) wait times, chronic disease risk factors, a medical liability crisis, and gaps in statewide policies and planning. Puerto Rico also faces additional challenges unique to the island, such as a lack of many data collection mechanisms that allow most states in the nation to efficiently and effectively review and address areas needing significant improvement.
Access to Emergency Care in Puerto Rico does not appear to have improved greatly since the 2009 Report Card; however, there are some areas of improvement. The number of registered nurses has increased by nearly 25%, from 395.3 to 494.3 nurses per 100,000 people. This positive trend is tempered, however, by exceedingly low per capita rates of specialists. Compared to the states, Puerto Rico has less than half the rates of emergency physicians; neurosurgeons; orthopedists and hand surgeons; plastic surgeons; and ear, nose, and throat specialists. While Puerto Rico has seen very slight increases in the rates of psychiatric care beds and staffed inpatient beds (3.7 and 243.2 per 100,000 people), two hospital closures in 2011 likely contributed to the overall increase in the already high hospital occupancy rate (79.2 per 100 staffed beds). All of these factors contribute to excessively long ED wait times (778 minutes from ED arrival to departure), meaning that patients can expect to wait 13 hours to be admitted into a hospital room.
In the Quality and Patient Safety Environment, Puerto Rico continues to fund an emergency medical services medical director position and has increased the number of emergency medicine residents considerably since the previous Report Card (from 7.4 to 12.3 per 1 million people). Puerto Rico has also implemented a uniform system for providing pre-arrival instructions, which can improve patient outcomes, and continues to maintain a territory-wide trauma registry. On the other hand, Puerto Rico has not worked to develop a stroke or ST-elevation myocardial infarction (STEMI) system of care, and while it has field trauma triage protocols, they are not specifically based on Centers for Disease Control and Prevention guidelines.
The proportion of patients with acute myocardial infarction (AMI) receiving percutaneous coronary intervention within 90 minutes of arrival has increased from 17% to 54% since the 2009 Report Card; however, these rates are significantly lower than in the states, where 93.1% of patients receive this level of care. Hospital adoption of electronic medical records and computerized practitioner order entry are also exceedingly low (12.5% and 25.0%, respectively), and few hospitals collect data on patients' race and ethnicity and primary language (17.5%). However, Puerto Rico reports a high proportion of AMI patients receiving aspirin within 24 hours before their ED arrival or during their time in the ED (94%).
Puerto Rico's Medical Liability Environment has not improved since the 2009 Report Card, despite numerous efforts to address the crisis. While the average malpractice award payment has mildly decreased, the number of award payments has increased (6.3 per 100,000 people) and is now more than twice the average across the states (2.4 per 100,000 people). In addition, the number of National Practitioner Databank Reports (49.4 per 1,000 physicians) is extraordinarily high and indicative of a particularly litigious environment. The number of insurers writing medical liability policies is among the lowest in the nation (1.6 per 1,000 physicians), which can result in excessively high premiums and poor policy coverage. Puerto Rico has done little to lighten this burden, having failed to pass significant expert witness rules or require pretrial screening panels before a case can be heard. Puerto Rico has provisions for alternative dispute resolution; however, it is at the judge's discretion to request that an arbitration panel review the case. Puerto Rico has not abolished joint and several liability, which would ensure that health care providers are only held liable for their own actions and not those of other parties.
In Public Health and Injury Prevention, Puerto Rico can boast some significant improvements since the 2009 Report Card. The proportion of traffic fatalities that are alcohol-related decreased 6 percentage points to be on par with the nation overall. Puerto Rico also continues to have a high rate of seatbelt use among front-seat occupants (91.9%), surpassing the national rate (84.0%), as well as a helmet requirement for all motorcycle riders. With regard to health risk factors, the infant mortality rate has declined slightly but is still significantly higher than the average across the states. On the other hand, the proportions of adults engaging in smoking and binge drinking have increased slightly but remain well below the national averages. One major concern for Puerto Rico is declining immunization rates among older adults: Only 28.6% of the elderly reported receiving an influenza vaccination in the previous year and fewer than 23% reported ever having received a pneumococcal vaccine.
Unfortunately, much of the Disaster Preparedness data for this Report Card were collected via a state-by-state survey of Disaster Preparedness officials that was not completed by Puerto Rico. What few data are available, however, provide evidence of a limited infrastructure for responding quickly and effectively in the event of a disaster or mass casualty event. Puerto Rico has no burn unit beds and only 70.1 intensive care unit (ICU) beds per 1 million people, compared to an average of 290.6 per 1 million across the states. Additionally, bed surge capacity is considerably lower than in the states (610.6 per 1 million people). This may be particularly problematic for Puerto Rico, since it cannot take advantage of mutual aid agreements from hospital and medical facilities in nearby states during an emergency.
Puerto Rico's failure to reform its Medical Liability Environment is a major concern, since an adversarial litigation environment can discourage health care providers from moving to or practicing in the area. Full or even partial abolishment of joint and several liability, already undertaken by 36 states, would provide one measure of fair protection for providers. Reforms that discourage frivolous lawsuits, such as pretrial screening panels or case certification, would also be an important step in taming Puerto Rico's litigious environment.
As noted above, Puerto Rico faces a health care provider shortage, particularly for emergency physicians and surgical specialists. Advancing medical liability reform would help to retain current providers. Puerto Rico should also investigate other reasons for provider shortages, such as the loss of talented physicians to the mainland or an inadequate pipeline for attracting talented high school and college students to medical schools. These provider shortages affect all aspects of health on the island, from routine preventive care and necessary emergency care to the territory's ability to prepare adequately for a disaster situation.
Little can be said about Disaster Preparedness due to a lack of information, but Puerto Rico should explore increasing its hospital capacity for responding to a disaster situation, in addition to expanding its workforce. Puerto Rico has very few ICU beds available and no burn beds, which may result in critical overcrowding in the event of natural disasters, such as hurricanes and floods. Although Puerto Rico has a Medical Reserve Corps, it should explore the development of an Emergency System for Advance Registration of Volunteer Health Professionals. This system standardizes the recruitment of emergency volunteers and provides guidance in verifying credentials, licenses, and hospital privileges so that the government can confirm that qualified medical response volunteers are mobilized quickly.
To improve the overall health of its citizens, Puerto Rico must address the critically low rates of immunizations among older adults in order to improve health outcomes and lessen the burden on the emergency system of care. Reducing rates of preventable deaths should be a priority, and Puerto Rico should continue outreach and education efforts to further lessen the impact of alcohol use in traffic fatality rates.
Finally, electronic medical records and computerized practitioner order entry can help reduce medication and treatment mistakes in hospitals, and Puerto Rico should encourage its medical facilities to speed up their adoption of these technologies.