The assessment of Puerto Rico’s emergency care system environment uses a similar methodology to that applied to the 50 states and DC. As such, the data presented for Puerto Rico are from the same sources as the data presented for the states with very few exceptions noted in the appendices. Since much of the data presented for the states did not include Puerto Rico, a true comparison was not possible, and a grade was not given.
Puerto Rico faces many of the same emergency care issues that confront numerous states, in addition to some unique challenges specific to the island. Puerto Rico lacks many of the 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 is at a critical juncture. The shortage of emergency physicians is rampant throughout Puerto Rico, where there are only 1.3 board-certified emergency physicians per 100,000 people. Contributing to the overall health care workforce shortage in Puerto Rico is the rate of registered nurses (395.3 per 100,000 people), lower than in any state in the nation and less than half the average across the states. Due to this health care workforce shortage, only three hospitals throughout the island have 24-hour coverage by trained emergency medicine physicians and Puerto Rico’s only trauma center is unable to provide 24-hour coverage. Puerto Rico also has a lower per capita rate of emergency departments and pediatric specialty centers (3.8 and 2.0 per 1 million people, respectively) than the rest of the nation. Finally, Puerto Rico has relatively few inpatient and psychiatric care beds, along with a high daily hospital occupancy rate, which can contribute to issues such as crowding and emergency department boarding.
The Quality and Patient Safety Environment in Puerto Rico benefits from funding for an EMS medical director position and a rate of emergency medicine residents (7.4 per 1 million people) only slightly lower than the average across the states. In addition, the Commonwealth has implemented a trauma registry. On the other hand, Puerto Rico lacks funding for quality improvement within the EMS system, and does not have stroke and STEMI systems of care or a uniform system for providing pre-arrival instructions. Perhaps reflective of these and other barriers, Puerto Rico has an extraordinarily low percentage of patients with acute myocardial infarction given PCI within 90 minutes of hospital arrival (17 percent). Despite a willingness and desire to reform the emergency medical system, the island’s developing emergency medicine specialty, which consists of a small group of emergency medicine-trained physicians, has had little success in doing so.
Puerto Rico also faces challenges with regard to the Medical Liability Environment, which has shown little improvement since the last Report Card. Puerto Rico has a higher rate of malpractice award payments (5.6 per 100,000 people) than the average across the states (2.4 per 100,000), though a comparatively low average malpractice award payment ($66,761).
Based on available data, Puerto Rico’s Public Health and Injury Prevention measures show mixed results. The traffic fatality rate is relatively low at 12.9 per 100,000 people, as is the percentage of adults who are obese or binge drinkers (24.7 and 13.8 percent, respectively). Puerto Rico also has significantly fewer adults who are current smokers than the nation as a whole (12.5 versus 20.1 percent, respectively). However, the island has low rates of immunization among older adults, with fewer than one-third of adults aged 65 years and older receiving annual influenza vaccines, and fewer than 30 percent having ever received a pneumococcal vaccine. The national rates are more than twice those rates. In addition, Puerto Rico has a high infant mortality rate (9.2 deaths per 1,000 live births) compared with the United States overall (6.9 per 1,000). Unfortunately, the dearth of additional public health data makes it difficult to provide a true comparison between Puerto Rico and the nation in many respects.
Disaster Preparedness in Puerto Rico could benefit significantly from improvements in the areas of planning and communications. While there is public health and emergency physician input into the state planning process, Puerto Rico lacks a real-time notification system to alert identified health care providers of a disaster event. The state also lacks patient and victim tracking systems, a medical communication system with one layer of redundancy, and a real-time syndromic surveillance system. Puerto Rico fares slightly better with regard to personnel preparedness by requiring training in disaster management and response to bio- and chemical terrorism for all EMS personnel and requiring EMS and essential emergency department personnel to be compliant with the National Incident Management System. With regard to volunteers, however, the state lacks any strike teams or medical assistance teams.
Recommendations. Puerto Rico policymakers should invest in data collection efforts that can be used to assess factors related to public health, access to care, and quality and patient safety. Failing to do so will likely result in funding allocations and interventions that are not scientifically based or that do not address the roots of the problems.
It is imperative that Puerto Rico also address its health care workforce shortage, which affects all aspects of access to medical care, from primary and preventive care to care provided by on-call specialists in the emergency department. Increasing the pool of emergency medicine and other specialist residents may help retain some proportion of those physicians, as might active recruitment efforts. However, Puerto Rico’s high rate of emergency medicine residents combined with the low rate of emergency physicians indicates a need to put in place mechanisms for retaining residents and attracting emergency physicians from the mainland. Providing a more favorable Medical Liability Environment may be a first step in drawing a broader health care workforce to the island and encouraging specialists to be available on call.
Puerto Rico also needs to address the lack of an emergency department diversion policy or protocol to ensure that the same standards are being applied throughout the island. Puerto Rico would benefit in this regard from a policy mandating that hospital diversion times be reported to health officials. Doing so would provide policymakers with the tools for assessing and addressing the root of the problem, enabling them to enact meaningful reform.
Finally, Puerto Rico’s Disaster Preparedness grade could be significantly improved through developing plans pertaining to special needs patients, those needing medications for chronic conditions, and dialysis patients. Puerto Rico could benefit from implementing an island-based health care volunteer registry, such as the Emergency System for Advance Registration of Volunteer Health Professionals, as well as developing medical assistance teams. In addition, Puerto Rico should assess its bed surge capacity in the event of a disaster to identify shortages in hospital capacity that could arise during a major disaster.