The Institute of Forensic Sciences (ICF, in Spanish) and the Demographic Registry turned to technology and training to improve the protocol that records deaths related to Hurricane Fiona to minimize the mistakes made five years ago when Hurricane María hit Puerto Rico.
The deaths linked to Hurricane Fiona, which slammed Puerto Rico on September 19, will presumably be known faster than in the María-related emergency because of the use of the platform called the Vital Information Tracking Application (VITA), which allows digitally recording of the different data items of a death certificate into the Demographic Registry, said ICF Director María Conte, and Wanda Llovet, director of the Registry.
Nearly half of the certificates are still being filled out manually. Llovet said that from June 1 to August 30, 52% of deaths have been reported through the electronic system and the rest manually.
This is largely because 39% of hospitals are still not using the new platform, waiting for their medical staff to be trained; those certificates are still being registered manually. Eighty percent of all deaths in Puerto Rico occur in hospitals or health centers where they are certified by doctors, and the ICF handles the rest.
There are 68 hospitals in Puerto Rico. According to the Department of Health’s Emergency Management Operational Plan. The 130 Diagnostic and Treatment Centers (CDT, in Spanish), are not included in this usage percentage of the platform because they will be integrated into a future stage.
Staff at the ICF and the Registry, as well as funeral agents, have already been trained. The tool is expected to eliminate discrepancies between ICF and Registry figures because both agencies use it, Conte noted.
Before VITA’s implementation, fully recording a death in the database was done manually and took an average of one to two months in non-emergency times and now takes eight to 10 days, the Department of Health (DS, in Spanish) estimated.
The process of completing a death certificate and recording a death — even electronically — includes several steps that depend on the type and place of death, whether the death is certified by a doctor or goes to the ICF for investigation. From one of these two places, the certificate — paper or electronic — passes to the funeral agent before the information is finally reviewed and validated by Registry staff, the last link in the official registration of a death in Puerto Rico’s mortality database.
However, Llovet said the Registry can already see the deaths and their causes immediately on this platform and its staff reviews the cases daily. Both officials added separately that they trust the diligence and accuracy with which the doctors fill out the death certificates, so the distinction can be made about which are hurricane-related deaths.
During Hurricane María, the death data collection system collapsed when the Demographic Registry’s offices were closed due to a lack of electricity, fuel for generators, and communications. When they were able to reopen the central office, they started logging the death certificates that were done on paper weekly and delivered to those offices, so the information was not available for many months. The information was finally provided to the Center for Investigative Journalism (CPI, in Spanish) after a court request for access to information in May 2018. Hurricane María hit Puerto Rico in September 2017.
Meanwhile, the ICF director said the new system should help take “immediate action and mitigate those situations that are causing those deaths” during natural disasters, unlike María when there was no information available because certifying deaths took a long time, as it was done manually.
“Now we’re much more on the lookout for what the situations are, the Registry is more aware of the report, the statistics are coming out faster and the doctors, in general, are more conscious,” Conte said.
The director of the Registry said that even when processed digitally, the steps followed are the same as those of the manual system, but recording the information electronically speeds up the process.
“The doctor is the one who certifies the cause of death. Subsequently, that certificate, which is document RD77, is sent to the funeral home that’s going to handle the funeral arrangements for them to complete the other part of the death certificate. Once the medical and demographic parts are completed, the funeral home moves on to submit the certificate to the Demographic Registry,” Llovet explained.
The director of the Registry added that “the time is reduced because I no longer need to have the staff enter the data after we receive the certificate. The information is entered directly from the hospital, the part that corresponds to the doctor. Later, it goes to the funeral home electronically. The funeral home fills out the part electronically as well, and when it gets to the Registry, that certificate is already fully electronic.”
On the other hand, Conte explained that, since an ICF pathologist must evaluate cremation cases, it is possible then to detect if a case is related to the hurricane, even if the death certificate does not say so.
Oversight system is created
Llovet said that a supervising committee comprising epidemiology staff from the ICF, and the Centers for Disease Control (CDC) was created, which meets several times a week to discuss the cases of deaths that have come in after Hurricane Fiona. She said the team’s epidemiologists check the news and get calls from hospitals about deaths that are suspected to be related to the hurricane.
However, she added that in cases of deaths not evaluated by the ICF, the certification that death is directly or indirectly attributed to Hurricane Fiona is established by a doctor.
According to the DS data, as of September 28, there were 24 cases of deaths associated with Hurricane Fiona, of which 13 are under investigation and 11 are confirmed. Of the confirmed deaths, there is one direct death and 10 indirect ones.
Both officials recalled that after Hurricane María, and due to mistakes in attributing the causes of death to the hurricane, doctors were trained to properly fill out the death certificates, based on CDC guidelines on how to document the deaths and tie them to an atmospheric event. They noted that after the pandemic, they saw doctors properly documented COVID-19 deaths. So, they’re relying on that accuracy being replicated when filling out death certificates after Fiona.
Meanwhile, Conte said the ICF is available to address medical consultations about potential hurricane-related deaths. The pathologist said doctors certify causes of death based on clinical conditions they treat on a daily basis and that it was after the deaths occurred after Hurricane María, that they became aware that patient conditions can be worsened by a hostile environment or condition. However, she said that as part of their training, forensic pathologists get a lot of education on how to link a death to an atmospheric event.
The director of the ICF also said the agency maintains open communication channels with hospitals, so that they can consult via email the cases that must be referred to Forensic Sciences.
“I want to emphasize that those cases [related to the hurricane] don’t necessarily have to be sent to Forensic Sciences unless it’s a traumatic death. But if it wasn’t a traumatic death, if it was an indirect death, because the person used oxygen at home and the power went out and they had a known medical condition, then the doctor doesn’t have to send us those cases, they don’t necessarily have to reach the ICF as long as a doctor certifies it as a hurricane-related death,” said the doctor in pathology.
Conte said they have also re-educated their staff regarding the CDC’s guidelines to carry out this type of screening. In addition, they are using the forms that the CDC uses to interview relatives and witnesses of these suspicious deaths, so that they can recognize if, in fact, they are attributable to the atmospheric event.
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Taasisi ya Sayansi ya Sheria (ICF) na Usajili wa Idadi ya Watu (DEMO) iligeukia teknolojia na mafunzo ili kuboresha itifaki ya kurekodi vifo vinavyohusiana na Kimbunga Fiona ili kupunguza makosa yaliyofanywa miaka mitano iliyopita wakati Kimbunga Maria kilipogonga Puerto Rico. "Kama ilivyoelezwa, ""vifo vinavyohusiana na Kimbunga Fiona, ambacho kilipiga Puerto Riko Septemba 19, vinaweza kujulikana haraka kuliko katika hali ya dharura inayohusiana na Maria kwa sababu ya matumizi ya jukwaa linaloitwa Vital Information Tracking Application (VITA), ambalo inaruhusu kurekodi kwa dijiti vitu tofauti vya data ya cheti cha kifo katika Usajili wa Idadi ya Watu,"" alisema Mkurugenzi wa ICF Maria Conte." Karibu nusu ya vyeti bado ni kujazwa manually. "Luvet alisema kuwa kuanzia Juni 1 hadi Agosti 30, 52% ya vifo vimeripotiwa kupitia mfumo wa elektroniki na wengine kwa mkono. """ Hii ni kwa sababu hospitali 39% bado hazitumii jukwaa jipya, zikisubiri wafanyikazi wao wa matibabu kufundishwa, na vyeti hivyo bado vimeorodheshwa kwa mkono. Asilimia 80 ya vifo katika Puerto Rico hutokea katika hospitali au vituo vya afya ambapo ni kuthibitishwa na madaktari, na ICF hushughulikia wengine. Kuna hospitali 68 nchini Puerto Rico. Kulingana na Idara ya Afya's Emergency Management Operational Plan. Vituo 130 vya Utambuzi na Matibabu (CDT) havijumuishwa katika asilimia hii ya matumizi ya jukwaa kwa sababu zitaunganishwa katika hatua ya baadaye. Wafanyakazi wa ICF na Usajili, pamoja na mawakala wa mazishi, tayari wamefundishwa. "Kama ilivyoelezwa, ""kitengo hiki kinatarajiwa kuondoa tofauti kati ya takwimu za ICF na za Usajili kwa sababu mashirika yote mawili yanatumia chombo hiki,"" Conte alisema." Kabla ya kutekelezwa kwa VITA, kurekodi kabisa kifo katika hifadhidata ilifanywa kwa mkono na ilichukua wastani wa mwezi mmoja hadi mbili katika nyakati zisizo za dharura na sasa inachukua siku nane hadi kumi, Idara ya Afya (DS) ilikadiria. Utaratibu wa kukamilisha cheti cha kifo na kurekodi kifo - hata kwa njia ya elektroniki - ni pamoja na hatua kadhaa ambazo hutegemea aina na mahali pa kifo, ikiwa kifo kinathibitishwa na daktari au huenda kwa ICF kwa uchunguzi. Kutoka moja ya maeneo haya mawili, cheti - karatasi au elektroniki - hupita kwa wakala wa mazishi kabla ya habari hiyo mwishowe kuchunguzwa na kuthibitishwa na wafanyakazi wa Usajili, kiungo cha mwisho katika usajili rasmi wa kifo katika hifadhidata ya vifo ya Puerto Rico. Hata hivyo, Llovet alisema Usajili tayari unaweza kuona vifo na sababu zao mara moja kwenye jukwaa hili na wafanyakazi wake wanachunguza kesi kila siku. "Maafisa hao wawili wameongeza kuwa wanaamini kwa bidii na usahihi ambao madaktari wanajaza vyeti vya kifo, ili kutofautisha kati ya vifo vinavyohusiana na kimbunga.""" Wakati wa Kimbunga María, mfumo wa ukusanyaji data ya kifo ulivunjika wakati ofisi za Usajili wa Idadi ya Watu zilifungwa kwa sababu ya ukosefu wa umeme, mafuta kwa jenereta, na mawasiliano. Baada ya kufunguliwa kwa ofisi kuu, walianza kurekodi hati za kifo ambazo zilifanywa kwenye karatasi kila wiki na kusafirishwa kwa ofisi hizo, kwa hivyo habari haikupatikana kwa miezi mingi. Taarifa hiyo ilitolewa kwa Kituo cha Uchunguzi wa Uandishi wa Habari (CPI) baada ya mahakama kuomba upatikanaji wa habari mnamo Mei 2018. Kimbunga Maria kilipiga Puerto Riko mnamo Septemba 2017. "Mkurugenzi wa ICF alisema mfumo huo mpya unapaswa kusaidia kuchukua ""hatua za haraka na kupunguza hali zinazosababisha vifo hivyo"" wakati wa misiba ya asili, tofauti na Maria wakati hakukuwa na habari inayopatikana kwa sababu kuthibitisha vifo ilichukua muda mrefu, kwani ilifanywa kwa mkono." "Sasa tunaangalia zaidi hali zipo, Usajili unajua zaidi ripoti, takwimu zinatoka haraka na madaktari, kwa ujumla, wana ufahamu zaidi", Conte alisema. Mkurugenzi wa Usajili alisema kwamba hata wakati wa usindikaji wa dijiti, hatua zinazofuatwa ni sawa na zile za mfumo wa mwongozo, lakini kurekodi habari kwa elektroniki huongeza kasi ya mchakato. <unk>Daktari ndiye anayethibitisha kisababishi cha kifo. Baada ya hapo, hati hiyo, ambayo ni hati ya RD-77, hutumwa kwa nyumba ya mazishi ambayo itafanya mipango ya mazishi ili kukamilisha sehemu nyingine ya cheti cha kifo. Mara baada ya sehemu za matibabu na idadi ya watu kukamilika, nyumba ya mazishi inakwenda mbele kuwasilisha cheti kwa Usajili wa Idadi ya Watu, <unk> Llovet alielezea. Mkurugenzi wa Usajili aliongeza kwamba <unk>wakati ni kupunguzwa kwa sababu mimi tena haja ya kuwa na wafanyakazi kuingia data baada ya sisi kupokea cheti. Habari huingizwa moja kwa moja kutoka hospitali, sehemu inayolingana na daktari. Baadaye, inasafirishwa kwa njia ya kielektroniki kwenye nyumba ya mazishi. "Kwa upande mwingine, Conte alielezea kwamba, kwa kuwa mtaalamu wa ugonjwa wa ICF lazima atathmini kesi za kufukuzwa, inawezekana kugundua ikiwa kesi inahusiana na kimbunga, hata ikiwa cheti cha kifo hakisemi hivyo. """ "Luvet alisema ""kamati ya usimamizi inayojumuisha wafanyakazi wa magonjwa ya kuambukiza kutoka ICF na Vituo vya Kudhibiti Magonjwa (CDC) viliundwa, ambayo hukutana mara kadhaa kwa wiki kujadili kesi za vifo vilivyotokea baada ya Kimbunga Fiona.""" "Wanasayansi wa epidemiolojia wa timu hiyo husema kuwa ""wanapokea simu kutoka hospitali kuhusu vifo vinavyodhaniwa kuwa vina uhusiano na kimbunga.""" Hata hivyo, amesema katika kesi za vifo ambavyo havijachunguzwa na ICF, uthibitisho wa kwamba vifo vimeathiriwa moja kwa moja au kwa njia isiyo ya moja kwa moja na Kimbunga Fiona huanzishwa na daktari. Kulingana na taarifa za DS, hadi Septemba 28, kulikuwa na visa 24 vya vifo vinavyohusiana na Kimbunga Fiona, kati ya hivyo 13 ziko chini ya uchunguzi na 11 zimethibitishwa. Kati ya wale waliothibitishwa kuwa wamekufa, mmoja ni wa moja kwa moja na wengine kumi ni wa moja kwa moja. "Wafanyakazi hao wawili walikumbuka kwamba baada ya Kimbunga Maria, na kwa sababu ya makosa katika kuashiria sababu za kifo kwa kimbunga, madaktari walifundishwa kujaza vyeti vya kifo kwa usahihi, kulingana na miongozo ya CDC juu ya jinsi ya kuorodhesha vifo na kuviunganisha na tukio la anga. """ "Waliongeza kuwa baada ya janga hilo, waliona madaktari wakirekodi vizuri vifo vya COVID-19.""" Kwa hiyo, wanategemea usahihi huo ufuatiliwe wanapofungua vyeti vya kifo baada ya Fiona. "Mwanamkubwa Conte amesema ICF iko tayari kutoa ushauri wa matibabu kuhusu uwezekano wa vifo vinavyohusiana na kimbunga hicho.""" "Mtaalamu huyo wa magonjwa alisema, ""Madaktari wanathibitisha sababu za kifo kulingana na hali za kliniki ambazo wanashughulikia kila siku na kwamba ni baada ya vifo kutokea baada ya Kimbunga Maria, kwamba waligundua kuwa hali ya mgonjwa inaweza kuzidi kuwa mbaya na mazingira au hali ya uhasama.""" Hata hivyo, kama sehemu ya mafunzo yao, wataalamu wa magonjwa ya kisheria hupata elimu nyingi juu ya jinsi ya kuunganisha kifo na tukio la anga. "Mkurugenzi wa ICF pia alisema shirika hilo linaendelea kuwa na njia za mawasiliano wazi na hospitali, ili waweze kushauriana kupitia barua pepe kesi ambazo lazima zielekezwe kwa Sayansi ya Forensic. """ "Nataka kusisitiza kwamba kesi hizo [zinazohusiana na kimbunga] hazihitaji kutumwa kwa Sayansi ya Sheria isipokuwa ni kifo cha kiwewe. "Lakini ikiwa haikuwa kifo cha kiwewe, ikiwa ilikuwa kifo kisicho cha moja kwa moja, kwa sababu mtu alitumia oksijeni nyumbani na umeme ulipotea na walikuwa na hali ya matibabu inayojulikana, basi daktari haipaswi kutupelekea kesi hizo, sio lazima wafikie ICF, kwa muda mrefu kama daktari atathibitisha kuwa ni kifo kinachohusiana na kimbunga. """ Conte alisema pia wamewaelimisha wafanyakazi wao kuhusu miongozo ya CDC ya kufanya aina hii ya uchunguzi. "Kwa kuongezea, wanafanya kazi kwa kutumia fomu ambazo CDC hutumia kuhoji jamaa na mashahidi wa vifo hivi vya mashaka, ili waweze kutambua ikiwa, kwa kweli, vinaweza kuhusishwa na tukio la angahewa. """ ¡APOYA AL CENTRO DE PERIODISMO INVESTIGATIVO! (Kituo cha Utafiti wa Kipindi) Tunahitaji msaada wako ili kuendelea kufanya na kupanua kazi yetu.