Emergency Care Must Continue Despite the Demands of COVID-19
With the rise of COVID-19, and construction of a new 100-bed COVID treatment center, expansion of Haiti’s busiest Emergency Department was put on pause. But as 2021 begins, the newly renovated Emergency Department is ready to open its doors.
Every morning from August to November last year, Assistant Site Manager Sanel Lise would stand at the entrance to the construction site at Hôpital Universitaire de Mirebalais where Build Health International (BHI) was completing a 4,360-square-foot expansion and redesign of the Emergency Department. Wearing a mask and holding a contactless thermometer, Sanel would take the temperature of each team member as they arrived.
Masks and temperature checks are just a few of the adaptations that have enabled BHI to restart critical health infrastructure projects during the pandemic. Globally, the engineering and construction sector has been hit particularly hard by the COVID-19 pandemic, with the Global Construction Activity Index dropping 24 points in Quarter 2 of 2020.
The COVID-19 pandemic put the Emergency Department project on pause for five month in early 2020 after Haiti announced its first two cases of the virus in March and immediately went into lockdown. Both patients were admitted to Hôpital Universitaire de Mirebalais for critical care — one of the few hospitals with equipment and specialized staff necessary to safely place patients on ventilators.
As COVID-19 cases rose rapidly around the world, BHI began shipping emergency supplies and personal protective equipment from our Boston-area warehouse to partners in Haiti and across Latin America and Africa. An all-Haitian team led the construction of two COVID-19 treatment centers — one in Haiti’s Southern Peninsula at St. Boniface Hospital, the other at Hôpital Universitaire de Mirebalais.
But both BHI and Zanmi Lasante — Partners In Health’s sister organization in Haiti — also recognized that individual and community health emergencies do not stop with a global emergency declaration. The leading causes of death in Haiti are stroke, heart disease and lower-respiratory infections — none of which are halted by a global emergency. It was critical that construction of the new Emergency Department at Hôpital Universitaire de Mirebalais restart as quickly as possible.
Revolutionizing care: Haiti’s first Emergency Department
Though small — only 15 beds and 4,500-square-feet — the original Emergency Department Hôpital Universitaire de Mirebalais has already transformed emergency care in Haiti.
Despite an exceptionally high need — 90 percent of trauma-related deaths and 75 percent of non-communicable disease deaths worldwide occurring in low- and middle-income countries — emergency medicine is often overlooked and under-resourced in global health. The same is true in Haiti where, until recently, no system of triage or formal training in emergency medicine existed. Prior to the devastating 2010 earthquake, a few facilities would keep a small department open 24 hours for emergency cases, but these were staffed by generalists and admitted patients first-come-first-serve, like a doctor’s office.
The earthquake, which damaged or destroyed 30 of the 49 hospitals in the affected area, brought into sharp relief the need for strengthened emergency services. At the time, none of the country’s medical schools or teaching hospitals trained doctors in emergency medicine.
“The temporary field hospitals set up by foreign teams had their own triage systems,” says Jim Ansara, BHI’s co-founder who was on the ground in Haiti in the wake of the earthquake. “But local health facilities and medical teams were unaccustomed to the systematic use of triage methods. Patients — transported by the community — surrounded the clinics waiting for care, but the need was overwhelming and there weren’t the systems to move through caring for a high volume of critical patients.”
When Hôpital Universitaire de Mirebalais opened in 2013, it introduced the first permanent specialized Emergency Department in the country. A year later, Zanmi Lasante launched Haiti’s first residency program in Emergency Medicine at the hospital. The first class graduated in 2017; 18 emergency doctors have now graduated the program, most of whom have stayed in Haiti and gone on to staff new emergency departments across the country.
Building a bigger dream: the new Emergency Department
“When we were first designing the Emergency Department in 2010, we didn’t have a lot of data to go on,” says Ansara. “We knew there was a huge need for these services, but the demand has been greater than even we imagined.”
In June, the CDC released a report finding that in the early months of the pandemic, US emergency room visits were down 42 percent as patients avoided hospitals out of fear of COVID-19. In Haiti, this avoidance is not an option. In low-income countries, like Haiti, emergency care is often patients’ primary access point into the health system. Barriers to accessing affordable primary care mean patients are often forced to delay seeking care until their disease or condition becomes critical. Today, the Emergency Department provides care to over 14,000 patients annually — of which 25 percent are pediatric cases and 20 percent are trauma-related.
At only 4,500-square-feet and 15 beds, it was clear that additional space and resources would be needed to continue to meet the high demand for services. “It’s incredible that this ED existed and was helping meet the need, but it was also straining and busting at the seams,” said Caitlin Candee, a site supervisor for BHI.
So, in 2019, Build Health International and Zanmi Lasante agreed to redesign the Emergency Department. The original Emergency Department was a big step forward for Haiti’s public health system, thus it was fitting that the redesign start with an equally big question: if money were no concern, what would the dream Emergency Department be?
The first answer: bigger! Much bigger. And safer for patients and staff alike.
In June 2019, Build Health International broke ground on the new emergency department — a renovation and expansion that would bring the facility to 8,860-square feet and 36 beds. “The old space was gutted,” says Candee. “We took out walls, we took out rooms, we demoed the ceiling, we demoed the electrical.”
Now, the new open layout allows for an improved line of sight from the nurse’s station to patients, enabling closer monitoring. Each wing — including intensive care, sub-acute care (casts, sutures), and observation — has a dedicated nurse’s station, prefabricated and tested for quality in Build Health International’s Boston-based workshop with materials and finishing donated by New England Lab & New England Caseworks.
The Emergency Department’s staged design can better accommodate fluctuations in patient volume. Larger and more flexible waiting areas will better accommodate patients’ families, who often play an essential role in care. Expanded storage areas will also help accommodate greater reserve supplies, mitigating the impact of unreliable supply chains and ensuring the hospital can continue providing critical care in times of crisis.
“We learned a lot in building the first emergency department and seeing how it has been used the past seven years,” says Miguel Vasquez, Project and Engineer Site Supervisor for the expansion. “We’re excited for the new facility to once again help elevate the highest standard of care in Haiti.”
January 2021: Addressing multiple crises simultaneously
After a series of stops and starts over the past year and a half, on January 11, 2021, the long awaited Emergency Department finally opened. “A resilient health system is one that can address multiple crises simultaneously,” says Ansara. Now, with both a COVID-19 treatment center and an emergency department that’s more than doubled in capacity, Hôpital Universitaire de Mirebalais is better equipped to address these dueling health crises and emerge stronger.
Ela Hefler is Build Health International’s Communications and Project Development Manager. She writes about the intersections of health and infrastructure, with a focus on the impact of BHI’s work on fragile health systems.
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