New research from the University of South Florida suggests evacuating nursing home patients before a storm increases the chance of both hospitalization and death.
The study -- which looks at hurricanes -- recommends nursing homes "shelter in place," or not evacuate unless a facility gets flooded or severely damaged.
Health News Florida's Daylina Miller recently spoke with Kathryn Hyer, the director of the Florida Policy Exchange Center on Aging at USF, about her research:
You testified recently before the U.S. Senate Special Committee on Aging that evacuating nursing home patients is not always the safest option during events like hurricanes. So what can you tell me about your study?
Our study is based on work that was funded by the National Institutes of Health. And in that study we looked at four different hurricanes. We looked at the hurricanes that were affected Texas and Louisiana, hurricanes Katrina, Rita, Ike and Gustav. Those were hurricanes in 2004 and 2008. In those studies, we carefully looked at the nursing homes that sheltered in place or stayed where they were before the storm, versus the nursing homes that are evacuated.
Our work indicated that regardless of whether places evacuated or sheltered in place, hurricanes created an increased rate of death. In fact, we found that an extra 277 deaths occurred and 872 hospitalizations occurred during those storms as a result of the hurricanes.
However, our work then looked at what were the different death rates and hospitalization rates for nursing homes that sheltered in place, versus those that actually evacuated. And we found that when you looked at those same buildings, the people who evacuated had higher death rates and higher hospitalization rates.”
So what are the factors that make it so much more dangerous to evacuate these patients as opposed to sheltering in place?
Well, I think it's very important to understand, that first of all, nursing home residents are fragile. These are vulnerable people for whom there are many different needs and requirements. They are in a nursing home because they require 24-hour care from skilled clinicians. So they're very sick. They have high levels of co-morbidities, these residents have high levels of diseases, and many of them suffer from congestive heart failure or diabetes. And many of them have cognitive impairments -- severe cognitive impairment -- Alzheimer's disease and other conditions that make it difficult for them to be able to be cared for outside of this skilled 24-hour care place.
The important part as well is that these individuals when they're in a nursing home receive, on an ongoing basis, carefully crafted care. They get their medications at normal times. They have an environment that is cooled and warmed the way it should be. They have food delivered on a normal basis and lots of skilled services being delivered. During a hurricane, during a disaster situation, those carefully scheduled routines obviously aren't able to be conducted in the way that you would love. And as a result, we believe that that kind of careful work is not able to be done during a disaster. So they are at risk. It is also true, and we know this from other studies, that there is a tension level within a facility that's getting ready to evacuate or getting ready just to prepare for the storm.
There is much more anxiety among the actual staff who work there and that also probably contributes to an increased anxiety for the residents of the home themselves. But we do believe that the medication schedule probably gets somewhat disrupted, the ability to deliver food in the normal way you would, the ability to have therapies, and all of that, gets changed during a disaster. And that is not good for the individuals for whom that is happening.
So what recommendations can you make moving forward?
Well, we have a whole series of recommendations. One of the first recommendations is that we believe that people do need to try to shelter in place. When we say shelter in place, we mean that you stay there until you can't stay there anymore. So there are situations where, even after the storm, there are roofs that blow off or there are problems where the building is not able to be sustained; you're not able to have the generator working and the conditions become too hot for residents to continue to remain. But ideally, places and buildings would be built in a way that allow them to be able to sustain and be able to keep residents during a storm.
The second recommendation we have is that generators be required. There are new regulations coming for nursing homes that are coming in on Nov. 15 that would require all nursing homes to have adequate alternative power to maintain the air temperature between 71 and 81 which is the requirement for a nursing home. And that would generally require a generator to be had. That is not true for assisted living. It is only nursing homes that are going to be required to have generators starting Nov. 15. But as we found out here in this storm, the generators were not always able to be sustained and that there were not adequate generators for many facilities in this state.
Another recommendation that we have is that emergency plans be published, and that both assisted living and nursing homes have their plans available for people who are interested in going to that assisted living or that nursing home to understand what the plan would be. Are they planning to stay unless it's a level three storm? Are they planning to stay or are they planning to leave no matter what happens? Exactly what plans people have and how well they've practiced those plans out or not is not clear.
We also believe that assisted living require much more oversight than they currently receive.
Another recommendation we have is that there be a more nuanced evacuation plan, that not all residents need to leave or all residents need to stay. And we currently do have that in most nursing homes in Florida. Have the evacuation of dialysis patients, for instance, or they certainly try to make sure that patients who receive dialysis get care before the storm.
And if it's going to be an extended period of time, they may actually transfer them to a different place. But we need to think much more carefully about who should stay and who should go based on their conditions and what you would expect to be the state of the facility after the evacuation.
Another recommendation we have is that nursing homes and assisted living be built in places where they can sustain storms. We have too many nursing homes and assisted living in floodplains and those buildings are not prepared. It appears that some are not prepared to deal with storm surge or to deal with even flooding on what could be easily a normal summer day in Florida.
We also believe that local emergency and state management preparedness management organizations, that actually are in control of the resources in an area, that they understand and learn more about assisted living and nursing homes in their communities, in their counties. In Florida, that is true. Most local emergency management systems do work with the nursing homes and some work with assisted living. But that needs to be done much more systematically. The nursing homes and assisted living facilities need to be incorporated into their drills and their preparedness scenarios and even some of the full-scale evacuation plans they may have or scenarios that they've done.
I believe, and I think my colleagues believe, that we also need some degree of litigation protection for people who are trying to do their job well after a disaster. There's a lot of Monday-morning quarterbacking and there are cases where people who have tried very hard and heroically tried to work in the nursing home, or in assisted living, are sued because there are bad outcomes.
Finally, we believe that there needs to be much more money that's spent from the federal government to allow this disaster preparedness work to be done more systematically. Immediately after Katrina, there had been money and much of that money was spent. Well it's part of the reason why we've had the improvements and changes we've had. But that money has dried up. And I think the results of both Harvey in Houston, and Irma here in Florida, have indicated that there needs to be more money that's available for studying and for understanding how to do training, to make sure that the disaster preparedness work continues and is done on an ongoing basis.
How have nursing home emergency plans changed since hurricanes like Andrew and Katrina- and now we have Harvey, Irma and Maria?
There have been substantial and important improvements since 2004, when there were four storms in 44 days here in Florida, and then in 2005 Katrina. Nursing homes were not routinely incorporated into this emergency planning scenario. Many states didn't even know where the nursing homes were. From an emergency preparedness position, there were places that were told to wait in line for water as though they didn't have 120 frail and vulnerable residents on average sitting in their building. There was very little, if any, recognition of the need to restore power on a priority basis, which remains one of our important recommendations, but it has really improved. You would be hard pressed today, in either Texas or in Florida, to not know where the nursing homes were.
It's not clear that everybody understands exactly where the assisted livings are. There are 3,000 assisted living facilities in Florida and they constitute about 94,000 beds. There were 680 nursing homes in Florida and there are about 4,000 or 5,000 beds in those nursing homes. So you can see that the assisted living, as well many more, are also on average much smaller. So it is a difficult issue to make sure that we capture the assisted living. But the nursing homes really have been incorporated into emergency preparedness plans.
The Nursing Home Association, along with the Agency for Healthcare Administration, had daily calls inviting all nursing homes in the state to call in to get updates to make sure that if they were having problems, that they could voice those problems on a call and be allowed to be entered into an emergency planning database that the state has.
Florida has done a remarkable job in trying to make sure that they know about the beds and the people and the nursing homes that are in the path of the storm and they have done a very good job of trying to update that. However, as you and I both know, when a disaster strikes, it's hard to make sure that you are logging in and giving updates on it on a daily basis for what's really going on. You're trying to take care of your patients, you're trying to make sure that things are done well.”
You talked about applying for a grant to further this research. What happens now for your team?
We’re going to try to make sure that we do everything we can to try to understand what has happened. We'll be working to try to capture some data now and do some preliminary work. We will be applying for both federal grants and potentially for some local foundation grants to try to make sure that we understand what has happened, what we can learn, and what can be done to improve the system.
Is there anything that I haven't asked about your research that you think people should know about?
I think it is really important that we understand that generators matter. There's been a new emergency rule put out by Gov. Scott that I actually agree with. That rule requires all assisted living and nursing homes to have generators that would sustain the air conditioning, as well as other components within the building, and that those requirements be met within 60 days.
There is obviously a lot of pushback on that 60-day requirement, but it is expensive. The estimation for nursing homes is that it's going to cost almost $3,000 a bed. So if a normal nursing home is 120 beds, that's $360,000 to put in a generator. That's not refitting a building to make sure that it can sustain that kind of a generator. The requirement also requires 96 hours or four days worth of fuel and that's not an inconsiderable amount of fuel and money. So these are important components for a firm disaster preparedness but they're not trivial costs.
It’s very important that we think about how buildings are built. ... And as we build new buildings, and there are new buildings that are being built in Florida, I think that we should be thinking about how emergency preparedness gets incorporated into the overall structure of those buildings.
I think it's really important for people to understand the logistics of an evacuation. That's part of why sheltering in place makes more sense in order for a building to evacuate. You have to have name tags or wristbands put on every resident. Every resident has to have a printed sheet with their information and their personal information, but not too much, because that would violate the laws. You have to have their latest medication administration record - what kinds of medications they take, what doses they take, and how frequently they get those medications.
In addition to that, you have to have put together in a waterproof bag that's large enough for this material. And also large enough for the resident to have in that same bag a change of clothes, personal effects that matter to them, potentially glasses, hearing aids, batteries for the hearing aids, materials that are important to them.
It's very important to realize that the majority of workers in a nursing home are certified nursing assistants who, on average, have about a $10- or $11-an-hour job. Ninety percent of them are women and many of them are moms with kids who need to make sure that those children come and accompany them along with their pets and their toys in order for those children to be able to be comfortably taken care of, but not such a distraction that the staffer can't do the work that needs to be done.
The workers are working on average 12-hour shifts - so they work 12 hours on and then they have 12 hours off. It's exhausting and they're very tired and they're working in conditions that are difficult sometimes without lights. They're trying to move residents on the floor. They're trying to reposition them. They're trying to help, including making sure that they give personal care or incontinence care. They're trying to make sure that they're doing this all with dignity and sensitivity to the individuals who are being evacuated. That's a big job and it's a job that requires not only logistics, but a lot of care and a lot of compassion. And I think the majority of individuals who are doing this work are doing it because they care about the residents.
It's also really important to understand that probably 60 to 70 percent of the residents of nursing homes have dementia. They have Alzheimer's disease or cognitive impairment. And for those residents it's really important that you have a routine that the people who are working with them know them, that you're dealing with care in a sensitive way.
That's part of the reason why some of these recommendations to evacuate to a normal shelter is not a reasonable expectation from my perspective. If you put people who are easily confused and upset when their routine is not there, or who they don't understand in that kind of situation, you are endangering them and probably others because they don't understand and they may act out. They may have what we call catastrophic responses, but they're scared, they're frightened. And what you need to have is more calming and predictable environment. And that's very difficult thing to do under the best of circumstances. But in a disaster area or a disaster time, it is harder to do.
It's also important to point out that in assisted living, the estimates are as much as 50 percent of the assisted living residents also have dementia. And there are many assisted living that are developed and designed specifically to do cognitive impairment and to work with people with Alzheimer's disease or other diseases.
