Avoiding relocation stress

Hurricane Katrina, a category 5 hurricane at peak strength, made landfall in the Gulf Coast on August 29, 2005. The hurricane caused massive destruction, displacing a million people and claiming more than 1,800 lives. Levees broke in New Orleans, submerging a majority of the city and leaving its inhabitants without food, water, and electricity for days. Medical help, security, and supplies were scarce from the beginning of the disaster.

The impact of Hurricane Katrina on the Gulf Coast population was far-ranging. Accounts of locals suffering from lasting detrimental conditions—such as post-traumatic stress syndrome, depression, and anxiety—have been substantiated. Not surprisingly, nursing homes and nursing home residents in the area were also affected.

There were 53 nursing homes in New Orleans at the time of the hurricane. The Louisiana Nursing Home Association stated that 21 nursing homes were evacuated before Katrina hit. As part of this evacuation, many elderly residents were left on buses without air conditioning, sent to locations without medications or medical histories, or put on flights to other nursing homes throughout the country without identification. Some places to which nursing home residents were evacuated were also susceptible to dangerous conditions. Some residents were evacuated to Galveston, Texas, but were then re-evacuated from there soon after arriving when Hurricane Rita threatened the area.

It was reported that at least 140 nursing home residents perished during Hurricane Katrina, some in the nursing homes and others during the evacuation. That is, 10% of the total deaths in Louisiana were nursing home residents. Many of the deaths occurred in the days following Katrina’s landfall due to lack of electricity, decreased supply of medication, and rising temperatures. Other nursing home residents died during evacuation in a widely publicized school bus fire.

The effects of Hurricane Katrina lasted beyond those initial few weeks. Several nursing homes were destroyed, and have not reopened. The authors followed 439 nursing home residents that were transferred to new facilities. After six months these residents were more likely to have suffered from a pressure ulcer when compared to other residents in the Gulf Coast region. Moreover, when compared to similar nursing home residents in the Gulf Coast region who were not evacuated as part of Hurricane Katrina, the mortality rate for these residents is almost double.

Necessary planning

Over the years, much has been written about relocation stress syndrome, reflecting on the often diminished health capacity of residents and their ability to be further challenged by the adverse circumstances associated with moving to different environments. The findings for those 439 residents would appear to be an extreme example of the potential negative influence of such moves; and, in this case, it may be more appropriately termed dislocation stress rather than relocation stress.

These findings are clearly tragic. They do, however, serve as a reminder of the importance of disaster planning. It is critical for nursing home evacuations to provide adequate transportation, communication, supplies, staffing, and shelter. Indeed, the Department of Health and Human Services has in the past reported that the problems associated with Hurricane Katrina can be tied to a lack of effective planning in this area.

Federal law requires Medicare- and Medicaid-certified nursing homes to maintain written evacuation plans for all potential emergencies and disasters. Yet, many plans are still found to be lacking. Post Hurricane Katrina, much emphasis has been placed on specific citations (F-517, F-518, K-48, and K-50) representing written emergency plans, staff training, written evacuation plans, and fire drills, respectively, which are part of the survey and certification process. Approximately 0.6% of facilities per year receive a F-517 citation (written emergency plans), 2.1% per year a F-518 citation (staff training), 1.2% per year a K-48 citation (written evacuation plan), and 7.9% per year a K-50 citation (fire drills).

Reviewing procedures

Clearly, it is important for facilities to train staff on all evacuation procedures and carry out periodic drills to ensure compliance. Evacuation plans should incorporate not only evacuation procedures, but take into consideration resident needs. Plans should be in place for both internal and external emergencies including: fire, severe weather, water and power outages, chemical spills, bomb threats, and radiological accidents.

Every staff member (from the receptionist to the charge nurse) should have a specific task during an evacuation, but they must also work together to ensure the safety of each resident. Nursing homes must provide adequate training and surprise drills for staff so that in the event of a real evacuation, the appropriate procedures would be carried out.

Beyond these very basic requirements, the general protocol for evacuation plans comprises: Hazard Analysis, Direction and Control, Decision Criteria, Communication, Community Coordination Procedures, and Specific Resident Needs. Provisions for sheltering in place include: Securing the Facility, Emergency Power, Food Supply, Water Supply, Staffing, Medication, and Serving as a Host Facility. Provisions for evacuation include: Transportation Contract, Evacuation Procedures, Host Facility Agreement, Food Supply, Medications, Transfer of Medical Records, Staffing, Resident Personal Belongings, Reentry, Water Supply, and Evacuation Route.

We examined evacuation plans collected from 2,134 nursing homes. Plan content varied, with 96% of facilities reporting Water Supply provisions, while only 31% had Evacuation Route covered. However, more problematic was the lack of detail in many plans. For example, with a Host Facility Agreement, ranking these from 1 to 10, with 1 representing “mentions host facility arrangements” to 10 representing “includes complete copy of host facility agreements and includes important contact information in evacuation plan,” the modal rank was only at 2, and fewer than 10% of facilities scored a 10.

Facilities can face a number of challenges during a disaster ranging from a decrease in supplies and lack of water and power, to a reduction in available staff. These issues can affect resident care and the ability to successfully carry out an evacuation plan. Yet these risks and difficulties also change over time, necessitating that evacuation plans should be continually updated to take into account any changes in the environment (e.g., problems with evacuation routes due to construction).

With the five-year anniversary of Hurricane Katrina upon us, and with this evidence of the downstream negative impact on residents of relocation, it is prudent to reexamine evacuation plans. Nursing homes care for the frailest of elders and it is critical to protect these residents by implementing, maintaining, and constantly updating disaster protocol.

Nicholas Castle is a professor with the University of Pittsburgh Department of Health Policy & Management. Castle serves on five editorial boards, including The Gerontologist and is a Fellow of the Gerontological Society of America. He can be reached at CastleN@pitt.edu.

Jamie C. Ferguson-Rome, MHA, is a project director with the University of Pittsburgh Department of Health Policy & Management. She can be reached at (412) 383-5363 or by e-mail at jamief@pitt.edu.

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