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entitled 'Disaster Preparedness: Preliminary Observations on the 
Evacuation of Hospitals and Nursing Homes Due to Hurricanes' which was 
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February 16, 2006: 

Congressional Committees: 

Subject: Disaster Preparedness: Preliminary Observations on the 
Evacuation of Hospitals and Nursing Homes Due to Hurricanes: 

During disasters, administrators of health care facilities are faced 
with decisions about how to operate and care for patients, including 
when and how to evacuate patients if the facility becomes unable to 
support adequate care, treatment, or services. Hospitals and nursing 
homes are required to have plans in place that describe how they will 
operate during emergencies. Hurricanes Katrina and Rita were incidents 
of national significance that highlighted the challenges involved in 
evacuating vulnerable populations, including those in hospitals and 
nursing homes. Federal officials used the National Disaster Medical 
System (NDMS) to help evacuate patients due to Hurricane Katrina--the 
first time the system has been used to evacuate such a large number of 
patients. Formed in 1984, NDMS is a partnership among the Department of 
Defense (DOD), the Department of Health and Human Services (HHS), the 
Department of Homeland Security (DHS), and the Department of Veterans 
Affairs (VA). 

We have begun work to assess the evacuation of hospital and nursing 
home patients due to disasters. We are performing this work under the 
Comptroller General's authority to conduct evaluations on his own 
initiative.[Footnote 1] To conduct our review, we obtained information 
on (1) who is responsible for deciding to evacuate hospitals and 
nursing homes, (2) what issues administrators consider when deciding to 
evacuate hospitals and nursing homes, and (3) what federal response 
capabilities support the evacuation of hospitals and nursing homes. The 
Senate Committee on Health, Education, Labor, and Pensions requested a 
briefing on the preliminary observations of our review. We briefed the 
committee with other committees of jurisdiction on February 16, 2006. 
This report documents our preliminary views as presented in those 
briefings. (See encl. I.) We anticipate completing our work in the 
summer of 2006 and will issue a final report at that time. 

To provide this information, we interviewed officials in Florida in 
areas that experienced hurricanes in 2004, including officials from 
three hospitals and three nursing homes that experienced Hurricane 
Charley, state officials, and local emergency management officials in 
two counties. In addition, we interviewed officials from national 
hospital and nursing home associations, Florida hospital and nursing 
home associations, and Louisiana nursing home associations. We also 
interviewed federal officials from DOD, HHS, DHS, the Department of 
Transportation (DOT), and VA. We also reviewed documents, including 
emergency management plans from Florida, Louisiana, Mississippi, local 
governments, hospitals, and nursing homes; federal documents such as 
the National Response Plan, which describes how the federal government 
assists in managing incidents of national significance; and other 
relevant federal documents. Our work was performed from January through 
February 2006 in accordance with generally accepted government auditing 
standards. 

In summary, we found that hospital and nursing home administrators are 
often responsible for deciding whether to evacuate patients from their 
facilities due to disasters, including hurricanes or other natural 
disasters. State and local governments can order evacuations of the 
population or segments of the population during emergencies, but health 
care facilities may be exempt from these orders. Hospitals and nursing 
home administrators told us that they evacuate only as a last resort 
and that facilities' emergency plans are designed primarily to shelter 
in place. Administrators consider several issues when deciding to 
evacuate or to shelter in place, including the availability of adequate 
resources to shelter in place, the risks to patients in deciding when 
to evacuate, the availability of transportation to move patients and of 
receiving facilities to accept patients, and the destruction of the 
facility's or community's infrastructure. Nursing home administrators 
must also consider additional factors, including that their residents 
generally have no other home and cannot care for themselves, and the 
necessity to locate receiving facilities that can accommodate residents 
for a long time. Finally, NDMS, a federal system, can provide 
assistance with evacuation of hospital patients, such as providing 
transportation from one location to another. Federal officials told us, 
however, that NDMS was not set up nor is it currently configured to 
provide assistance evacuating nursing homes. In our ongoing review, we 
are continuing to examine the vulnerabilities of nursing homes in 
future disasters, particularly hurricanes. 

We discussed the facts contained in this report with DOD, HHS, DHS, and 
VA officials, and they generally agreed with them. 

We are sending copies of this report to congressional committees and to 
the Secretaries of Defense, Health and Human Services, Homeland 
Security, Transportation, and Veterans Affairs. We will also make 
copies available to others upon request. In addition, the report will 
be available at no charge on GAO's Web site at http://www.gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7101 or bascettac@gao.gov. Major contributors 
to this report were Linda Kohn, Assistant Director; La Sherri Bush; 
Nkeruka Okonmah; and William Simerl. 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care: 

Enclosure: 

List of Committees: 

The Honorable John Warner: 
Chairman: 
The Honorable Carl Levin: 
Ranking Minority Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Charles E. Grassley: 
Chairman: 
The Honorable Max Baucus: 
Ranking Minority Member: 
Committee on Finance: 
United States Senate: 

The Honorable Michael B. Enzi: 
Chairman: 
The Honorable Edward M. Kennedy: 
Ranking Minority Member: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Susan M. Collins: 
Chairman: 
The Honorable Joseph I. Lieberman: 
Ranking Minority Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Larry E. Craig: 
Chairman: 
The Honorable Daniel K. Akaka: 
Ranking Minority Member: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Duncan L. Hunter: 
Chairman: 
The Honorable Ike Skelton: 
Ranking Minority Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Joe Barton: 
Chairman: 
The Honorable John D. Dingell: 
Ranking Minority Member: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Tom Davis: 
Chairman: 
The Honorable Henry A. Waxman: 
Ranking Minority Member: 
Committee on Government Reform: 
House of Representatives: 

The Honorable Peter T. King: 
Chairman: 
The Honorable Bennie G. Thompson: 
Ranking Minority Member: 
Committee on Homeland Security: 
House of Representatives: 

The Honorable Steve Buyer: 
Chairman: 
The Honorable Lane Evans: 
Ranking Minority Member: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable William M. Thomas: 
Chairman: 
The Honorable Charles B. Rangel: 
Ranking Minority Member: 
Committee on Ways and Means: 
House of Representatives: 

The Honorable Tom Davis: 
Chairman: 
Select Bipartisan Committee to Investigate the: 
Preparation for and Response to Hurricane Katrina: 
House of Representatives: 

Disaster Preparedness: Preliminary Observations on the Evacuation of 
Hospitals and Nursing Homes Due to Hurricanes: 

Briefing for Congressional Committees: 

February 16, 2006: 

Evacuation of Hospitals and Nursing Homes Due to Hurricanes: 

* Purpose and Key Questions:  
* Scope and Methodology:  
* Background: 
* Preliminary Observations: 

Purpose and Key Questions: 

Hurricane Katrina was one of the worst natural disasters in U.S. 
history. Some inpatient facilities, including hospitals and nursing 
homes, evacuated due to the hurricane. Some facilities evacuated before 
the storm, while others evacuated after the storm because they were 
unable to sustain operations. 

To assess the evacuation of hospital and nursing home patients, we 
reviewed the following questions: 

1. Who has responsibility for deciding to evacuate hospitals and 
nursing homes? 

2. What issues do administrators consider when deciding to evacuate 
hospitals and nursing homes? 

3. What are the federal response capabilities to support the 
evacuations of hospitals and nursing homes? 

Scope and Methodology: 

We interviewed: 

* officials in Florida in areas that experienced hurricanes in 2004, 
including officials from three hospitals and three nursing homes that 
experienced Hurricane Charley, state officials, and local emergency 
management officials in two counties; 

* officials from national hospital and nursing home associations, 
Florida hospital and nursing home associations, and Louisiana nursing 
home associations; and: 

* federal officials from the Departments of Defense (DOD), Health and 
Human Services (HHS), Homeland Security (DHS), Transportation, and 
Veterans Affairs (VA). 

We reviewed documents, including: 

* emergency management plans from Florida, Louisiana, Mississippi, 
local governments, hospitals, and nursing homes; 

* federal documents such as the National Response Plan, which is the 
framework for how the federal government assists in managing incidents 
of national significance; and other relevant federal documents. 

We conducted our work from January through February 2006 in accordance 
with generally accepted government auditing standards. 

Agency Comments: 

* We discussed the facts contained in this briefing with DOD, HHS, DHS, 
and VA officials. 

* The officials generally agreed with the facts. 

Background: National Disaster Medical System: 

* Formed in 1984, the National Disaster Medical System (NDMS) is a 
partnership among DOD, HHS, DHS, and VA. 

* NDMS's mission includes providing health and other emergency services 
in collaboration with states and other public or private entities. 

* In 2002, Congress transferred NDMS from HHS to DHS, which is 
responsible for the program's activation, administration, and funding. 

NDMS consists of three functions: 

* medical response, which includes health assessments, health care, 
equipment, supplies, and other services at the site of an incident; 

* patient evacuation, which includes communication and transportation 
to evacuate patients from a mobilization center near the incident, such 
as an airport, to reception facilities; and: 

* "definitive care", which includes medical treatment beyond emergency 
care provided upon inpatient admission to an NDMS treatment facility 
(typically a nonfederal hospital that has signed an agreement with 
NDMS). 

Within NDMS, DHS has lead responsibility for medical response; DOD has 
lead responsibility for patient evacuation; and DOD and VA have lead 
responsibility for managing "definitive care."  

Background: National Response Plan: 

* The National Response Plan (NRP) describes how the federal government 
assists in managing incidents of national significance. 

* Under the NRP, DHS can activate NDMS to respond to incidents, 
including a presidentially declared major disaster or emergency under 
the Robert T. Stafford Disaster Relief and Emergency Assistance Act. 
[NOTE]  

* Under the NRP, HHS has overall responsibility for coordinating the 
public health and medical response to incidents, including NDMS 
coordination. 

NOTE: The Stafford Act established programs and processes by which the 
federal government supplements state and local resources in major 
disasters or emergencies. 

Background: Facility Emergency Plans: 

* Hospitals and nursing homes are required to have emergency plans in 
place. 

* The Centers for Medicare & Medicaid Services requires hospitals and 
nursing homes that receive Medicare or Medicaid payments to maintain 
emergency plans. 

* The Joint Commission on Accreditation of Healthcare Organizations 
requires that hospitals and nursing homes it accredits maintain 
emergency plans that include processes for evacuations. 

* For our purposes, evacuation refers to moving all patients out of a 
hospital or nursing home to another location. 

Question 1: Responsibility for Evacuation Decisions Often Falls to 
Facility Administrators: 

Hospital and nursing home administrators often have the responsibility 
for deciding whether to evacuate their patients or to shelter in place 
during a disaster. 

* State and local governments can order evacuations of the population 
or segments of the population during emergencies, but health care 
facilities may be exempt from these orders. Administrators told us that 
they evacuate only as a last resort and that facilities' emergency 
plans are designed primarily to shelter in place. 

* Officials from two Florida counties told us that they can recommend 
that hospitals and nursing homes evacuate their facilities, but the 
final decision is made by the hospital or nursing home administrator. 

Question 2: Administrators Consider Several Issues When Deciding to 
Evacuate Hospitals and Nursing Homes: 

The facility must have adequate resources to shelter in place. 

* Examples of resources include staff, supplies, food, water, and 
power. Without these resources, a facility may be unable to care for 
patients at the facility, and therefore may be more likely to evacuate. 

Risks to patients must be considered in deciding when to evacuate. 

* Evacuating too soon may place patients needlessly at risk if the 
potential threat does not materialize. 

* Evacuating at the same time as the general public may increase risk 
to patients' health if traffic congestion and other road complications 
increase travel time. 

* Evacuating too late increases risk if patients do not arrive at their 
destination before a storm strikes. 

Evacuating a hospital or nursing home requires a facility to secure 
transportation to move patients and a receiving facility to accept 
patients. 

* Hospital and nursing home association representatives told us that 
facilities are likely to have arrangements for these services locally, 
but they are less likely to have arrangements with organizations in 
other localities or states, as was necessary for an event such as 
Hurricane Katrina. 

* Hospital and nursing home representatives told us that their 
contracted transportation providers would be unlikely to support them 
during a major disaster because local demand for transportation would 
exceed supply. For example, a nursing home in Florida had to request 
transportation from a source approximately 2 hours away because local 
resources were not available. 

The destruction of facility infrastructure due to a storm may force a 
facility administrator to decide to evacuate after the event due to 
building damage or a lack of utilities. For example, a nursing home in 
Florida evacuated after Hurricane Charley i n 2004 because the 
facility's roof was destroyed and the facility lost power and water 
service. 

The destruction of community infrastructure, such as the loss of 
communications systems and transportation routes, can further 
complicate the decision to evacuate. For example, during Hurricane 
Katrina, the destruction of communications systems left hospital and 
nursing home administrators unable to receive basic information, such 
as when assistance would arrive. 

Nursing home administrators must also consider additional factors. 

* Nursing home administrators told us that they cannot reduce the 
number of residents because residents generally have no other home and 
cannot care for themselves. In contrast, hospital administrators told 
us that it is common to discharge as many patients as possible before a 
disaster to reduce the number of patients who need to be sheltered or 
evacuated. 

* When a nursing home evacuates, the administrator must locate 
receiving facilities that can accommodate residents for a potentially 
long period. For example, a nursing home administrator in Florida told 
us that the facility had to relocate residents for over 10 months 
because of damage to the facility. 

Question 3: NDMS Can Provide Assistance to Hospitals with Patient 
Evacuations, but Does Not Address Nursing Homes: 

NDMS, a federal system, is designed to evacuate patients who need 
medical care from an area near the incident site to reception areas 
where they can receive continuing medical care. 

* Hurricanes Katrina and Rita were the first times that officials used 
NDMS to evacuate such a large number of patients-moving them to patient 
reception areas in the southern United States. 

* VA and DOD officials estimate that NDMS reception areas received 
about 2,900 people due to Hurricanes Katrina and Rita. 

* Officials told us that the total number of patients evacuated is 
unknown because patients may be evacuated by means other than NDMS, 
including private, local, or state resources. 

NDMS has agreements with nonfederal hospitals to receive evacuated 
patients, but does not have agreements with nursing homes. Federal 
officials told us that NDMS was not set up nor is it currently 
configured to provide assistance evacuating nursing homes. 

Preliminary Observations and Next Steps: 

Hospital and nursing home administrators often have the responsibility 
to decide whether to evacuate their facilities, and must weigh the 
potential risks. 

The federal government can assist hospitals with patient evacuations 
using NDMS, but the system does not address nursing home needs. 

We are completing our work to assess the evacuation of hospital and 
nursing home patients and to examine the vulnerabilities of nursing 
homes in future disasters. 

We expect to complete our work in the summer of 2006. 

[End of slide presentation] 

(290528): 

FOOTNOTES 

[1] 31 U.S.C.  717(b)(1) (2000).