EDITORIALS

Disaster: Nursing Homes Needto be Prepared

Nina Tumosa, PhD

David Dosa and his colleagues1 have shown us that, onceagain, in the absence of formal rules and regulations, nothingworks better in an emergency than staying calm and usingsome common sense. Whether the emergency is a hurricaneof unprecedented power or an ice storm that has causedwidespread power outages, there are guidelines that adminis-trators can and do use to determine the best course of actionunder the current circumstances. Saliba et al.2 reported thatnursing facilities received limited post-disaster assistance fol-lowing the Northridge earthquake. Problems included staffabsenteeism, communication problems, and insufficient waterand generator fuel.

Briefly put, the choices are to evacuate or to shelter in place.And, as was so publicly demonstrated in 2005 with both Hur-ricane Katrina in the Gulf Region and Hurricane Rita in Texas,decisions to either evacuate or to shelter in place sometimeshave to be reversed in light of new information.

The first lesson coming out of this paper is that you cannever be overly prepared for an emergency. As we all realize,long-term care facilities house the frail,3,4 those with demen-tia,5 and often many persons with low-grade delirium.6 Thesepersons are highly vulnerable and are at increased risk ofdeath. Involuntary relocation of residents from nursing homeshas been associated with increased falls.7 Emergencies are nottimes to be relying on either guardian angels or the kindnessof strangers because both are rather busier than usual duringan emergency. Most of the administrators who Dosa and hiscolleagues1 interviewed thought that they were prepared foremergencies and, at least superficially, they were. It was onlyas the emergency dragged on that flaws in the fabric of theirpreparedness became evident. They had generators, only tolearn that fuel had to be pumped by electricity, which was notavailable in a wide-scale disaster. They had 3 days’ worth ofdiapers, bedding, and food, only to learn that they needed aweek’s worth of those supplies. They had contracted for trans-portation, only to learn that bus drivers had already evacuated

St. Louis VAMC GRECC, St. Louis, MO; Division of Geriatric Medicine, SaintLouis University School of Medicine, St. Louis, MO.

Address correspondence to Nina Tumosa, PhD, Division of Geriatric Medicine,Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis,MO 63104. E-mail: tumosan@slu.edu

Copyright ©2007 American Medical Directors Association

DOI: 10.1016/j.jamda.2007.01.002

EDITORIAL

and that buses could be, and were, commandeered by stateand federal officials to evacuate prisoners. They educated theirstaff members as to why they would be needed at work duringa crisis, only to be reminded that blood is often thicker thanwater. Many staff members chose to evacuate with theirfamilies rather than to remain with and/or evacuate with theresidents. Some administrators, anticipating that this mightbe true, either offered to let family shelter at the nursing homeor to evacuate with the residents. Even those administratorsexperienced dangerously high levels of staff absenteeism duringthe hurricanes. During Hurricane Elena in Pinellas County,Florida, staff had problems passing through police checkpointsto get to work and there was a high rate of staff burnout.8

So what are administrators to do to become appropriatelyprepared for an emergency? Do they continue to learnthrough bitter experience over time and, as a result, becomemore and more prepared with each emergency? Do they try tofind time to train staff about the special needs of the elderlyresidents in times of crisis, especially those with mental orsensory losses, and to practice evacuations with volunteerssubstituting for residents? Do they cause their facilities tobecome more island-like, more isolated and independent,incurring increasing costs in order to be ready for “anything”?

The answer to each of these questions is both yes and no.Experience is a great teacher but the learning curve is costlywhen the pupils are ill and frail, as most nursing homeresidents are. Practice evacuations are theoretically feasibleand practically impossible given the shortages in staff and theother demands on their time. No nursing home can be anisland, even though it should be prepared to subsist at leastbriefly until outside help can arrive. No matter how true allthis may be, it helps neither the nursing homes nor theresidents to limit the answers to emergency preparedness tothese strategies. In fact, there are more things that an admin-istrator and the staff can do. Those options were outlined bothby Dosa et al.1 and in the articles that they cited. There hasbeen no loss of lessons learned about how long-term carefacilities can improve both decision making and proceduresinvolving emergency preparedness. However, by concentrat-ing on lessons learned about how to incorporate new strate-gies into future planning or by bemoaning how hard it is toretain critical staffing during an emergency or by reiteratingthe vulnerability of frail elders during the physically demand-

ing and technically difficult evacuation, we are at risk of

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missing the most important lesson of all. Administrators feltabandoned by state and federal agencies. They were given tofeel that nursing home facilities are not a priority for anyonebut themselves in an emergency.

This is outrageous. This is ageism at its ugliest. This is asituation that has to be changed.

The first step towards change is to address the factors thatcontribute to that perception of abandonment. Dosa et al.1

give us a place to start in this campaign. They point out that,to date, there have not been articulated clear lines of respon-sibility of the public towards frail and vulnerable people livingin private facilities. Although the federal government, in theform of reports from the Office of the Inspector General9 andthe Government Accountability Office,10 has recommendedstrengthening of government oversight and the developmentof reporting relationships between state inspection agenciesand emergency response agencies, no template for the foot-print of such oversight has been provided, nor is there anyapparent intention to provide any funding to facilitate thedevelopment of these relationships. It appears that the federalgovernment has abdicated any responsibility it may have hadtowards the oldest and sickest of its citizens at the time oftheir greatest need. As Leonard et al.11 showed after Hurri-cane Marilyn, there is a need for outreach teams for thehome-bound and nursing home residents who cannot makeexcursions to medical aid stations that are established by theNational Disaster Medical System.

The good news is that these vulnerable citizens are notwithout friends. Nursing home residents have three secretweapons in this fight to be given higher priority in an emer-gency: themselves, facility staff, and their informal (family,friends, and volunteers) caregivers. Residents are repositoriesof experience. Many have already weathered (successfully,obviously) a myriad of emergencies. They have life experi-ences that they can share on how to be prepared for and howto survive an emergency. And they have the best notion ofhow much assistance they now need to survive new emergen-cies. The secret to success here is to gather that informationbefore, not during, an emergency and to put it to use. Thatinformation is best used by the staff. Staff members knowintimately the needs of the residents and the limitations ofthe facility. They can identify the gaps in services that needto be filled. Then these needs must be catalogued andaddressed. For this task, informal caregivers are invaluablepartners in emergency preparedness. They can lead thegrass-roots efforts needed to develop a regional or state-wide resource/training center dedicated to the publichealth and safety of nursing home residents during emer-gencies. This center would coordinate the training andcertification of professionals, paraprofessionals, and infor-mal caregivers in geriatric emergency preparedness.

This center would be responsible for the development ofminimum standards of training of staff and volunteers,establish reasonable expectations for the care of residentsduring both an emergency and the recovery phase fromthat emergency, define the roles of caregivers during emer-gencies, and develop policies to minimize sensationalism

and individual profit that often comes from disasters. The

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center could also work to modify Good Samaritan laws toprotect rescuers who are assisting disaster victims who areremoved from the disaster site. It can address how to getlong-term care facilities recognized as providing essentialservices and therefore in need of priority restoration ofpublic utility services following loss of power. Like mostgood ideas, the development of such a center would requirevolunteer labor and some funding. Modest funding wouldestablish a public office, support the presence of dedicatedpersonnel to organize those volunteers to represent thecause at critical meetings, and do fund-raising activities.This is a small price to pay for increased security of ourmost vulnerable elders. Indeed, several philanthropies havealready shown an interest in supporting work on improvingthe care of the elderly in emergencies. These include theJohn A Hartford Foundation, Atlantic Philanthropies, theRobert Wood Foundation, Retirement Research Founda-tion, AARP Foundation, the Kaiser Family Fund, and theUJA-Federation of New York. Regional and local founda-tions can undoubtedly be convinced to join in this nobleeffort.

Emergency planning is everyone’s business and must ad-dress all three phases of the emergency: preparedness, re-sponse, and recovery.12 As long-term care facilities have de-veloped their emergency plans, they have learned the value ofsharing those plans with sister facilities and local school, fire,and police districts. A priority is the development of alterna-tive housing for evacuees. In Hurricane Georges in Key West,the local jail was used to house more than 300 nursing homeresidents.13 It is essential that facilities develop a simple sheetproviding essential information, including medication for allresidents, that can be available during transitional care. Thiscould be the same form as suggested by Terrell and Miller14 foruse in transitional care between nursing homes and emer-gency departments. The development of electronic healthcare records would be an even better solution.15 Facilitieshave learned that they need to include staff and their familiesin the planning. What has not happened is their inclusion inthe regional and state plans where the authority resides tocommandeer supplies and equipment and to reset priorities.The development of a center to serve as the stakeholder thatis invited to the table during regional planning sessions andto represent the interests of all vulnerable elders, whethercommunity- or facility-based, is the proximal goal here. Thiscenter would also be responsible for coordinating plans forhomebound elders and other persons in the community withspecial needs. It is my belief that this is an area that should beintegral to the expanded role of the medical director.16 Theultimate goal is to ensure quality of life for all of us. And thatis what this is all about: to do unto others as we would havethem do unto us.

REFERENCES1. Dosa DM, Grossman N, Wetle T, Mor V. To evacuate or not to

evacuate: Lessons learned from Louisiana nursing home administratorsfollowing hurricanes Katrina and Rita. J Am Med Dir Assoc 2007;8:142–

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2. Saliba D, Buchanan J, Kington RS. Function and response of nursingfacilities during community disaster. Am J Public Health 2004;94:1436 –1441.

3. Morley JE, Perry HM 3rd, Miller DK. Something about frailty (editorial).J Gerontol A Biol Sci Med Sci 2002;57:M698–M704.

4. Morley JE, Kim MJ, Haren MT, Kevorkian R, Banks WA. Frailty and theaging male. Aging Male 2005;8:135–140.

5. Christensen MD, White HK. Dementia assessment and management.J Am Med Dir Assoc 2006;7:109–118.

6. Lyons WL. Delirium in postacute and long-term care. J Am Med DirAssoc 2006;7:254–261.

7. Capezuti E, Boltz M, Renz S, Hoffman D, Norman RG. Nursing homeinvoluntary relocation: clinical outcomes and perceptions of residentsand families. J Am Med Dir Assoc 2006;7:486–492.

8. Mangum WP, Kosberg JI, McDonald P. Hurricane Elena and Pinellascounty, Florida: Some lessons learned from the largest evacuation ofnursing home patients in history. Gerontologist 1989;29:388–392.

9. Department of Health and Human Services, Office of the InspectorGeneral, Nursing Home Emergency Preparedness and Response During

Recent Hurricanes, OEI-06-06-0020 (Washington, DC: August 2006).

EDITORIAL

10. Government Accounting Office, Disaster preparedness: Limitations inFederal Evacuation Assistance for Health Facilities Should Be Addressed,GAO-06-826 (Washington, DC: July 2006).

11. Leonard RB, Spangler HM, Stringer LW. Medical outreach after hurri-cane Marilyn. Prehospital Disaster Med 1997;12:189–194.

12. Hyer K, Brown LM, Berman A, Polivka-West L. Establishing and refin-ing hurricane response systems for long-term care facilities. Health Aff2006;25:407–411.

13. Wylie T, Cheanvechai D, Seaberg D. Emergency response team:Hurricane Georges in Key West. Prehosp Emerg Care 2000;4:222–226.

14. Terrell KM, Miller DK. Challenges in transitional care between nursinghomes and emergency departments. J Am Med Dir Assoc 2006;7:499 –505.

15. Gloth FM 3rd, Coleman EA, Phillips SL, Zorowitz RA. Using electronichealth records to improve care: Will “high tech” allow a return to “hightouch” medicine? J Am Med Dir Assoc 2005;6:270–275.

16. American Medical Directors Association. Roles and responsibilities ofthe medical director in the nursing home: Position statement a03. J Am

Med Dir Assoc 2005;6:411–412.

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