Chapter 6: Congregate and Residential Care Facilities

Whether planning for sheltering-in-place, moving patients from one facility to another similar facility, or being prepared to take care of and manage individuals from facilities that failed to plan adequately for emergencies, the transportation evacuation planning process should generally occur in parallel with the development of the special needs planning. CRCFs, local EMAs and health departments, and community and faith-based organizations should all work together to ensure the safety of medically vulnerable individuals living in the community.

Clearly, the decision to evacuate whole communities in general is difficult. [58] The evacuation and movement of clients/patients, in whole or in part, of a residential skilled care facility is an action of last resort and must not be treated lightly. In 2006, the GAO released a report, Preliminary Observations on the Evacuation of Vulnerable Populations Due to Hurricanes and Other Disasters that states:

“Hospital and nursing home administrators face challenges related to evacuations caused by hurricanes, including deciding whether to evacuate and obtaining transportation. Although state and local governments can order evacuations, health care facilities can be exempt from these orders. Facility administrators are generally responsible for deciding whether to evacuate, and if they decide not to evacuate, they face the challenge of ensuring that their facilities have sufficient resources to provide care until assistance arrives. If they evacuate, contractors providing transportation for hospitals and nursing homes could be unlikely to provide facilities with enough vehicles during a major disaster such as a hurricane because local demand for transportation would likely exceed supply. Nursing home administrators told us they face unique challenges during evacuations. For example, they must locate receiving facilities that can accommodate residents who may need a place to live for a long period of time.”

Using case studies, the HHS Agency for Healthcare Research and Quality (AHRQ) report Emergency Preparedness Atlas: US Nursing Home and Hospital Facilities illustrates how emergency management agencies can use GIS mapping to locate hospitals and nursing homes. The report provides certain guidance for nursing home emergency evacuation including collected information on disaster-related planning and roles nursing homes could play in regional preparedness such as arranging hospitals to transfer their less-critically ill or recovering patients to nursing homes.

This chapter provides ideas, good practices, and general guidance for transportation evacuation planners. It is not meant to supplant or override local, state, and federal regulations, or to provide legal advice. Each community must know and understand the responsibilities, regulations, and liability issues.

Legal Considerations

The federal government requires all facilities that receive Medicaid and Medicare funding to have emergency plans in place and train their staff. [59] Furthermore, individual states, as part of the licensing process, often put in place additional regulations for skilled care facilities (e.g., nursing homes and other long-term care sites) to meet emergency planning guidance. These regulations are often reviewed over the course of regular, ongoing re-licensing inspections as well as during other periodic peer reviews conducted for the purpose of accreditation. Finally, local fire codes, health safety standards, and emergency rules may apply depending upon what standards have been established in each locality.

Since this particular topic is relevant in the context of the overall primer, but not directly or indirectly overseen or regulated by the US DOT, specific recommendations are not being provided. Rather, the discussion will focus on a checklist for planning and documented issues relating to the transportation of certain populations such as transfer trauma. (See related case studies in Annex 5.)

It is important to recognize that the difference between planning requirements and actual disaster outcomes in the areas of evacuation and transportation is in a state of flux. Legal cases involving St. Rita's Nursing Home [60] and the death of residents in New Orleans as a result of Hurricane Katrina are underway. On September 9, 2007, the owners of the nursing home were acquitted on negligent homicide and cruelty charges; however, the owners still face other civil lawsuits. A case involving a bus fire in Texas during the movement of elderly patients and the transport of their oxygen tanks in the evacuation for Hurricane Rita [61] is also ongoing.

According to Weston and Tokesky's report, Impacts and Contributions of Older Persons in Emergency Situations: A Case Study of Hurricane Katrina in the United States of America [62], some states, such as Florida, have legislation in place that make it illegal to leave individuals who are in the care of nursing homes or other CRCFs at the “doorsteps” of shelters or hospital emergency rooms. Although CRCFs are supposed to have emergency plans in place, the unfortunate reality is that some facilities do not, and they may depend on transportation agencies, government entities, and other facilities to provide help during an emergency. Accountability issues are still being addressed and continue to evolve.

Transportation Needs of CRCFs

During an evacuation involving CRCFs , it is assumed that most residents will need transportation, including transportation requiring medical assistance en route. For single facility evacuations, this may be addressed through mutual-aid agreements that provide for public and private sources, possibly to include ambulances, Advanced Life Support (ALS) and Basic Life Support (BLS), ambulettes, vans and buses, and paratransit vehicles. In emergency events with a larger geographic scope, demand for these limited services is high and existing arrangements may not be available when needed. Demand for such vehicles exceeds supply in most locations. [63], [64]

In 2008, the AHRQ, released the Mass Evacuation Transportation Model, which estimates the time required to evacuate patients from healthcare facilities. The Transportation Model is accessible from the AHRQ Web site. This model was tested in two locations—New York City and Los Angeles. A companion report (the Mass Evacuation Transportation Model: User Manual) provides instructions on how to run the model. This work is part of an AHRQ project to support development of a national strategy for the design, development, and implementation of an interagency mass patient and evacuee movement regulating and tracking system.

Vehicles

Assignment of individuals to transportation types should be based on the minimum needs of the individual. Vehicles should also be appropriate to transport necessities such as wheelchairs, scooters, medical equipment, and service animals. Common vehicle types needed for CRCFs may include the following:

• Buses: Passenger buses may be from public or private sources. Commonly used are school buses, public transit buses, and private bus lines. Buses are an excellent choice for the most mobile of evacuees, although there is a wide variety of accessibility in this area and many are able to easily transport people in wheelchairs. Such buses include low-floor buses that “kneel” to accommodate wheelchairs and buses with expanded capacities inside to transport multiple people with wheelchairs. In urban areas, there may be significant “pedestrian” populations needing transportation; thus, advance accommodation and prompt/advance evacuation of CRCFs is essential if local public transportation is the primary source of accessible vehicles.
• Ambulances: Types of ambulances potentially used for evacuation include those designed for emergency transport (e.g., ALS, BLS, Mobile Intensive Care Unit) and patient transport vehicles. Due to limited availabilities, ambulances should be reserved for those individuals who definitively need such transport. Generally, ambulances are reserved for those individuals with a present or anticipated life support need.
• Ambulettes: Ambulettes are vehicles that provide non-emergency assisted transportation to individuals. This service is commonly privately owned and is used for transportation to medical appointments, for example. Ambulette companies should not overextend service agreements during disaster to avoid complications in response.
• Vans, Sport Utility Vehicles, and Other Vehicles: Many individuals with special needs may be transported in non-specialized vehicles, if available. This does not include the centralized dispatch of transportation and may complicate evacuee tracking, so care must be taken to coordinate such transportation within the facility’s larger plan.

Transportation service providers must plan for 24-hour access to vehicle keys and appropriate documents in the event that drivers must provide services after normal operating hours. These provisions should be clearly stated in emergency operations plans as well as operator checklists and field guides. Essential telephone numbers must be a part of such plans and documents in the event that primary sources for vehicle key access are not responsive.

Fuel sources must be pre-identified to ensure the ability to re-fuel as needed for repetitive trips. Coordination with local emergency management personnel at both evacuation locations and destinations is recommended to ensure no operational interruptions. Appropriate arrangements must be made with fuel vendors and other agencies (e.g., state DOTs) to provide services.

Vehicle Identification/Credentialing

All vehicles used for transporting evacuees must be clearly marked to avoid confusion and inappropriate routing of evacuees. Vehicles should have placards with transport information (such as pick-up facility and shelter destination) and/or identification information (e.g., color-coded placards corresponding to “tickets” given to evacuees to ensure they are on the right transportation service) and should have the capability to announce verbal instructions. All vehicles should be properly registered and insured with up-to-date safety inspections.

Vehicle Operators

During larger emergency events, it is not uncommon for personnel to be in shorter supply than under normal conditions, as operators may also be victims of the unfolding event (e.g., live on the coast during a hurricane event). Therefore, it is recommended that transportation providers coordinate with appropriate agencies as per local procedure (e.g., DOT, law enforcement, EMA) in the event that drivers from other jurisdictions or agencies are available to assist. This could include counterparts from other locations within the same state, qualified drivers who are members of Community Emergency Response Teams (CERTs) or other agencies such as the ARC, volunteer firefighters, or the National Guard. Mutual-aid collaboration is normally available through local EMAs for such responses.

Coordinated Dispatch

The responsibility for dispatching evacuation vehicles is contingent on local arrangements. Normal dispatch operations should be used to the greatest extent possible to minimize confusion with new procedures. It is possible that the CRCF will contact the provider directly, or in some locations, the coordination of scarce transportation resources may be the responsibility of an EMA. In any case, it is essential to become familiar with common practice in your area to avoid resource conflict and failure of service delivery. It is essential to ensure that the vehicle dispatched is able to maneuver into and out of the access points of the CRCF.

Tracking

Tracking of both individuals and vehicles is an essential procedure when several transportation sources are employed for evacuation.

Each transportation agency should monitor vehicle movement during emergency events in the event conditions worsen during evacuations—dispatchers can then keep vehicles from dangerous areas, such as low-water crossings or damaged roadways. Information essential to vehicle record keeping includes driver name, vehicle number, times departing and arriving from facilities, mileage, and telephone/radio contact information. [65] Such information is also essential for reimbursement of costs following the disaster, if such programs are available.

People with specific medical needs will need a continuation of medical attention. CRCF managers will need to know where those individuals are to ensure appropriate caretakers are notified and able to serve the individual. Individuals with conditions such as dementia or certain mental illnesses must be accounted for to ensure their safety during evacuation events.

Evacuation registries for special needs populations are increasingly being used to pre-identify individuals possibly needing evacuation assistance. By comparing lists to transportation records, shelter registrations may use these registries to ensure identification and tracking of individuals. The HIPAA and other privacy regulations shall be adhered to during all tracking processes to ensure respect for each evacuee.

Responding to Medical Emergencies while En Route

Relocation of individuals can create severe stress and anxiety under the best of conditions, and this can be exacerbated by transportation during a disaster of people with difficult medical or mobility conditions. Not only are the evacuees concerned with the home or possessions they are leaving, but they are also concerned with their health, ability to adapt to a sheltering environment, access to medical care or personal assistants, and safety in the temporary situation.

Some evacuees may experience transfer trauma, which is the physical manifestation of the stress of being relocated. During transport, this could exacerbate existing conditions, requiring medical attention. 

Connecting Local Transport to Longer-Distance Transport

Intermodal transportation may be necessary if evacuations cover a large geographic area or local facilities cannot support evacuation efforts. Buses, ambulettes, ambulances, and other vehicles may provide transportation to train stations, airports, or other transportation terminals. Prior arrangements must be made with such terminals to ensure there is a specific plan for persons with disabilities. Some communities have plans in place to transport people from several locations to a centralized staging area where they can be transferred to another mode of transportation more suitable for longer-distance travel.

Security

People in custodial care must remain in such care during all transportation efforts. Custodial care is a widely defined term that includes situations such as those involving prisoners or daycare attendees. Prison systems are charged with providing transportation for inmates separate from general populations and other custodial care facilities. This transportation will require that vehicles are properly staffed and may require additional escort vehicles for security purposes.

Standard operating procedures (SOPs) for custody should be followed to ensure the safety of these people as well as transportation providers. Each facility should refer to relevant procedures and regulations governing their jurisdictions and facilities. Common custodial situations may include patients with dementia, young children under institutional care (including daycare), persons in psychiatric care facilities, and other such facilities. Security should be at appropriate levels for the individuals in custody, such as ensuring children do not leave designated areas and that people without proper credentials or identification do not remove them from custody.

Service Animals

Service animals are allowed in private transportation and shelter locations that serve the public as protected by the ADA. Unfortunately, incorrect information and false assumptions sometimes result in people not evacuating due to the real or anticipated rejection of a service animal. Transportation providers that do not regularly work with people who have service animals may not be aware of federal requirements to allow such animals access to vehicles. These requirements must be communicated not only to the planners, but also to dispatchers, drivers, and other personnel that may come in contact with a service animal. Service animals should remain with their owners to the greatest extent possible.

As recommended by the National Fire Protection Association (NFPA), the person with the service animal should specify how to handle the animal, how to assist the animal if it becomes disoriented or otherwise disturbed, and the special needs for feeding and watering the animal. [66] Careful handling of service animals is essential, as aggressive animals may be denied access to shelters and that could compromise the health and safety of the animal’s handler. Chapter 7 provides more information on this subject.

Evacuating versus Sheltering-in-Place

Evacuating patients from nursing homes and other care facilities is not without risk, even with the best of planning intentions. A report released by the HHS, Nursing Home Emergency Preparedness and Response During Recent Hurricanes, cites several problems with the evacuation of some nursing homes. [67] Twenty nursing homes were evaluated in Alabama, Florida, Louisiana, Mississippi, and Texas; 13 evacuated residents, while 7 sheltered-in-place. The report indicates that while all 20 nursing homes experienced challenges, the nursing homes that evacuated experienced the most problems including “transportation contracts that were not honored, lengthy travel times, complicated medication needs, host facilities that were unavailable or inadequately prepared, inadequate staffing, insufficient food and water, and difficult re-entry to facilities.” [68] In addition to the findings from the HHS report, the GAO report indicates that several conditions spur evacuation planning, in particular, when jurisdictions develop procedures for financial reimbursement of transportation agencies and address legal liability concerns. [69]

Transfer Trauma

It has been documented that when older people with medical conditions are moved during an evacuation, the chances of transfer trauma increase. Transfer trauma can affect patients both mentally and physically, and although transfer trauma is more indicative of the frail elderly, conditions of heat, extreme cold, and high humidity can cause those with chronic conditions to deteriorate quickly. Transfer trauma can result in death and must be taken seriously. [70] According to the Agency on Aging (AOA), “this condition affects elders impacted by a disaster that results in being uprooted from routines and familiar surroundings. This type of change can lead to aggravation, depression, serious illness, and even death among the elderly.” [71] Therefore, it is important for CRCFs and local emergency planners to be aware of this possibility when making an evacuation decision.

Medical Issues

When planning for and executing an evacuation, a number of medical issues should be considered by state and local planners.

Personnel

Staffing is always a major concern, whether sheltering-in-place or evacuating residents. Often during an emergency or disaster, staff cannot get to their facility due to various factors including transportation issues from the emergency, family obligations, or inability to respond. Transportation personnel and other emergency responders may have similar difficulties. 

In addition to preparing transportation personnel, staff at CRCFs must also be prepared and evacuated with their patients. When evacuating patients from CRCFs, agencies must consider medical and facility staff as well as transportation staff. Without medical and facility staff and transportation personnel, an evacuation risks failure, leaving people’s lives in jeopardy as witnessed during Hurricanes Katrina and Rita as well as other disasters. Pre-planning, developing mutual-aid agreements, and identifying key partners are an effective method for transportation agencies to employ. Pre-planning and working with partners will enable agencies to, for example, identify primary and back-up evacuation routes and resources including accessing gasoline and knowing which towns are along the way. In addition, developing mutual-aid agreements will be critical if vehicles break down or there is an emergency or other need for assistance.

Equipment

Transferring equipment during an evacuation must be considered in planning and exercises of facility plans. Equipment may include what is referred to as DME, such as, but not limited to:

• Oxygen tanks [72]
• Orthotics/prosthetics
• Apnea monitor
• Bath and bed lifts
• Canes
• Wheelchairs
• Incontinent supplies
• Electronic speech aids
• Halter monitors for heart conditions
• Hearing aids
• Specialized medical cots
• Portable TTYs
• Medications.

CRCFs require specialized equipment above and beyond the equipment of what might be appropriate for the general population. Transporting some DME may not be feasible. Therefore, it is important that transportation agencies that have agreements with CRCFs discuss what can and cannot be transported during an emergency evacuation. A list of supplies should be established and agreed upon based on the criteria for each facility. In addition, it may be necessary to work with DME supply companies for delivery arrangements for frequently used personal supplies such as portable oxygen.

Medicine

Medicine is critical for both sheltering-in-place and evacuations. Facilities that are evacuating patients to another like facility should bring additional medications along and not be dependent on the facility they are evacuating to, as they may have limited supplies. When transporting medical/pharmaceuticals, consider the following:

• It is best to place medicines in a plastic zip-lock bag or waterproof container with the type of medication and when they are to be distributed written on the outside.
• Medical records must be kept with the patient with backups in place.
• When possible, transport patients with family member(s) or someone from his/her support network.

Evacuation Contingency Planning for CRCFs

During Hurricane Rita [73], as evacuations got underway, many evacuees’ vehicles ran out of gas or overheated and broke down. [74] One scenario to consider during the transportation planning stage is what to do if the vehicle transporting patients from a CRCF breaks down or runs out of gas. In this situation, transportation agencies are a key player in continuity of patient care. How would transportation agencies manage this situation? Consider the following:

• Will you divert to a special needs shelter? If so, do you know where they are located?
• Do you have communications established with local EMAs and EMS?
• Do transportation staff know how to request assistance and resources? Are they aware of this type of contingency plan, and will staff know what to do?
• Do you have medical records on board to ensure continuity of patient care?
• If you divert to another location, will you be able to keep family/support members with the patient? How do transportation agencies accommodate family/support members in this situation?

Consider how different types of evacuation might impact transportation agencies and CRCFs. For example, how would a hurricane evacuation (that is activated several hours prior to gale force winds) differ from an evacuation of a high rise due to fire or smoke conditions (where the need to evacuate is immediate for all individuals in danger)? These types of scenarios should be considered during planning and exercises, and drills should be conducted to test the plans. Consider different scenarios including:

• Timing of the evacuation (should special needs populations be evacuated prior to others?)
• Specialized equipment to assist with the process
• Different scenarios and the types of evacuation that would occur
• Dealing with medically fragile people who are at high risk.

Shelter Considerations

Although this primer does not specifically focus on sheltering issues, there are a few key points that are relevant to transportation of patients from CRCFs. Personnel, equipment, and medications will need to be transported with the patients and sheltered at the facility where patients are being evacuated. In addition, if a facility chooses to shelter-in-place, provisions to maintain life-sustaining equipment must be made, and transportation agencies may need to assist in transferring such equipment.

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