Nursing homes face an impossible decision during hurricane season this year — whether or not to evacuate their residents amid the Covid-19 pandemic, risking the health and well-being of their patients and staff in the process.

Even in normal times, evacuation decisions are tough: Research shows that moving frail residents can exacerbate already burdensome health conditions and increase hospitalizations. But failing to evacuate can leave residents vulnerable to power outages, flooding, and even death. This year, as the coronavirus pandemic rages across the Southeast in particular, that decision is even harder — hospitals are already overburdened and social distancing isn’t necessarily possible in evacuation vans or temporary shelters.

Nursing home residents are also far more vulnerable to Covid-19 than the general population.

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Federal rules require nursing homes to develop emergency preparedness plans annually, and to train their staff on them — but both the thoroughness of the plans and the training behind them vary from facility to facility and year to year, experts told STAT. And given the extra burdens on nursing home staff during the last six months, at least one health workers union is concerned that some of the preparations so far aren’t enough to keep patients and staff safe.

“We have been so entangled with all of the pandemic issues that the conversation never took place,” said Jude Derisme, the vice president of the health care union 1199 SEIU, which represents 400,000 working and retired health workers along the East Coast, including in Florida. “Where are they going to go? What is the process?”

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A spokesperson for the American Health Care Association and National Center for Assisted Living, which represents some 1,400 nursing homes across the U.S., emphasized that all nursing home are required to have a plan in place, and pointed to educational materials they have made available to help facilities plan ahead, including on hurricanes and Covid-19.

In the average hurricane season, nursing home evacuations are complicated affairs: Preparing involves making decisions about everything from how to move bedridden or paralyzed patients, how to explain what’s happening to people with dementia, and how to keep medications refrigerated if the power goes out.

Most places divide staff into two groups: those who will travel with the patients and those who will remain behind, to prepare for residents’ returns. They run drills, attend workshops, and work with the other health care facilities in their area in the hope of ensuring that resident care is uninterrupted.

The decisions — often made at the last possible minute, since the potential path of a storm can move from one state to another in less than 24 hours — are consequential. When the owners of St. Rita’s nursing home in the New Orleans area decided not to evacuate during Hurricane Katrina in 2005, 35 of the 60 residents drowned in the floodwater.

Medicare updated its emergency preparedness requirements in the wake of that tragedy and others like it, requiring nursing homes to make a plan, every year, for any potential hazard in a facilities’ area. Hurricane preparedness plans must address issues like how the facility will handle loss of power, maintaining supplies throughout the storm, and how patients will be transported if an evacuation is called for. State agencies often also recommend the plan include guidelines about how to make the call to evacuate.

“Health care evacuations fall into the category of things that no one really wants to talk about because they’re really, really awful,” said Emily Landon, the chief infectious disease epidemiologist at University of Chicago Medicine.

This year, evacuations may be really, really, really awful —  facilities will have to account for Covid-19 during a hurricane evacuation. And that means a host of new issues to consider, according to facility managers and state officials.

Nursing homes are already short on personal protective equipment for workers and residents — an issue that will only worsen during an evacuation where it will be nearly impossible to adhere to social distancing guidelines while moving and evacuating patients. Some nursing homes have started to move their Covid-19-positive residents into a single facility, leaving caregivers concerned about where so many residents will go — especially considering hospitals in the southeastern area like Mississippi and Louisiana are reaching capacity.

Temporary shelters, too — like the Houston Astrodome, used to shelter evacuees after Hurricane Harvey, or the Houston Convention Center, where many rode out Katrina — may also be a no-go during Covid-19, since large congregations indoors clearly escalate the risk of a major Covid-19 outbreak.

Derisme, the health worker union vice president, said he’s especially concerned about how and whether nursing homes will take into account caregivers’ own health risks. Staffers with serious illnesses or other underlying health conditions, for example, might need to be given priority for tasks that limit their exposure.

The Covid-19 pandemic has also, already, stretched many caregiving staffs too thin, he said. The injuries associated with lifting or moving patients — as would likely be necessary during an evacuation — are already on the rise. Some facilities don’t have enough protective equipment, too, he worried.

Moving all the residents in a nursing home into buses that are not well-equipped for handling people in wheelchairs or walkers — and working in a tight time limit — is bound to lead to injuries and increased rates of Covid-19 infections amongst staff, says Vincent Mor, a professor of health services, policy and practice at the Brown University School of Public Health who studies the the experiences of elderly residents at nursing homes. He thinks maintaining 6 feet of distance while lifting someone out of their bed is impossible. Doing it with limited PPE is a recipe for disaster, he said.

AHCA/NCAL, the trade group for nursing homes, echoed those concerns, too, and said state, local and federal government agencies should prioritize supplies and resources like PPE and tests.

Derisme shares Mor’s concerns — but puts the blame on the nursing home facilities themselves.

“We had a huge fight with the nursing homes … about getting those basic supplies to care for residents,” said Derisme. “Now on top of it you have the lack of supplies for the workers to protect themselves.”

Many facilities do have plans in place, and states have procedures in place to make sure those plans are thorough and executable.

Denis Rainey’s draft emergency plan runs about 150 pages long — and that’s before a nursing home personalizes it to its facility. Rainey is the senior vice president of facilities and emergency management at ALG Senior, a group that owns and operates nursing home facilities in seven states including coastal states like Mississippi, Florida, and North Carolina.

Their Covid-19 plan is relatively straightforward: If they need to evacuate, they’ll move patients via buses, vans, or ambulances to the nearest sister facility outside the storm’s path. They did so successfully in 2018, transporting about 550 residents in 24 hours to avoid Hurricane Florence. This year, however, they’ll move any Covid-19 positive residents together, with staff equipped with proper protective equipment. The sister facilities will have wings set up to keep them separate from others.

Nursing homes from 25 counties in Southeast Texas also participated in a  evacuation exercise, held remotely this year, hosted by the Southeast Texas Regional Advisory Council, which helps coordinate region-wide hurricane and emergency planning for the health care industry there.

“It’s seeing a part of a bigger picture and knowing that you have somebody else you can rely on to run a question by,” said Lori Upton, the group’s vice president.

This year, the exercise forced nursing homes and hospitals to consider a hurricane making landfall amid the coronavirus pandemic — a situation Upton said led to fruitful conversations about potential issues ranging from how to transport Covid-19 positive patients to how negative pressure rooms will be affected if an HVAC unit goes down temporarily.

Nursing homes modified their plans based on feedback from the workshop; many have an even more thorough transport plan than the one outlined by ALG Seniors: They plan to transport Covid-19-negative patients first, then to transport positive patients — a way to make sure that Covid-19 is not transferred by vehicles that are reused or staff.

They also have a unique way to address a concern shared by ALG Seniors: how to prevent potential spread of Covid-19 if a resident wanders off during a routine stop on the ride to the new facility. Upton said residents wear hot pink vests during transport with a waterproof pocket in the front that includes their personal information and health conditions — like whether they are positive for Covid-19. Upton said nursing homes in the Southeast region plan to limit — or potentially, to completely eliminate — such pit stops for the Covid-19-positive patients.

The Red Cross, which often assists with and organizes temporary shelters in the wake of hurricanes, also told STAT it is making plans for potential nursing home evacuees.

Broadly, the group is working this year to identify hotels and dormitories that could serve as temporary shelters. Although hotel rooms might normally be divvied up on a first-come, first-serve basis, this year the group plans to consider evacuees’ Covid-19 risks.

“If we have a limited amount of hotel space and we have to prioritize, our prioritization is for the most vulnerable to Covid-19,” said Brad Kieserman, the vice president of disaster operations and logistics for the American Red Cross.

Kieserman emphasized that the American Red Cross is prepared to assist in sheltering nursing home residents as they always are — this year care for the vulnerable elderly population has been an “area of focus,” and that the group has already recruited health care workers in potential hurricane-affected areas from nursing schools to add to their existing on call staff.

Nearly all the plans make clear, however, that evacuation is a last resort — in large part because it’s so dangerous for residents. More people died evacuating from Hurricane Rita than died in the damage, for example.

And it’s particularly hard on nursing home residents. In a study of nursing home residents who lived through Hurricanes Katrina, Rita, and Gustav, those who evacuated suffered higher rates of hospitalization and death —  residents were 3% to 5% more likely to die and 2% to 8% more likely to be hospitalized 90 days after evacuating.

“We really don’t want to evacuate unless it’s the right decision to make,” said Denis, the ALG Senior vice president. “We’re going to shelter in place as much as we can.”

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