Janelle J. Christensen, Ph.D., M.P.H . May 22, 2013

1. Evacuate or Shelter in Place?Hurricanes, Long-term Care, and Providing for People with Alzheimer’s disease or a Related Dementia (ADRD) Janelle J. Christensen, Ph.D., M.P.H. May 22, 2013

2. Objectives Provide a recent history of long-term care during hurricanes and the resulting regulations. Provide an overview or best practicesfor sheltering in place or evacuating. Present risk reduction strategiesfor both the caregiver and the person with ADRD. Cover regulations and best practices for staff and resident safety when evacuating and sheltering in place during a storm.

3. Overview • Framework and Orientation • Recent history of long-term care during hurricanes. • Disaster preparedness regulations for skilled-nursing facilities. • Federal • State • Deciding to evacuate or shelter in place. • Present risk reduction strategiesfor both the caregiver and the person with ADRD. • Evacuating to non-clinical buildings

4. Anthropology & Public Health Dementia Disaster Preparedness Risk Socio-economic Status Senility Personhood Alzheimer’s Disease Age Caregiving Hurricane Amnesia Risk Fatigue Vulnerability

5. Part 2: Recent History-2004 Hurricane Season, Florida Charley Frances Ivan Jeanne Dennis Katrina Wilma Rita

6. Part 2- History- Skilled Nursing Facility Locations Kali S. Thomas, 2007

7. Florida 2004-2005 http://www.nwfacf.com/images/florida.gif http://www.usawx.com/cartoon3y.jpg

8. Variation in Code Brown, Hyer, Polivka-West (2007) “A Comparative Study of Laws, Rules Codes, and Other Influences on Nursing Homes’ Disaster Preparedness In the Gulf Coast States” Behavioral Sciences and the Law, Volume 25, pp. 655-675

9. Florida Requirements and Recommendations

10. Part 2: Recent History- Katrina (2005) • Over 64% of Hurricane Katrina deaths were over 65 years old(even though they made up less than12% of NOLA’s population). Can this be prevented? (Brinkly 2006; Brunkard et al. 2008; Jenkins et al. 2008).

11. St. Rita’s- Hurricane Katrina 35 deaths in St. Rita’s nursing home after Katrina. Link to article

12. Part 2: Recent History- Hurricane Rita Link to Article

13. Part 2: Recent History- Regulations http://www.amda.com/tools/clinical/SUMMIT%20REPORT%20FINAL.pdf Florida Health Care Association (AHCA) University of South Florida John A. Hartford Foundation

14. Federal Law “Most nursing homes nationwide met Federal requirements for written emergency plans and preparedness training. However, we identified many of the same gaps in nursing home preparedness and response that we found in our 2006 report.” 4-13-2012 Link to Site

15. Part 2: Recent History- 2011-2012 • Irene • Isaac • Sandy http://blogs.palmbeachpost.com/cartoonistry/files/2012/10/08-28-11webtoon.jpg

16. Part 2: Recent History- Sandy

17. Part 2-Hurricane Sandy

18. Hurricane Sandy A map showing the thousands of LTC facilities in the path of Hurricane Sandy. October 29, 2012 by Long-Term Living staff

19. Link to Article

20. Part 2-Hurricane Sandy “Nursing Home Is Faulted Over Care After Storm” New York Times Headline on November 12, 2012: ByMICHAEL POWELL and SHERI FINK Link to Article: Promenade nursing home in Rockaway Park, Queens, NY “Cold, thirst, fear: The situation grew so dire that the next evening, as the vestiges of the storm blew across the peninsula, ambulances arrived, evacuated the nearly 200 patients over several hours and deposited them in emergency shelters in the city. “ (Chang W. Lee/The New York Times)

21. Evacuating without electricity

22. Expert Recommendations- AHCA 3. Shelter in place, when possible, and harden the physical plant to withstand hurricane winds and provide emergency power. 4. Long term care providers must know their storm surge/flood zone, the capacity of the facility’s infrastructure to withstand hurricane winds, and must develop viable plans for evacuation or sheltering in place in accordance with their facility’s risk.

23. Hurricane Sandy A map showing the thousands of LTC facilities in the path of Hurricane Sandy. October 29, 2012 by Long-Term Living staff

24. Storm Surge

25. Storm Surge

26. Hurricane Sandy A map showing the thousands of LTC facilities in the path of Hurricane Sandy. October 29, 2012 by Long-Term Living staff

27. Link to article.

28. Part 2: Recent History-Regulations

29. Overview • Framework and Orientation • Recent history of long-term care during hurricanes. • Disaster preparedness regulations for skilled-nursing facilities. • Federal • State (focus on Florida) • Deciding to evacuate or shelter in place. • Present risk reduction strategiesfor both the caregiver and the person with ADRD. • Evacuating to non-clinical buildings

30. Expert Recommendations- AHCA 3. Shelter in place, when possible, and harden the physical plant to withstand hurricane winds and provide emergency power. 4. Long term care providers must know their storm surge/flood zone, the capacity of the facility’s infrastructure to withstand hurricane winds, and must develop viable plans for evacuation or sheltering in place in accordance with their facility’s risk.

31. Recommendations • Shelter in place if possible, BUT: • If your facility is a high risk of flooding, wind damage, or prolonged power outages, it is better to evacuate before the storm. • If your facility is damaged during the storm, you might have to evacuate anyway. • Resources (EMS services and other facilities) are even more strained during and after a storm.

32. Decision Making

33. Part 3: Deciding to Evacuate or Shelter in Place (AHCA) http://www.amda.com/tools/clinical/SUMMIT%20REPORT%20FINAL.pdf Florida Health Care Association (AHCA) University of South Florida John A. Hartford Foundation

34. NIHDosa et al. (2011)

35. Question 1 • 1. Which of the following is an external factor that nurses/ administrators need to consider when deciding to evacuate or shelter in place before a hurricane? • a. Storm Surge Zone or Flood Zone • b. Staff availability • c. Stockpiled supplies • d. Generator hook-ups to machinery

36. Decision Making

37. Question 2 Which of the following is NOT an internal factors that nurses/ administrators have to consider before evacuating for a hurricane? a. Stockpiled supplies b. Strength of the storm c. Staff availability d. Resident Acuity e. Physical Structure of building

38. Decision Making

39. Overview • Framework and Orientation • Recent history of long-term care during hurricanes. • Disaster preparedness regulations for skilled-nursing facilities. • Federal • State (focus on Florida) • Deciding to evacuate or shelter in place. • Present risk reduction strategiesfor both the caregiver and the person with ADRD. • Evacuating to non-clinical buildings

40. Acuity- Evacuation and Dementia

41. Hyer, Brown, Christensen, Thomas (2009) Applied Nursing Research 22, e9-e14 Christensen, Brown, Hyer (2012) Geriatric Nursing 33, 5 pp. 375

42. Challenges for NH Biggest problem for those sheltering in place: • Prolonged power outage Biggest problems for those evacuating: • Finding transportation. • Finding and an appropriate place to evacuate.

43. Sheltering in Place Biggest problem for those sheltering in place: • Prolonged power outage • Changes in the environment (power outages, putting up hurricane shutters or evacuating to an unfamiliar place) can be confusing and disruptive for people with dementia. • You might see some stress-related behaviors that you might not normally see.

44. Sheltering in Place: Generators • Where is the generator located? • What is it hooked up to? • Air Conditioning/ Heat? • Laundry? • Food Preparation? • Lights? • Machines? • Elevators? • Lights? • Where will fuel supplies come from? Wander Guard Systems?!

45. Stress Related Behaviors Activities during and after hurricanes Research has shown that: 1) music therapy, 2) touch (massage) therapy, 3) and exercise are can help people with dementia reduce stress (and stress related behaviors).

46. Sheltering in Place • Are staff families allowed to shelter in your facility during the storm? • More likely to come to work? • Are resident families allowed to shelter in the facility during the storm? • How can they (legally) assist? • Is it calming for the resident? • Training the family in stress reduction • Assisting with activities if not direct care

47. Evacuating Biggest problems for those evacuating: • Finding transportation. • Finding and an appropriate place to evacuate to. • Are Wander Guard systems compatible? • Staff must be aware of alternate exits through which residents can elope and consider interventions to prevent this from occurring.

48. Example “I had a 7-bed secure unit, so I had these 7 people who were prone to wandering… We were able to put [the people with dementia] separate from the rest of the residents in the gym or cafeteria. And we were able to keep the doors locked, but there is a lot going on there because, well, the kitchen is located in the same space, so there is a lot of in and out.” [DON with 13 years’ long-term-care experience; evacuated to an elementary school during Hurricane Charley]

49. Question 3 Which of the following can be an elopement risk when evacuating to a different facility? a. Height of the toilets b. Number of plugs to accommodate equipment c. Number of entrances and exits d. Number of unprotected windows e. All the Above

50. Other Concerns in Non-clinical Buildings • Caring for residents on the floor (on mattresses located on the floor) • Choking hazard • Potential for staff injury when transferring • Lack of power plugs • Unprotected windows