United States Government Accountability Office

Washington, DC 20548 

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.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 

 1

31 U.S.C. § 717(b)(1) (2000).

GAO-06-443R Evacuation of Hospitals and Nursing Homes 
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. 

2 GAO-06-443R Evacuation of Hospitals and Nursing Homes
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. 

Cynthia A. Bascetta 

Director, Health Care 

Enclosure

3 GAO-06-443R Evacuation of Hospitals and Nursing Homes
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 

4 GAO-06-443R Evacuation of Hospitals and Nursing Homes
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 

5 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

Disaster Preparedness: Preliminary 

Observations on the Evacuation of 

Hospitals and Nursing Homes Due to 

Hurricanes

Briefing for Congressional Committees

February 16, 2006

6 GAO-06-443R Evacuation of Hospitals and Nursing Homes 
Enclosure 

2

Evacuation of Hospitals and Nursing Homes 

Due to Hurricanes

• Purpose and Key Questions

• Scope and Methodology

• Background

• Preliminary Observations

7 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

3

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?

8 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

4

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).

9 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

5

Scope and Methodology

• 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.

10 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

6

Agency Comments

• We discussed the facts contained in this briefing with DOD, 

HHS, DHS, and VA officials.

• The officials generally agreed with the facts.

11 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

7

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.

12 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

8

Background: National Disaster Medical 

System

• 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.”

13 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

9

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.

1

• Under the NRP, HHS has overall responsibility for

coordinating the public health and medical response to

incidents, including NDMS coordination.

1 The Stafford Act established programs and processes by which the federal government supplements state and 

local resources in major disasters or emergencies.

14 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

10

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.

15 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

11

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.

16 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

12

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.

17 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

13

Question 2: Administrators Consider Several Issues 

When Deciding to Evacuate Hospitals and Nursing 

Homes

• 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. 

18 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

14

Question 2: Administrators Consider Several Issues 

When Deciding to Evacuate Hospitals and Nursing 

Homes

• 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 in 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.

19 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

15

Question 2: Administrators Consider Several Issues 

When Deciding to Evacuate Hospitals and Nursing 

Homes

• 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.

20 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

16

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.

21 GAO-06-443R Evacuation of Hospitals and Nursing Homes
Enclosure 

17

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.

(290528) 

22 GAO-06-443R Evacuation of Hospitals and Nursing Homes
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