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Using fire truck ladders to reach patients on high floors, fire and police rescue crews worked through the night to evacuate the 193 patients. The ones in intensive care were transferred immediately to other hospitals in ambulances, while patients in less critical condition were moved into a nearby municipal gymnasium and then transferred to other facilities, officials said.

The governor of the Lazio region, Francesco Rocca, said from the scene that three people were killed and an investigation would determine the cause of the fire. He acknowledged “notable delays� in updating Italy's aging hospitals with sprinkler systems and other fire safety infrastructure.

The fire department initially said four people were killed. Menditto said during a news conference that only three deaths were directly caused by the blaze, while a fourth death was unrelated to the fire.

He said prosecutors do not believe the fire was set intentionally but the working hypothesis guiding the investigation was related to manslaughter charges, without any suspects identified.

Video released by the fire department showed fire crews trying to reach the upper floors of the hospital on ladders to get to patients as smoke billowed out. Both Menditto and Rocca, the governor, praised firefighters and police officers for a “truly exceptional� overnight operation to evacuate the patients, especially those who could not walk on their own, and to get them transferred to other hospitals.

Italian Premier Giorgia Meloni offered condolences to the families of the victims.

Rome's chief firefighter, Cmdr. Adriano De Acutis, said crews were now focused on securing and removing valuable medicines, especially drugs used to treat cancer, since the hospital will be unusable for the foreseeable future.

Tivoli, which is located about 35 kilometers (20 miles) northeast of the center of Rome, is a popular tourist destination. It is best known for the archaeological sites of Villa d'Este and Villa Adriana, both of which are UNESCO World Heritage Sites.