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State of California—Health and Human Services Agency
California Department of Public Health

AFL 22-23.2
June 14, 2023

All Health Care Facilities

Guidance for Response to Surge in Respiratory Viruses among Pediatric Patients
(This AFL supersedes AFL 22-23.1)

​​​This AFL has been superseded - please see AFL 23-30​. ​​​​​

​All Facilities Letter (AFL) Summary 

  • This AFL provides guidance to facilities on planning for and responding to pediatric surge related to respiratory syncytial virus (RSV) and other respiratory viruses.
  • This AFL also provides guidance documents to assist facilities when submitting program flexibility requests to accommodate pediatric surge.
  • This AFL revision notifies facilities that the temporary waiver related to space requirements due to the COVID-19 emergency expired February 28, 2023. Facilities who have a continued need for flexibility beyond the end of the declared COVID-19 emergency may submit a program flexibility request. 


In October 2022, an early wave of RSV activity hitting levels similar to seasonal peaks in prior years and circulation of other respiratory viruses led to increased hospitalizations among infants and young children and contributed to stresses in the pediatric healthcare delivery system in California and across the US. Pediatric available bed capacity decreased in CA. Influenza activity in California also started early with statewide status moving from “low" to “moderate" activity and high levels in southern California, with the predominant strain (Influenza A H3N2) generally associated with more severe influenza seasons.

COVID-19 activity also increased as noted by increased wastewater surveillance and  case rates, test positivity, and statewide new admissions increase of almost 16%. In addition, the relatively mild seasons for flu and RSV over the past two years likely leaves more susceptible children who have lower immunity as a result of fewer exposures. Multiple respiratory viruses, including influenza and COVID-19, were expected to increase in the following months, further stretching California hospital resources for both adults and children. 

The California Department of Public Health (CDPH) is recommending that all healthcare facilities, including inpatient and outpatient facilities without existing pediatric services, explore short-term measures to expand capacity for evaluation and treatment of pediatric patients, as has already occurred in some facilities in California and across the US.

The following information is intended for healthcare facility administrators and offers considerations for pediatric surge measures both within the facility and across facilities within the county and region in light of respiratory viruses and flu activity and a potential increase in COVID-19 cases and hospitalizations. Guidance for healthcare providers regarding vaccination, testing, treatment, and preventive measures to manage illness from respiratory viruses can be found in November 12, 2022 Health Advisory and prior AFLs.

Additionally, on February 7, 2023, CDPH released AFL 23-13 to notify facilities that the space waiver described in AFL 20-26.13 allowing hospitals to reconfigure space and adjust the classification of beds without requesting individual  program flexibility expired on February 28, 2023. Facilities who have a continued need for flexibility beyond February 28, 2023 may submit a program flexibility request.

Program Flexibilities 

CDPH has the authority to grant program flexibility from regulatory requirements if the facility requesting the program flexibility demonstrates its ability to meet statutory/regulatory requirements in an alternate manner. Requests for program flexibility must include justification for the program flexibility request and adequate supporting documentation that the proposed alternative does not compromise patient care. Hospitals can request a program flexibility on the Risk and Safety Solutions (RSS) website:

  1. Submit all requests through CDPH Flex Waiver Webpage
  2. For first time waiver applicants, providers will receive an invitation from CDPH to create a password, the provider's username is their email address. The provider may log in at Flex Waiver Webpage  (only using Google Chrome, Mozilla Firefox or Microsoft Edge). Detailed instructions for registering and submitting an application will be available.
  3. After successfully submitting an online application, the system sends a confirmation e-mail with an identification number (tracking ID number) to the provider's designated point of contact listed on the application. All correspondence regarding the application will be sent to the point of contact. CDPH must receive all required documentation to process the application.

All requests must include:

  • Each regulation for which the facility requests flexibility
  • An explanation of the alternative concepts, methods, procedures, techniques, equipment, personnel qualifications, bulk purchasing of pharmaceuticals, or pilot projects the facility proposes to use
  • Supporting evidence demonstrating how the facility's alternative concepts, methods, procedures, techniques, equipment, personnel qualifications, bulk purchasing of pharmaceuticals, or pilot projects meet the intent of the regulation

If you have an urgent request that requires a response within 24 hours, select the option indicating the request is an emergency. For all other requests indicate non-emergency. Some examples of the types of requests a facility might request are team nursing or implementing documentation by exception.

For more detailed guidance on how to complete a request through the RSS website, facilities may refer to CDPH's examples of urgent program flexibility requests to accommodate pediatric patient surge by temporarily implementing pediatric team nursing (PDF) or adding a pediatric supplemental service (PDF).

Guidance for Facilities

All Acute Care Facilities

The following should be considered in all acute care facilities:

  • Activate the Hospital Incident Command Center to manage the surge, facilitate communicate and coordination of resources. Technical Specialists to participate from Infectious Diseases and Infection Control.
  • Review, update, and leverage existing facility and/or Health Care Coalition (HCC) pediatric surge plans. Consistent with historical precedent, prepare for and consider implementation of measures to expand capacity to accommodate a surge of at least 20% over licensed capacity. Sample surge plans, along with additional information and resources are available through the US Department of Health and Human Services Pediatric Surge Resources webpage.
  • Prepare to expand staffing and bed capacity using existing waivers and program flexibilities described above.  Facilities should consider strategies such as team nursing models for expanding staff. Consider the use of triage tents and utilize other appropriate clinic or hospital space to ensure readiness for volumes exceeding current capacity.
  • Assess supply of medicines and supplies. Review supply chain for durable medical equipment (e.g., pediatric respiratory support supplies, ventilators, personal protective equipment) and medicines (e.g., antibiotics, antipyretics, inhaled beta-2 agonists, oseltamivir, anti-inflammatories, intubation related medications) related to the current surge needs.
  • Develop pediatric expertise. Identify providers and staff who have past experience in pediatrics. To the extent possible, consider training non-pediatric staff – including physicians, nurses, and respiratory care providers – on pediatric care measures to maximize existing workforce and leverage staff to address surge needs related to among hospitalization of children. Sample training materials and videos are available through Western Regional Alliance for Pediatric Emergency Management (WRAP-EM) (PDF) and OpenPediatrics.

Facilities with Inpatient Pediatric Units, such as Pediatric Wards, Pediatric Intensive Care Units (PICUs), and Neonatal Intensive Care Units (NICUs)

Facilities with existing inpatient pediatric units, such as children's hospitals and some community hospitals, are best able to manage complex pediatric patients that may not be suitable for settings less familiar with this population.  In addition to expanding capacity using the measures noted above, the following should also be considered:

  • Expand provider capacity and privileges by training and credentialing pediatric and family practice outpatient providers to provide inpatient care. 
  • Engage licensed staff (RN/RT as examples) who are not currently assigned as inpatient and develop a refresher training and have them assist in providing care within their licensure.
  • Explore potential for in-facility patient movement, particularly for mixed facilities offering care services to neonatal, pediatric, and adult populations. For example, consideration can be given to the following:
    • Manage adult-size children who have conditions common to both children and adults (e.g., appendicitis, trauma, sepsis) on adult medical/surgical units;
    • Manage infants with non-communicable illnesses (e.g., hyperbilirubinemia, poor feeding) in well-baby nurseries or post-partum wards; and
    • Manage infants with acute respiratory illnesses in Special Care Nurseries and/or NICUs while maintaining stringent infection prevention and control precautions, including separating space and staff (e.g., dedicated beds, bays, rooms, etc.) where possible.
  • Work with hospital networks and local professional organizations to support provision of just-in-time training for community hospital providers – including physicians, nurses, and respiratory care providers – who may be less familiar with pediatric care.
  • Provide telemedicine/zoom support for community adult care organizations to provide guidance and support for care of pediatric patients.
  • Prioritize admission for critically ill pediatric patients at facilities with limited pediatric resources.
  • Revitalize transfer agreements and telehealth consultative services with hospital networks, with a focus on preserving dedicated pediatric facilities for those requiring the most serious and/or most specialized care.

Inpatient Facilities without Inpatient Pediatric Services

Facilities without existing inpatient services should consider expanding services to care for adult-size children as young as age 12 years who have conditions common to both children and adults (e.g., appendicitis, trauma, sepsis), starting with older adolescents and lower acuity patients. 

If not already established, develop relationships with pediatric inpatient and outpatient providers to support appropriate triage, referral, consultative, and training processes

Facilities with Emergency Rooms

  • Review standard winter surge planning to incorporate a larger than expected pediatric surge component and adjust supply and staffing levels accordingly. Given the shortage of available pediatric trained traveler staff, consider other surge staffing models, including using paramedics as nurse-extenders as they are still allowed to work at fixed sites through the existing State of Emergency.
  • Prepare to board admitted pediatric patients for a longer period than usual, as inpatient pediatric bed availability becomes scarce. Boarding pediatric patients may have different needs than adults for security, monitoring, and space for care givers.
  • Develop fast track flow team that triages, evaluates and discharges low acuity patients to assist with overcrowding and reducing those leaving without being seen. 

Outpatient Facilities

Consideration should be given to the following measures:

  • Expand capacity to provide pediatric care services, via in-person and/or high-quality telehealth services, particularly during mid-morning and mid-evening time periods when emergency department utilization traditionally increases.
  • Utilize high-quality remote care options (e.g., phone advice lines, video visits) supported by emergency department referral decision support for after-hours advice and consultation.
  • Offer and encourage timely COVID-19 and flu vaccinations for all eligible patients.
  • Identify appropriate high-risk infants/young children and contact to administer prophylactic palivizumab per guidance from the American Academy of Pediatrics as soon as possible
  • Identify appropriate patients for early antiviral administration for influenza and/or COVID-19 to reduce risk of progression to severe disease, in accordance with CDC recommendations.

ALL Healthcare Facilities

  • Promote and facilitate influenza and COVID-19 vaccination and boosters for all staff and patients
  • Share and disseminate messages to parents and caregivers to increase education about viral respiratory illnesses, including: getting up to date on vaccination for influenza and COVID-19, supportive care at home, signs and symptoms concerning for severe illness, and when to seek health care.
  • Prepare for increased call volume and appropriate phone triage from patients, caregivers and potential referrals for respiratory infections and care.

Additional Resources:

Facilities should coordinate with their respective MHOAC program (utilizing locally established resource requesting procedures/tools) to request medical/health resources they are unable to obtain through established vendors, day-to-day mutual aid process, corporate relationships, or pre-existing agreements.


If you have questions about this AFL, please contact your local district office.


Original signed by Cassie Dunham

Cassie Dunham

Deputy Director



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