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

AFL 22-33
December 16, 2022

Acute Psychiatric Hospital (APH)
General Acute Care Hospital (GACH)

Guidance for Response to Surge in Respiratory Viruses Among Adult Patients

​All Facilities Letter (AFL) Summary

This AFL provides guidance to hospitals on planning for and responding to surge due to increases in Coronavirus Disease 2019 (COVID-19), influenza, and other the respiratory viruses in the coming months.


An early wave of respiratory syncytial virus (RSV) activity recently hitting levels similar to seasonal peaks in prior years and circulation of other respiratory viruses has led to increased hospitalizations. Influenza activity in California has also started early with statewide status moving from "moderate" to "high" activity in California, with the predominant strain (Influenza A H3N2) generally associated with more severe influenza seasons. COVID-19 activity is also increasing as noted by increases in wastewater surveillance and recent increases in case rates, test positivity, and statewide new hospital admissions. In addition, the relatively mild seasons for flu and RSV over the past two years likely leaves patients with lower immunity as a result of fewer exposures. Multiple respiratory viruses, including influenza and COVID-19, are expected to increase in the coming weeks, further stretching California hospital resources. 

The following information is intended for hospital administrators and offers considerations for surge measures both within the hospital and across hospitals within the county and region in light of current respiratory viruses and flu activity and a potential increase in COVID-19 cases and hospitalizations. 

Space Waiver

Due to the current space waiver described in this AFL 20-26.13, hospitals have the ability to reconfigure space and adjust the classification of beds without requesting individual program flexibility. The California Department of Public Health is temporarily waiving specified hospital licensing requirements and suspending regulatory enforcement of the following requirements: all statutory and regulatory provisions related to the configuration and use of physical space and classification of beds in a hospital. Hospitals may reconfigure space as needed.

Surge Measures for Hospitals

The following should be considered in all hospitals:

  • Prepare to extend staffing using existing waivers and program flexibilities such as out of state staff, team nursing models, triage tents, and hospital space conversion to ensure readiness for volumes exceeding current capacity. Hospitals should work with their clinical care teams to communicate staffing plans and to seek input.
  • Ensure appropriate personal protective equipment (PPE) is available to protect staff. To the extent they are already applicable, facilities must also continue to adhere to Cal/OSHA's standards for Aerosol Transmissible Diseases (ATD), which requires respirator use in areas where suspected and confirmed COVID-19 cases may be present, and the Emergency Temporary Standards (ETS) that requires all unvaccinated workers be provided a respirator upon request. Employers and employees should consult those regulations for additional applicable requirements.
  • Consider providing a dedicated break nurse and increasing the staffing of allied health workers to ensure that the care team has the necessary support.
  • Develop expertise. Identify providers and staff who have experience with prior surges. To the extent possible, consider training staff on care measures to maximize existing workforce and leverage staff to address surge needs.
  • Assess supply of medicines, supplies, and equipment. Review supply chain for durable medical equipment (e.g., 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.
  • Review, update, and leverage existing hospital 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.
  • Expand capacity to provide care services, via in-person and/or high-quality telehealth services, particularly during mid-morning and mid-evening time periods when emergency department (ED) utilization traditionally increases.
  • To increase patient flow in the ED, consider utilizing a triage registered nurse (RN) to perform a medical screening exam to assess for a stable medical condition and refer appropriate patients to lower-level provider for a same day appointment, particularly for those hospitals with established relationships with urgent care facilities. Or facilities may want to consider the creation of teams that includes a physician and triage nurses in completing these medical screening exams. Note that nonphysicians can conduct the medical screening exam only if the hospital medical staff bylaws/rules and regulations allow it.
  • Utilize high-quality remote care options (e.g., phone advice lines, video visits) supported by ED referral decision support for after-hours advice and consultation.
  • Implement visitor screening program to identify and restrict visitors with symptoms of a respiratory virus.
  • Proactively address patient flow dynamics. Deploy the full gamut of actions to reduce points of resistance in the patient flow journey, including for example: discontinuation of resource intensive orders like continuous monitoring or isolation precautions as soon as appropriate, proactive identification of patients ready for a lower acuity of care (especially transfer out of ICU and hospital discharge), creation of discharge waiting areas, and low and high acuity pathways for emergency department flow.

On December 2, 2022, US Department of Health and Human Services (HHS) Secretary Becerra issued a letter detailing the regulatory flexibilities in place to help health care providers and suppliers continue to respond to COVID-19 can also be used to address the many challenges faced during the spread of non-COVID-19 illnesses, including RSV and flu. 

In addition to the measures described above, hospitals must comply with the requirements in the State Public Health Officer Hospital and Health Care Surge Order which requires in part that when a general acute care hospital has any one of the following conditions — (1) less than 20% of staffed adult Intensive Care Unit (ICU) beds available for three consecutive days; (2) is utilizing alternative spaces for in-patient surge capacity, including but not limited to cafeteria, hallway, and/or conference room; (3) is utilizing tents or other outside structures for in-patient surge capacity for three consecutive days; or (4) is utilizing a team nursing model for three consecutive days — then the hospital shall immediately notify the following in writing:

a. Medical and Health Operational Area Coordinator (MHOAC);
b. Local Public Health Officer; and
c. CDPH Licensing and Certification District Office.

The order further specifies that when a region, as defined by the CDPH Public Health Officer Regions, has less than 10% of staffed adult ICU beds available for a period of three consecutive days or when an individual general acute care hospital has zero ICU capacity, then the following shall apply for seven days:

a. All general acute care hospitals in the county who do have ICU bed capacity must accept transfer patients when clinically appropriate and directed by the Medical and Health Operational Area Coordinator (MHOAC).

The surge order requiring level loading during surge conditions remains in effect until rescinded.


CDPH recently updated Guidance on Quarantine and Isolation for Health Care Personnel (HCP) Exposed to SARS-CoV-2 and Return to Work for HCP with COVID-19 (AFL 21-08.9) on 12/2/22 which includes updated work restrictions criteria inclusive of critical staffing shortages.

Safely Discharging Patients to Skilled Nursing Facilities (SNFs)

As the respiratory virus season has already begun with ongoing COVID-19, surges in hospital admissions and ED visits can affect hospital capacity. Hospital discharge planners should work collaboratively with SNF and the local health department (LHD) to facilitate the safe and appropriate placement of SNF patients. Hospitals should proactively communicate with SNFs early to facilitate transfers. SNFs should be prepared to provide care safely without putting existing patients at risk during the COVID-19 pandemic and upcoming virus season. Please see AFL 22-31 for additional information. 

Assistance with Medi-Cal Patient Discharges to SNFs

The Department of Health Care Services will temporarily prioritize Treatment Authorization Request (TAR) adjudications and Preadmission Screening and Resident Review (PASRR) processing in regions experiencing extraordinarily high hospital patient censuses and delayed GACH-to-SNF transfers of Medi-Cal patients.

COVID-19 Therapeutics

Once an individual is diagnosed with COVID-19, early treatment with COVID-19-specific agents is the only existing strategy to markedly decrease risk of serious illness, hospitalization, and death. Hospitals are encouraged to work with their outpatient partners to ensure that every symptomatic patient who tests positive for COVID-19 is evaluated for COVID-19 treatment within 24 hours of seeking care to reduce the risk of hospitalization and death.

Additional information related to COVID-19 therapeutics can be found at the CDPH COVID-19 Treatments webpage.

If patients are already at the point of hospitalization, those who are hospitalized for COVID-19 should be treated in accordance with hospital protocols. Patients who are hospitalized for a non-COVID reason and have incidental, symptomatic SARS-CoV-2 infection should be evaluated for COVID-19 treatments to reduce morbidity and mortality. There is also early, but growing, evidence that treatment of mild-moderate COVID-19 may reduce the risk of long COVID.

See the attached chart for information related to Coverage of COVID-19 testing, immunizations, and therapeutics during and after the federal PHE (PDF).

Influenza Therapeutics

Antiviral treatment is recommended as soon as possible for any patient with suspected or confirmed influenza who:

  • is hospitalized;
  • has severe, complicated, or progressive illness; or
  • is at higher risk for influenza complications.

Decisions about starting antiviral treatment for patients with suspected influenza should not wait for laboratory confirmation of influenza virus infection. Empiric antiviral treatment should be started as soon as possible in the above priority groups. The Centers for Disease Control and Prevention (CDC) has issued prioritization guidance in the event of influenza antiviral shortages.


Hospital admission and/or discharge workflows should ensure patients are up to date with key vaccinations, including COVID-19 boosters and the flu vaccine, to prevent future hospitalization and death from these viruses.

Request for Resources

Hospitals 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. For critical staffing shortages, please submit the request to your MHOAC recognizing that staff deployed under state contracts will be at the hospital expense via a Memorandum of Understanding.

Pharmaceutical Supply Chain Challenges

CDPH is aware of challenges obtaining albuterol nebulizer solution; Facilities should be aware of recently renewed Pharmacy Board waivers for dispensing in Emergency Departments.


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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