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

AFL 22-33.1
June 14, 2023

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

Guidance for Response to Surge in Respiratory Viruses Among Adult Patients
(This AFL supersedes AFL 22-33)


​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.
  • 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 respiratory syncytial virus (RSV) activity hitting levels similar to seasonal peaks in prior years and circulation of other respiratory viruses led to increased hospitalizations. Influenza activity in California 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 also increased as noted by increases in wastewater surveillance and 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, were expected to increase in the following 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. 

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 the end of the declared COVID-19 emergency may submit a program flexibility request to CDPH.

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).

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. 


CDPH 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 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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