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

AFL 23-30
October 10, 2023

All Hospitals

Guidance for Response to Anticipated Adult and Pediatric Surges in Respiratory Virus Transmission
(This AFL supersedes AFL 22-23.2)


​All Facil​ities Letter (AFL) Summary​

  • ​​​This AFL provides guidance to hospitals on planning for and responding to an anticipated surge in adult and pediatric illnesses due to respiratory viruses, particularly in response to recent rises in SARS-CoV-2 transmission and anticipated seasonal rises in other respiratory pathogens.
  • This AFL contains links to resources with clinical recommendations related to vaccination of eligible individuals for SARS-CoV-2, influenza, and respiratory syncytial virus (RSV), and administration of recommended early treatments to reduce illness severity.
  • This AFL revision reminds facilities that this is the first respiratory virus season since expiration of the temporary waiver related to space requirements due to the COVID-19 emergency, which ended in February 2023 in California. Facilities that anticipate needing flexibility to prepare for surges should submit a program flexibility request. ​


Last fall, California experienced a surge in cases of respiratory viral illness—including but not limited to SARS-CoV-2, influenza, and respiratory syncytial virus (RSV)—that strained health care facilities statewide.  Recently there has been a nationwide rise in SARS-CoV-2 cases and hospitalizations, and indications that RSV is rising in the southeastern states.  While local influenza and RSV transmission remain low, seasonal activity of those viruses is expected to increase in the coming weeks to months. 

The following information is intended for hospital administrators and offers considerations for surge measures in anticipation of rising caseloads.  ​

Surge Measures for Hospitals

The following should be considered in all hospitals:

  • 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 and can play a role during surge events for pediatric and/or adult patients. To the extent possible, consider training staff on care measures to maximize existing workforce and leverage staff to address surge needs.
  • 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. 
  • Monitor for updates on guidance on work restrictions for COVID-19 cases. Note that CDPH's 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 includes updated work restrictions criteria inclusive of critical staffing shortages. CDPH will continue to reassess these and monitor evolution of CDC recommendations as well.
  • Assess supply of medicines, supplies, and equipment for adult and pediatric patients and order resources when necessary through your regular suppliers. 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, COVID-19 therapeutics, anti-inflammatories, intubation related medications) related to the current surge needs.  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.
  • Review, update, and leverage existing hospital surge plans to address adult and/or pediatric surge. Consistent with historical precedent, prepare for and consider implementation of measures to expand capacity to accommodate a surge of at least 20 percent over licensed capacity. 
  • Expand capacity to provide care services for pediatric and/or adult patients, via in-person and/or high-quality telehealth services, specialty care, ICU, particularly during mid-morning and mid-evening time periods when emergency department (ED) utilization traditionally increases. Health care facilities can also look to streamline staff onboarding (PDF) to increase service provision.
  • Take measures to increase ED patient flow, such as utilizing a registered nurse (RN) or other qualified medical professional 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 include 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 programs to identify visitors with symptoms of a respiratory virus.
  • Proactively address inpatient 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.
  • Safely discharge patients to skilled nursing facilities (SNFs). Hospital discharge planners should work collaboratively with SNFs and local health departments (LHDs) 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 and respiratory virus season.

Facilities that anticipate needing flexibility to prepare for surges must submit a program flexibility request to CDPH and obtain approval for any alternative use of space or bed classification.

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.

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 pedi​atric team nursing (PDF).

For additional information on applying for a program flexibility please visit the Centralized Program Flexibility Webpage.

For disease specific clinical guidance please see our recent California Health Advisory for ​Respiratory Virus Season 2023-2024​ and the CDPH Centers for Infectious Disease website. This guidance underscores the importance of optimizing respiratory virus prevention and treatment measures, including timely vaccination and prompt antiviral treatment. ​


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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