In response to the COVID-19 pandemic, the State of California and its jurisdictions took an aggressive two-pronged strategy starting in March of implementation of NPIs and intensive health care system planning to meet the predicted surge in demand related to COVID-19 infections.
Based on early modeling of the outbreak, State leaders estimated the need to expand the existing health care delivery system to accommodate an additional 50,000 excess hospitalizations above the State licensed bed capacity by the end of April.
To meet that need, State leaders partnered with hospital systems, local health jurisdictions, and local emergency medical service agencies to expand health care capacity across California. Strategies included obtaining federal assets, working with hospital partners to expand capacity within their existing infrastructure, supporting additional acute care facilities specifically dedicated to COVID-19 patients, and creating alternate care sites in partnership with local government. In addition, many counties partnered with local health care systems to develop their own alternate care sites.
Fortunately, with the early implementation of NPIs, the trajectory of COVID-19 shifted in California, with excess hospitalizations from confirmed COVID-19 cases peaking at below 4,000 per day. However, the strategies that hospitals employed to create reserve capacity – postponing non-emergent procedures and leveraging virtual care – resulted both in significant financial shortfalls and serious concerns for deferred care, including chronic care, cancer screenings and childhood vaccinations.
The success of our NPIs afforded the State time to build the capacity to address future waves of COVID-19. Critical capabilities we have developed to date include:
Given forecasted COVID-19 resurgence due to increased movement, coupled with seasonal influenza during fall and winter, California must ensure it is prepared to address community and health system impacts and responses.
One learning from the spring of 2020 is that prematurely curtailing routine care to prepare for projected COVID-19 patients unnecessarily reduces access to care for Californians as a whole. This guidance provides a different, more nuanced approach in which counties work with hospitals to develop COVID-19 County/Regional Surge Plans, hospitals surge in real time to care for COVID-19 patients, and the state provides support to both hospitals and alternate care sites as needed.
Importantly, given the size and diversity of California, the trajectory of the pandemic will vary across the State, and therefore surge planning should be tailored to local and regional conditions while being coordinated statewide.
Given the enhanced data capabilities for both tracking and forecasting the pandemic, California has an ability to respond to increased demand in a more dynamic fashion. While surge status should primarily be determined by individual acute care hospitals, it must be coordinated at the county or regional level based on a holistic analysis of public health metrics and the collective status of hospitals and other health care capacity in the area. The surge status levels described below are at the county/regional level.
Importantly, the increase in hospital census needs to be considered in the context of both 1) percent of hospitalized patients who are COVID+, and 2) regional and statewide capacity and context. When multiple regions are experiencing surges in COVID+ hospitalizations, local county health officers, hospitals, and the State will need to be more aggressive in both reinstituting NPIs and ensuring sufficient acute care capacity.
It is critical that local county health officers coordinate public health orders, including decisions to scale back routine health care services, with the State.
The guiding principle for California's surge planning process is to develop solutions that are State guided, county or regionally partnered, and health care facility based.
State guided. The State provides regional and statewide guidance and directives to reduce disease transmission and ensure health care capacity. It conducts ongoing monitoring of county transmission, hospital utilization and surge capacity; targets engagement to counties with concerning case rate or hospital metrics; and mandates reinstitution of community measures when needed. The State also provides supply and workforce assistance in emergent situations, and coordinates mutual aid across counties and regions.
County or regionally partnered. Health Care Coalitions, working with local health officers, build on existing surge plans and convene key stakeholders, including local hospitals, to develop COVID-19 County/Regional Surge Plans as described below. It should be determined at the outset whether the Surge Plan will be focused on a single county or involve multiple counties. Local health officers authorize public health orders for NPIs; county government departments and agencies enforce public health orders.
Health care facility based. All hospitals in an area should take an active role in responding to COVID-19 patient care needs as a shared public health responsibility. Each hospital updates and manages its existing surge plan to specifically incorporate COVID-19 considerations and coordination with the Surge Plan.
The State's Health Care Coalitions should serve as the starting point for developing COVID-19 County/Regional Surge Plans, with the local health officer(s) serving a co-convener. Importantly, in the context of COVID-19, a decision should be made whether a county specific or regional plan will be pursued.
The Surge Plan should utilize and expand on existing facility, county and Health Care Coalition surge plans to include COVID-19 specific considerations. It should incorporate and build on existing and ongoing work by the local health departments including county variance attestations and mitigation plans. The Surge Plan is intended to be a high-level response plan, identifying the experts and specialized resources that exist within the county/region, demonstrating how hospitals will create surge capacity, describing how health care assets and resources will be deployed, how care will be coordinated across the continuum of care, and outlining the mechanisms/processes that will be used to determine how and when non-pharmaceutical interventions (NPIs) should be enforced or reinstituted.
Please note the Surge Plan guidance below assumes the following all-hazards basics are already in place through planning, exercise, and response activities:
The following topical prompts are designed to guide county/regional planning group discussions and planning, and provide consistency across the State. Health Care Coalitions, in concert with local health officers, are advised to convene key local stakeholders to review this guidance by August 14, 2020.
Health Care Coalitions
Local Public Health Departments
County EMS /LEMSAs
Medical Health Operational Area Coordinators (MHOACs)/ Regional Disaster Medical Health Specialists (RDMHS)
Skilled Nursing/Long Term Care Facilities (traditionally not a part of HCCs)
Other groups to consider include ambulatory surgical centers, clinics and physician groups; community-based organizations, particularly those connected to communities of color; correctional facilities, and key business and elected leaders.
Lead entities for key functions (e.g. alternate care facility operations, PPE tracking, etc).
Population covered by the plan, including demographics and special populations related to COVID-19 (e.g. age, comorbidities, congregate living settings)
Type of healthcare facilities covered in this plan, including acute care, SNF, and transfer facilities
Local/regional special considerations (e.g. geographic challenges, language barriers, federal correctional facilities, high risk industries)
Available resources (e.g. telemedicine capabilities, alternate care facility sites)