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California Releases Healthcare Surge Guidelines

By Eric Toner, M.D., February 29, 2008

On February 19, 2008, the California Department of Public Health released its Standards and Guidelines for Healthcare Surge during Emergencies. The guidelines, comprising four volumes, along with training materials and a reference manual, are available online at This is an impressive effort to cover the multitude of difficult issues related to emergencies that overwhelm the healthcare system. The manuals offer practical solutions and useful tools for a number of these issues. In addition, a thorough listing and interpretation of the relevant laws and regulations that affect surge planning is included.

  • Foundational Knowledge: This section includes descriptions of healthcare surge, California’s existing emergency response system, and the role of healthcare providers in that system. Importantly, this section articulates the need to change from individually-focused patient care to population-based care in a catastrophic health emergency.

  • Volume I—Hospitals: This volume addresses emergency preparedness for hospitals, and includes guidance on increasing capacity and augmenting staffing during a mass casualty event.

  • Volume II—Government-Authorized Alternate Care Sites: This volume covers planning considerations and specific guidance for site locations, staffing models, standards of care, administrative protocols and federal and state reimbursement for government-authorized alternate care sites.

  • Volume III: Payers: In addition to recommending what health plans must consider in planning for patient surge, this volume outlines changes to contract provisions that will simplify administrative and reimbursement requirements.

  • Reference Manual: This reference manual provides an overview of relevant federal and state laws, regulations and standards, along with legal interpretations and implications for use during an emergency. Information about the Hospital Incident Command System and funding sources that may be available during a declared healthcare emergency are also included.

Accompanying each volume is a training guide and training materials. For Volumes II (Hospitals) and III (Alternate Care Sites), there are Operational Tools Manuals that include forms, checklists, and templates to be used to implement recommendations outlined in the Standards and Guidelines Manuals.

While a thorough description of this 1,900-page document is beyond the scope of this brief report, there are several aspects worth highlighting. Among the topics detailed in the Foundational Knowledge document is that of allocation of scarce medical resources during an emergency, which is referred to as “transitioning from individual care to population-based care.” This section considers the ethical principles involved and reviews several relevant publications. In the Hospital manual, standard of care is addressed as well and a population-based standard of care is proposed. This is important because any disaster resulting in a surge of patients which exceeds the capacity of hospitals to provide care in the usual ways will produce some change in patient care routines. What is meant by “standard of care,” how that differs from hospital protocols and procedures, and how standards of care may change depending on circumstance are areas of great confusion to many clinicians and emergency planners.

Volume I: Hospitals also describes a number of surge capacity augmentation strategies such as cancellation of surgeries, early discharge, and cohorting. In addition, it discusses strategies to augment the hospital workforce during a crisis and includes several credentialing and skills tracking tools. Strategies and tools to deal with anticipated shortages of supplies and pharmaceuticals are included as well. This section is useful because it details clearly, concisely, and in one place, most of the surge capacity augmentation strategies that have been proposed. This list and the accompanying tools should be a valuable resource to hospital planners.

Volume II: Alternate Care Sites addresses sites established by governmental agencies for patient care during an emergency involving significant patient surge, but it does not address sites established by hospitals to expand their facilities or tents used by emergency medical services for field triage. The document recognizes that, because resources may be limited, the level and type of care provided at an ACS will differ from that typically provided in a hospital. The manual includes criteria and tools for selecting an ACS and discusses how the ACS would fit within the incident command structure. Staffing, equipment and supplies, and administrative issues are discussed, as is reimbursement. This discussion and these tools are important because providing hospital-like care in a facility without a hospital’s infrastructure (gases, suction, supplies, pharmacy, etc.) will be very difficult.

All individuals responsible for disaster planning for healthcare should take the time to read these documents. They contain a thorough review of the many difficult issues and add needed clarity particularly to the legal and regulatory questions. Healthcare emergency planners will find the included checklists, forms, and other tools very useful. 

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