Hospitals and medical providers in Washington state periodically encounter a high number of patients seeking medical care due to widespread medical events such as the annual flu outbreak. The recent events in Las Vegas highlight another type of tragic medical surge event. During surge events, hospitals often seek guidance from the Department of Health related to surge capacity, variances, EMS requirements, etc. The following FAQs were developed by the Department of Health to assist Washington state hospitals in making business decisions in order to meet patient needs. These FAQs are for informational purposes only and are not intended to serve as specific legal advice. Please refer to your hospital emergency preparedness plan and legal counsel for guidance.
Medical Surge is the ability to provide adequate medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community. It encompasses the ability of the healthcare system to survive an event and maintain or rapidly recover operations that were compromised.
- Can hospitals extend emergency department care beyond 24 hours for unanticipated surge capacity?
Yes. We recognize that length of stay will vary during surge times. However, to the extent they are able, facilities are encouraged to find space other than the emergency department for care beyond 24 hours.
- During an epidemic can a hospital exceed their approved number of inpatient and/or emergency department beds? Will using extra beds, maybe in hallways, possibly be overlooked during an inspection? Or is there a process to request a temporary increase in beds (and if so, what is the process)?
A hospital can exceed its approved number of inpatient and/or emergency department (ED) beds in surge/emergency situations. We realize that there are times when hospitals become very busy and may resort to placing beds in hallways to manage short term needs, particularly during emergencies or surge situations. While this is allowable, hospitals must continue to have the capacity to maintain patient safety and well-being, fire and life safety regulations, infection control standards, and building structural integrity.
If exceeding licensed bed capacity is necessary, the hospital should make a written request for an exemption as required in WAC 246-320-026. The request may be made by e-mail. The exemption request should include:
- A brief description of the unique circumstances requiring the exemption;
- The number of additional beds required to meet patient needs and the expected duration the additional beds will be required to address the emergent need; and
- An acknowledgement that:
- Patient safety, health or well-being is not being threatened;
- Fire and life safety regulations, infection control standards, or other codes or regulations will not be reduced;
- Structural integrity of the building would not be impaired.
The exemption request should be sent to the Department of Health, Office of Community Health Systems prior to setting up inpatient beds exceeding licensed bed capacity. The Department of Health will provide a response to requests within 24 hours. Approval of the exemption doesn't authorize the hospital to increase the number of state licensed beds. The exemption approval will be time limited and allow the hospital, under the described unique circumstances, to set up and operate beds beyond the licensed limitation.
A Certificate of Need review and approval isn't required for the temporary set up of beds needed to meet surge requirements. If the hospital seeks a permanent increase in its licensed bed capacity, a Certificate of Need review and approval is required.
- Are there special considerations for Critical Access Hospitals who may exceed their licensed bed capacity?
For critical access hospitals, the requirements are different since federal rules don't allow these hospitals to go over their 25-bed limit. However, there are creative ways for critical access hospitals to manage surge events, such as using observation beds and holding patients in the ED to manage inpatient volume.
- Who has the authority to make the decision to divert patients to another hospital when resources are temporarily unavailable?
A hospital should refer to its diversion policy for the emergency department to divert patients to another hospital. Note that being on divert does not change the requirements for screening and stabilization under EMTALA. Patients presenting to the hospital must still be screened and stabilized as required by law.
- Do hospitals need to follow a formal process for converting areas necessary to handle surge capacity?
No, there is no formal Construction Review Services (CRS) process for accommodating surge capacity. CRS is available to provide technical assistance to facilities upon request.
- Can the Washington state Secretary of Health waive the Certificate of Need review requirements to increase my hospital's bed capacity beyond its current licensed beds to deal with a medical surge?
Certificate of Need (CoN) review isn't required for increasing capacity during surge events. Please refer to the process above for requesting an exemption in these circumstances. Once the emergency has passed, the hospital's inpatient bed capacity must go back to the previous CoN-approved pre-emergency level. A permanent increase in licensed bed capacity does require a Certificate of Need review and approval; the requirement cannot be waived by the Secretary.
- Can a hospital apply for an 1135 waiver during surge events?
An 1135 waiver can be granted only if there is a presidential and HHS Secretary emergency declaration.
- If a hospital has Prospective Payment System-Exempt Psychiatric or Rehabilitation Units, can those beds be converted to Medical Surgical beds?
Although under state law there is no need for a Certificate of Need review to use the beds temporarily to deal the medical surge, federal rules do not allow converting beds that are part of an Inpatient Psych or Rehab PPS-Exempt Unit for use by med surgical patients.
- Can EMS transport individuals to an urgent care clinic rather than to a hospital emergency room when they know resources - beds and people - have been exhausted?
Washington rules don't allow EMS to transport patients to urgent care clinics. Hospitals can support the Department of Health to encourage patients to call their primary health care provider, discuss their symptoms and seek medical advice on whether they need to go to the emergency department. However, once EMS is activated a patient can be transported by EMS only to an emergency department.
- What pharmacy implications might I consider during a medical surge situation?
Hospital pharmacies should work with wholesalers to ensure there is an adequate supply of Tamiflu or other needed medication available.
In rural areas, medical staff might consider a collaborative drug therapy (CDT) agreement with pharmacists within their community so individuals have greater access to needed medication such as Tamiflu. This agreement could be time limited.
For questions related to pharmacy, please call the Pharmacy Commission at 360-236-4946.
Revised November 21, 2017