Hospital Surge

DOH is encouraging health care facilities, providers, and local health jurisdictions to work together on mitigating health care capacity issues at the local level. These collective efforts include providing effective isolation and quarantine of COVID-19 cases, communicating to the public about the current situation and associated health risks, facilitating patient transfers to hospitals that have capacity, discharging hospital patients to long term care, adult family homes, or home health services as appropriate, and recruiting additional staff and volunteers.

Mitigation Strategies for Health Care Facilities

STEP 1: Declare an internal triage and activate your emergency response plan.

This is the hospital-level approach for determining which emergency department (ED) patients need attention first. This happens when ED visits are higher, such as during flu season, not just for COVID-19.

STEP 2: Notify your health care coalition.

As soon as your facility begins experiencing high capacity, notify your health care coalition (HCC).

STEP 3: Bring in all available staff.

This could include staff from other areas of the hospital, clinics, or retired health care workers (operating in positions appropriate for their licensing status).

Leverage community resources to support staffing. For example, work with childcare providers to enable staff to work.

STEP 4: Cancel all elective cases.

If you haven't already, cancel all elective cases.

STEP 5: Discharge anyone who can be discharged.

Rapidly discharge all eligible patients. To facilitate rapid discharge, DSHS and HCA are offering incentives to long-term care facilities.

Leverage community resources to support. For example, retired health care workers can serve as patient “sitters.”

STEP 6: Request volunteers.

Your local emergency management (EM) or public health department should know about MRC (medical reserve corps) capabilities in your area. If volunteers cannot be found locally, local EM will elevate the request to the state.

Visit to learn about requesting volunteers.

STEP 7: Adopt a tiered staffing model.

Extend your workforce with a tiered staffing model. This approach to staffing allows trained and experienced intensivists or others with critical care clinical experience to direct care for large numbers of critically ill patients.

Examples of tiered staffing models are available from the National Institutes of Health.

STEP 8: Consider contracted staffing services.

The current surge in COVID-19 cases has caused significant stress on the health care system in Washington. The most pressing challenge facing the health care system (hospitals, long-term care facilities and EMS agencies) is staffing. The types of staff required to support facilities include nurses, certified nursing assistants, respiratory therapists, EMTs/paramedics, and other clinicians.

Many healthcare facilities and agencies already have staff augmentation contracts, but those contracts may be unable to meet current needs. DOH has leveraged the federal General Services Administration (GSA) contract for experienced out-of-state healthcare personnel to provide round-the-clock support at healthcare facilities in Washington. These are not federal resources; they are contracted staff who we have access to through a federal government contract with a company called “ACI Federal.” Costs for ACI staff are approved by the GSA and are fair market value. If contracted staff are working solely on COVID-19 activities, costs may be considered 100% cost reimbursement eligible through the Federal Emergency Management Administration (FEMA) until December 31, 2021. If staff are diverted to non-COVID-19 activities by the requesting facility, FEMA may determine the entire cost is not eligible, details outlined in the contract.

To access this resource:

For more information, including staffing costs, please email

STEP 9: Request a local alternate care facility (ACF).

Alternate care facilities (ACFs) can help move dischargeable patients out of the hospital facility. They can be staffed by volunteers. An ACF can be a different space in the same facility, a hotel, gym, or school. ACFs can support patients waiting to be discharged but haven't been processed.

Requests for ACFs must be submitted to your local emergency management (EM). Your EM will look for local resources, and if none are available, will submit the request to state EM. When locating this type of resource, local and/or state EM will also consider staffing availability.

Crisis Standards of Care

What are crisis standards of care (CSC)?

Washington's Disaster Medical Advisory Committee (DMAC) is continually engaged in planning for and updating the state crisis standards of care (CSC). The CSC are based on the ethical framework developed by the National Academies of Medicine, which stresses the importance of an ethically grounded system to guide decision-making in a crisis standards of care situation. The framework also defines surges capacity within the healthcare systems, during normal operations and disaster operations, as a continuum from conventional to contingency (mitigating the surge) and finally crisis.

What is the continuum of care?

Conventional Capacity

The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan.

Contingency Capacity

The spaces, staff, and supplies used are not consistent with daily practices, but provide care to a standard that is functionally equivalent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources).

Crisis Capacity

Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the setting of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant and adjustment to standards of care (Hick et al, 2009).

How was CSC planning developed?

Planning and discussions about what are the most equitable way to provide care to as many people as possible when we are experiencing CSC has been going on for several years both locally and nationally. Many physicians, nurses, other hospital and outpatient staff, emergency planners and experts on ethics have wrestled with these hard decisions. As a result of this long-term and very thorough process, Washington State has developed and adopted a plan and procedures for how limited resources can be extended as far as possible to benefit as many patients as possible. When the entire healthcare system in Washington is in the status of crisis standards of care, these guidelines and recommendations are used as the basis for healthcare providers and systems to make decisions on care, in as equitable a way as possible, when there aren't enough resources, and a surge in patients.

What are examples of scarce resources?

Depending on the crisis the following may be considered scarce resources: ICU beds, PPE, ventilators, staff, and more.

Who has the authority to declare CSC?

If Washington must apply Crisis Standards of Care, the Secretary of Health will issue the order and any accompanying guidance for clinically, ethically, and equitably making these types of difficult decisions.

Is Washington currently using CSC?

Health care capacity is stretched across the state. We recognize that at different points in time, different facilities are having to provide care without all the resources they would normally use to provide care. If we were to experience this situation statewide in a manner that impacts access to life-saving care, DOH will provide statewide guidelines to ensure care is provided in an equitable and safe way. These guidelines are the crisis standards of care.

Currently, Washington's health care systems are providing care during a crisis. At this time, there are no immediate plans to apply crisis standards of care across the state, but we continue to monitor the situation closely. If applying crisis standards of care across the state becomes necessary, guidance developed through DMAC and approved by DOH will be utilized.

How can health care facilities plan for CSC, in the event CSC could be implemented?

The following resources are available to assist health care facilities in planning for CSC.

Scarce Resource Management and Crisis Standards of Care
Triage Teams Guidebook (PDF)
Unique triage ID number generator (XLSX)
Triage team randomizer (XLSX)

In a CSC situation, loss and trauma will impact all involved. How is mental health addressed in a CSC situation?

Please see the following documents:

What is WA DOH's CSC allocation process?

Please see the Washington State Crisis Standards of Care Triage Team Operational Guidebook (PDF) for an in-depth view of this process.

Is equity addressed the CSC allocation process?

Yes. Equity is a priority of the department and will continue to be in our public health process and in any crisis situation.

Which patients would be part of CSC allocation process?

The patients being reviewed are the ones who have and/or need the scarce resource.

What is a “tiebreaker”?

A tiebreaker situation occurs only when there are not enough medical resources for patients who have the same likelihood to survive to discharge (i.e., are in the same priority level in the prioritization scale). There are many factors that clinicians must consider when determining prognosis prior to this step but it is important to be mindful of equity and to ensure implicit bias does not impact these decisions. More information is available in the Washington State Crisis Standards of Care Triage Team Operational Guidebook (PDF).

Why is 6-month survival considered?

The idea is that someone with recognized less than 6-month survival likely does have a more limited short-term survival as well. 6-month survival may be a surrogate for general burden of comorbidity, robustness, general health substrate before their current hospitalization.

This is considered in relation to all triage team questions and is not an independent factor that acts outside of triage team. Triage team uses that information to determine the best status for the patient on the priority scale.

The point of six month and hospice eligibility is not only based on data that shows that escalation of care particularly ICU care is not medically beneficial (increased survival) and more importantly there is no correlation between access to ICU care with improved patient and family satisfaction in last 6 months of life.

If Washington State declares CSC would that impact institutions and patients in neighboring or referring states?

Washington State declaring CSC does not legally impact other states. However, it could lead to some impacts on the healthcare systems in other states as we saw when Idaho declared CSC.

Why must Triage Team clinicians be actively practicing? We have some recently retired from clinical practice physicians who would like to serve on the teams.

Actively practicing clinicians have requirements they must meet to practice. Washington State also has strict requirements for clinical licenses. These requirements are to ensure capable clinicians are making these important decisions. However, CSC would be an extraordinary circumstance and recently retired or licensed out of state clinicians would be under consideration on a case-by-case basis. The goal of these requirements is to get the most capable team.

There are a lot of roles to fill when it comes to the Triage Teams. What if we do not have that many people or someone with that expertise?

We recommend each person only take on one role, if possible, because of the burden of CSC and the work entailed of each role. It may not be possible to have each role filled by one individual, the idea is to do the best you can given the circumstance.

People in the community to consider if you do not have enough people to fill roles:

More Resources