The purpose of the Hospital Surge Plan Checklist and Resources is
to assist hospitals in developing and/or updating their plans for
response to a significant surge event, as well as to provide
tools, examples and guides to assist with plan development and
The purpose of the Family Information Center (FIC) Planning Guide
for Healthcare Entities is to support healthcare partners in the
development of a detailed plan to provide information, support
services and reunification assistance to family members of
Development of the Family Information Center Planning Guide for
Healthcare Entities was led by the Los Angeles County Emergency
Medical Services Agency and developed in coordination with a
multi-disciplinary Project Oversight Group. Project Oversight
Group members provided strategic guidance regarding guide
development, validation, and implementation.
Hospitals may release individually-identifiable patient
information to another hospital or health facility for the
purpose of diagnosis or treatment of a patient.
A hospital may release individually-identifiable patient
information to a public or private entity authorized by law or by
its charter to assist in disaster relief efforts, to notify, or
assist in the notification of (including identifying or
locating), a family member, a personal representative of the
patient, or another person responsible for the care of the
patient, of the patient’s location, general condition or
death.However, unless the following steps interfere with the
ability to respond to the emergency, the hospital must follow the
following steps before disclosing information if the patient is
present and has the capacity to make health care decisions:
Obtain the patient’s agreement to the disclosure;
Provide the patient with the opportunity to object to the
disclosure (if the patient objects, no disclosure may be made);
The hospital may reasonably infer from the circumstances
based on the exercise of professional judgment that the patient
does not object to the disclosure. If the patient is not present
or is unable to agree or object, then the hospital may determine
whether the disclosure is in the best interests of the patient
and, if so, disclose only the information that is directly
relevant to the disaster relief organization’s involvement with
the patient’s health care.
Note: a “public or private entity authorized by law or by its
charter to assist in disaster relief efforts” could include Red
Cross, other hospitals, first responders, etc.
Unless the patient has requested that information be withheld
(“no information” or “John Doe” patients, information about the
general condition (undetermined, good, fair, serious, critical,
deceased) and location of an inpatient, outpatient or emergency
patient may be released to other third parties only if the
inquiry specifically contains the patient’s name. This is the
maximum information that may be released under this provision of
the law (this provision is meant to allow visitors, clergy,
florists, etc. to find patients) – however, CHA recommends that
hospitals use their discretion when exercising this authority.
For example, it is reasonable to give a room number to a florist
who asks, “Which room is Bernice Hathaway in?” However,
disclosing this information to the media would likely not comply
with the HIPAA “minimum necessary” standard. And of course, a
hospital should not notify other third parties of a patient’s
death before the next-of-kin is notified.
If there are mass casualties, the spokesperson may release
basic patient information such as the aggregate number of
victims, their sex and their general conditions. However,
individually-identifiable patient information may not be released
without the patient’s consent.
Reference: California Civil Code Sections 56.10(c)(15),
56.1007, and 56.16; 45 C.F.R. Section 164.510 (a) and (b)(4).
Primarily developed for use by hospitals, but also
beneficial for use by other providers and health plans, this
manual contains information on general emergency response
planning and related integration activities for hospitals.
This manual also includes guidance for hospitals related to
increasing capacity and expanding existing workforce during
a surge, augmenting both clinical and nonclinical staff to
address specific healthcare demands, addressing challenges
related to patient privacy and other relevant operational
and staffing issues during surge conditions.
This manual addresses the assets under a hospital’s control that
can be used to expand capacity and respond to a healthcare
Pediatric surge planning involves identifying knowledge gaps and
insufficiency of pediatric specific supplies. The purpose of this
Pediatric Surge Training Course is to help prepare general acute
care facilities to the challenges of pediatrics. The course is
designed for a target audience that has knowledge of disaster
The Emergency Preparedness Team at Rady Children’s Hospital
prepared this manual. This team includes physicians, nursing,
behavioral health, surgeon, safety supervisor, trauma, pharmacy,
security and disaster planning experts. The curriculum
development team conducted in-depth research of best practices
and other existing curricula to bring best practice.
The goal of this curriculum is to prepare hospitals and clinics
have the tools to respond more effectively in a disaster which
involves a surge of child victims.
Flu season is here and some hospitals are experiencing an influx
of patients in their emergency departments. This may require the
need to set up a tent for triage. CHA would like to remind
hospitals that the California Department of Public Health (CDPHi)
has provided guidance on preparing for tent use. On January 20,
2010, CDPH issued the Approval for Health Care Facility Use of
Surge Tents. This document is in addition to the provisions for
written approval of tent use described in AFL 09-39 issued
October 30, 2009. CHA also released a related memo on November
22, 2011. These documents are intended to expedite the approval
of the operation of surge tents and they remain in effect for the
2015 flu season.
Due to the recent increase in influenza patients, hospitals
should review requirements for tent use. According to a new State
Fire Marshal (SMF) policy, tents with labels do not have to be
annually recertified. Other current requirements are detailed in
the attached California Department of Public Health (CDPHi)
guidance. Hospitals should note that the CDPH Licensing and
Certification (L&C) district office must provide written
approval for tent use as explained in All Facility Letter 09-39.
In the absence of any specific suspension of statute or
regulation by Governor’s Executive Order, tents will be approved
for use only as waiting rooms; to conduct triage and medical
screening exams; and to provide basic first-aid and outpatient
treatment that meets all applicable rules and regulations. Any
other use may require a program flex. The SFM approves the
nonflammable material used in tents, and requires each section of
the top and sidewalls of tents designed to hold 10 or more
occupants to have an SFM-approval label. Hospitals should only
use tents with an SFM label. If no labels are affixed to tents,
hospitals should contact their local fire jurisdiction.
Local fire marshals, depending on their jurisdiction, may
have a variety of requirements as prerequisites for tent use.
Hospital owners should be in contact with their local fire
marshals now to learn the requirements prior to the use of a
OSHPD will review utility connections for tents that
originate in, pass through or pass under buildings regulated by
OSHPD. OSHPD will also require that tents do not obstruct the
required means of egress from the hospital. OSHPD is willing to
pre-approve the use of a tent when a hospital can specifically
designate where it will be located on the hospital grounds.
Hospitals are encouraged to receive this preapproval. This can be
scheduled through a field review by area compliance staff.
All SNF, NF and SNF/NF are required by Federal regulations to
“have detailed written plans and procedures to meet all potential
emergencies and disasters, such as fire, severe weather, and
missing residents” [ CFR 483.75 (m) F Tag 517 ].
California’s Health and Safety Code (H&S) and California’s
Code of Regulations – Title 22, (T22) specify the “details” that
are required in the facility emergency plan. To help you prepare
for the external disaster plan review during the annual survey
process, DHS has prepared the following optional self assessment
tool for your use.