FAQs: Resuming Hospital Operations

My hospital has been asked by the county to provide a letter of support so our county can re-open faster than the rest of the state. Should I write a letter of support?  If so, what should I include in it?

Hospitals are not required to submit a letter of support, and the decision about whether to submit one should be made by hospital executive leadership. There are no requirements about the content of such a letter. The county is asking you to submit a letter of support because the state requires counties to submit three documents to get permission to re-open early: (1) an attestation from the county public health officer that the county meets certain readiness criteria, (2) a letter of support from the Board of Supervisors, and (3) a letter of support from the local hospitals.

The state’s guidance for counties includes factors that may be helpful to hospitals considering writing a letter of support. It’s important to emphasize that the state’s guidance contains requirements for the county to meet to re-open ahead of the rest of the state. These are not requirements that a county must meet to open on the same schedule as the rest of the state. In addition, these are not requirements that a hospital must meet, or attest in writing to meeting – even if the county requests the hospital to do so. A hospital should not feel pressured to submit a letter of support if it believes doing so is unwise.  

At least one county has asked its hospitals to provide an “attestation.” The state requires that counties submit a “letter of support” from local hospitals, not an attestation. Of course, a county may ask a hospital for an attestation — but a county cannot require a hospital to submit an attestation or a letter of support. Doing either one is within the discretion of the hospital.

The state’s guidance requires counties to consider the following hospital-related factors:

Hospital capacity. A determination must be made by the county that hospital capacity, including ICU beds and ventilators, and adequate PPE are adequate to handle standard health care capacity, current COVID-19 cases, as well as a potential surge due to COVID-19.  f the county does not have a hospital within its jurisdiction, the county will need to address how regional hospital and health care systems may be impacted by this request and demonstrate that adequate hospital capacity exists in those systems. The county must attest to:

  • County (or regional) hospital capacity to accommodate a minimum surge of 35% due to COVID-19 cases in addition to providing usual care for non-COVID-19 patients. Counties are asked to describe how this surge would be accomplished, including surge census by hospital, addressing both physical and workforce capacity.
  • County (or regional) hospital facilities have a robust plan to protect the hospital workforce, both clinical and nonclinical, with PPE. Counties are asked to describe the process by which this is assessed. 

The questions that a county should consider when addressing hospital capacity are:

  • Is there daily tracking of hospital capacity including COVID-19 cases, hospital census, ICU census, ventilator availability, staffing, and surge capacity?
  • Are hospitals relying on county MHOAC for PPE, or are supply chains sufficient?
  • Are hospitals testing all patients prior to admission to the hospital?
  • Do hospitals have a plan for tracking and addressing occupational exposure?

In addition, the guidance requires counties to consider the following skilled-nursing facility-related factors:

Vulnerable populations. A determination must be made by the county that the proposed variance maintains protections for vulnerable populations, particularly those in long-term care settings. The county must attest to:

  • Skilled-nursing facilities (SNFs) have a more than 14-day supply of PPE on hand for staff, with an established process for ongoing procurement from non-state supply chains. Counties are asked to list the names and contacts of all SNFs in the county along with a description of the system the county has to track PPE availability across SNFs. 

The questions that a county should consider when addressing SNF capacity are:

  • How many congregate care facilities, of what types, are in the county?
  • What is the COVID-19 case rate at each of these facilities?
  • Do facilities have the ability to safely isolate COVID-19 positive individuals?
  • Do facilities have the ability to safely quarantine individuals who have been exposed?
  • Is there sufficient testing capacity to conduct a thorough outbreak investigation at each of these facilities? 
  • Do long-term care facilities have sufficient PPE for staff, and do these facilities have access to suppliers for ongoing PPE needs?
  • Do these facilities (particularly SNFs) have access to staffing agencies if and when staff shortages related to COVID-19 occur?

When can hospitals resume care that has been deferred for the COVID-19 surge? 

On April 27, the California Department of Public Health released guidelines for gradually resuming the many health care services that have been deferred in response to the surge of COVID-19 patients. The guidelines offer a statewide framework while noting that all facilities should comply with local guidelines and recognize local or regional circumstances that require different timelines for resumption of services. Among the other considerations for health care facilities that the guidelines describe for a gradual reintroduction of services:

  • COVID-19 indicators (e.g., infection rates, hospitalizations, emergency department admissions, ICU beds, and skilled-nursing facility outbreaks)
  • Adequate personal protective equipment
  • Availability of testing when knowing the COVID-19 status of staff or patients is important for clinical care and infection control
  • Consultation with local public health officers
  • Availability of qualified staff
  • Having patient flow systems and infection control precautions in place

The guidelines also address care prioritization and scheduling, outpatient visits, hospital and outpatient surgery care, dental services, skilled-nursing facility operations, and more.