Points of contact and advice for hospitals during surge issues

December 5, 2018

The Washington State Department of Health (DOH), in collaboration with WSHA, would like to offer hospitals a reminder regarding best practices and points of contact during challenges connected to a disaster or medical surge event. DOH is prepared to offer hospitals assistance regarding capacity and regulatory issues if such an event occurs.

In addition to the DOH hospital medical surge email, the recommended points of contact are:

  • Nancy Tyson – Executive Director for Healthcare Facilities and Certificate of Need. Phone: (360) 236-4796; Email: Nancy.tyson@doh.wa.gov
  • Julie Tomaro – Hospital Coordinator/Nursing Consultation Advisor. Phone: (360) 236-2937; Email: Julie.Tomaro@doh.wa.gov

DOH’s Division of Health Systems and Quality Assurance advises that hospitals may exceed approved number of inpatient and/or emergency department situations when surge issues occur, and that there are times when hospitals may resort to placing beds in hallways to manage short term needs during exceedingly busy times. This is allowable; however, hospitals must ensure that they retain capacity to maintain patient safety and well-being. This includes following fire and life safety regulations and maintaining infection control standards and building structural integrity.

Furthermore, according to WADOH, if exceeding licensed bed capacity becomes necessary, the hospital should submit a written request for exemption as required in WAC 246-320-026. It should be sent to the Department of Health’s Office of Community Health Systems prior to setting up inpatient beds exceeding licensed bed capacity. A response will be provided within 24 hours. If approved, the exemption will be time limited and specific to the circumstances.

The exemption request can be made over email and should include:

  • A description of the unique circumstances leading to the exemption request
  • The number of additional beds required, as well as the duration the additional beds will be needed
  • Acknowledgement that patient safety, health or well-being is not threatened; fire and safety regulations, infection control standards and other code regulations will be maintained; and building structural integrity will not be impacted

Additional information can be found at the Hospital Capacity Workgroup’s online FAQ page.


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Washington State Hospital Association
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Suite 1400
Seattle, WA 98104

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