It’s the same every winter – all across the U.S., hospitals are full and patients are backed up in our emergency rooms. Doctors hate it, hospital administrators hate it, nurses hate it, and patients hate it. Every winter, we say we’ll do better next year but we never do. The fundamental problem is that we plan on hospital occupancy and staffing based on averages over the course of a year and fail to account for seasonal variations in hospital admissions, and intensive care unit utilization.
In the past, the winter surge in hospital occupancy was attributed to seasonal influenza. Every year, the surge in flu cases results in more patients in our hospitals, ERs, and ICUs – typically in December, January, or February. “Cold and flu season” in adult hospitals was blamed on influenza, but that was because in the past, we only routinely tested for influenza. We knew that there were other seasonal respiratory viruses but unlike influenza, there was no specific anti-viral treatment for any of them so it wasn’t cost effective to order a $1,000 test for viruses that we could not do anything about. One of the benefits of the COVID pandemic was the increased availability of low-cost home tests for viruses. For less than $10, you can get a home test kit for COVID, influenza A, and influenza B. A home test kit for RSV costs about $25.
Respiratory viruses can result in hospitalization for viral pneumonia. They can also trigger asthma exacerbations, COPD exacerbations, and heart failure exacerbations that can result in hospitalization. Although influenza, RSV, and COVID usually cause the most serious infections, other respiratory viruses can also result in hospitalization and ICU admissions including mycoplasma (a pseudo-virus), human metapneumovirus, adenovirus, parainfluenza virus, and even the lowly rhinovirus. All of the common respiratory viruses peak at different times each winter. Moreover, the two major subcategories of influenza – A & B – also peak at different times. But the big 3 respiratory viruses – influenza, COVID, and RSV – account for the most hospitalizations and are the main contributors to hospital and ER congestion each winter. Influenza alone causes 127 hospitalizations for every 100,000 people in a community – for those over age 65, the hospitalization rate is 401 per 100,000. For infants, the hospitalization rate for RSV is 850 per 100,000.
An important predictor of when the big 3 respiratory viruses will peak in the U.S. is when they peak in Australia. As a southern hemisphere country, Australia’s winter is during our summer so Australia experiences its respiratory virus season in the June/July/August time period. Although not a perfect predictor, what happens with respiratory viruses in Australia during our summer frequently indicates what the U.S. will experience six months later, during our winter. The Australian Respiratory Surveillance Report is published online every 2 weeks by the Australian Department of Health, Disability, and Aging. At the time of this blog post, the most recent report covers epidemiological data through June 29, 2025.
It appears that Australia’s COVID peak occurred in June whereas influenza and RSV are still on the rise. If this same trend occurs in the U.S., then we should see COVID admissions peak in December 2025 and then RSV and influenza admissions peak in January 2026. As a result, we should plan on our emergency rooms, hospitals, and ICUs having a surge in patients in December and January. What hospitals do now will determine how they fare during this winter patient surge.
What hospitals should do right now
The management decisions that hospitals make today will determine how well they handle the inevitable census surge in 6 months. Fortunately, there are some very effective measures that hospitals can take to ensure that they get through this surge safely and financially secure.
- Anticipate nursing staffing needs. The number of inpatient nurses a hospital needs in July is very different than the number needed in January. It is a mistake to budget the same total nursing FTE’s each month for the entire year. Instead, budget for more FTEs in December and January. Get signed contracts for seasonal and part-time nurses now. Look to the population of nurses who have left the workforce recently because of young children at home to care for and nurses who have recently retired but would be willing to work for a month or two each year on a contingent basis. During respiratory virus season, it will not just be the patients getting sick, but so will the nurses and this will result in a seasonal increase in call-offs because of illness. Failure to secure more nursing FTEs will result in having to pay more in nursing overtime, lower nursing satisfaction, and inability to fully staff inpatient beds.
- But it is not just nurses. Additional inpatient beds puts more demand on all sorts of other hospital departments. Do you have enough housekeeping staff? Food services staff? Pharmacy staff? Phlebotomists? Registration staff? Think critically about all of the people in the hospital that it takes to provide care for an inpatient and be sure that you don’t end up with a staffing bottleneck in a department that you hadn’t even thought about.
- Manage your hospitalists. Plan now to have more hospitalists in the hospital each day during December and January. This may require adding a full hospitalist service during these months or adding at least a swing shift hospitalist to help with admissions. Tactics include limiting hospitalist vacations during December and January, hiring locus tenens hospitalists, re-hiring recently retired physicians for part-time work, and increasing the number of shifts existing hospitalists do in January & December while decreasing the number of shifts in other months. Because it takes weeks or months to credential new physicians to the hospital’s medical staff, identify specific locus tenens physicians and recently retired physicians looking for part-time work now so you can have them fully credentialed with hospital privileges on December 1st when you suddenly need them.
- Manage vacations. This applies to everyone – nurses, doctors, pharmacists, lab technicians, etc. Minimize the number of allowed planned vacations during December and January. The result will be that the hospital is fully staffed during these months. This can be unpopular for many of the staff who want to be off over the Christmas/New Year’s holidays so it usually takes careful communication from hospital administration and careful attention to scheduling by department managers.
- Send your orthopedic surgeons on vacation. Well, not all of them because you’ll still be dealing with people slipping on the ice and breaking their hips. But try to reduce the number of elective surgeries that require overnight hospitalization in December and January. By reducing the hospital’s elective surgical admissions, you will free up beds for the surge in respiratory virus infections. However, this does come with some cost because those elective surgical admissions are far more financially lucrative than emergency medical admissions.
- Be able to flex up the number of hospital and ICU beds. When patient admissions increase, you have to have some place to put them. If the hospital tries to maintain 85% or 90% capacity based on the hospital’s midnight census, then the number of beds needed in January will be more than the number of beds needed in July. Plan now to open unoccupied rooms on December 1st. For larger hospitals, this may mean opening up entire nursing units that are currently decommissioned.
- Fight vaccine misinformation among staff. Next season’s influenza and COVID vaccines will not be available for another couple of months. It is quite clear that the U.S. Department of Health and Human Services under the leadership of Robert F. Kennedy, Jr. is turning decidedly anti-vaccine against the advice of all of the major physician professional organizations. The resulting normalization of vaccine misinformation will predictably affect vaccination rates among hospital staff. The nurses and doctors are at the highest risk of getting a respiratory virus infection from sick patients. If these nurses and doctors get infected, it will increase absenteeism and increase patient length of stay due to more hospital-acquired respiratory viral infections. If your 30 unvaccinated nurses all get influenza and COVID, that is going to mean more work for the 100 nurses that were responsible and got vaccinated. Start staff vaccine education now.
- Fight vaccine misinformation among patients. Patients are even more susceptible to misinformation from anti-vaxxers like RFK, Jr. Hospitals should develop their own vaccine schedule guidelines that primary care providers and other outpatient providers can use in the event that federal government vaccine recommendations are not aligned with those of physician professional organizations. A communication strategy should be created to encourage appropriate use of influenza, COVID, and RSV vaccinations among outpatients. The CDC found that in 2024-2025, influenza vaccines were approximately 70% effective in preventing influenza-related hospitalization in children and 50% effective in preventing hospitalization in adults. To put this in perspective, you can prevent 1 hospitalization for every 250 adults over age 65 who get a flu shot. Patients at highest risk of requiring hospitalization when infected by influenza are those with congestive heart failure, COPD, blood disorders, and the elderly. When RSV and COVID are added into the mix, regular vaccinations can prevent a large number of hospitalizations. Hospital and community communication campaigns are essential to ensure that as many at-risk patients as possible get preventive vaccinations in the fall. Keep a weekly tally of how many hospitalizations have statistically been prevented based on how many annual influenza, COVID, and RSV vaccinations have been given and publicize it on the hospital’s internet site.
- Don’t forget about case management. Most hospitals have staff dedicated to facilitating discharges. Sometimes these are nurses, sometimes they are social workers. They are the ones who help line up home health services and help arrange admissions to nursing homes. Winter respiratory virus season means more patients needing supplemental oxygen at discharge and more patients needing to go to a skilled nursing facility. And each winter, every other hospital in town is trying to line more patients up with home health and SNFs so it becomes more difficult for a case manager to get any given patient discharged. Plan on increasing your case management staff during December and January.
- Take measures to minimize ER boarding. When the hospital is full, patients needing admission back up in the emergency room. As a consequence, there are fewer ER rooms to see those patients with emergencies and they back up in the waiting area or just leave without being seen. There are specific tactics that hospitals can take to reduce ER boarding and hospitals should start preparations now in anticipation of boarding problems in December and January.
- Monitor the data. The hospital’s electronic medical record and other computer systems can provide all sorts of realtime patient throughput metrics. Some of these include ER wait times, ER boarding numbers, daily admission numbers, length of stay, midnight census, and ER left without being seen percentages. In addition, state departments of health and the CDC provide weekly epidemiological data and regional hospital utilization data. All of these metrics can provide early warnings to the hospital that a surge in admissions is eminent. This can allow the hospital to be proactive rather than reactive with respect to increasing staffing and opening additional inpatient beds.
- Meet with the leaders of other local hospitals. Let’s say you do everything right and have additional beds and staffing ready to go in your hospital in December. But, if the other hospitals in the area did not also do so, then they are going to try to send you their overflow patients. You’ll still find yourself out of beds and out of nurses and all of your prudent preparations will have been for naught. Not only do hospitals need to prepare for respiratory virus season, but the entire community needs to prepare. Work with the other hospitals to be sure that they are taking similar measures in order to accommodate their own census surge this winter.
An ounce of prevention is worth a pound of cure…
Managing a hospital during flu season is like piloting a ship in a sea of icebergs. If you wait until an iceberg is right in front of you, you’ve waited too long to change course around it and a collision is inevitable. But if you make a small course correction a few miles out from that iceberg, you will have smooth sailing. Prepare your hospital for respiratory virus season now and you will get through the winter with smooth sailing.
July 8, 2025
