September 2022


September 2022

I.C.C. van der Horst

Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands


I.C.C. van der Horst –

Forecast with eyes wide open – a perspective on the upcoming winter


Since the onset of the coronavirus disease of 2019 (COVID-19) pandemic, many patients have become infected. In addition, many have been admitted to intensive care due to the severity of the disease, exacerbated comorbidities or new diseases occurring concomitantly with COVID-19. Whether the upcoming winter will be challenging is currently unknown. Many factors influence the need for intensive care. A recent Dutch forecast stated that the need for intensive care might be low or at least lower than anticipated. For patients and professionals, this forecast is welcome. However, this statement might appear somewhat short-sighted.

Several factors seem to be overlooked when stating that winter will be calm.
First, the likelihood of other infections remains high, even if COVID-19 appears a less intense driver of hospital and ICU admissions.[1] This is especially true if the basic measures used to prevent the spread of COVID-19, which also had effects on other infections during the pandemic, are followed less strictly. Furthermore, several populations characterised with comorbidities at risk for admission to care facilities have had less attention and intensive treatment, such as rehabilitation in lung patients, due to scarce resources and increased demand such post-COVID syndrome care. This makes worse outcomes and higher hospital and ICU admissions due to infections more likely.[2]

Second, the rates of acute cardiovascular diseases have increased since the COVID-19 pandemic. For example, the incidence of myocardial infarction, heart failure and stroke is significantly higher.[3] In addition, the number of ambulance transports in the Netherlands for serious indications has been approximately 15% higher for months.

Third, more and more data are becoming available on the post-COVID syndrome, informing us on the sequela of COVID-19, including respiratory, neurological and non-specific symptoms.[4] Thus, on top of the existing pulmonary, cardiovascular and other morbidities in the Dutch population, which might have received less attention than desired during the pandemic years, the highly prevalent post-COVID syndrome most likely makes patients more vulnerable to a worse disease trajectory when suffering any intercurrent winter infection. If so, this will drive increased admission or readmission to intensive care.

Finally, even if the incidence of ICU admission due to COVID-19 or another infectious diseases remains low over the winter, the effect of milder infections on our professionals' health directly impacts the human resources for care availability.

The view of many policymakers on the near future is currently focused on patients with COVID-19. It is not in the same magnitude as during the first waves but it is still primarily considering the effects of COVID-19. The focus of many intensive care professionals has already shifted towards comorbid patients, who might be particularly exposed to winter risks. The goal of care is not only to treat a single patient but to be responsible for caring for all (intensive care) patients. The intensive care networks show responsibility for patients and have updated their winter plans to care for as many patients as possible if necessary while ensuring that the quality of care is up to standard. Furthermore, novel initiatives such as a rehabilitation unit to intensive care and employing technology and interprofessional collaboration are being explored and implemented. Still, the number of beds necessary for high-quality critical care should be based on an educated guess that considers the upcoming impact of coronavirus infections and all the variables that drive admission to our intensive care.[5]

A matching number of professionals is mandatory to run that number of beds. Because, even after the pandemic, it remains wise to prepare based on an accurate calculation of bed occupancy rates, while taking uncertainties in the complex interplay between population morbidities, (planned) acute care treatments and intercurrent winter infections into account.

If we want to prepare our teams for the near future, we should base our decisions on evidence showing that the impact of the virus goes beyond COVID-19 disease.[6,7] In this way, we can be prepared, and only prepared professionals to keep calm.


  1. van Westerloo DJ. Pandemics then, now and yet to come. Neth J Crit Care.
  2. Gardiner L, Singh S. Inequality in Pulmonary Rehabilitation – The
    challenges magnified by the COVID-19 pandemic. Chron Respir Dis. 2022.
  3. Douad G, Lee S, Alfaro-Almagro F et al. SARS-CoV-2 is associated with changes in
    brain structure in UK Biobank. Nature. 2022;604:697-707.
  4. Wortel SA, Bakhshi-Raiez F, Termorshuizen F, de Lange DW, Dongelmans DA,
    de Keizer NF; Dutch COVID-19 Research Consortium. Comparison of patient
    characteristics and long-term mortality between transferred and non-transferred
    COVID-19 patients in Dutch intensive care units: A national cohort study. Acta
    Anaesthesiol Scand. 2022. doi: 10.1111/aas.14129.
  6. Wortel SA, Bakhshi-Raiez F, Tjon Sjoe Sjoe WG, van der Zwan EPA, de Keizer NF,
    Dongelmans DA. The role of the Dutch National Intensive Care Evaluation registry
    during the COVID-19 pandemic. Neth J Crit Care. 2022;30:152-155.