'Tis the season - Flu, RSV, and COVID: A heads-up from down under

Across Australia, pediatric centres have just come through a challenging respiratory virus season - driven by influenza, RSV, and COVID - with unusually high volumes among infants and young children, shifting viral patterns, and sustained pressure on emergency departments and inpatient units. As Canadian hospitals begin to experience early increases in respiratory illness, pediatric leaders are watching closely for signals of what may lie ahead.

In this “just-in-time” episode, Dr. Lindy Samson, Chief Medical Officer and Chief of Staff at CHEO, speaks with Dr. Sarah McNab, Director of General Medicine at the Royal Children’s Hospital in Melbourne, to unpack what truly defined Australia’s season. Their conversation explores why influenza surged earlier and harder than expected, how testing strategies and triage pathways evolved, where hospitals struggled to keep pace with demand, and what helped support clinical teams during periods of extreme pressure. Dr. McNab offers practical insights on vaccine uptake, ED flow, inpatient capacity, and communication with families - highlighting which approaches proved valuable and which fell short.

Drawing connections to the early trends Dr. Samson is already seeing in Canada, this episode provides a cross-continental perspective for pediatric leaders preparing for a potentially difficult winter. Whether you are supporting emergency operations, managing inpatient pressures, or monitoring viral activity in your region, this discussion offers actionable, firsthand guidance to help anticipate and respond to the respiratory virus season ahead.

(Recorded December 10, 2025, this conversation reflects the best available insights at a rapidly evolving moment in Canada’s viral season.)

Transcript

Paula Robeson  00:00
 Welcome to SPARK: Conversations, Children's Healthcare Canada's Podcast Series. I'm Paula Robeson, Director of Research and Knowledge Mobilization at Children's Healthcare Canada, and today I'm delighted to be speaking with Dr. Lindy Samson and Dr. Sarah McNabb to bring you “just in time” episode. As many of you are preparing for what may be a challenging, viral season, we're bringing you this special, timely conversation. Dr. Samson is Chief of Staff and Chief Medical Officer at CHEO, a children's hospital in Ottawa, Ontario, Canada, and Dr. Sarah McNabb is a General Pediatrician and Director of General Medicine at the Royal Children's Hospital in Melbourne, Australia. For their full speaker bios, please visit our website at www.ChildrensHealthcareCanada.ca. We hope their insights help support your planning in the weeks ahead. Dr. Samson, over to you.

Lindy Samson  00:55
Thanks so much, Paula. And it's so nice to be here together with you, Sarah. And here we are again in Canada with what looks to be the start of, indeed, as Paula said a really challenging viral respiratory season. You know several regions across the country are starting to experience a very steep uptick in children presenting with what turns out to be influenza A. And that started you know, very steeply about two and a half weeks ago, two weeks ago - and is starting to really challenge our emergency departments and our inpatient capacity. Even though we've been, you know, implementing and strategizing and, you know, taking lessons learned from previous seasons and, you know, putting new things in place. Yet here we find ourselves again. And in fact, last week here at CHEO, we had the largest number of children ever seen waiting to be seen in our emergency department. And most of them, like the overwhelming majority, were children with low acuity illnesses and just couldn't find care anywhere else in the system. And of those that have needed to be admitted and over the last week, we have seen already for us here at CHEO, more than 60 children admitted. But really the overwhelming majority, way more than majority, are not immunized. In fact, we've only been able to confirm immunization in three kids, and most of others are confirmed that they weren't immunized. And so you know, all of our teams across the country are preparing for what appears to be a very challenging few weeks ahead. And so we're so thrilled, Sarah, that you are here to share your experience from the Southern Hemisphere. We often rely on our colleagues and friends and collaborators in Australia to sort of brainstorm together and learn from each other. And so, so pleased to be joined by Sarah McNabb, a pediatrician who lived through the viral season just a few ending a few short weeks ago there. And you know, we're hoping you can walk us through what happened in Australia. And we know that, you know, share some of your wisdom and advice that Canadian pediatric centers should be thinking about right now. And we, we hope you can start by just giving us a little overview.

Sarah McNab  03:24
 Thank you so much for having me. It's you're very interesting to hear very similar stories to what we have just been through in Australia. We've had a very, very solid flu season. You know, certainly the numbers across Australia were much increased in terms of admissions compared with the year before. So a really big challenge for us and I'm worried about the challenge that you as Canadians have ahead of you. Really similar themes to what you've experienced in terms of vaccine numbers, which have dropped off remarkedly compared to pre-pandemic rates. So, if we compare our flu vaccine coverage of the less than five year olds in 2020 compared with now, it's more than halved, which is really concerning and possibly is contributing, or probably is contributing to the large numbers of flu that we're seeing.

Lindy Samson  04:27
 Yes, so it does sound like a, you know, similar situation in terms of the context of the definitely, the immunization status. We're, of course, waiting for our final understanding of what our numbers are, and feel like we're still at a moment where we can, you know, change the trajectory a little bit. But I'm going to ask you more about that in a minute. I want to start by asking, you know, was there a specific moment or event or some indicators early on - that in retrospect or even in real-time led you to realize that, you know, this was going to be, you know, a bit of a challenging year for you? 

Sarah McNab  05:04
 Yes, and no, we probably didn't have that, you know, that day that you're describing, that you had last week where the numbers were suddenly very high. What we've seen that's been a little bit different this flu season across Australia's it's been a bit more relentless. So, it's been a longer, broader flu season than what we would typically see. So while we didn't have those typical couple of weeks of absolutely being inundated, we found that, you know, it was, you know, it was stretching for much longer than we thought that it would. And we've still been having flu, you know, a reasonable amount of flu cases right up into, you know, November, which is, of course, nearly summer for us.

Lindy Samson  05:50
 So as we I'm sitting here in a very snowy Ottawa today, summer seems very far away, but I think that even off the top, is an important consideration for us, that if the season it's going to be more prolonged - even if we're having very high numbers up front, we're going to need to prepare for a sustainable response.

Sarah McNab  06:11
 That's exactly it. Because, as you know, you know, I suspect your teams would be similar to our teams, in that we can all sort of bunker down and work really hard for those few peak weeks, but keeping everything you know, the team motivated and sustained, and making sure that you know our access to care is sustainable is so important. And particularly when you've got staff that also get knocked out by illness.

Lindy Samson  06:35
 Yeah, thanks for that. Maybe we can just continue with that. So were there any sort of new strategies or new approaches that you use for this? I think Australia's similar to Canada and that our Health Human Resources are already working sort of flat out. And are, you know, we're facing challenges in ensuring that our staff are able to come to work and well and have a sustainable presence. So did you do you have any advice for us?

Sarah McNab  07:08
 Yes, look, I think it's probably all things that you've learned through the pandemic. You know, the good and the bad of the pandemic. One thing is that where, I think, certainly at the hospital that I work in, which is the largest tertiary pediatric hospital in our state. We're much better now at protecting ourselves and protecting our patients from picking up viruses from each other. So our mask wearing when we're seeing sick patients is just completely different to what it was pre- 2020. It's much - we don't wear masks routinely in hospital for non-infectious children, but we are wearing masks with lot more diligence than I was in 2019 that's for sure. So I think that we've been able to protect our workplace in a way that we weren't able to pre-pandemic. The flip side of that is we're much better at staying home when we're sick, which is what we should be doing, of course, but it's not how our workplace has necessarily been traditionally staffed. So, you know, we were, we have always been staffed for a workplace that turns up, you know, for better or worse, whether in sickness and in health. You know, we've had, you know, we've had staff who've come to -  pre-2020, stuff that would come to work unwell, which wasn't good for anybody. And it is much better, of course, that staff are staying home when they're unwell now. But we're not, we're not staffed for it. So really, in terms of the forward thinking capacity to be able to flex when staff are unwell is so important, and we've put a few things into place at our hospital so flexible staff. We have in our junior medical staff, we have a relief roster so staff that any day of the week can flex to different positions across the hospital to try and help cover gaps. And we've started the same at consultant levels. So, attending level. I know we all use different language across countries, but at our pediatrician and inpatient hospitalist level. We've got more flexible staffing. So it's really something that I would encourage all of your hospitals across Canada to be thinking of. Do you have a backup system for when your staff are unable to come to work? Because, as you know, the viruses do tend to spread amongst staff at the same time. So being as flexible as possible is really important.

Lindy Samson  09:39
 That's really, really helpful; that flex staffing perspective at different levels, and I think you were referring primarily at the, you know, medical trainee level and medical consultant level or medical staff. Can you share about some strategies on the nursing and respiratory therapy side. Because we're also challenged that way. And of course, you know, when you have 28 people calling in sick on a given day, and we agree we want them to stay home so we don't spread things. What strategies would you be considering that?

Sarah McNab  10:15
 So my nursing colleagues have been better at this historically, I think so the culture amongst our nursing staff was far, far ahead of our medical staff. So the staffing, in many ways, has already been built up to be more flexible from a nursing perspective and from a respiratory therapist perspective. We don't have that role specifically - we have physiotherapists who work in that way. One thing that our nursing staff do is move across wards and make sure that they're getting experience in different areas. It's a much larger workforce, so their ability to be able to flex is already inbuilt in a way that it's not with our medical staff. But again, that flexibility that, you know, cross-training across disciplines, so that our nursing staff are able to work in areas that are not necessarily the area that they usually work in. But to be able to be supported in work in areas that that they're not typically employed too, has been really helpful.

Lindy Samson  11:22
 Oh, that all sounds that all sounds really good. And did you - either this viral season or in previous ones - you know, reconsider what that nursing model of care looked like? In terms of who was there on the team, and not only with nursing, but with physicians and physician extenders and things like that.

Sarah McNab  11:40
 Yeah, absolutely. So one thing that we've got in our hospital is a short stay unit. So that's been a model of care that has been really, really helpful for our hospital in terms of having a group of very senior nurses, and very senior - I was going to say - very senior junior doctors, some of our more experienced junior doctors. Who really run what we aim to be a 24/7 ward. Now, obviously all of the wards are 24/7. But this is a ward where we're aiming to discharge when the patient is well enough, rather than just within routine hours. So our model of care is very criteria led so when a patient comes in, they are put on to what is called a criteria led discharge. Which is essentially a nursing lead discharge, which means that when the patients hit certain goals, and for children with flu, that's often, you know, being off oxygen, being able to feed independently without any additional hydration through a tube. Then they're ready to go home. And so what we're trying to do is take away that reliance for a ward round to come around and discharge a patient. And to put the power back in the family's hand and into the nursing staff's hands. So that we can really improve access through the hospital. So that's a model of care that has been around for about a decade, and that we keep on refining. That particular ward through COVID was our pandemic ward, so really upskilled our staffing during that time. And they've gone back to business as usual, which is bronchiolitis and flu through the winter months.

Lindy Samson  13:27
 And is that happened just in one physical space, or does that nurse led discharge model kind of expense extend to other areas?

Sarah McNab  13:36
 Yeah, great question with theoretically, it can be in any ward of the hospital, but this particular ward is the best at it, if that makes sense. So it's because we try to cohort the patients who are, again, very much, very much on a on a particular care pathway. We they've been really good at being able to upskill in that area, and we've really pushed the criteria led discharges on that particular ward. We're also staffed at junior medical staff level more robustly than the other wards, so that we can take the emphasis of it being a senior medical staff member needing to be there to do all of the decision making.

Lindy Samson  14:21
 Thanks for sharing that. Can we maybe switch a little bit to the emergency department environment, as we know, you know, lots and lots of children come in to be seen, much fewer need to be admitted. And in Canada, at least, anyways, we don't have a robust or enough patients in the community connected to primary care physicians or primary care practices. And so we're seeing more coming to the emergency department. So just wonder maybe you can share what that looks like in Australia? And then also, if you had any strategies to sort of keep kids from coming to emerge. Unless, of course, they needed to, then we want to see them. 

Sarah McNab  15:03
 Yes, oh, look, it sounds it sounds so similar. It's so good that we're connecting and having these conversations. Because you could be speaking about the state that that I live in. Where, in my opinion, primary care has been underfunded and it means that that patients are having to come to emergencies, for their, you know, for their care that could otherwise be seen if they had quick access to an affordable primary care physician. So there's a few different initiatives that are they're big, but they're worth talking about, because, you know, if you're looking at investment across Canada, some of these things have been really successful in fundamentally investing in primary care is the way to go. But there's a few other things that have been introduced in my state in in recent years. 
 
 So one thing that our government has invested in is urgent care facilities, which are similar in many ways, to emergency departments; although they're not attached to hospitals, so therefore urgent conditions that are unlikely to be needed to be admitted into hospital. So things like injuries, you know, sutures that might be needed, but also acute respiratory infections. Where it's unlikely that a child needs to be admitted into hospital, but where a parent wants a physician to see the child. 
 
 The other thing that I was really skeptical about, but has been very successful that's been started in Victoria, the state that that I live in, is a virtual emergency department that is statewide. So this is a group of emergency physicians, emergency nurses, general practitioners, so our primary care physicians and pediatricians - who staff a virtual emergency department. So, families across our state have a number that they can call, and they telehealth. And they get an opinion on whether they need to present in person. But they can also do things like give prescriptions virtually and care virtually. And that has actually been an incredible resource for families who just don't know if their child in the middle of the night needs to present to an emergency department or not. And again, I was a little skeptical, but it has been incredibly successful in terms of the numbers that they see. But also they've done surveys that show that the families, if they hadn't been able to access that service, would have presented to a physical emergency department. So, it's obviously a very big initiative that takes a while to get off the ground, but in terms of future planning, if that's not something that Canada already has in place, it's definitely worth linking in and finding out more information about that type of service.

Lindy Samson  18:04
 And is that something that you think is operating in every state in Australia? Yeah. Or is it unique?

Sarah McNab  18:11
 No, it's not. It's not yet, but I think people are seeing what's happening in Victoria and how successful it's been. Again, fundamentally, I think these are kids that if they could have got into their primary care physician, would have got into their primary care physician. But of course, in the middle of the night that's extra difficult. So yeah, it's been an interesting and very relatively unique initiative that's sort of come about in the post - I'm talking about the pandemic a little too much, but in the post-pandemic era where we all got used to telehealth and used to doing medical assessments on telehealth. It's been a nice silver lining to be able to use that in a in a creative way.

Lindy Samson  18:56
 And as you say, we're in the same situation where primary care has been under resourced and supported for so long, and it's going to take some time to build up. We're focusing on that, but it's going to take some time to build up. So we need these at least, at the very least, interim measures to sort of ensure that kids can be seen when they need to be seen. But at the right level of the system and not have to come into a hospital unless they really need to. So I really, that's it. I really like that, and I like the state-wide. In Canada, it would be province or territory wide. But I really, I really think that's something for us to consider. We don't really have that whole approach here at this point in time, so that's helpful. 
 
We did talk a few times already about the both in Canada here and also what you experienced in Australia - the low uptake of influenza immunization. And of course, here in Canada, which I think is also global; generally uptake of childhood immunizations are lower than where we were pre pandemic. And I just wonder if you did any sort of mid-season rethinking or reframing and were able to make a difference in what you were seeing in terms of vaccine rates?

Sarah McNab  20:12
 Yes, it's still an area that I don't think we've been successful enough on. So yes, we've tried, but nothing that's had a really positive effect. So, our vaccine rates this year were lower than last year for flu in children. So it's it's really disappointing that the trust seems to have shifted in terms of vaccine uptake and vaccine acceptability. Something that's been relatively new in recent years for Australian children is that the vaccine from six months to five years is now free. It wasn't always free for children who didn't have additional medical needs, but that's now free, and yet our rates are still low. We have mandatory vaccinations for healthcare workers in hospitals. So, we're doing well, and that's a great initiative to help protect our staff and help protect cross infection within a hospital, but the community levels are still low. We've got, you know, experts trying to understand that. We're certainly trying to push media onto that. And I think that still, unfortunately, the community think that flu is, is a common cold, or is, you know, something that is a rite of passage in children. And we get, of course, incredibly affected by the very sick children that we see, thankfully, not very frequently, but too frequently in hospital for something where we know there's a vaccine. Which is obviously the most devastating conversation to have with families whose children have been particularly affected.

Lindy Samson  21:55
 Something that we've been talking about here is what is, is there a better way to get the message out? So, should we go to certain communities, look for community leaders to sort of champion the message. And / or is there value with, you know, children's hospitals partnering with public health to sort of convey the message? I don't know if you have any thoughts or if you've tried that, and if anything helped? 

Sarah McNab  22:17
 Yeah, we certainly have tried. You know, partnering with our health department has been, we've have done that. We certainly. I think community leaders is something that is constantly a work in progress. How do we get to the families who need to hear this message? We think that our hospital is, you know, it's a trusted name in our community. And so, we have put out, you know, information on the social media of our hospital, videos. Family stories, I think resonate, at least anecdotally, we hear that family stories resonate. So we do try to, you know, profile families that have been deeply affected by severe flu. It is just a tricky one. It's not on our mandatory schedule of vaccines in Australia so well, it's funded for six months to five years. It's not on the routine schedule that children that children need. And you know, children in Australia need vaccines to go to childcare and to school unless they have exemptions. So it's not in that. So I think families either don't think about it or don't trust it, or don’t think it's worthwhile. And again, you know, I think this is where we can learn from each other. If you find that the silver bullet that helps, we would love to hear it, but we're constantly trying to push the message that that it is important. 

Lindy Samson  23:51
 Yeah, I think we're all trying we, you know, we're all trying to work on what would work. And I think speaking to families is really important to understand what would help, especially maybe those that then find themselves, unfortunately, with a very sick child. As you said, when they haven't been immunized. So yes we should continue to compare notes on that and learn from each other. I do wonder. We've been speaking a lot about influenza, but of course, here and everywhere, we know it's not just influenza, it's RSV and it's all the other viral respiratory infections. Did you find this season any different than others? Were there a lot of coinfections at the same time? Or were there - did it sequence out in what we would consider a more traditional way that our viral seasons unfold?

Sarah McNab  24:38
 Yeah, so certainly, the wave of the virus season was similar to what it what it used to be. Obviously, there were a few disrupted years there where the viral season with lockdowns changed along the way. We're back to the usual patterns again, except for the fact that this, this flu season, was more prolonged, you know, blunter, but more prolonged than other seasons. And yes, we saw all of the usual suspects back with a vengeance. So things like RSV. We have just introduced RSV prevention into both pregnancy and into newborn babies. I don't have the updated statistics on how that's impacted our RSV season, yet. It was new this year in our state, so we were a little bit slower than many other countries and many other states in Australia, actually. So we're hoping next year again, the uptake will be better of that. 
 
 The thing that is worth mentioning that I'm sure is worldwide, is the coinfection with serious bacterial infection and flu. So some of our sickest children with group A strep this year at our hospital, also were coinfected with flu. Which is, you know, something that I think we're still trying to understand at a at a virology and bacteriology level. But it is very much worth saying, and I think that matters for a few reasons. You know, one is if we hope that if we can prevent flu, we can potentially prevent some of these serious bacterial infections from becoming as devastating as they are. But also, because, you know, of course, if we see flu on a swab, we also have to be thinking about serious bacterial infections rather than, Oh, it's flu. We can send them home. They're fine. Which I'm probably telling your listeners how to suck eggs, but it's always a message that's worth mentioning. I hope that's also a Canadian phrase and not one of that was one of our -

Lindy Samson  26:47
 And of course, some years are worse than other with those secondary bacterial infections. So what I'm hearing is especially group A strep can be frightening and significant. So that's helpful information to know. We hadn't heard much about that aspect from the southern hemisphere yet. So also important to think about. Did you then have a different approach at all to your viral respiratory panel testing, or, you know, as a means to try and understand which ones were at higher risk and which ones weren't?

Speaker 2  27:21
 Look this, I think, is a constant battle between our clinicians and our epidemiologists and researchers in that, certainly at the hospital that I work at, there's been a de-emphasis on swabbing. So, in our emergency department, if you've got a child who presents with a viral infection, they have frequently not swabbed. As opposed to a few years ago, when we were swabbing pretty much everybody. Now there's a de-emphasis, if we don't think it's going to change management, because for that individual child, a swab is unpleasant. Of course, that does affect our you know, our knowledge of what to expect from the season, how prepared we can be, the messages that we can hand on overseas. And it's striking that even with decreased swabbing rates, we still saw, well, you know, the hospital that that I worked in, that I work in, a 30% uptick compared with last year in terms of children who were admitted with influenza. So it's yeah, it's a constant push and pull between wanting the information for broader knowledge and the impact on the individual child, and of course, the cost of doing widespread testing on every child that comes in with respiratory and viral symptoms.

Lindy Samson  28:45
Yeah, interesting. I think again, it is always that tension, and for some organizations or hospitals that don't all have single rooms, then we would do more swabbing from an isolation perspective. But of course, for most children, and what we're seeing so far, you know, otherwise healthy children with a relatively mild respiratory infection; we are also trending away from doing routine testing. Yeah, so it's interesting to see.

Sarah McNab  29:18
 I do think that one thing that's different at a community level is that flu testing. We can go into a pharmacy here and pick up a flu test that we can do ourselves and get an immediate response. So a lot of families are doing that themselves. That's not data that we have available to us. But certainly, as a mum, we hear a lot about flu in the community where children have done or where families have just gone to the pharmacy and tested themselves.  Which is helpful in many ways, because you know, if their child is relatively well, not needing medical attention, and they know what it is, I think some families feel you know, that they at least know what to expect if they know that virus is.

Lindy Samson  30:03
 I just wanted to come back to RSV for a minute. You mentioned that this was your first season using, you know, prevention in pregnant women and in newborns, and that's just launching here in Canada as well. Some provinces were starting our second season, and we did actually notice an impact in the first season, it was late. And so we are very hopeful that as more that becomes more available across the country, and really targeting women in pregnancy and the newborns that that we will notice a big difference. Because, of course, in many years, RSV has been our number one concern, and not so much influenza. So it'll be interesting to see globally, what that impact is, and hopefully will meaningfully reduce the number of little children, especially needing to come in.

Sarah McNab  30:50
 Yes, you know, I've often joked, you know, my ultimate day, you know, will be when we actually feel like we don't have a role. You know, when, when the bronchiolitis numbers get so low that that winter doesn't really feel like winter so. 

Lindy Samson  31:07
 Well, let's hope that happens for the kids of the world, but also for the providers and the system. You mentioned when we were talking about immunizations, that at least in your state, you have mandatory vaccine for healthcare workers with influenza. That is not something that is in place, although we very much encourage that that in Canada. So I wonder if that actually decreases the number of people calling in sick significantly and / or you still needed to come up with other strategies to sort of manage the workforce, while people were appropriately staying home if they were well? If they were unwell. Sorry. 

Sarah McNab  31:51
 Yeah we've had that in place for a long time. Certainly, I can't actually think, but I would say at least a decade, we've had mandatory flu vaccines for our healthcare workers. It. So I don't, I can't compare statistics around sick leave, but you know, it must assume that it helps, and I think it's part of a real emphasis in our hospital and in our hospital system about protecting healthcare workers from getting sick themselves, but also from cross infecting other patients. So we have a real emphasis on things like hand hygiene, where we're constantly audited and put against KPIs. Mask wearing is, as I said, not mandatory anymore, but something that is socially accepted, generally accepted. Our patients don't seem to blink at all if we come into a room masked. And, yes, a general emphasis on making sure that we're looking after our health so that we can look after other people's health. I mean, but of course, despite being vaccinated for flu, and again, our whole hospital is - there are all of the other viruses that we don't have the vaccines for. So we still have, I've just come off the back of a virus myself, despite all of this. I don't think I got it at work, though. And we, yeah, we, there's so many other viruses that can affect us, so it probably has reduced our sick leave but it's, you know, sick leave still occurring.

Lindy Samson  33:28
 Okay, that's great. So sir, I can't thank you enough for sharing your experiences with us. So I just wonder, you know, based on your work at the hospital and through Women and Children's Healthcare Australasia, whether you have any sort of final words of wisdom or advice to pass along to us, if you can recall what it was like for you at the beginning of the season this year. Is there anything that you wish you could have told yourself,n ow? Could tell yourself back then, that we could benefit?

Sarah McNab  33:59
 It's a good question. Good luck, I think is the main thing. No look. I actually think this community of practice in terms of speaking to people, you know, sharing across hemispheres is really, really helpful. But within Australia, we also constantly talking to each other. As you know, I'm a Director of my department, so I speak to my counterparts across the country, and we just as much as being a really good morale boost, it's also very, very helpful to know what's happening in other states across the country and what new initiatives they're coming up with. So that we can constantly be striving towards keeping our patients as healthy as they possibly can be, and preferably out of hospital for their sake. 

Lindy Samson  34:48
 That's great. And you know, we're so fortunate. Children's Healthcare Canada, which is our host of our conversation today, actually serves as that convening function for us in Canada, and we can allways sort of do it just in time, question to someone, but have these more structured conversations. So that's really good words of wisdom, and we'll take your good luck wishes as embark on this. I can't tell you enough how helpful this has been. I've been scribbling little notes, like takeaway notes. But you know a couple of things that I would highlight, that emphasis on flexible staffing models, but also on where people, where people work. Which I think is really something interesting for us to take away, both on the physician side with our medical learners, but also in the, you know, the nursing staffing model as well. And this focused area, or this emphasis on, you know, nurse directed or directed discharging that can happen. You know, the care can unfold in the way it needs to unfold in real time. And then, you know, meeting the needs of patients, discharge kids as soon as they're ready to go. And of course, I hear we're all battling the primary care, you know, supporting the revamping of primary care in the meantime, those sort of ED diversion practices and strategies. And so I really - what resonated is the sort of statewide approach to a virtual or for us, it would be province and territory of virtual care option. Which can even just buffer between the, you know, very basic questions that parents might have, but even more significant management to avoid coming to coming to the hospitals. So those are just my like off the top pearls. And then the one last one is the secondary bacterial infections that you saw with group A strep especially, and so lots of takeaways for us to think about. And I'm hoping we can check in at the midway point of our season and just let me know how we're doing as you're preparing for next year, and see if you have any other thoughts.

Sarah McNab  36:57
 Yes, that sounds fantastic. It's been absolutely lovely to talk.

Lindy Samson  37:03
 Really lovely. So Paula, we'll turn it back over to you.

Paula  37:07
 Wonderful. Thank you so much Dr. Samson and Dr. McNab for sharing your experiences and expertise today, as children's hospitals and community hospitals across Canada continue to navigate the early stages of this respiratory viral season. We hope these lessons will help inform our planning, strengthening our surge strategies, and supporting our teams on the front line. At Children's Healthcare Canada, our goal is to provide you with the most relevant, actionable information when you need it most, and we'll continue to share updates and conversations as the season evolves. 
 
 Thanks to everyone for listening, for your leadership and for all you do to support children, families and the pediatric workforce across the country. Please stay well, and we'll be back with more soon. And to stay up to date on all of our offerings, please visit childrenshealthcarecanada.ca and subscribe to SPARK: News, the biweekly e-bulletin, if you haven't already. Thank you both so much.