More Americans are currently hospitalized with Covid-19 than at any other point in the pandemic, a grim indicator that the third big wave of cases in the US may be the worst wave to date.

On November 11, 65,368 people across the United States were in the hospital after testing positive for the novel coronavirus, according to data reported by the Covid Tracking Project. That’s significantly higher than the last peak of 59,940 recorded on April 15, when the New York City area was the epicenter of the US outbreak. (As the Covid Tracking Project notes, the national and state hospital data have been erratic and incomplete, and reported totals may continue to shift.)

What’s clear from the data is that Covid-19 has migrated across the country to new hot spot regions this fall. In the spring, hospitalizations were overwhelmingly concentrated in the Northeast. In the summer, more than half of hospitalized Covid-19 patients were in the South and West: states like Arizona, California, Florida, Georgia, and Texas.

Now the Midwest, Great Plains, and Mountain West are the new hot spots, and some former hot spots are warming back up as well, with cases and hospitalizations beginning to surge again. “There’s so many places, with so many people, that the numbers are just drastically higher,” said Daniel McQuillen, an assistant professor of medicine at Tufts and a senior physician in the division of infectious diseases at Beth Israel Lahey Health, at a Wednesday Infectious Diseases Society of America briefing.

As of November 11, Texas had the highest number of hospitalizations of any state (6,779). Illinois was in second place with 5,042 people in the hospital; other Midwestern states like Michigan, Indiana, and Wisconsin have seen spikes in cases in recent weeks and now have more than 2,000 people hospitalized each.

“The hospitalization number is the best indicator of where we are,” Eric Topol, a professor of molecular medicine and director of the Scripps Research Translational Institute, told Vox this summer. That’s because it’s a better measurement of the severity of the pandemic than general Covid-19 testing, which only finds a fraction of cases and includes more mild cases. “We’re going to go to new heights in the pandemic that we haven’t seen before. Not that what we saw before wasn’t horrifying enough.”

Some states like Utah and North Dakota have lower total hospitalizations but also fewer hospitals and hospital beds — and they’re now reaching a woeful tipping point of hospitals stretched to maximum capacity.

“Here in Salt Lake City, we provide a lot of [specialized infectious disease and ICU care] to people in four states as far away as Montana, Arizona, and Wyoming … and our hospitals and caregivers are extraordinarily stressed,” Andrew Pavia, the chief of pediatric infectious diseases at the University of Utah School of Medicine, said at the IDSA briefing. “Our ICUs are full, but that includes overflow ICUs that have been purpose-built, taking advantage of the time we’ve had to plan.”

mandatory face masks, restrictions on bars and restaurants, and for the federal government to fix testing and contact tracing problems. “It should be an all-points bulletin to really bear down on this, because otherwise there’s no limit on where this might go,” said Topol.

The good news is that infectious disease experts think many hospitals are much better prepared to handle surges in Covid-19 patients than they were in the spring. For the most part, they have the equipment they need and they know how to deploy it. They also have more standardized protocol for treating the sickest patients.

Yet hospitals in hot spots across the country are maxing out their staff, equipment, and beds, with doctors warning that the worst-case scenario of hospital resources being overwhelmed is on the horizon if their states don’t get better control of the coronavirus.

“ICU beds don’t take care of people — you need staff,” said Pavia of the University of Utah School of Medicine. “And one of the things that many of the Western states have in common is a relative shortage of the people we need to take care of very sick people during a pandemic like this: ICU doctors, probably most importantly ICU nurses, and infectious disease physicians, respiratory therapists. These folks have been working flat out for eight or nine months, and three months into the surge, they’re exhausted, they’re stressed.”

Staffing is a universal problem in hot spots. Gov. Gary Herbert of Utah said the state will have to bring in out-of-state nurses to help with the surge, and officials and health care providers in South Dakota, Tennessee, Arizona, and Wisconsin are requesting them too:

In Texas, officials are setting up medical tents in El Paso and Lubbock in response to the rapid rise in hospitalized Covid-19 patients and a dwindling number of hospital beds. “El Paso, Texas, is almost completely out of ICU beds; Lubbock, the same thing,” said McQuillen.

“We are the 11th-largest city in the state of Texas and we have two field hospitals on their way to town,” Jarrett Atkinson, Lubbock’s city manager, told KCBD on Tuesday. “I can absolutely assure you that never in my career did I think we would be deploying field hospitals to Lubbock, Texas.”

According to McQuillen, both El Paso and Lubbock have been “much less stringent with their populations [mandating] simple things like wearing masks, and socially distancing.” He compared that to Massachusetts and other Northeast states where he says strict measures during the spring surge made a big difference in reversing the steep climb in cases and hospitalizations. Yet too many states ignored that critical lesson, and now are paying the price.

While daily Covid-19 hospitalizations are surging, another key metric, daily deaths, reached 1,562 on November 11, the highest it has been since May during the first surge, according to the Covid Tracking Project. It’s an ominous sign that deaths could reach unprecedented levels in the coming weeks and months, given that cases and hospitalizations are now at new highs.

It’s possible, experts say, that fewer people who are hospitalized will end up dying in this winter stage of the pandemic as compared to the spring. As Vox’s Julia Belluz reported, there have been significant improvements in mortality in the US and Europe in the past several months, as doctors’ understanding of Covid-19 and how to treat it has improved:

Now, there’s strong evidence that common steroids like dexamethasone can reduce the risk of mortality in severely sick inpatients. Putting patients to rest on their stomachs instead of their backs (a practice known as proning) also seems to help.

Though there’s still a lot of progress to be made, the treatment approach has become more standardized over time, said Jen Manne-Goehler, an infectious disease doctor at Brigham and Women’s and Massachusetts General hospitals. When she started treating Covid-19 patients in the spring, it felt like practice was changing every few days. Now it’s more streamlined — and that’s undoubtedly helping with survival, too.

That said, if hospitals in the hard-hit states run out of beds and staff to treat the incoming flow of patients, more people who could have been saved may die. When ICU staff are stretched, “ICU patients just didn’t get the same attention,” intensive care doctor Lakshman Swamy, who works with the Cambridge Health Alliance, told Belluz.