When Florian Hoffmann and his team look at the occupancy of the beds in the children’s intensive care unit in the morning, the picture has been the same for weeks and months: everything is full. Most of the time even overcrowded. So there are already one or two too many children who have come to the emergency room with an infection and need intensive treatment. Florian Hoffmann is a senior physician at Dr. from Haunerschen Children’s Hospital of the Ludwig Maximilians University in Munich. He says: “We stand in front of our board every day and discuss which children are there, which ones can possibly be moved and, above all, which children are competing for a possible free place.”
One or two children too many doesn’t sound like an emergency to laypeople. But it is, and has been for a long time – not just in winter. The RSV and flu waves are currently rolling at a normal level (PDF), but all four children’s hospitals in Munich have been deregistered from the rescue control center for emergency care since December, both the normal wards and the intensive care units. A necessary, but ultimately only symbolic process, because refusing to treat emergency patients would violate the professional duty of doctors. That’s why emergency doctors and rescue control centers can forcibly assign children, so-called acute occupancy, which is currently everyday life in large clinics, even though there are actually no resources for these patients.
The tumor is not urgent enough
“We cancel major operations that have been planned for a long time every day,” says Hoffmann. “Now we’re sending home another family who would have had a major operation tomorrow because the child has no chance of getting a free intensive care bed. Something acute came up and unfortunately that’s how it goes all the time.” A torture for the families. Because we’re talking about children with tumors in the brain or stomach, children with tracheostomy or malformations. Often the children are already there, have not eaten anything in order to be prepared for the anesthesia, and are then sent away again. Of course, there are also time-critical interventions. “An incredibly tense situation,” says Hoffmann. Planned check-ups for other seriously ill children who, for example, are ventilated at home and need the ventilation setting checked, currently have little chance of getting a place because the clinics cannot coordinate emergency patients.
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The German Interdisciplinary Association for Intensive Care and Emergency Medicine (Divi), whose vice president is Florian Hoffmann, conducted an ad hoc survey in German pediatric intensive care units at the beginning of February. Of the 130 clinics surveyed, 91 responded. The result: There were a total of 86 free beds in the 91 children’s intensive care units – that’s an average of 0.94 free beds per clinic, i.e. less than one per location.
However, since the Corona pandemic, we have known at the latest: a free bed is not just a free bed. According to the survey, of the 629 beds in the 91 children’s intensive care units, only 409 can currently be used. The rest are closed because there is a lack of staff to provide care, due to illness among hospital employees, but above all due to the general shortage of nursing staff. Divi is therefore once again calling for better working conditions and better pay for nursing staff. Not just for reasons of appreciation: The lack of nursing staff is not just due to health policy – which can be clearly seen in the example of Munich.
Too expensive to live on
The numbers from the Divi survey clearly showed that the large clinics in metropolitan areas have the most closed beds, says Florian Hoffmann. These are the very clinics that are supposed to take in seriously ill children and complex cases. “The number of nursing staff here is decreasing not only because of overload, but also because the constant struggle to find out who gets a bed is bothering them,” says Hoffmann. “Many people are moving away. Because a one-room apartment in Munich now costs over 1,000 euros, who can afford that on a nursing salary?”
Given the current working conditions, which often require short-term shift changes and work starts at six o’clock, commuting is hardly an option. Housing must remain affordable for the hospital staff, says Hoffmann. Another problem is the lack of childcare places. “People have to cancel their shift because the kindergarten is going on a company outing or doesn’t open until 8:30 a.m. and closes again at 4:30 p.m. How do you want to make shift work in nursing attractive when this antediluvian childcare system prevails in Germany?”
In addition, there are stresses in everyday hospital life that take up unnecessary time. When patients are transferred, for example, the treating doctors themselves have to manually transfer the medication from one patient data management program to the other. Because it is so error-prone, this procedure takes a lot of time and a four-eye system. Digitalization does not seem to have arrived here, as can be seen in the search for a free bed in other hospitals, which the doctors usually have to take on themselves. “It often takes hours,” says Hoffmann. “As a senior physician, I’m sitting on the phone because there’s no assistant who could take on something like that.”
And once a bed has been found, transport still has to be found. “There were currently cases where we had to wait 12 to 14 hours for transport because a high proportion of the transport services’ cars were not in use due to a lack of staff,” says Hoffmann. When it comes to transporting children, experienced colleagues are often needed to ride or fly with them. “In the worst case, a colleague has to drive from Munich to Passau and back again with a child after his 10-hour shift in the emergency room – essentially in his free time.”
Vaccinations and telemedicine
Thema:
RS-Virus
RS virus: “When I hear that cough, I already know: It’s RSV”
RS virus: Hundreds of thousands of children are currently missing out on protection from the RS virus
There are several adjustment screws that need to be adjusted in order to change the dramatic situation in pediatric intensive care medicine. A lot of things have been wrong for years and many measures would only achieve the necessary effects after years. But there is a current demand that could at least provide short-term relief – by reducing the seasonal waves of infections. As a spokeswoman confirmed when asked, Divi wants to call on the standing vaccination commission (Stiko) to make a recommendation for the RSV vaccination in pregnant women as well as the new antibody against RSV for infants and for the flu vaccination in children – as is the case in others is already common in countries. The idea is that if more children in this country were protected from RSV and flu, children with heart defects or brain tumors could continue to receive adequate treatment even in winter. In Luxembourg, for example, it has been shown that, thanks to passive immunization of newborns and infants, 40 percent fewer children had to be treated in hospital for RSV than in the previous year.
A further attempt to improve the situation is expected to start in Bavaria in the summer if funding is approved. The children’s clinics want to set up and expand a telemedicine network in a pilot project. A change has been observed in Munich for several years: While children from small clinics in the Bavarian area used to be transferred to Munich because the competence for the complex disease lies more in the large university clinics, the opposite is now sometimes happening. Children from Munich are being moved to small clinics because there is no more space – sometimes as far away as Passau or Aschaffenburg.
Because we want to continue to provide these children with the expertise of large pediatric intensive care units for complex underlying diseases, telemedical consultations and visits by telephone or video will be possible in the future in order to provide the children with optimal care together. “We are currently planning our network in Bavaria because it is a state matter. But of course it is clear that if a child from Coburg has to be transferred to a university hospital and Dresden, for example, has a free bed, that we have to connect across the state borders and this child “Don’t bring them to Munich, where there might not be any space at all,” says Hoffmann.
Children’s hospitals: In crisis
Children’s hospitals: Treat the deficit first, then the children
Jörg Dötsch: “In some regions there is now a severe undersupply”
Of course, such projects do not solve the big and well-known problem that children’s hospitals are falling deeper into deficit every year. From an economic point of view, treating children is not worth it because, like adults, only a flat rate is charged per treatment, even though almost every treatment for children takes longer than for adults. Families are also involved in the treatment in children’s hospitals, so there is a need to talk, which also takes time and ties up staff.
It has long been recognized by experts that pediatric medicine cannot be billed on a per-case basis. Over the years, the children’s hospitals have literally collapsed because of this, says Hoffmann. Federal Health Minister Karl Lauterbach (SPD) wants to change the system with the hospital reform, but the federal and state governments still do not agree.