RSV surge pressuring German children's hospitals

An infant who has just been resuscitated is admitted to a fully occupied children's hospital. For this to happen, a 3-year-old must wait the third day in a row for the heart operation he urgently needs.

Then there is the child who was transferred 150 kilometers (93 miles) one night from Hannover to Magdeburg because every bed was full — and the other 21 nearby hospitals also had no space. There are hundreds of children who spend the whole night gasping and wheezing in the emergency care waiting area only to be sent back home. Or who are being treated in normal wards when they should really be in the intensive care unit.

"Children die because we can no longer care for them," warned Michael Sasse, senior physician of pediatric intensive care medicine at the Hannover Medical School (MHH). Drastic words for a drastic situation.

For Mehrak Yoosefi, this warning comes dangerously close to reality. The pediatrician at Berlin's Charite hospital said: "All of the children's medical care facilities are currently operating 24/7. Our capacities are exhausted; we can no longer ensure care. We must ensure that we manage it so that no child dies in this time." 

RSV most dangerous for the youngest

This time — December in Germany — is the peak season for cold viruses. According to the Robert Koch Institute, the country's public health agency, almost one in 10 people in Germany is currently suffering from a respiratory illness — that equates to about 9 million people.

The viruses are particularly rampant among schoolchildren aged between 5 and 14. The common and contagious Respiratory Syncytial Virus (RSV) is usually experienced as mild by most adults and older children — but it can be especially dangerous for young children and babies. It affects the respiratory tract and can cause severe illness, with some patients needing artificial respiration.

The fact the virus is now hitting Germany with full force has a lot to do with the COVID-19 pandemic. Because of mask-wearing mandates and lockdowns, young children were less likely to be infected with RSV in recent years — and now the infections are catching up.

That has dire consequences for the German health system, which was already chronically overloaded. Yoosefi, who also wears a mask to avoid becoming sick herself, said: "Sometimes we are unable to admit these children to hospital because we have no available beds. Sometimes we cannot give children breathing support because we do not have enough equipment available to monitor their oxygen saturation. These are children who might be having trouble breathing. Children are currently being discharged earlier than they normally would or being transferred earlier out of intensive care to general wards."

Hardly any hospital beds available 

According to a survey by the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), half the clinics in Germany have had to turn away children for pediatric intensive care. Out of 110 children's hospitals, 43 had no beds available in their general wards.

What's more, although there are enough pediatric intensive care beds, almost 40% cannot be used due to a lack of staff. "We are all totally overworked," said Yoosefi, the pediatrician from Berlin's Charite teaching hospital. "There are not enough staff to cope with this huge influx."

It is not as if the German children's hospitals failed to anticipate what is facing them this winter. In January, Mehrak Yoosefi approached politicians with the Initiative Berliner Kinderkliniken, an action group of pediatricians from clinics across Berlin. There was no response. The group sent a second open letter with their urgent pleas to the top Berlin health official, Ulrike Gote of the Greens, and federal Health Minister Karl Lauterbach, of the center-left Social Democrats (SPD), in September. "We predicted this wave of illness. And now, of course, there is utter dismay because it has turned out to be so much worse than we thought."

Politicians did react, but slowly — too late for this winter. The Bundestag, Germany's federal parliament, approved a package of health legislation that is to inject more cash into the struggling children's hospitals. An extra €300 million ($314 million) is due to be provided in 2023 and 2024, plus €120 million to support maternity facilities. But what really upsets Yoosefi is the proposal from Lauterbach — a trained epidemiologist — to manage the current crisis: to pull staff from other wards to work in the children's departments.

Disadvantages of generalized training 

In January 2020, Germany's Ministry of Family Affairs proudly announced that training to become a qualified nurse was becoming more modern and attractive. However, almost three years later, the children's hospitals have come to the painful realization that the so-called generalized nursing training, with which employees are permitted to work across all age groups and areas of care, has some disadvantages.

Professor Jörg Dötsch, cirector of the pediatric department of the University Hospital of Cologne and president of the German Society of Pediatrics and Adolescent Medicine, sees a threatening gap in nursing.   

"A few years ago, it was decided to bring German nursing training in line with European customs. And it was hoped that some of these people might then specialize in pediatric nursing. The problem is that not enough of them are. Perhaps even more critical is the fact that in some states, these opportunities for specialization are not offered at all," he said.

Funding model does not suit care for children

The way German health funding is structured also puts children's hospitals at a disadvantage. Since 2004, hospital services have been paid for at a flat rate based on the diagnosis or procedure, instead of the amount of time and effort taken to complete it. While drawing a blood sample from an adult usually takes only a few minutes, taking one from a small child and explaining things to her or his parents takes half an hour. "You need a lot of energy and time because children and young people — and their parents — have vastly different care needs," pediatrics director Dötsch said.

Still: Health Minister Lauterbach has announced that in future, medical necessity rather than economic constraints should guide decisions on hospital treatments. The current health funding system of "low price, high volume," like in discount supermarkets, should soon be over.

Mehrak Yoosefi, the Berlin pediatrician, can hardly wait. "Pediatrics needs to be out of this flat-rate payment system; there needs to be another way of funding it."

This article was originally written in German.

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