DÄ internationalArchive22/2021Pediatric Emergencies—Worsening Care Bottlenecks as Exemplified in a Major German City

Research letter

Pediatric Emergencies—Worsening Care Bottlenecks as Exemplified in a Major German City

Dtsch Arztebl Int 2021; 118: 373-4. DOI: 10.3238/arztebl.m2021.0155

Hoffmann, F; Landeg, M; Rittberg, W; Hinzmann, D; Steinbrunner, D; Böcker, W; Heinen, F; Kanz, K; Bogner-Flatz, V

LNSLNS

Children and adolescents are entitled to the best possible medical care (1). According to a survey of more than 50 pediatric hospitals in Germany, resources and staffing levels are increasingly scarce—resulting in critical shortfalls in the necessary staffing levels and risk to clinical inpatient care that cannot be compensated (2). The timely delivery of care for children with life threatening illness who potentially require intensive care is only the tip of this particular iceberg.

Data documenting emergency care for time-critically and life-threateningly ill children in Germany are lacking.

This retrospective analysis aims to explain emergency care for children with life-threatening illness, using the major city of Munich as an example. As the primary endpoint we analyzed the forced centralized allocation to pediatric emergency departments for patients at maximum risk—which happens although the hospitals are officially registered with the emergency medical services as temporarily ”closed” because of lacking treatment capacity (for example, because beds are unavailable as a result of staff shortages).

Method

Since 2013, centralized allocations in Munich have been arranged by the emergency medical services Munich with the help of a web based IT system (IVENA eHealth, mainis IT, Frankfurt) and triaged into three defined sighting categories:

  • SC1: emergency treatment
  • SC2: inpatient treatment
  • SC3: outpatient treatment.

In the context of a retrospective data collection we analyzed the data collected by IVENA eHealth from 1 January 2015 to 31 December 2019 for all persons aged <18 years as regards SC 1 triaged emergencies and the proportion of centralized allocations to pediatric intensive care departments. A more detailed description of the methods is given by Rittberg et al (3).

For the emergency treatment of time-critically and life-threateningly ill children in the state capital Munich and the adjacent rural district, four pediatric intensive care departments are available (1× pediatric only, 2× mixed neonatal-pediatric, 1× pediatric cardiology). Designated emergency trauma rooms for children as the first port of call are set up in three of these. We defined as the primary endpoint the number of forced centralized allocations and as the secondary endpoint the rate of notifications to emergency medical services’ control centers from departments unable to accept any further patients for emergency care.

Results

In the 5 year observation period, a total of 49 193 pediatric patients were allocated to a hospital by the emergency medical services. Of these, 2694 children (5.5%) were triaged to the highest and most urgent category SC1, of whom 1554 (58%) required immediate intensive medical care.

An analysis of the rates of forced centralized allocations in the emergency category SC1 by age group, a continuous increase with the highest values was seen in toddlers in 2019 (Table).

Centralized allocations relative to total allocations by age group and for the total population in category
Table
Centralized allocations relative to total allocations by age group and for the total population in category

The Figure shows the rate of notifications for the five year period (2015–2019) from pediatric intensive care departments of Munich’s pediatric hospitals to emergency medical services’ control centers that they are unable to accept any further patients for emergency care. In this time period, forced centralized allocations to Munich’s pediatric intensive care departments notably increased.

Rates of availability of pediatric intensive medicine over the study period 2015-2019 based on the number of departments who had notified the emergency services that they did not have capacity to admit new patients/total number of available departments
Figure
Rates of availability of pediatric intensive medicine over the study period 2015-2019 based on the number of departments who had notified the emergency services that they did not have capacity to admit new patients/total number of available departments

In 2015, 5.6% of forced centralized allocations were to a pediatric intensive care department, whereas by 2019 this had risen to 27%. In 2019, one in four forced allocations of a time-critically ill or seriously injured child to a pediatric intensive care department had to be undertaken as a forced centralized allocation.

Discussion

In 2015–2019 in Munich, the rate of forced centralized allocations by the emergency medical services for pediatric patients triaged as the highest category of urgency (SC1) had substantially increased. Simultaneously the rate of notifications from pediatric intensive care departments to emergency medical services’ control centers that they are unable to accept any further patients for emergency care increased.

These data show a long-term bottleneck in emergency care for time-critically and life-threateningly ill children that has increased over the years. This means that increasing numbers of pediatric emergency patients who require immediate acute treatment in order to revert or stabilize life-threatening conditions are admitted by means of forced centralized allocation by the emergency medical services to a pediatric hospital that has notified the emergency medical services that its pediatric intensive care department is unable to accept any further patients because of lacking capacity. Such SC1 forced centralized allocations affect primarily toddlers and infants who—in contrast to older children and adolescents—cannot be treated in hospitals for adults as an alternative. The aim should be immediate admission of such patients to healthcare institutions that can offer qualified pediatric immediate care and further treatment after the time-critical emergency.

An international comparison shows that in the USA the number of pediatric intensive care beds increased between 2001 and 2016 by 42%, from 5,7 per 100 000 children (1:17 416) to 8/100 000 children (1:12 464) because of increasing medical complexity (4). Using this as an orientation point, Munich would have to have 19 pediatric intensive care beds available at all times for the 237 000 children living in the city. In reality the number is 13–15 beds (data query DIVI intensive care register 4 November 2020). From this perspective, a third of intensive care capacity is lacking every day.

The real pressure on existing capacities became even more notable if one remembers that the catchment area of Munich’s pediatric intensive care units includes the surrounding area and the pediatric hospitals located there, which have no pediatric intensive care departments themselves.

This study confirms that the requirement for sufficiently available medical care for children that—as Germany’s social code (SGB V § 12) stipulates—the funding bodies are to guarantee is not even met in time-critical life-threatening emergencies. Forced centralized allocations in order to deliver care to critically ill or injured children is a last resort that places a high burden on all directly involved parties. For the affected children it is more than that—a structurally exponentiated emergency. Better funding for pediatric medicine and making nursing in highly qualified and specific pediatric care more attractive as a profession could be important solution strategies.

Acknowledgments

We thank Messrs Florentin von Kaufmann and Uwe Bothe for evaluating the date from the integrated emergency medical services of Munich’s Professional Fire Services, Ms Martina Fischer and Ms Janina Esins of the Robert Koch-Institute/DIVI intensive care register, and Thomas Nicolai for critically reviewing our manuscript. We also thank Mr Gerrit Wiegand at mainis for evaluating the heatmaps of the pediatric intensive care departments.

Florian Hoffmann, Maximilian Landeg, Wendelin Rittberg, Dominik Hinzmann, Dieter Steinbrunner, Wolfgang Böcker, Florian Heinen, Karl-Georg Kanz, Viktoria Bogner-Flatz
LMU Klinikum, Campus Innenstadt, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität München (Hoffmann, Heinen)
florian.hoffmann@med.uni-muenchen.de

Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Notfallaufnahme Innenstadt, Klinikum der Ludwig-Maximilians-Universität München (Landeg, Rittberg, Böcker, Bogner-Flatz)

Klinik für Anästhesiologie und Intensivmedizin am Klinikum rechts der Isar der Technischen Universität München (Hinzmann)

Rettungszweckverband München, München, Deutschland (Hinzmann, Steinbrunner, Bogner-Flatz)

Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar der Technischen Universität München (Kanz)

Regierung von Oberbayern, München, Deutschland (Kanz)

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript received on 27 November 2020, revised version accepted on 15 February 2021.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Hoffmann F, Landeg M, Rittberg W, Hinzmann D, Steinbrunner D, Böcker W, Heinen F, Kanz KG, Bogner-Flatz V: Pediatric emergencies— worsening care bottlenecks as exemplified in a major German city.

Dtsch Arztebl Int 2021; 118: 373–4. DOI: 10.3238/arztebl.m2021.0155

1.
United Nations: Convention on the rights of the child. CRC 1989.
2.
Weyersberg A, Roth B, Köstler U, Woopen C: Gefangen zwischen Ethik und Ökonomie. Dtsch Arztebl 2019; 116: A1586–91 VOLLTEXT
3.
Rittberg W, Pflüger P, Ledwoch J,et al.: Forced centralized allocation of patients to temporarily ‘closed’ emergency departments—data from a German city. Dtsch Arztebl Int 2020; 117: 465–71 VOLLTEXT
4.
Horak RV, Griffin JF, Brown A-M, et al.: Growth and changing characteristics of Pediatric Intensive Care 2001–2016. Crit Care Med 2019; 47: 1135–42 CrossRef MEDLINE
Rates of availability of pediatric intensive medicine over the study period 2015-2019 based on the number of departments who had notified the emergency services that they did not have capacity to admit new patients/total number of available departments
Figure
Rates of availability of pediatric intensive medicine over the study period 2015-2019 based on the number of departments who had notified the emergency services that they did not have capacity to admit new patients/total number of available departments
Centralized allocations relative to total allocations by age group and for the total population in category
Table
Centralized allocations relative to total allocations by age group and for the total population in category
1.United Nations: Convention on the rights of the child. CRC 1989.
2.Weyersberg A, Roth B, Köstler U, Woopen C: Gefangen zwischen Ethik und Ökonomie. Dtsch Arztebl 2019; 116: A1586–91 VOLLTEXT
3.Rittberg W, Pflüger P, Ledwoch J,et al.: Forced centralized allocation of patients to temporarily ‘closed’ emergency departments—data from a German city. Dtsch Arztebl Int 2020; 117: 465–71 VOLLTEXT
4.Horak RV, Griffin JF, Brown A-M, et al.: Growth and changing characteristics of Pediatric Intensive Care 2001–2016. Crit Care Med 2019; 47: 1135–42 CrossRef MEDLINE