The morning meeting at the Gross-Gerau District Hospital begins with bad news. "One the other, the clinics around us are closing their doors,” says hospital director Erika Raab. "The hospital in Odenwald” isn’t taking any new patients and "Bergstrasse" is also about to close, she says. And now it's the turn of Darmstadt, a medium-sized city located just south of Frankfurt. "The hospital in Darmstadt is asking if we still have any beds free,” Raab says, peering out at the silent group of about a dozen doctors and nurses gathered in the meeting room. She already knows the answer. "OK, we’re already having to prioritize ourselves.”
Raab, 46, is the managing director of a hospital outside Frankfurt that has 220 beds. It's 8:30 a.m. and she is leading the morning meeting, known to staffers as the "pandemic round," in a white smock. She's still wearing it as she hurries through the hospital corridors to collect information on the current coronavirus patients and to find ways to free up more beds for COVID-19 victims. That those patients will come is "as certain as Christmas,” says Raab. All you have to do is look at the rapidly increasing number of infections in Germany to see that.
In the rural district of Gross-Gerau, located just southwest of the coronavirus hotspots Frankfurt and Offenbach, the incidence rate is more than 200 coronavirus cases per 100,000 inhabitants a week. Studies, and past experience, show that around 10 percent of those cases require hospitalization. And of those patients, anywhere between one in five and one in 12 will end up in an intensive care unit at some point. "For us that means it's going to get really bad really soon,” says Raab.
The hospital has cancelled outpatient operations, and surgeons have been requested to focus on emergencies and otherwise help out as back-up staff for the internists. The internists, in turn, are increasingly needed to provide care in the coronavirus wards. Pregnancy classes that prepare women and their partners for birth have been cancelled, and midwives have been asked to assist the nurses in the wards.
But Raab doesn’t think that will be enough. The hospital head sits in her office and leafs through official notifications of excess work that have been filed by her overworked staff. There are complaints about too much overtime, about being required to work through breaks and about paperwork that takes deep into the night to complete. And about the increasingly time-consuming cleansing and disinfection of isolation rooms.
In Ward 2, a doctor reports how a 92-year-old coronavirus patient suffering from dementia tore off his ventilator mask several times during the night and tried to get out of his bed. Fortunately, the nurses were able to calm him down.
A few days earlier, two of the six nursing staff assigned to the ward were absent at short notice on night duty. One had to go into quarantine because of COVID and the other had called in sick. The four remaining nurses had to care for 39 patients, including 13 who were in isolation rooms and five who needed a "high level of care,” Raab says. It was too much for the nurses and one wrote a formal complaint to management. "We can’t rule out the possible endangerment of the patients,” the complaint reads.
For Raab, this has been a crisis that had been foreseeable for months. She thinks Germany grew too complacent after the first wave of the coronavirus. Plus, there were no pictures of dying COVID-19 patients in crowded hospital corridors in the spring the way there were in northern Italy, she says, and people assumed that would also be the case in the fall.
Politicians also kept insisting that the German health-care system is one of the best in the world and that it had stood up to the test. Meanwhile, many additional ventilators, they noted, had been purchased and the capacity of intensive care units was greatly expanded. What could go wrong?
In the meantime, however, politicians are expressing growing alarm. "The situation is threatening to slide out of control,” Tobias Hans, the governor of the state of Saarland, said last Tuesday. "We are threatened with the kind of conditions seen in Bergamo in the spring, with overcrowded hospitals and gymnasiums converted into emergency hospitals” and medical staff "far beyond their limits.”
It’s a gloomy forecast that isn’t just limited to small hospitals in rural areas - it also applies to well-equipped, high performance clinics in the big cities. Ulrich Frei, an internist and a board member for patient care at Berlin’s Charité University Hospital, offers a simple calculation: "If around 1,500 people in the capital city were to get infected each day, and 2 percent of them, as we are seeing here, end up in an intensive care unit with a time delay of around two weeks, that would mean around 30 new intensive care patients every day in Berlin alone.” Some would probably have to be placed on ventilators for several weeks.
Saarland Governor Tobias Hans
Frei says there are already well over 200 COVID-19 patients in intensive care units in Berlin – more than at the peak of the first wave in April. He says the city still has reserve capacity, including a temporary container hospital with 73 beds that can be used as intensive care units. Almost 20 of those beds, though, are already occupied. And with the large number of new patients, it is only a matter of days before contingency emergency wards like that are full.
No one knows yet how big the second wave will be. Much hinges on how well the new partial lockdown and contact restrictions in place since the beginning of November work. But given the fluctuation of new daily infection figures of between 10,000 and 20,000 people, the second wave will result in "more than double as many patients” in the intensive care units in November than during the first wave in the spring, predicts Gerald Gass, the president of the German Hospital Federation (DKG).
How are hospitals going to cope with that? In the Rhine-Main area, the intensive care units at the large "Level 1” hospitals in Frankfurt and the suburb Offenbach were already at well-over 80 percent of capacity at the beginning of last week, and by that Tuesday, they had reached 90 percent capacity, according to an internal status report. Frankfurt’s University Hospital, which doesn’t release any figures on the number of people being treated in its intensive care unit, has been trying for the past several days to send corona patients to other smaller hospitals in the vicinity, as far away as Bad Nauheim, a town located 30 kilometers away.
Managing Director Raab (second from left) and hospital staff: "It's going to get really bad soon."Foto: Peter Jülich / DER SPIEGEL
A system for the distribution of patients has begun emerging in Germany. Rolf Lamberts, senior physician in the intensive care unit at the Gross Gerau District Hospital, was sitting in a colleague's office a week ago Friday when someone from a large Frankfurt hospital called. The official said a 56-year-old COVID-19 patient had been in a normal hospital bed for the past four days, but urgently needed an intensive care bed and there were none left in Frankfurt. Lamberts didn't have to think for long. Though his ICU ward is small, and five of its six beds were already occupied, he agreed to take the patient anyway.
Lamberts, too, had to move patients to other hospitals when their condition worsened. The Gross-Gerau hospital doesn’t have an ECMO, a state-of-the-art machine that can take over the complete function of the lung if necessary. Lamberts managed to find a free ECMO slot for his patient not too far away in Wiesbaden. In return, the Gross-Gerau clinic took in a malaria patient from the Wiesbaden hospital.
Ten minutes after the call from Frankfurt, Lambert’s smartphone rang again. This time, it was a small clinic in the southern part of the state calling not about a corona case but an acute poisoning. "I’m sorry,” Lambert said, "but I just gave away my last bed.” His colleague Zeynep Babacan, head of the COVID unit, immediately called the gate of the district hospital. "No new admissions to the ICU - at least until 9 a.m. tomorrow.”
A few days prior, the hospital had been forced to close its emergency room once before due to overcrowding, a function of the many COVID-19 cases. During that time, ambulances were asked to deliver patients to other hospitals, an unpleasant situation for the medical staff. "I actually became a doctor to help people in need,” says Babacan.
If it were just a matter of technical equipment, the district hospital would still have reserves. Lamberts says he has two additional intensive care beds that he could put to use immediately, and there are at least two more that could be made available later. The rooms and the necessary equipment are there, he says. In the summer, the hospital spent 400,000 euros to acquire new ventilators. The problem is that you need people who can operate the devices, says Managing Director Raab.
The hospital, which is owned by the local government, recently went through bankruptcy proceedings and had to reduce its staff size as a result. Since then, the hospital has been forced to cut corners everywhere, even under normal operating conditions. Raab says that the additional burdens created by COVID-19 can only be overcome if other services at the hospital are significantly reduced. Or suspended entirely if things get really bad.
The situation is similar in small and large hospitals all across Germany: It’s not the equipment that is creating the decisive bottleneck in corona patient care - it’s the lack of qualified staff.
Two years ago, the services union Ver.di criticized the shortage of up to 80,000 nurses in Germany’s hospitals. That shortage is now making itself painfully apparent right where they are most needed in the pandemic: in the intensive care units.
The consequences of the shortfall were recognized earlier this month by the very experts in Germany who are tasked with providing the overview of the number of intensive care beds that are available in the country. "We have been receiving a lot of feedback that the beds we had reported as being free in fact weren’t available at all,” says Christian Karagiannidis of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI).
DIVI has been commissioned by the German Health Ministry to keep a daily updated register of free intensive care capacities. Karagiannidis suspects that a number of hospitals didn’t just report the number of intensive care beds that they could immediately occupy but also included those that had been planned as "emergency reserves,” without the necessary staff. As such, he says, it should be assumed that there are currently "significantly fewer” intensive care beds available than suggested in the official DIVI reports.
Indeed, it turns out that the German health care system has slid into the second wave less well prepared than it looks on paper. That view is shared by the German Hospital Association, the body representing many operators and owners of hospitals.
At times, association President Gass says, DIVI has reported there were 32,000 intensive care spots in Germany. That would be about 10,000 more intensive care beds than in April. But even before the pandemic, the hospitals had several thousand vacancies for nurses and doctors, says Gass. In the intensive care sector alone, around 4,700 jobs for nurses remain unfilled. And they are unlikely to be filled in the foreseeable future because the pool of possible hires is "practically empty.”
It usually takes five years to train highly specialized intensive care nurses. Back in the summer, Heyo Kroemer, the chairman of the board at Charité University Hospital, reported that many hospitals had increased their intensive care capacities considerably after the first wave of the coronavirus. "But I doubt there's enough nursing staff to handle those capacities if we have to use them," he says.
The hospitals are trying to compensate. "We have reduced the number of surgical interventions by 20 percent and will reduce them even further,” says Charité board member Frei. He says that if operating theaters were closed, it would be possible to deploy freed-up surgical and anesthesia nurses in intensive care units, at least to a limited extent.
However, fewer routine operations also means lower revenues for the hospitals. This has prompted many to appeal to German Health Minister Jens Spahn to restart a program from last spring - which expired on Oct. 1 - that saw the federal government paying subsidies to hospitals to keep beds free for coronavirus patients.
Medical experts, though, warn that there are too many operations and treatments that really can’t be postponed. It might be possible to delay a hip replacement for a few weeks or months, but heart attacks, strokes and severe forms of cancer usually have to be treated immediately.
Hospitals also often need more staff for corona patients than for routine cases. "With heart attacks, two or three patients can be relatively well cared for by one nurse,” Matthias Kochanek, the head of internal intensive care medicine at the Cologne University Hospital, said recently. But with COVID-19 patients, "you almost need one-to-one care.”
In the state of Saxony, hospitals are now having to rely on medical students just to ensure that COVID-19 patients get any treatment at all. They thought they had the situation well under control for a long time, says Michael Albrecht, the medical director at University Hospital Dresden. But last week, the hospital experienced a flood of patients. For the first time, the hospital’s intensive care units were no longer sufficient. At the same time, an increasing number of doctors and nurses are contracting the infection. Albrecht says that the numbers of infections in the nursing sector are "extremely high” in some areas.
Last week, the Agaplesion Clinic in Lower Saxony had to deal with 70 suspected cases of the coronavirus among medical staff, reports Torsten Rathje, a trained intensive care nurse and staff representative at the hospital. He says 30 nurses and doctors had to be sent home into quarantine. The others, those who weren’t showing symptoms, were asked to isolate themselves when at home, but to still come to work to keep the hospital running.
The state government in Lower Saxony also moved last week to increase the number of permitted working hours for healthy nursing staff to 60 hours a week. Daily shifts can now be extended to up to 12 hours. Soon, the minimum staffing levels for intensive care units set in agreements with workers in the state are also expected to be lowered. "That’s the way to totally burn people out,” Rathje says, criticizing the move.
The mood in intensive care units has deteriorated tangibly, according to an online survey commissioned by DIVI that will soon be published in an industry magazine for doctors. Out of 1,100 survey participants, almost three-quarters of whom were nurses, almost half reported that their motivation had decreased compared to the first wave of the pandemic. Most of those polled expressed frustration because financial aid that has been promised by the government to alleviate the situation still hasn’t arrived. Almost all respondents feared a worsening of their working conditions.
Some of the reasons so many nursing positions remain vacant in hospitals are the long working hours, shifts that aren’t compatible with raising a family and weekend work in addition to relatively little money for an extremely high level of responsibility. That’s how one 43-year-old intensive care nurse from the Ruhr region in the state of North Rhine-Westphalia with 15 years of professional experience describes it. After the birth of her child, she says she tried, but failed, to negotiate somewhat more family friendly working hours. She now works for a home care service.
Her experience is in line with the findings of an online survey conducted by the Marburger Bund medical association taken in March 2019. Of the just under 2,500 intensive care nurses, 37 percent declared they would abandon their profession in the next five years because their working conditions had deteriorated so badly. Some 34 percent said they wanted to reduce their working hours.
Erika Raab, the head of the district hospital in Gross-Gerau, says she doesn’t want to even think about what that would mean for the hospitals. At the moment, she has more than enough to do just making sure that her staff who are still healthy can deal with the growing number of coronavirus patients. "The daily mantra is the same as always,” she says at the end of the morning meeting: "Get through it."