The premature baby ward at Itzehoe Hospital is threatened with closure because too few premature babies are being cared for there. The director of the clinic warns of a blow to pediatric medicine in Schleswig-Holstein as a whole.
17 milliliters of breast milk every two hours, less than what fits into a normal shot glass – that’s all Nika needs. “Initially it was two to three milliliters,” says mother Viviane Tietz, who is standing in front of an incubator in the children’s intensive care unit at Itzehoe Hospital. With her left hand she reaches through a flap and caresses her daughter’s body, with her right she holds a syringe in which the amount of milk seems like a leftover residue. The mother presses very gently on it to feed the milk through a tube To transport the little ones’ stomachs.
It’s warm in the room and even warmer in the incubator. Nika shouldn’t have it much colder than in her mother’s womb, which she wasn’t supposed to leave for another two months. Nika was born in the 28th week of pregnancy by emergency cesarean section because pregnancy poisoning endangered her life and that of her mother. That was four weeks ago and the girl weighed 730 grams at the time. Nika has now almost doubled her weight, and yet the tiny mask that helps the child breathe still seems huge.
Viviane Tietz gave birth to her daughter Nika via emergency cesarean section. There was a risk of pregnancy poisoning.
Prohibition of performance threatens for Itzehoe Clinic
The Itzehoe Clinic is a good place for children like Nika, who belongs to the group of extremely premature babies. Official quality data shows that Itzehoe achieves top values - and yet these children could soon no longer be allowed to be treated there. Because the health insurance companies have deprived the clinic of the highest level of care. The company sues and can initially continue to provide care, but if it loses, according to the state government, there is a risk of a ban on services. And even if the clinic were to win in court, care for premature babies in Itzehoe would be no more secure than that in Heide and Flensburg, where it is also in jeopardy – and with it possibly inpatient pediatric medicine itself. At least on the West Coast.
Discussion about Minimum number of cases for clinics
But from the beginning: In Germany, the Federal Joint Committee (G-BA) in Berlin regulates who has to care for which premature babies. This provides for three levels for so-called perinatal centers, to which children with certain birth weights or times are assigned (level 1, for example, for premature babies up to 1,250 grams or children born before the 29th week). In order to receive a certain status level, the clinics must have special technical and staffing equipment and, in the case of the highest level of care, must also demonstrate an annual minimum case volume.
For a long time this was 14 children under 1,250 grams, in 2023 the minimum number of cases rose to 20 and this year to 25 cases. The Itzehoe Clinic did not reach the minimum number of 20, but benefited from an exception. The health insurance companies no longer agreed to this, while it still applies to Heide and Flensburg, which are also below the required minimum amount.
More cases, more quality?
The reason for increasing the minimum number of cases: Special cases – such as children born very prematurely – should be treated in places that have as much experience with this as possible – and this depends largely on the number of cases. Large professional associations such as the Society for Perinatal Medicine therefore criticize the high number of level 1 centers in Germany (last year more than 160) and the average number of cases that is too low. They also consider the minimum amount of 25 to be too low – and advocate more concentration.
Overall, this plays an important role in the question of the future structure of the German hospital system, about which the federal government is currently negotiating with the states – and is one reason why the discussions are proceeding rather slowly. Regionally, the concentration of tasks sometimes raises difficult questions, as can be seen in the care of premature babies in Schleswig-Holstein and at the Itzehoe Clinic.
Dr. Georg Hillebrand is medical director of the Itzehoe Clinic. He worries about the future of premature baby care.
For the goal, Pregnancies to extend, clinics will be “punished”
Dr. Georg Hillebrand is the medical director of the clinic and head of pediatric medicine. When he talks about the impending closure of his Level 1 center, he seems visibly affected. “I don’t close myself off from the quality discussion,” says Hillebrand. “But we have been working for years to deliver demonstrably good quality here, and all of this has now been in vain because of a single number that is hardly suitable for measuring the quality of a perinatal center.”
For example, one of the center’s most important tasks is preventing premature births: “For every actual very early premature birth, there are around six to eight women with a threatened one,” explains Georg Hilleband. “We have also become good at prolonging these pregnancies – and are now being punished for it.”
Triplet mother: “My only goal was to last as long as possible”
This morning the parents Svenja Hamelau-Lüders and Steffen Lüders came to Itzehoe with their nine-month-old triplets Linnea, Frida and Thore. Level 1 centers are also responsible for triplet births in this country, especially if they are announced as early as Svenja Hamelau-Lüders’ case: “I was only in the 23rd week when my gynecologist noticed an open cervix and a shortened cervix,” says the mother.
At the time, the triplets had an estimated birth weight of just over 500 grams each. “My only goal was to last as long as possible,” says the 32-year-old, who bursts into tears when she thinks about that time. In the end, she was in the perinatal ward for ten weeks – and the children were each born by cesarean section weighing more than 1,500 grams. They stayed in the clinic for six weeks afterwards.
Svenja Hamelau-Lüders and Steffen Lüders’ triplets were born nine months ago.
Children’s hospitals as a whole are in danger
Georg Hillebrand takes great pleasure in telling about cases like these. Strictly speaking, for him they are not only a statistical but also a financial problem. The care of extremely premature babies is one of the few “lucrative” areas in pediatric medicine that is often difficult to pay off. In Schleswig-Holstein, too, children’s clinics have been closed or downsized in recent years, and many existing wards only survive through cross-financing – either through proceeds from other clinics or through proceeds from areas such as premature baby care.
Pediatric medicine in a “downward spiral”?
This also applies to the Itzehoe Clinic. According to Hillebrand, the 15 to 20 cases in recent years generated an average of one million euros. “That’s a fifth of the children’s clinic’s total revenue,” he says. The doctor speaks of a downward spiral that pediatric medicine could fall into if very small premature babies were no longer allowed to be cared for. Because the requirements for Level 2 centers are hardly lower than for Level 1 centers, Hillebrand sees the danger of having to switch to Level 3 and dismantle structures in the medium term. “All children benefit from these, not just premature babies,” he says.
This morning, in addition to little Nika, six other premature babies are in the intensive care unit. Her mother is usually with her during the day, and at night she sleeps in a small apartment on the hospital grounds. “So I’m always close to them,” says Viviane Tietz, who also receives psychological care at the clinic. “It’s still very difficult for me to process the failure to give birth,” she says.
What happens if Itzehoe closes?
If Itzehoe were to be eliminated, other centers would have to take over the cases. This would particularly affect the locations of the University Hospital Schleswig-Holstein (UKSH) in Kiel and Lübeck, which may have to build up capacity. The UKSH did not want to comment on this; instead, a spokesman referred to the state departments responsible for hospital planning.
The Ministry of Health simply says that it has repeatedly pointed out to the Federal Joint Committee in Berlin about impending difficulties in providing care, particularly in rural regions. The increase in the minimum number of cases has been rejected at all times and is advocated for a lower limit on the number of cases or for alternative concepts.
Push for a model project for premature babies in SH
Georg Hillebrand is also hoping for an alternative concept, perhaps even a Schleswig-Holstein model project. “For me it’s not about any status, but about a sustainable construct for the whole of Schleswig-Holstein,” he says. He could imagine changing the weight limits for premature babies and, for example, only concentrating children under 750 grams in level 1 centers. “If they have exceeded a critical threshold, they could be transferred to well-equipped and well-funded Level 2 centers closer to home,” says the doctor.
One of them, says Georg Hillebrand, could also be Itzehoe.
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NDR television | Schleswig-Holstein Magazine | 02/12/2024 | 19:30 o’clock