On the role of intensive care in the SARS-2/Covid-19 epidemic

>> The authors have already addressed the role of intensive care medicine and the use of intensive care care indicators in detail in previous position papers (Tp4, Chapter 1.1.3 No. 3, Tp6.1 Chapter 3.3). Indicators from this area were recently central to the political arguments justifying the "federal emergency brake," supported by several professional societies that strongly emphasized the impending overload of intensive care structures – while other associations (e.g., the German Hospital Federation) held a contrary view.
In this situation, the group of authors decided to differentiate between objectively grounded assessments and interest-driven evaluations in a more in-depth analysis by issuing a topic-focused statement. This text does not represent a comprehensive statement on the entire complex of hospital planning, but rather concentrates on the intensive care situation during the SARS-CoV-2/COVID-19 epidemic, considering both the situation in Germany and international contexts. The text is divided into eight sections and includes a brief analysis of the acute care structure, the healthcare system's responses to the epidemic, international comparisons of procedures, and specific analyses, for example, on the ratio of intensive care to general ward capacity used for COVID-19, as well as the need for intensive care in relation to the reporting rate. Particular attention is paid to the availability and consistency of data.
1. Acute inpatient care
One of the central tasks of health policy is to determine the need for inpatient treatment and to initiate the necessary processes. In Germany, the responsibility for ensuring the necessary inpatient treatment capacities lies with the federal states, while the federal government determines the legal framework for the financing of treatment costs through statutory health insurance.
There is no uniform hospital planning process across the 16 states: While previously the determination of need was based solely on projections of the current situation and population trends, in recent years almost all states have incorporated qualitative elements into hospital planning. These elements include expert panels, quality standards for personnel and technical requirements, and other qualitative criteria. This was based on the 2016 amendment to the Hospital Financing Act, which introduced quality as an equally weighted parameter for inpatient care, alongside need and cost-effectiveness. Furthermore, planning is becoming more differentiated in several states: For example, some states have switched from bed and capacity planning to performance-based planning in specific disciplines.
However, the legal options available to the federal states for hospital planning are limited. According to the jurisprudence of the Federal Constitutional Court and the Federal Administrative Court, a realignment of the planning and financing structures in the hospital sector is relevant to the professional practice of private and non-profit hospital operators and must be measured against the standard of Article 12 of the Basic Law. The economic consequences of not being included in the hospital plan can be severe for hospital operators and may lead to hospital closure. This would amount to a restriction of their professional choice. Therefore, strict requirements exist for establishing the criteria for inclusion in and/or exclusion from the hospital plan. Planning decisions aimed at reducing overcapacity and redundancies are practically impossible without or against the consent of the hospital operators.
Overall, the total number of hospitals decreased by 81 TP3T between 2009 and 2019. While the number of public hospitals fell by 15.91 TP3T and the number of non-profit hospitals by 16.121 TP3T, the number of private, for-profit hospitals increased significantly by 8.541 TP3T, raising their relative share of the total number of hospitals from 321 TP3T to 37.821 TP3T (see Table 1).
The decrease in the number of hospital beds (Table 2), however, amounts to only about 21,000 total beds. Specifically, the number of beds in privately owned hospitals increased by 14,210,000, while those in public and non-profit hospitals decreased by 3,740 and 6,731,000, respectively. Clearly, this indicates a concentration of hospital beds in a smaller number of hospitals.
According to the OECD, Germany has the highest number of hospital beds in Europe and the third highest among OECD countries (see Fig. 1). While the EU average is 3.6 beds per 1,000 inhabitants, this average is significantly higher in Germany at 6.4 beds.

Summary
Despite bed reductions, Germany still has significant overcapacity in inpatient care. Patients are admitted to hospitals more frequently for illnesses that can be treated on an outpatient basis than in most other EU countries.
2. Equipment with intensive care beds in the
international comparison
Previous studies have revealed significant differences in the number of intensive care beds between European countries. The proportion of the population aged 65 and over also varies across European countries. For example, in 2019, the percentage of this age group ranged from 14.11 in Ireland to 221 in Italy (EU average: 20.31).5,6 It is important to consider demographic differences because the need for medical care increases with the age of patients due to the higher morbidity rates among older people, at least for some disease groups.
In international comparison, Germany has a high density of intensive care beds. This is according to a press release from the Federal Statistical Office dated April 2, 2020. The data was based on surveys conducted by the OECD in ten of its member states.7
According to this data, at the end of 2017 there were a total of 28,031 intensive care beds in 1,160 hospitals in Germany, which corresponds to approximately 33.9 intensive care beds per 100,000 inhabitants. The majority of these (27,864 intensive care beds) were located in general hospitals providing top-level or maximum care.
Austria (28.9 intensive care beds per 100,000 inhabitants) and the United States (25.8) had a similar number of beds. In contrast, the capacities in the countries in Europe that were particularly hard hit by the coronavirus pandemic—England (10.5), Spain (9.7), and Italy (8.6)—were significantly lower (see Fig. 2).

Summary
Germany has a high number of intensive care beds compared to other (European) countries (2017: 33.9 per 100,000 inhabitants).
3. Corona pandemic in other European countries: Initial reactions in spring 2020
The first wave of the coronavirus pandemic posed major challenges for hospitals. A key aspect of the effectiveness of national measures is the ability to equip the healthcare system with the necessary resources in a timely manner. Therefore, experiences from several countries are briefly presented here.
In Austria, from April 8, 2020, approximately 7,500 additional beds from other facilities (e.g., rehabilitation facilities) and 1,735 new regular beds were made available for Covid-19 treatment.
In France, whose intensive care units were initially overwhelmed only in the north during the first wave, and later also in the east, the number of intensive care beds was increased from 5,000 to 8,000 starting in March, and military hospitals were opened to treat the civilian population in order to provide greater bed capacity. The army was called in to distribute patients evenly across the country, from overburdened to less burdened regions; 644 patients were transferred to neighboring countries (Austria, Germany, Switzerland, Luxembourg).
Patients were also redistributed in the Netherlands; in Groningen, for example, 32 of the 34 intensive care patients came from North Brabant and Limburg. Belgium set up 759 new intensive care beds, and Finland converted recovery rooms into intensive care units.
Italy actively reorganized its hospital bed provision, creating entire "aseptic" wards and new flexible intensive care units for patients infected with Covid-19, while postponing elective surgeries. In Lombardy, intensive care capacity was increased by 376 beds by converting regular wards into intensive care units (by March 16). The city of Milan transformed industrial spaces into hospitals. In some regions, the Ministry of Civil Protection set up military hospitals with additional intensive care and nursing beds. Patients requiring critical care from affected regions were airlifted to other regions as needed.
In the UK, new temporary hospitals were built at seven locations to provide additional intensive care capacity (e.g., 500 beds at London's Nightingale Hospital). Furthermore, new guidelines and rules for inpatient treatment were introduced (including a significant expansion of telemedicine), making approximately 33,000 additional beds (excluding intensive care beds) available.
In Sweden, an additional 524 intensive care beds were gradually created during the crisis, thus doubling the intensive care bed capacity (the normal capacity is around 500 beds).

Summary
In several European countries, intensive care was restructured or significantly expanded based on a lower level of basic equipment.
4. Course and procedure in
Germany
In Germany, the SARS-CoV-2/Covid-19 epidemic unfolded in three so-called "waves" over the past 16 months. The first episode was classically characterized by the emergence of individual clusters of varying sizes ("Ischgl"), the second increase by the rapid spread among insufficiently protected vulnerable groups (90% of the case fatality rate in people over 80 years of age), and the third increase by the spread among working-age and younger people.
The healthcare system and health policy initially responded by securing and mobilizing available resources, particularly in inpatient care.11 Intensive care played a central role in this, as severe interstitial pneumonia, a predisposition to thromboembolic complications, and the resulting multi-organ failure in some infected individuals necessitated intensive care treatment. It quickly became clear that the available intensive care capacity would be of paramount importance. Simultaneously, there was an unexpected decrease or shift in inpatient cases: the number of cases fell by 141 in 2020, the number of hospital days decreased by 151, and, particularly in smaller hospitals with fewer than 300 beds, occupancy dropped to 62.11 (all hospitals: 67.31).12.
In order to maintain hospital care, and especially intensive care, in light of the initially uncertain course of the epidemic, different procedures were chosen. According to Augurzky et al., 13 three „regimes“ can be distinguished:
Regime 1: uniform compensation payment (16.3. to 12.7., Covid-19 Hospital Relief Act) for each additional free bed compared to 2019;
Regime 2: staggered compensation payment (13.7. to 30.9.) with five categories (360, 460, 560, 660 and 760 euros, psychiatric and psychosomatic hospitals 280 euros per day);
Regime 3: the individual compensation payment (from 18.11. according to local conditions (e.g. reporting rate)).

The aforementioned Covid-19 Hospital Relief Act14 also stipulated that
• Hospitals will receive an additional bonus of €50,000 for each additional intensive care bed created,
• Hospitals will receive a supplement of 50 euros per patient to cover additional costs, particularly for personal protective equipment, from April 1st to June 30th, 2020. This supplement can be extended and increased if necessary.
• the so-called „provisional care allowance value“ is increased to 185 euros15.
• In addition, the Corona compensation agreement between statutory health insurance funds (GKV), private health insurance funds (PKV) and the German Hospital Federation guaranteed hospitals a compensation payment for revenue losses due to the decline in the number of cases related to SARS-CoV-2, amounting to 851 TP3T in 2020 compared to 2019.16

Alongside these measures, however, the social and institutional climate must not be overlooked. Without a doubt, the Covid-19 pandemic has placed, and continues to place, an extreme burden on the healthcare system and hospitals. Especially in the initial phase from March onward, fear was widespread, and the psychological strain on healthcare staff, particularly in intensive care units, was immense. During the first "wave" in spring 2020, approximately 3,000 patients per day received intensive care treatment (see Figure 3 for the progression). Protective equipment was in short supply everywhere, and at that time, no one was even considering a possible vaccine. Hospitals reduced their capacity to reserve it for potential Covid-19 cases, elective surgeries were postponed, and intensive care capacity was significantly expanded (su).
During the "second wave," which brought around 6,000 patients per day to intensive care units, the regional networks between hospitals were already functioning. Protective equipment was now available in sufficient quantities, but hospitals still struggled with significant staff shortages because many employees were still becoming infected themselves. This only changed with the start of the vaccination campaign.
When the "third wave" spread in Germany in March 2021, staff shortages decreased significantly because employees had since been vaccinated. The country is currently still in lockdown, but now a curfew is also in effect to prevent a dramatic overload of intensive care units, where around 4,500 patients are currently being treated.
According to the Federal Office for Social Security, €10.2 billion had been paid out as compensation for lost revenue to hospitals by December 31, 2020.17 A total of €530 million was claimed as premiums for nearly 11,000 additional intensive care beds.18 This increase is greater than the total number of intensive care beds available in France, a country with 66.97 million inhabitants. Throughout 2020, an average of 21,000 inpatient and 41,000 intensive care beds were required to treat COVID-19 patients – with significant differences in terms of time and location.19.
The loud warnings from a professional association, the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI), about overcrowded intensive care units and „British conditions“ therefore require further explanation, especially when political decisions are (also) based on these calls.20 This is all the more true because there are also opposing voices from within the health system, for example from the German Hospital Federation.21.

Summary
Following a period of strain due to inadequate organization and resources during the first wave, the second wave saw a significant increase in the workload of medical staff. Partly due to staff vaccinations, the situation stabilized somewhat during the third wave. In 2020, an average of 21,000 inpatient beds and 41,000 intensive care beds were used to treat COVID-19 patients – with considerable variations in terms of time and location. €10.2 billion was paid out to hospitals as compensation and €530 million as bonuses for nearly 11,000 additional intensive care beds.
5. Crucial deficit:
Insufficient data available regarding usage
Since the beginning of the epidemic, there have been loud warnings from politicians and professional associations about intensive care units becoming overwhelmed and about the need for triage for intensive care. The implicit threat was that patients would have to be "let suffocate." This fear-based campaign played a crucial role in the implementation of contact restrictions. However, these statements cannot be verified in terms of their factual basis; at the very least, the dramatic nature of the claims is contrasted by a clear lack of usable data. Neither the intensive care bed registry operated by the Robert Koch Institute (RKI) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides information on gender, nor are data on comorbidities and other risk factors published at the time a patient required intensive care. The responsible authorities have so far failed to establish a complete registry or even a representative sample for this crucial question.22,
This allows us to answer the question of what the further demographic and clinical characteristics of intensive care patients with Covid-19 are. Therefore, no statement can be made about the severity of the illness or the treatment effort.
Until May 6, 2021 (!), the RKI and DIVI authorities were unable to provide information on the average age of patients requiring intensive care. With the data now available, the age dependency of the disease as a whole can be clearly illustrated: the average age of all infected individuals is significantly younger than that of hospitalized patients and, in particular, those requiring intensive care. The deceased have the highest average age (see Fig. 4). However, since the age of all patients is not known, these data must be interpreted with caution. The average age of COVID-19 patients in intensive care is between 60 and 70 years, which is difficult to reconcile with the alarmist claims that the average age of patients requiring intensive care is decreasing dramatically.
More detailed information on the age structure can be found in Figure 5.24 The statement by DIVI officials that 30- to 40-year-olds are now in intensive care units can therefore be clarified by stating that they account for 2.81% of all COVID-19 patients in intensive care units, meaning that, in absolute terms, approximately 130 patients of this age group are affected nationwide. 7.81% of the patients in intensive care are 40–49 years old, 221% are 50–59 years old, but the majority of patients are older than 60 years (median 65 years).
The discussion surrounding comorbidity, which already played a significant role in the context of mortality data, resurfaces: it is crucial to know whether the COVID-19 infection was the primary reason for patients' admission to the intensive care unit (ICU), or whether admission was due to another underlying condition—in other words, whether patients were admitted because of or with SARS-CoV-2/COVID-19. Analogous to the now common expression "mortality with or from COVID-19," the more appropriate term here would be "need for intensive care with or because of COVID-19." Precise data on this distinction are not available. Assuming a prevalence of 1% in the population, this would mean that among approximately 20,000 ICU patients, there are at least 200 patients who do not require intensive care because of COVID-19 (but nevertheless require care and treatment as such). Younger patients with serious underlying health conditions would be more affected than older patients, because the chance of requiring intensive care solely due to SARS-2/Covid-19 is very low for younger people.
In this situation, characterized by a lack of data, only indirect conclusions can be drawn based on data available for the entire infected group. It is known only that the age distribution of all infected individuals has changed significantly (regardless of hospitalization and intensive care treatment). The decrease in reporting rates in the older age groups suggests a high prevalence of the virus in nursing and care homes and the increasing vaccination rate, particularly among the elderly population.
Furthermore, the hospitalization rate has decreased. However, the absolute increase in hospitalizations reported by the RKI (as of May 11, 2021) in the 35-59 and 60-79 age cohorts (see Fig. 6) is not accompanied by an increase in the relative risk of hospitalization (see Fig. 7). This statement is important because the media frequently reports an increased risk of hospitalization in the younger age groups.
It must also be emphasized that the case fatality rate for all infected individuals has declined significantly since January. With roughly the same reporting rate („incidence“) at the beginning of January and at the end of April, the number of daily deaths has decreased from approximately 900 to about 250 (see also Fig. 8). Overall, there is little evidence to support an increase in the severity of illness requiring intensive care.

Summary
The lack of data on demographic and clinical characteristics at the time of requiring intensive care makes a more detailed analysis almost impossible. Therefore, a scientific basis for the official campaign and the interventions of some professional societies, which are based on individual fears of not being admitted to intensive care, cannot be derived. Data on the average age have only recently become available and show no decrease in the mean age of COVID-19 patients receiving intensive care. A lack of data on comorbidities precludes a distinction between "requiring intensive care with or because of COVID-19." The improvement in general data on the prognosis of the infection (average age, hospitalization, mortality) casts doubt on a relevant deterioration in intensive care.
6. Rating based on international data
Nevertheless, the situation is confusing given the increased number of COVID-19 patients in intensive care units. On the one hand, medical professionals, especially the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), are sounding the alarm unmistakably. On the other hand, key stakeholders in the healthcare system, including healthcare providers, are criticizing this alarmism and questioning whether dramatic accounts might eventually desensitize people instead of making them more receptive to the message. According to Gerald Gaß, Chairman of the German Hospital Federation, conditions like those in Bergamo are not foreseeable in Germany. In North Rhine-Westphalia, too, some doctors consider the warnings of a collapse to be exaggerated, particularly given that, despite a high reported incidence rate, only a maximum of one-quarter of all intensive care beds are occupied by COVID-19 patients.26.
Chapter 2 presented an international comparison of intensive care capacities. Regarding the question of how intensive care capacity in Germany should be assessed from the specific perspective of treating COVID-19 patients, the ratio of intensive care beds (relative to population size) to the reported case rate ("incidence rate") is relevant. Figure 9 shows this rate ("intensive care bed-reported case rate ratio") for Germany and several other European countries (as of April 30, 2021). The result is unequivocal: No other country in Europe has a better ratio of reported cases to intensive care capacity than Germany.
In a European comparison, it remains striking that in Germany the proportion of COVID-19 patients requiring intensive care is significantly higher than in other European countries (ICU/hospitalization ratio). On April 27, 2021, 411,300 of hospitalized COVID-19 patients in Germany were being treated in intensive care units, while this was only the case for 251,300 patients in Switzerland and 111,300 patients in Italy (see Table 3). Clearly, Germany is determining the need for intensive care treatment for COVID-19 patients much more quickly than other countries. The alternative explanation, that German citizens infected with COVID-19 are significantly more severely ill than other Europeans, can be ruled out with a high degree of certainty. This situation even appears to be increasing over time: A steadily growing number of hospitalized COVID-19 patients are receiving intensive care (see Figure 10a).
Figure 10b clearly shows that currently the number of Covid-19 patients receiving intensive care in German hospitals has even exceeded the number of hospitalized patients not receiving intensive care.
On April 27, 2021, according to DIVI, 5,050 patients were receiving intensive care (see Fig. 3). This number corresponds to approximately 41,000 cases out of 145,336 infected individuals (week 16, April 27, 2021, data as of May 7, 2021). The RKI had hospitalization data for 102,023 infected individuals, according to which 5,759 patients (41,000 cases) were being treated in hospital. Of these 5,759 patients, 5,063 required intensive care according to the RKI (DIVI: 5,050), a highly contradictory finding. It should be noted that the data is preliminary due to possible late reports and that the hospitalization status was not known for all infected individuals.
If we instead look at the data from the earlier 12th calendar week, the following picture emerges: On March 30th, the RKI reported a total of 116,631 infections for calendar week 12. Hospitalization data was available for 87,289, of whom 6,071 patients (71,000,300) were hospitalized. Based on the reported rate (116,631), this would equate to 8,112 hospitalized COVID-19 patients. According to the RKI, 3,595 of them required intensive care (DIVI: 3,588), which corresponds to 441,000,300 cases.29

Summary
Germany occupies a unique position both with regard to the ratio of intensive care needs to the reporting rate (intensive care reporting rate ratio) and with regard to the ratio of patients requiring intensive care to hospitalized patients (intensive care needs/hospitalization ratio): In no other country are so many infected individuals treated in intensive care compared to the reporting rate, and in no other country are so many infected individuals hospitalized in intensive care units. This situation is even increasing over time and urgently requires closer examination (impending over-provision). The data is also extremely contradictory in this regard (e.g., more patients requiring intensive care than hospitalized patients).
7. Bed numbers: continued lack of internal consistency
Serious doubts also arise regarding the reported intensive care bed figures. Figure 11 shows the daily number of available beds reported by the RKI (Robert Koch Institute) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) in blue, as used for reporting and likely also for funding. However, downloading the same figures from the DIVI archive as of May 1, 2021, yields the red line, which shows significantly lower values for the entire period and especially for the summer of 2020. While the RKI reported 33,367 intensive care beds on July 30, 2020, the figure for that date is now only 30,340. This discrepancy persisted until March 2, 2021 (after which the figures were adjusted) and cannot be explained by a change in documentation methods. Either incorrect counting occurred in the past for reasons yet to be clarified, or there was a subsequent "correction" of the figures, which would also require explanation (of course, a targeted reduction in beds is theoretically possible). In any case, the question arises as to how a discrepancy of almost 3,000 reported beds could have arisen retrospectively, which corresponds to about a third of all intensive care beds in France or three times the total capacity available in Sweden. It would also be necessary to investigate whether and to what extent lump sums were paid for keeping these beds available, and to what extent the total of €530 million in investment grants for the creation of new intensive care beds were accessed and disbursed (see Chapter 4).
Figure 12 shows the trend in available and occupied beds. The number of available intensive care beds (first red, then blue) has been steadily declining to its current level of under 24,000, even though, given the looming triage situation, one would have expected an expansion. From August 2020 onward, a reserve capacity of almost 12,000 beds appears (the total capacity even exceeded 40,000 beds in August 2020), but this also decreases in parallel with the number of available beds (red line in Figure 12). The question arises, however, as to what these beds are actually being held for – if not in the event of a pandemic. Remarkably, despite the epidemic, the number of occupied intensive care beds (green) has remained constant. The number of free beds (turquoise), on the other hand, is decreasing, in parallel with the decrease in the total capacity (blue).
Perhaps the best way to put it is this: These figures raise far more questions than they answer. In any case, the decline in available beds appears to be a consequence of the decrease in overall capacity rather than an increase in demand from Covid-19 patients.30
Regarding the occupancy of intensive care units, it remains striking that COVID-19 patients account for at most a quarter of all intensive care patients (see Fig. 12). Against this backdrop, the claim that COVID-19 patients alone are responsible for the overload of intensive care units appears only partially credible. Currently, many hospitals are postponing elective procedures to avoid competition for intensive care beds between these patients and those infected with the coronavirus. However, it must be taken into account that the number of elective procedures in Germany is disproportionately high compared to other countries. Elective procedures are extremely important financially for hospitals (so). However, significant regional differences must be considered; the situation in North Rhine-Westphalia differs from that in Schleswig-Holstein or Berlin.30 It must also be considered that large centers attract more patients because they have access to therapeutic options that are not available elsewhere, such as ECMO therapy.

Summary
The number of intensive care beds has been decreasing since last summer, even though efforts to expand intensive care capacity would have been expected given the "triage" discussions. This decrease corresponds exactly to the decrease in available beds, so the drop in available beds should be interpreted as a consequence of a decrease in overall capacity rather than as a result of increased use by Covid-19 patients. A retrospective "correction" of intensive care capacity has taken place, which is unrelated to the changed counting method. The number of occupied intensive care beds has not changed. Questions regarding financing, the significance of the hospital plan, and the availability bonuses and their incentive effect remain unanswered.
8. Availability of intensive care capacity
What has repeatedly caused confusion in recent weeks and months is the availability of intensive care beds. Figure 12 clearly shows that there has been a significant decrease in the number of available intensive care beds over the last 12 months.
Staff shortages are frequently cited as the reason. Several media outlets reported that 9,000 nurses left their profession between the beginning of April and the end of July 2020, citing figures from the Federal Employment Agency. However, these figures are not very meaningful, as they include both geriatric nurses and hospital nurses, who suffered significant financial hardship due to the lack of patients and canceled surgeries during the pandemic. It has not been determined to what extent intensive care nurses were among those affected. In any case, there was no coordinated, publicly visible, and sustained effort by the country's political leadership to encourage nurses to return to the profession; at least, the authors' research found no corresponding reporting in the national press.
Whether and how many nurses have actually left the profession cannot be statistically proven. According to the German Hospital Federation, there has not been a mass exodus of nurses. In a recent publication, the Federal Employment Agency even stated that in 2020 (up to October), the number of employees subject to social security contributions in elderly and nursing care actually increased by 43,000.31 The increase was in the double digits: The number of employed nurses and geriatric nurses rose by 141,000 (to 1.11 million and 615,000, respectively). Nevertheless, the adequate supply of qualified personnel, especially in (intensive care and elderly) nursing, has been a topic of discussion for years. Promised, reduced, and ultimately sometimes unpaid bonuses certainly do not help in this regard.
One possible reason for the decrease in intensive care beds since August 2020 could be that the Federal Ministry of Health (BMG) set a minimum staffing level for nursing personnel in intensive care units (day shift) starting August 1st.
The minimum staffing levels for nursing staff (maximum 2.5 patients per nurse; night shift 3.5 patients per nurse) have been reinstated. These levels had been suspended in March 2020 due to the coronavirus pandemic. Shortly before the start of the "third wave," the minimum staffing levels were reduced again (day shift 2 patients per nurse; night shift 3 patients per nurse).

Summary
The objective data regarding the available number of nursing staff is unreliable. There is a lack of institutions that generate independent information on this topic. A decrease in the number of actively working nursing staff cannot be statistically proven. Current data from the Federal Employment Agency even suggests a significant increase in the number of employees subject to social security contributions in this sector; however, according to insider information, the professional qualifications do not always meet the requirements. There have been no high-profile and sustained appeals from political leaders to recruit nursing staff from retirement, encourage them to return to work, or train nursing personnel from other fields, even though such programs would have been the most obvious measure. Such appeals could easily have included financial or non-financial incentives.