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The spread of the coronavirus disease 2019 (COVID-19) pandemic has shown important spatial heterogeneity of in-hospital COVID-19 cases and deaths between countries and regions. Across metropolitan France, the healthcare system has been overwhelmed by the pandemic surge unequally over the regions, leading to the inability to provide care in areas with outpaced resources [1, 2]. In response, mass inter-regional transfers of critically ill patients have been organized. Distribution of evacuation and mutual-aid agreements were coordinated by Regional Health Authorities, and not as a typical day-to-day transfer system. Critical care transports were performed by specialized ground and aeromedical teams (including intensivists and emergency physicians). However, the evacuation of multiple critically ill patients raised important issues [3]. Overall, we do not know whether the mortality rates of transferred patients are closer to the ones observed in the sending regions, or conversely, in the host regions. The objective was to assess whether patients transferred from outpaced regions had better outcomes compared to patients with similar severity taken in charge in the regions with surges in patient volume.
We performed a cross-sectional study using data from the French hospital discharge database (HDD), exhaustive for all public and private hospitals. We included patients from the three metropolitan French regions that organized mass inter-regional transfers. Patients were included according to the following criteria: adults (≥ 18 years old), with invasive mechanical ventilation, admitted in intensive care unit (ICU) between 2020-03-01 and 2020-05-31, with ICD-10 diagnosis code of COVID-19. To identify whether inter-regional transfers were associated with the ICU case fatality, a multivariate logistic regression model was carried out, including variables with p < 0.2 in bivariate analysis. A descending stepwise process was used to select the final model. The Supplement details the methods.
Among the 6160 patients included, ICU-to-ICU inter-regional transfers were realized for 400 patients (6.5%) (Supplementary Fig. 1). Patients were less likely to be transferred if they had a higher Charlson comorbidity index or initial specific care supports such as prone position, renal replacement therapy, ECMO (Table 1 upper section). Age, sex, and SAPS II were not associated with the decision of transfer. Case fatality was 39.5% (2278/5760) for patients not transferred and 14.3% (57/400) for patients transferred. Among the factors significantly associated with case fatality, ICU-to-ICU inter-regional transfers were predictors of survival (adjusted OR: 0.26 [0.2–0.3], p < 0.0001) after adjustment on comorbidities and severity (Table 1 lower section).
This study has limitations: (i) the study is from the “first wave”, therapeutic approaches have evolved since; (ii) healthcare systems vary across countries; thus our results should be extrapolated with caution; (iii) the lack of granularity of the database could be a limiting factor, but conversely it is an exhaustive real-life record of all patients hospitalized without initial selection bias.
The regions overwhelmed by the pandemic surge have experienced an unprecedented shortage of ICU beds and qualified ICU staff. We demonstrated that the benefit to remove patients from areas with outpaced resources was greatly superior to the risk of complication due to long-distance transfers of ventilated patients. In conditions with regional planning and trained teams [3], ICU evacuations are an appropriate solution to help manage the spatial dimension of the pandemic.
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Restrictions apply to the availability of these data and so are not publicly available. However, data are available from the authors upon reasonable request and with the permission of the institution.
Abbreviations
- HDD:
-
Hospital discharge database
- ICU:
-
Intensive care unit
- SAPS II:
-
Simplified Acute Physiology Score II
- SD:
-
Standard deviation
References
Rimmelé T, Pascal L, Polazzi S, Duclos A (2020) Organizational aspects of care associated with mortality in critically ill COVID-19 patients. Intensive Care Med. https://doi.org/10.1007/s00134-020-06249-2
Gaudart J, Landier J, Huiart L et al (2021) Factors associated with the spatial heterogeneity of the first wave of COVID-19 in France: a nationwide geo-epidemiological study. Lancet Public Health. https://doi.org/10.1016/S2468-2667(21)00006-2
King MA, Niven AS, Beninati W et al (2014) Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 146:e44S-60S. https://doi.org/10.1378/chest.14-0735
Acknowledgements
We thank all staffs of health care facilities who contributed to the Hospital Discharge Database implementation.
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The authors declare that they have no sources of funding for the research.
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AG, LGG, LG, EL conceived and designed the study and were involved in drafting the manuscript. LG performed the data retrieval and LG, EL, AG, and LGG performed the statistical analysis. LG, EL, AG, AK and LGG were involved in the interpretation of the data, in drafting the manuscript and made critical revisions to the discussion section. LG, EL, AG, AK, and LGG read and approved the final version to be published.
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No nominative, sensitive or personal data of patients have been collected. Our study involved the reuse of already recorded and anonymized data. The study falls within the scope of the French Reference Methodology MR-005 (declaration 2205437 v 0, august 22nd, 2018, subscripted by the Teaching Hospital of Tours), which requires neither information nor consent of the included individuals. This study was consequently registered with the French Data Protection Board (CNIL MR-005 number #2018160620).
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Guillon, A., Laurent, E., Godillon, L. et al. Inter-regional transfers for pandemic surges were associated with reduced mortality rates. Intensive Care Med 47, 798–800 (2021). https://doi.org/10.1007/s00134-021-06412-3
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DOI: https://doi.org/10.1007/s00134-021-06412-3