TRANSCOV: Mass medical evacuations to decrease the intensive care burden

Results from the TRANSCOV cohort of patients with severe COVID-19 suggest that mass medical transfers may be the best strategy to avoid overburdening frontline services.

Last updated on 24 November 2025

In brief

  • During the first wave of the COVID-19 epidemic, patients with severe symptoms were transferred to distant intensive care units (ICUs) to reduce workload in epidemic areas. Mortality was lower in transferred than in nontransferred patients.
  • Was this lower mortality solely a reflection of the selection of healthier patients? The TRANSCOV cohort study was conducted to clarify this. Its results were published in the 10 September 2025 issue of Chest.
  • The TRANSCOV cohort has been labeled as a National Research Priority by the National Orientation Committee for Therapeutic Trials and other researches on COVID-19 (CAPNET). It was funded by the DGS of the Ministry of Health, the Ministry of Higher Education, Research and Innovation, and ANRS MIE.

The context

In early March 2020, the first wave of the COVID-19 pandemic brutally hit certain regions of France, particularly the East and Paris regions. The high number of patients with severe symptoms overwhelmed intensive care unit (ICU) capacity, resulting in bed occupancy rates of over 200% and in an overrepresentation of patients with severe COVID-19 (over 90% in some ICUs).1

To relieve pressures, it was decided to transfer some patients to more distant ICUs in less affected regions. Early studies looking at these transfers found a 3- to 4-fold decrease in mortality, but were unable to know whether the benefit of transfer comes from the selection of healthier patients, who were therefore more likely to stand the consequences of a long-distance transfer.2-4

Objectives and methods

The TRANSCOV cohort study is a multicentre retrospective study involving the ICUs of the origin hospitals and the ICUs of the destination hospitals (in France and neighbouring countries). The analysis published in CHEST includes 285 patients with severe COVID-19 transferred to distant ICUs and 667 control patients (not transferred, but who could have been eligible for transfer) admitted simultaneously to the same origin ICU. Patients were transferred to another region between 13 March 2020 and 10 April 2020.

The aim of the study was to compare outcomes during the ICU stay of transferred patients with those of the control group ‘eligible’ for medical evacuation.

Data collection included:

  • The patients’ sociodemographic characteristics, risk factors, and comorbidities
  • Dates of the first COVID-19 symptoms, hospitalization, and ICU admission
  • The Knaus scale and the Clinical Frailty Scale (CFS) scores 12 to assess the patients’ functional status and general health levels before admission
  • The patients’ status at ICU admission based on the Simplified Acute Physiology Score II (SAPS II)
  • Lung lesion extent on CT imaging,
  • Ventilation settings and results of the first arterial blood gas test
  • The occurrence of a list of clinical events and therapeutic procedures during the ICU stay: shock, acute kidney injury, thromboembolic events, seizure, delirium, psychiatric disorders, ICU-acquired weakness, hospital-acquired infections, use of neuromuscular blockade, extracorporeal membrane oxygenation, prone position (and number of prone sessions, if used), and tracheostomy

Study results

Age and comorbidity levels were similar in the two groups. The 28-day mortality was 7 times lower in transferred patients than in nontransferred patients. Although minimised in this study by the choice of an eligible control group, a better prognosis among transferred patients undoubtedly explains in part the difference in ICU mortality in favour of transfer. A second more likely explanation is that the benefit of transfers stems from extrading patients from an overcrowded clinical environment. Transferred patients then receive better care in less overburdened care units.

Mass transfers are an appropriate strategy for mitigating the impact of an overwhelming intensive care demand.

Our results suggest that mass transfers organized as early as possible, perhaps simultaneously with or even before the use of overflow surge beds, might be the best strategy to avoid overloading the frontline services.

Olivier Grimaud, et al

References

  1. Collange O, et al. ICU reorganisation to face the first COVID-19 epidemic wave in a tertiary hospital. Anaesth Crit Care Pain Med 2020;39(6):731-732
  2. Sanchez M-A, et al. Impact of ICU transfers on the mortality rate of patients with COVID19: insights from comprehensive national database in France. Ann Intensive Care 2021;11(1):151
  3. Guillon A, et al. Inter-regional transfers for pandemic surges were associated with reduced mortality rates. Intensive Care Med 2021;47(7):798-800
  4. Painvin B, et al. Inter-hospital transport of critically ill patients to manage the intensive care unit surge during the COVID-19 pandemic in France. Ann Intensive Care 2021;11(1): 54