Within and across European countries, there is great divergence in hospital bed and intensive care unit (ICU) capacity. To alleviate pressure on intensive-care capacity, national and regional governments and hospitals have started to help each other by transferring critically ill patients from the worst-hit regions.
We have examined how France, Italy, the Netherlands and Spain have been organizing this effort both within their borders, but also with the help of other countries including Austria, Germany, Luxembourg and Switzerland. The countries were identified using the COVID-19 Health Systems Response Monitor (HSRM) based on the information available (up to 24 April 2020).
High-speed trains provide a safe, fast and spacious environment to transfer patients in France and Spain
Countries show a variety of ways to transfer patients out of saturated hospitals in the hardest-hit regions to other facilities across the country with free capacity. France deploys trains, helicopters, private planes and even a warship to relieve hospitals. The high-speed trains (TGV) have increasingly been used for this purpose since late March. The TGV can carry more people than an ambulance or helicopter and it is much faster than road transportation. In addition, it offers a smooth ride in a spacious and safe environment for patients and staff. Patients from Paris and the region Grand Est are transferred by medically outfitted TGVs to less-overwhelmed regions, in particular to Brittany and Normandy in the country’s northwest and South-western France. Overall, in total 644 patients have been moved across the country until April 19, with the first patients being transferred from Mulhouse and Colmar to Marseille and Toulon on March 18. The SNCF reported that since March 26, ten transfers carrying in total 202 ICU patients have been transported by TGVs.
Also in Spain, after an announcement by the Ministry of Transport, three speed trains were converted early April to transfer COVID-19 patients across the Spanish regions – available to regional health authorities if they need them. The trains have the capacity to transfer up to 24 critical patients each to regions with spare ICU capacity. Although the trains have not been used for this purpose yet because pressure on ICU beds has abated in the worst-hit regions, the trains are on standby if the need arises in the future.
Ambulances, buses and helicopters have moved patients in the Netherlands and Italy
To relieve hospitals in the province of Brabant in the Netherlands, which has seen the largest outbreak in the country, a large-scale operation was set up to transfer both ICU and non-ICU COVID-19 patients to various hospitals in northern provinces (Groningen, Friesland and Drenthe). At the start of the operation, between 500 and 700 patients were expected to need a transfer. The Army, which has experience with medical transport from their missions abroad, coordinated the operation. Starting during the weekend of March 20, up to 100 patients per day have been moved until early April and now patients are transferred only sporadically. The operation included eight Mobile Intensive Care Units (MICUs), a special ICU bus that can hold up to six ICU patients at a time and regular ambulances for non-ICU patients. To ensure a smooth ride which is critical for keeping the ICU patients stable and allowing staff to do their job, the police provided escorts. Also two helicopters (one equipped for ICU patients) took part in the operation.
To address the limited ICU bed capacity resulting from the COVID-19 pandemic in Italy, especially in northern Italy, on March 5 the head of the National Civil Protection mobilized the CROSS (Remote operations center for medical rescue operations). The CROSS is one of the two centers in Italy that is activated in case of emergencies or catastrophes and coordinates requests from the regions to then transfer COVID-19 patients to different hospitals and to other regions depending on the availability of beds. Ambulances with specific equipment and trained staff, as well as helicopters and planes from the Italian Air Force are available to conduct these transfers. As of April 2, 105 patients were transferred from Lombardy, among these 32 were sent to Germany and the other 73 to other regions in Italy. On April 5, patients’ transfers from Lombardy to other regions were suspended as the ICU capacity in Lombardy hospitals was deemed sufficient to receive and treat both COVID-19 and non-COVID-19 patients in critical conditions. The CROSS is still operative.
Some countries with spare ICU capacity are admitting patients from the worst-hit areas
Most transfers of patients between European countries have taken place from the French department Grand Est, Northern Italy as well as the Netherlands to Austria, Germany, Luxembourg and Switzerland. Until April 20, Germany has admitted 229 seriously ill patients with COVID-19 from other European countries for treatment since the outbreak of COVID-19. Most patients were from France (130 patients), 44 patients came from Italy and 55 from the Netherlands. Planes and helicopters operated by the German Airforce, SwissAir and the Italian Airforce have picked up intensive care patients from France and Italy. The German Air Force Airbus A310 ‘MedEvac’ can accommodate up to six intensive care patients and 38 acute care patients of which 16 can have medical monitoring. More than 30 French COVID-19 patients were admitted in Swiss hospitals in ten different Cantons using ambulances and helicopters. Austria took in at least 11 intensive care patients from Italy (at least five from Alto Adige) and three intensive care patients from France. Lastly, in total at least 11 French intensive care patients were airlifted to Luxembourg for treatment. The Luxembourg Air Rescue provided ambulance jets and two helicopters that supported the French Urgent Medical Aid Service and airlifted French intensive care patients to Hamburg and Dresden, Germany.
Cross-border transfer of patients was in most cases initiated after high-level interaction between different jurisdictions
The solidarity across European regions results from different initiatives on various levels. For example, the head of the local government of the Haut-Rhin administrative district in France requested help to Baden-Württemberg and to the Swiss Cantons of Basel-Stadt, Baselland und Jura. Within hours, local politicians in Germany and in all three Swiss cantons promised help. In the meantime, the French Embassy in Bern and the consulates in Zurich and Geneva contacted other Cantons and in the end, ten cantons agreed to admit patients from Haut-Rhin.
The Dutch Minister of Health asked the Minister of Health in neighbouring North-Rhine Westphalia (Germany) for support while the country was facing a scenario in which ICU capacity could become exhausted. In total, 68 hospitals in the state of North-Rhine Westphalia were willing to offer treatment to up to 107 Dutch patients. The transfer of COVID-19 patients between the Netherlands and North Rhine Westphalia is jointly coordinated by the Münster University Hospital and the Erasmus Medical Center Rotterdam. On April 20, the Minister president of North Rhine-Westphalia initiated the ‘Cross-Border Task Force Corona’ in cooperation with the Netherlands and Belgium, which aims among others to coordinate all activities in the border region’s fight against COVID-19, including information exchange, ICU bed capacity and cross-border traffic.
Furthermore, in mid-March a member of the German federal parliament from Saxony who is also a member of the committee for German-Italian cooperation in parliament initiated the transfer of eight patients from Lombardy to his region.
Policy lessons and implementation
The transfer of critically ill COVID-19 patients illustrates that there has been real solidarity and willingness to help between hospitals, regions and countries both within and across national borders. The transfers have involved enormous logistical efforts and the rapid organization of resources, material and highly qualified staff. High-level interactions between governments up to the Ministerial level as well as involvement of different sectors (e.g. Ministries of Transport, the Military) seem to have played a key role in setting these arrangements up quickly. In some regions such as the Grand Est in France and Brabant in the Netherlands, patient transfers have helped to relieve the enormous pressure on the system. In the Grand Est, for example, about one of four ICU beds could be freed up.
There is no single best solution to transfer patients. Depending on the local context, it can take place by rail, road or air, as long as the safety of patients can be guaranteed. However, the need to transfer critically ill patients may point to some extent to weaknesses in a health system’s preparedness for pandemics. An alternative and more efficient solution may be to relieve congested hospitals by sending qualified staff to hospitals and by keeping facilities or spare capacity available that can be quickly scaled up in times of crisis. Transfers should probably remain the last resort option, although countries are well advised to have plans available when overwhelming crisis situations occur.
Juliane Winkelmann, Giada Scarpetti, Cristina Hernandez-Quevedo, Ewout van Ginneken