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Which Patient Should Be Chosen? The National Transferal System for the Management of COVID-19 Intensive Care Patients. A Retrospective Multicentre Cohort Study in Germany, 2020 – 2022
19 Pages Posted: 21 Jan 2023More...
Background: The German ‘Cloverleaf’ concept established a nation-wide coordination mechanism and provided recommendations for COVID-19 patients suitable for transferal to alleviate pressure on overstretched intensive care units (ICUs). We analysed the characteristics and outcomes of transferred patients to provide clinical evidence to facilitate clinical decision making on which patient to transfer safely.
Methods: We analysed 48 of the 66 cloverleaf ‘east’ transferals (73%) in which the federal state of Thuringia was involved (either referring or admitting). Transferals took place in two waves: 1st wave: 27 patients; December 2020 – January 2021; 2ndwave: 21 patients; December 2021 – January 2022. We compared first- and second-wave transferals with the total cohort and with key outcomes of non-transferred patients. Our variables were individual characteristics (age, sex and BMI), general health (comorbidities) and clinical status at time of referral (respiratory and cardiovascular status).
Findings: The oxygenation index (OI) (PaO2 (mmHg)/FiO2) is the only meaningful indicator for successful referral (threshold > 160 mmHg) regardless of age, BMI or other patient-specific characteristics. Second, patients benefit from being transferred to a distant region that is less impacted by the pandemic (low 7-day incidence) and to hospitals with advanced to high service levels (hospital size above 600 beds). Transport duration (time) and mode (airlift/ambulance) had no effect on the short- (days) or long-term (weeks) outcome.
Interpretation: Clinical evidence suggests that COVID-19 patients with moderate to mild respiratory failure (OI > 160 mmHg) should be transferred to regions less impacted by the pandemic, regardless of the time or distance required to reach a hospital with an at least advanced service level.
Funding: The study was conducted both as part of the research group ‘pandemic preparedness’ that was funded by the state chancellery of the federal state of Thuringia (Chapter 8230 Number 68204) and by the BMBF funding program of Photonics Research Germany (No. 13N15745) associated with the Leibniz Centre for Photonics in Infection Research (LPI). The LPI was initiated by Leibniz-IPHT, Leibniz-HKI, UKJ, and FSU Jena and was part of the BMBF national roadmap for research infrastructures. The funders had no influence on research questions, results or publication.
Declaration of Interests: The authors declare that they do not have a conflict of interests in regards to this publication.
Ethics Approval: A data protection and ethical agreement was requested and obtained in January (and July for an amendment) 2021 (Number 2021 – 2331-Daten) from the ethics committee and data protection office of Jena University Hospital. This study and its data collection were also approved by the data protection office of the Ministry of Health of the state of Thuringia (27 January 2021).
Keywords: SARS-CoV2, COVID-19, ICU, transferal, health system capacities, pandemic preparedness
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