Stig Walravens, Patrick Van de Voorde, Nick Cleymans, Olivier Degomme
When disaster strikes or armed conflict reaches a region, civilian healthcare institutions — hospitals, nursing homes, psychiatric facilities, and long-term care facilities — may simultaneously become untenable as care environments across a wide geographic area. Infrastructure fails, staff cannot access sites, threats escalate, or patient loads overwhelm remaining capacity. In such circumstances, mass medical evacuation — the deliberate, organised transfer of multiple medically dependent patients out of endangered or overwhelmed institutions — may be deployed not merely as a response to a single facility crisis, but as a regional health system strategy. Rather than reacting institution by institution, health authorities may survey which facilities across an affected region require evacuation and systematically move patients to safer areas, using mass medical evacuation as a tool to protect and restore the functional capacity of healthcare across the entire affected region [1,2,3]. Mass medical evacuation has been documented across a wide range of disaster types and resource settings. Following Hurricane Katrina (2005), nursing homes and psychiatric hospitals in Louisiana faced evacuation decisions with little logistical support [4,5]. The Fukushima nuclear accident (2011) prompted mandatory evacuations of hospitals and nursing homes, with evacuation-related mortality among frail residents substantially exceeding the harm avoided by leaving the contamination zone [6,7,8]. Similarly, following Hurricane Irma (2017), disaster-related institutional disruption was associated with significantly higher hospitalisation and mortality at 30 and 90 days among nursing home residents [9]. During COVID-19, France alleviated the most impacted hospitals by interregional transfers of ventilated intensive care patients with no higher mortality than non-transferred patients [10,11,12], and in 2021 a tertiary hospital in Zhengzhou, China transferred over 11,000 inpatients — including more than 600 critically ill — following catastrophic urban flooding [13]. In conflict settings reporting is more scarce. Medicalised trains in Ukraine moved nearly 2,500 patients from 11 frontline cities, with the case mix shifting over time from trauma to chronic and non-acute referrals as the conflict evolved [14]. Although most reporting comes from high-resource settings, these challenges are not confined to them: in low- and middle-income countries, institutional evacuation most often occurs against a backdrop of already constrained healthcare capacity and heightened disaster vulnerability [15]. Despite this breadth of experience, the evidence base remains fragmented. Existing reviews have addressed specific sub-problems: logistics and barriers of hospital evacuation planning [1,2], decision-making determinants [3], ICU-specific evacuation guidance [16], and long-term care preparedness [17]. Crucially, most of this literature focuses on the evacuation of a single institution, rather than on the regional challenge of coordinating evacuation across multiple facilities within a disaster-affected health system. Crucially, it remains unclear how mass medical evacuation is organised and applied as a regional health system intervention, and what its consequences are for the quality and safety of healthcare across the affected area, both during the acute phase and in its aftermath. The evidence that does exist reveals a complex risk-benefit balance. Evacuation carries its own mortality, particularly for frail, elderly, critically ill, and psychiatrically vulnerable patients [6,7,8,18], yet failure to evacuate in the face of an escalating threat may carry greater risks still [4,9]. It remains poorly understood under what conditions, for which patient populations, and through which organisational arrangements organised mass medical evacuation succeeds in protecting patients and restoring regional healthcare capacity. This scoping review aims to map the available evidence on mass medical evacuation of civilian healthcare institutions in (sub)acute conflict or disaster settings, including how such programmes are organised and the barriers and enablers reported, and their contribution to the quality and safety of regional healthcare. 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