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Abstract Objectives Patients hospitalized for COVID‐19 frequently develop hypoxemia and acute respiratory distress syndrome (ARDS) after admission. In non‐COVID‐19 ARDS studies, admission to hospital wards with subsequent transfer to intensive care unit (ICU) is associated with worse outcomes. We hypothesized that initial admission to the ward may affect outcomes in patient with COVID‐19 ARDS. Methods This was a retrospective study of consecutive adults admitted for COVID‐19 ARDS between March 2020 and March 2021 at Stanford Health Care. Mortality scores at hospital admission (Coronavirus Clinical Characterization Consortium Mortality Score [4C score]) and ICU admission (Simplified Acute Physiology Score III [SAPS‐III]) were calculated, as well as ROX index for patients on high flow nasal oxygen. Patients were classified by emergency department (ED) disposition (ward‐first vs. ICU‐direct), and 28‐ and 60‐day mortality and highest level of respiratory support within 1 day of ICU admission were compared. A second cohort (April 2021‒July 2022, n = 129) was phenotyped to validate mortality outcome. Results A total of 157 patients were included, 48% of whom were first admitted to the ward (n = 75). Ward‐first patients had more comorbidities, including lung disease. Ward‐first patients had lower 4C and similar SAPS‐III score, yet increased mortality at 28 days (32% vs. 17%, hazard ratio [HR] 2.0, 95% confidence interval [95% CI] 1.0‒3.7, p = 0.039) and 60 days (39% vs. 23%, HR 1.83, 95% CI 1.04‒3.22, p = 0.037) compared to ICU‐direct patients. More ward‐first patients escalated to mechanical ventilation on day 1 of ICU admission (36% vs. 14%, p = 0.002) despite similar ROX index. Ward‐first patients who upgraded to ICU within 48 h of ED presentation had the highest mortality. Mortality findings were replicated in a sensitivity analysis. Conclusion Despite similar baseline risk scores, ward‐first patients with COVID‐19 ARDS had increased mortality and escalation to mechanical ventilation compared to ICU‐direct patients. Ward‐first patients requiring ICU upgrade within 48 h were at highest risk, highlighting a need for improved identification of this group at ED admission.

Abstract Objectives Studies have found that prolonged boarding time for intensive care unit (ICU) patients in the emergency department (ED) is associated with higher in‐hospital mortality. However, these studies introduced selection bias by excluding patients with ICU admission orders who were downgraded and never arrived in the ICU. Consequently, they may overestimate mortality in prolonged ED boarders. Methods This was a retrospective cohort study at a single center covering the period from August 14, 2015 to August 13, 2019. Adult ED patients with medical ICU admission orders and at least 6 hours of subsequent critical care in either the ED or the ICU were included. Patients were classified as having either prolonged (>6 hours) or non‐prolonged (≤6 hours) ED boarding. Downgraded patients were identified, and mortality was compared, both including and excluding downgraded patients. Results Of 1862 patients, 612 (32.9%) had prolonged boarding; at 6 hours after ICU admission order entry, they were still in the ED. The remaining 1250 (67.1%) had non‐prolonged boarding; at 6 hours after the ICU admission order entry, they were already in the ICU. In‐hospital mortality in the non‐prolonged boarding group was 18.9%. In the prolonged boarding group, 296 (48.4%) patients were downgraded in the ED and never arrived in the ICU. Including these ED downgrades, the mortality in the prolonged boarding group was 13.4% (risk difference ‐5.5%, 95% confidence interval [CI] ‐8.9% to ‐2.0%, P = 0.0031). When we excluded downgrades, the mortality in the prolonged boarding group increased to 17.4% (risk difference ‐1.5%, 95% CI ‐6.2% to 3.2%, P = 0.5720). The lower mortality in the prolonged group was attributable to lower severity of illness (mean emergency critical care SOFA [eccSOFA] difference: ‐0.8, 95% CI ‐1.1 to ‐0.4, P