Initial Ward Admission Followed by Early Respiratory Intermediate Care Transfer and In-Hospital Mortality

Background/Objectives: Respiratory intermediate care units (RICUs) manage patients with severe respiratory disease requiring advanced monitoring and non-invasive respiratory support. Early identification of patients requiring RICU care after emergency department (ED) assessment remains challenging. This study assessed whether initial admission to a conventional hospital ward followed by early RICU transfer was associated with in-hospital mortality among patients ultimately admitted to a RICU. Methods: We conducted a 10-year prospective observational cohort study including consecutive patients admitted to the RICU of a tertiary hospital after ED assessment. Patients admitted directly from the ED to the RICU were classified as the direct RICU admission group. Patients initially admitted to a conventional ward and transferred to the RICU within 48 h were classified as the early ward-to-RICU transfer group. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included ICU admission and hospital length of stay. Multivariable logistic regression was used to assess the association between admission pathway and in-hospital mortality. Results: A total of 1784 patients were included: 1285 (72%) in the direct RICU admission group and 499 (28%) in the early ward-to-RICU transfer group. In-hospital mortality was higher in the early ward-to-RICU transfer group than in the direct RICU admission group (13.43% versus 5.76%; p < 0.0001), as were ICU admission rates (6.01% versus 2.57%; p = 0.0004). In the complete-case multivariable model, early ward-to-RICU transfer remained associated with higher in-hospital mortality after adjustment for sex, ECOG performance status, APACHE II score at ED presentation, Charlson Comorbidity Index, heart failure, and interstitial lung disease (OR 2.99, 95% CI 1.96-4.56; p < 0.0001). Conclusions: Among patients ultimately admitted to a RICU after ED assessment, initial ward admission followed by early RICU transfer was associated with higher in-hospital mortality. These findings suggest that initial ward admission followed by early RICU transfer may help identify a clinically vulnerable subgroup among patients ultimately requiring respiratory intermediate care. However, because admission pathway may be influenced by evolving severity, diagnostic uncertainty, treatment decisions, and organisational factors, no causal inference can be made from this observational study.