{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T10:30:32Z","timestamp":1786357832941,"version":"build-2736575974"},"reference-count":39,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T00:00:00Z","timestamp":1786320000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Med. Sci.","Medical Sciences"],"abstract":"<jats:p>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 &lt; 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\u20134.56; p &lt; 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.<\/jats:p>","DOI":"10.3390\/medsci14040470","type":"journal-article","created":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T09:24:53Z","timestamp":1786353893000},"page":"470","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Initial Ward Admission Followed by Early Respiratory Intermediate Care Transfer and In-Hospital Mortality"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5892-3893","authenticated-orcid":false,"given":"Txomin","family":"Zabala Hern\u00e1ndez","sequence":"first","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8474-2479","authenticated-orcid":false,"given":"Susana","family":"Garc\u00eda Gutierrez","sequence":"additional","affiliation":[{"name":"Biosistemak, Research Unit, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"},{"name":"Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Carlos III Health Institute (ISCIII), 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amaia","family":"Aramburu Ojembarrena","sequence":"additional","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amaia","family":"Garc\u00eda Loizaga","sequence":"additional","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Myriam","family":"Aburto","sequence":"additional","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francisco Javier","family":"Moraza Cortes","sequence":"additional","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1199-9166","authenticated-orcid":false,"given":"Cristobal","family":"Esteban Gonzalez","sequence":"additional","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mar\u00eda","family":"Gasc\u00f3n P\u00e9rez","sequence":"additional","affiliation":[{"name":"Biosistemak, Research Unit, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1778-5196","authenticated-orcid":false,"given":"Mar\u00eda Jos\u00e9","family":"Legarreta Olabarrieta","sequence":"additional","affiliation":[{"name":"Biosistemak, Research Unit, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ane","family":"Uranga","sequence":"additional","affiliation":[{"name":"Department of Pneumology, Biobizkaia Health Research Institute, Osakidetza Basque Health Service, Galdakao-Usansolo University Hospital, 48960 Galdakao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1343","DOI":"10.1183\/09031936.02.00058202","article-title":"Respiratory intermediate care units: A European survey","volume":"20","author":"Corrado","year":"2002","journal-title":"Eur. Respir. J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1097\/01.cpm.0000237194.49445.41","article-title":"Intermediate Respiratory Care Units","volume":"13","author":"Ferrer","year":"2006","journal-title":"Clin. Pulm. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1001\/jama.1990.03450090079031","article-title":"One Year\u2019s Experience with a Noninvasively Monitored Intermediate Care Unit for Pulmonary Patients","volume":"264","author":"Krieger","year":"1990","journal-title":"JAMA"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1056\/NEJM199509283331301","article-title":"Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease","volume":"333","author":"Brochard","year":"1995","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1164\/rccm.201106-1094OC","article-title":"Outcomes of Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the United States, 1998\u20132008","volume":"185","author":"Chandra","year":"2012","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_6","first-page":"CD004104","article-title":"Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease","volume":"7","author":"Osadnik","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1016\/j.arbres.2009.04.015","article-title":"Cuidados respiratorios intermedios: Un a\u00f1o de experiencia","volume":"45","author":"Aburto","year":"2009","journal-title":"Arch. Bronconeumol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1016\/j.arbres.2019.06.008","article-title":"An\u00e1lisis de costes y mortalidad de una unidad de cuidados intermedios respiratorios. \u00bfEs realmente eficiente y segura?","volume":"55","year":"2019","journal-title":"Arch. Bronconeumol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"894","DOI":"10.1016\/j.rmed.2004.11.014","article-title":"Costs of the COPD. Differences between intensive care unit and respiratory intermediate care unit","volume":"99","author":"Bertolini","year":"2005","journal-title":"Respir. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e000178","DOI":"10.1136\/tsaco-2018-000178","article-title":"Assessment of the intermediate care unit triage system","volume":"3","author":"Plate","year":"2018","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_11","first-page":"8038460","article-title":"Utilisation of Intermediate Care Units: A Systematic Review","volume":"2017","author":"Plate","year":"2017","journal-title":"Crit. Care Res. Pract."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1159\/000516329","article-title":"Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study","volume":"100","author":"Grosgurin","year":"2021","journal-title":"Respiration"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1016\/j.arbres.2021.10.004","article-title":"Unidad de Cuidados Respiratorios Intermedios (UCRI) en la pandemia COVID-19 en Espa\u00f1a. La realidad","volume":"58","author":"Mediano","year":"2022","journal-title":"Arch. Bronconeumol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"S40","DOI":"10.1016\/S0140-6736(15)60355-5","article-title":"Delay to admission to critical care and mortality among deteriorating ward patients in UK hospitals: A multicentre, prospective, observational cohort study","volume":"385","author":"Harris","year":"2015","journal-title":"Lancet"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"4083494","DOI":"10.1155\/2022\/4083494","article-title":"Delayed Admission to the Intensive Care Unit and Mortality of Critically Ill Adults: Systematic Review and Meta-analysis","volume":"2022","author":"Kiekkas","year":"2022","journal-title":"BioMed Res. Int."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.ajem.2016.09.066","article-title":"Impact of delayed admission to intensive care units on patients with acute respiratory failure","volume":"35","author":"Hsieh","year":"2017","journal-title":"Am. J. Emerg. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1186\/s13613-021-00930-5","article-title":"On behalf of the MARS Consortium. Association between delay in intensive care unit admission and the host response in patients with community-acquired pneumonia","volume":"11","author":"Pereverzeva","year":"2021","journal-title":"Ann. Intensive Care"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e258498","DOI":"10.1001\/jamanetworkopen.2025.8498","article-title":"Emergency Department Triage Accuracy and Delays in Care for High-Risk Conditions","volume":"8","author":"Sax","year":"2025","journal-title":"JAMA Netw. Open"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.jcrc.2018.08.012","article-title":"Predicting early deterioration of admitted patients at the Intermediate Care Unit","volume":"48","author":"Plate","year":"2018","journal-title":"J. Crit. Care"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"100220","DOI":"10.1016\/j.opresp.2022.100220","article-title":"Unidades de Cuidados Respiratorios Intermedios: Preguntas y respuestas","volume":"4","author":"Sampol","year":"2022","journal-title":"Open Respir. Arch."},{"key":"ref_21","first-page":"3","article-title":"Respiratory Support Units: Guidance on Development and Implementation","volume":"12","author":"Messer","year":"2021","journal-title":"Br. Thorac. Soc. Rep."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1136\/thx.53.9.798","article-title":"Intermediate respiratory intensive care units in Europe: A European perspective","volume":"53","author":"Nava","year":"1998","journal-title":"Thorax"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J. Chronic Dis."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1097\/00000421-198212000-00014","article-title":"Toxicity and response criteria of the Eastern Cooperative Oncology Group","volume":"5","author":"Oken","year":"1982","journal-title":"Am. J. Clin. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1097\/00003246-198510000-00009","article-title":"APACHE II: A severity of disease classification system","volume":"13","author":"Knaus","year":"1985","journal-title":"Crit. Care Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1841","DOI":"10.1016\/j.ajem.2020.05.053","article-title":"Prognostic utilization of models based on the APACHE II, APACHE IV, and SAPS II scores for predicting in-hospital mortality in emergency department","volume":"38","author":"Rahmatinejad","year":"2020","journal-title":"Am. J. Emerg. Med."},{"key":"ref_27","first-page":"361","article-title":"Undertriage of patients requiring direct admission to intensive care from the emergency department for medical conditions: Impact on prognosis and associated factors","volume":"33","author":"Aniyar","year":"2021","journal-title":"Emergencias"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1016\/j.annemergmed.2025.11.018","article-title":"Association Between Emergency Department Undertriage or Overtriage with Timeliness of Care and Patient Outcomes","volume":"87","author":"Sax","year":"2026","journal-title":"Ann. Emerg. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1016\/j.ajem.2025.10.024","article-title":"Emergency department triage associated with timeliness of care for patients with septic shock","volume":"98","author":"Sax","year":"2025","journal-title":"Am. J. Emerg. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e2413955","DOI":"10.1001\/jamanetworkopen.2024.13955","article-title":"Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children with Sepsis","volume":"7","author":"Lane","year":"2024","journal-title":"JAMA Netw. Open"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1155","DOI":"10.1016\/S0140-6736(06)68506-1","article-title":"Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: A meta-analysis","volume":"367","author":"Peter","year":"2006","journal-title":"Lancet"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Bouam, M., Binquet, C., Moretto, F., Sixt, T., Vourc\u2019h, M., Piroth, L., Ray, P., and Blot, M. (2023). Delayed diagnosis of pneumonia in the emergency department: Factors associated and prognosis. Front. Med., 10.","DOI":"10.3389\/fmed.2023.1042704"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2053","DOI":"10.4187\/respcare.02225","article-title":"Influence of the Admission Pattern on the Outcome of Patients Admitted to a Respiratory Intensive Care Unit: Does a Step-Down Admission Differ from a Step-Up One?","volume":"58","author":"Valentini","year":"2013","journal-title":"Respir. Care"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1097\/CCM.0000000000002993","article-title":"Effect of Emergency Department and ICU occupancy on admission decisions and outcomes for critically ill patients","volume":"46","author":"Mathews","year":"2018","journal-title":"Crit. Care Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"826","DOI":"10.1183\/09031936.00154209","article-title":"The impact of a delay in intensive care unit admission for community-acquired pneumonia","volume":"36","author":"Phua","year":"2010","journal-title":"Eur. Respir. J."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1824","DOI":"10.1016\/S0140-6736(13)62631-8","article-title":"Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study","volume":"383","author":"Aiken","year":"2014","journal-title":"Lancet"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1587","DOI":"10.1097\/CCM.0000000000001015","article-title":"Patient Mortality Is Associated with Staff Resources and Workload in the ICU: A Multicenter Observational Study","volume":"43","author":"Neuraz","year":"2015","journal-title":"Crit. Care Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1177\/0141076820925436","article-title":"Clinical impact of multi-parameter continuous non-invasive monitoring in hospital wards: A systematic review and meta-analysis","volume":"113","author":"Sun","year":"2020","journal-title":"J. R. Soc. Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1159\/000433557","article-title":"Opening of a Respiratory Intermediate Care Unit in a General Hospital: Impact on Mortality and Other Outcomes","volume":"90","author":"Confalonieri","year":"2015","journal-title":"Respiration"}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/470\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T09:47:36Z","timestamp":1786355256000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/470"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,10]]},"references-count":39,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medsci14040470"],"URL":"https:\/\/doi.org\/10.3390\/medsci14040470","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,10]]}}}