Abstract Rationale Acute respiratory failure (ARF) requiring non-invasive support (HFNO, NIPPV, CPAP here termed together as NIV) is common and presents with a broad range of severity. Admission of such patients to one of several different levels-of-care (intensive care unit ICU, intermediate-care unit IMC or ward) may be reasonable depending on hospital setup/capability. However, the distribution of level of care for admission of these patients and their outcomes across different hospitals is unknown. Methods In a retrospective cohort study of eight US health systems of the Common Longitudinal ICU data Format (CLIF) Consortium from 2018-2024, we included adults receiving NIV for 6 hours in the ED and who were subsequently admitted to the hospital. We excluded patients who received invasive mechanical ventilation (IMV) or were “comfort measures only” in the ED. The primary process outcome was the first unit-type after the ED (ICU, IMC or ward), and the primary patient outcome was in-hospital mortality or discharge to hospice. Secondary outcomes included length of stay (LOS), intubation, and escalation to a higher level of care. Data were reported by first admission site (ICU, IMC, ward) using pooled means and standard deviations (SDs) or counts and percentages as appropriate. Results Of 31,648 qualifying ED encounters, mean age was 67 years (SD = 16) and 50% were female. A total of 16,063 patients (51%) were admitted to ICUs, 5,806 (18%) to IMCs, and 9,779 (31%) to wards (Table 1). Of the encounters, 13,025 (41%) occurred at hospitals that had an IMC capable of admitting ARF patients directly from the ED. NIPPV was the most common form of support in the ED (67%), then HFNC (28%) and CPAP (5%). In-hospital death or discharge to hospice occurred in 20% of ICU, 17% of IMC, and 10% of ward admissions. LOS (penalized for death or hospice) corresponded to level of care: 18.7 days (SD = 20.3; ICU), 15.7 days (SD = 18.6; IMC), and 11.9 days (SD = 16.1; ward). Among those who were not DNI, progression to IMV occurred in 18% of ICU, 7% of IMC, and 5% of ward patients. Among all encounters, care escalation occurred in 12% of IMC and 13% of ward admissions. Conclusion Among patients presenting to the ED with acute respiratory failure managed with NIV, nearly half were admitted outside the ICU. Outcomes in IMC and ward settings support the use of these care settings for select patients with ARF. This abstract is funded by: John’s Hopkins School of Medicine Dean’s Year of Research Funding, National Institutes of Health, National Heart, Lung, and Blood Institute K23HL169743
Goldfarb et al. (2026) studied this question.