Compared to direct ICU admission, admission from the ED to the ward is associated with increased mortality in patients who meet COVID‐19 ARDS criteria during their hospitalization, despite lower 4C and similar SAPS‐III risk scores at the time of hospital and ICU admission, respectively.

Patients with rapid progression had the worst outcomes, and current risk stratification tools fail to identify these patients at the time of admission.

Future work should focus on validating these findings in larger cohorts and developing tools to identify “rapid progressors” at the time of ED disposition.

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.

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