• Nicole V Lucas, Jennifer Rosenbaum, Derek L Isenberg, Richard Martin, and Kraftin E Schreyer.
• Department of Emergency Medicine, Temple University Hospital, 1316 W. Ontario Street, 10(th) floor Jones Hall, Philadelphia, PA 19140, United States.
• Am J Emerg Med. 2021 Nov 1; 49: 100103100-103.

IntroductionThe initial surge of critically ill patients in the COVID-19 pandemic severely disrupted processes at acute care hospitals. This study examines the frequency and causes for patients upgraded to intensive care unit (ICU) level care following admission from the emergency department (ED) to non-critical care units.MethodsThe number of ICU upgrades per month was determined, including the percentage of upgrades noted to have non-concordant diagnoses. Charts with non-concordant diagnoses were examined in detail as to the ED medical decision-making, clinical circumstances surrounding the upgrade, and presence of a diagnosis of COVID-19. For each case, a cognitive bias was assigned.ResultsThe percentage of upgraded cases with non-concordant diagnoses increased from a baseline range of 14-20% to 41.3%. The majority of upgrades were due to premature closure (72.2%), anchoring (61.1%), and confirmation bias (55.6%).ConclusionConsistent with the behavioral literature, this suggests that stressful ambient conditions affect cognitive reasoning processes.Copyright © 2021 Elsevier Inc. All rights reserved.

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