Prolonged ED Stays, Boarding Times Among Older Adults Underscore Systemic Hospital Strain

Prolonged emergency department (ED) length of stays and boarding times for older adults significantly increased between 2017 and 2024, highlighting systemic challenges for hospitals across the US, according to a research letter published in JAMA Internal Medicine.¹

The researchers noted that extended ED stays in older adults are associated with a higher risk of adverse events, such as mortality and delirium, as well as treatment delays, worse patient experiences, and loss of privacy. To improve care for this population, CMS implemented the Age-Friendly Hospital Measure in January 2025.²

This policy requires hospitals to limit total ED length of stay to under 8 hours and ensure admission to occur within 3 hours of the decision to admit. However, national data on these measures have been lacking.¹ To address this gap, the researchers conducted a cross-sectional study to establish national benchmarks.

The recent increase in prolonged emergency department (ED) stays and boarding times for older adults reveals systemic challenges in US hospital care. | Image Credit: chrisdorney - stock.adobe.com

Using the Epic Cosmos health records database, which includes data from 1633 hospitals, 295 million patients, and 78 million admissions, they analyzed ED encounters from January 2017 to December 2024.³ They focused on 2 key metrics for patients aged 65 and older, namely the proportion with an ED length of stay over 8 hours and the proportion of admitted patients waiting more than 3 hours from bed request to admission.¹

In 2017, 12% of 4,564,359 ED encounters involved a length of stay over 8 hours. By 2024, this rose to 20% of 12,392,737 encounters. The largest increase occurred in academic hospitals, where prolonged stays grew from 22% of 1,787,179 encounters in 2017 to 36% of 4,311,417 encounters in 2024.

During the same period, boarding times over 3 hours increased from 22% of 1,787,179 encounters in 2017 to 36% of 4,311,417 encounters in 2024. Again, the largest increase was seen in academic hospitals, where boarding rose from 31% in 2017 to 45% in 2024.

Trend analyses showed small annual increases in both measures from 2017 to 2020 (length of stay, 1.1% [95% CI, 0.6-1.6]; boarding, 2.8% [95% CI, 1.5-4.0]), followed by sharper rises from 2020 to 2022 during the COVID-19 pandemic (length of stay, 4.2% [95% CI, 1.7-6.7]; boarding, 6.1% [95% CI, 2.5-9.8]). In contrast, from 2022 to 2024, both trends slightly declined (length of stay, –1.7% [95% CI, –2.3 to –1.1]; boarding, –3.2% [95% CI, –4.5 to –1.9]).

Although further investigation is needed, the researchers suggested the increases may be driven by growing patient complexity, increased demand, and ongoing staffing and resource shortages.

Lastly, they acknowledged the study's limitations, one being that Epic overrepresents larger and academic hospitals. Also, not all hospitals that use Epic contribute to Cosmos. Despite this, the researchers expressed confidence in their findings and emphasized the need to address the declining ED experience for older US adults.

"Worsening ED LOSs [lengths of stay] and boarding contribute to ED crowding, reflect systemic health care dysfunction, and, most importantly, harm individual patients," the authors concluded. "Addressing these trends is critical to safeguarding both the health of older adults and the health systems caring for them."

References

1. Haimovich AD, Berry SD, Landon BE. Prolonged emergency department stays for older US adults. JAMA Intern Med. doi:10.1001/jamainternmed.2025.2006
2. FY 2025 hospital inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) proposed rule—CMS-1808-P fact sheet. CMS. April 10, 2024. Accessed June 30, 2025. https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective
3. Fast facts on US hospitals, 2024. American Hospital Association. 2024. Accessed June 30, 2025. https://www.aha.org/system/files/media/file/2024/01/fast-facts-on-us-hospitals-2024-20240112.pdf