Boarding’s Hidden Clinical Tax on Older Adults

TL;DR: The data are clear. For adults 65+, more time waiting in the ED after the admit decision correlates with higher delirium, increased adverse events and mortality, and longer hospital stays. In today’s tighter bed environment, that harm loops back into more boarding tomorrow.

What the evidence actually shows

Delirium and severe agitation rise with boarding duration.
A 2024 multicenter cohort found ED boarding duration to be a direct risk factor for developing delirium or severe agitation during the subsequent inpatient admission. Risk increased as boarding time increased, even after adjustment for confounders. 1

“Night in the ED” is not benign for older adults.
In a French cohort of 1,598 patients aged ≥75, those who spent a night in the ED had higher in-hospital mortality and more adverse events than similar patients moved to a ward before midnight; median length of stay was longer as well (9 vs 8 days; rate ratio 1.20). Among patients needing help with ADLs, overnight ED stay carried an adjusted relative risk of 1.81 for in-hospital death. 2

Longer ED time is linked to longer inpatient time.
A 2025 review reports that ED stays over 12 hours were associated with ~12% longer inpatient stays and ~11% higher hospitalization costs in UK data, with Australian data showing up to ~50% longer hospital stay when ED time exceeded 12 hours. Independent studies across settings repeatedly tie longer ED time to longer inpatient LOS. 3

The cycle: occupancy → boarding → worse outcomes → longer LOS → more occupancy.
Recent commentary in JAMA summarizes the dynamic for older adults: when beds are full, ED boarding extends, which increases the likelihood of delirium or mobility complications, which lengthens the inpatient stay, which sustains higher occupancy. 4

This matters more now because occupancy is structurally higher.
US hospital occupancy averaged about 75% across 2023–2024, up from roughly 64% in the pre-pandemic decade, meaning there is less buffer to absorb delay. Higher baseline occupancy amplifies the downstream effect of each additional boarding hour. 5

Why older adults are uniquely vulnerable

Delirium susceptibility: Age-related vulnerability to delirium means stimuli and sleep disruption in the ED can push frail patients into acute cognitive decline, which in turn drives falls, restraint use, and longer recovery. Large geriatric reviews connect longer ED boarding with increased delirium, morbidity, mortality, and post-acute placement needs. 8
Functional reserve: Time lost to immobility while boarding deconditions patients who already have limited reserve, raising the risk of pressure injury and prolonged PT/OT needs that lengthen stays. Findings that persons living with dementia spend ~3 hours longer in the ED underscore how baseline impairment compounds risk. 7

What to track (and publish) if you want this to improve

Admit decision → bed arrival (by age band and service line).
Make the interval for patients 65+ a primary throughput KPI, not just an ED metric. This is the modifiable time window most directly tied to delirium and LOS.
Night-in-ED rate for older adults.
Report the proportion of admitted patients ≥75 who remain in the ED past midnight and their outcomes the following week. The 2023 cohort provides a benchmark signal for harm when nights are spent in the ED.
Delirium incidence within 72 hours of admission.
Track incident delirium (CAM-positive or equivalent) in the first three inpatient days and segment by prior ED time buckets (e.g., <6 h, 6–12 h, >12 h). Recent cohorts demonstrate a graded association.

What actually helps

Escalation triggers tied to hours, not shifts.
Adopt explicit hour-based escalation for boarded admits aged 65+: bed management escalation at 4 hours; clinical leader escalation at 8; executive/house-wide interventions by 12. Evidence linking time thresholds to worse outcomes justifies a staged response.

Prioritize older adults for the first available ward bed.
Where clinical acuity allows, move older adults off ED stretchers to inpatient space faster to reduce delirium risk. The night-in-ED mortality signal supports prioritization when trade-offs exist.

Standing orders to prevent delirium during boarding.
Lights-down protocols overnight, noise reduction, orientation cues, mobility prompts each shift, and hydration checks reduce modifiable delirium risk while patients remain in the ED. Reviews recommend embedding prevention bundles as default care for older adults.

Unclog upstream and downstream at once.
Use parallel discharge moves (transport, meds-to-bed, family coordination) to free ward beds earlier in the day. Every upstream bed released decreases older-adult nights in the ED and trims the feedback loop into tomorrow’s boarding. Evidence tying long ED time to longer LOS makes this an inpatient leadership problem, not just an ED one.

What to tell executives

Boarding isn’t just an ED problem. With hospitals ~75% full nationwide, there isn’t enough slack. Focus on older adults: shorten admit-to-bed time, cut “night in ED” rates, and run delirium-prevention bundles while they wait.
Stopping one overnight in the ED matters. For patients 75+, each avoided night lowers mortality and length of stay. The frailer the patient, the bigger the benefit.