Causes of Delayed Transfers From the Emergency Department to Speciality Units: A Prospective Observational Study at a Tertiary Care Centre

Background: Delays in transferring patients from the emergency department (ED) to speciality units cause overcrowding and poor outcomes. The causes of prolonged ED boarding exceeding 24 hours remain understudied, especially in Indian tertiary centres. Methods: This prospective observational study over six months at a central India tertiary care hospital enrolled adults (≥18 years) staying ≥24 hours in the ED without speciality transfer (n=510). A delay was defined as time from ED registration to the speciality unit's documented transfer decision exceeding 24 hours. Causes were classified as patient-related (e.g., poor prognosis: Sequential Organ Failure Assessment (SOFA) ≥ 13, cancer patients) or system-related (e.g., ICU/high-dependency unit (HDU) bed waits, interdepartmental disputes). We assessed ED stay, hospital length of stay (LOS), and discharge status. Data were analysed using descriptive statistics. Results: System causes predominated (70%): speciality ICU/HDU bed waits in 169 (33.1%) patients and interdepartmental disputes in 166 (32.5%). Poor prognosis ranked third in 135 (26.5%) patients. Of 510 patients boarded >24 hours, 438 (85.9%) received delayed transfer (delayed transfer group) and 72 (14.1%) stayed in ED without transfer (non-transferred group). Among the 438 transferred patients, median ED stay before transfer was 51 hours (IQR 48-72 hours); 310 (70.7%) were transferred within 72 hours. In the delayed group, 301 (68.7%) were discharged, 71 (16.2%) died, and 66 (15.1%) left against medical advice; median hospital LOS was seven days. The non-transferred group had a shorter LOS (median 2.5 days). Conclusion: Despite efficient 24-hour unit rotations, pre-decision system bottlenecks drive prolonged ED boarding. Hospital-wide bed dashboards, dedicated surge ICU beds, and ED transfer authority for long boarders would improve patient flow in resource-constrained settings.