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Aims and Objectives We studied the impact that boarding medical admissions in the ED awaiting a bed had on those patients and the wider system. Medical patients constitute 66% of ED admissions but wait longer so are 81% of boarding hours.Method and Design Mixed-effects regression analysis study controlled for age, comorbidity, deprivation, time and month of arrival and the number of patients in each hospital with no criteria to reside. We looked at 50,000 medical admissions via three Emergency Departments in one ICB, and 150,000 ambulance responses, from 2022-25.Abstract 4469 Figure 1Delay related harms of medical boarding in ED on those patients: predicted mean (solid line) and 95% confidence intervals on the predicted mean (shaded areas) based on different durations of boarding time (in hours). Note that inpatient length of stay is measured in daysResults and Conclusion Direct, Delay Related Harm:Boarding patients more than 4 hours after their decision to admit (DTA) has a number needed to kill (NNK) of 69. This constitutes 11% of deaths of medical admissions.For every 4 hours from the DTA that medical patients wait for a bed, their inpatient length of stay increases by 8.4 hours.For ED delay more than 4 hours, the number needed to cause readmission within 30 days was 218.Indirect, Crowding Effects:Each increase in medical patients boarding equal to 20% of the number of Majors and Resus cubicles resulted in:10 minutes additional ambulance handover time8 minutes delay to Cat 2 ambulance response time, 52 minutes delay for category 312 minutes increased ED length of stay for all non-admitted ED patients.These results tally with those of Jones et al 2022 for mortality. They demonstrate robust evidence on the direct harm to medical admissions as well as to other patients.Prolonged length of stay of Medical patients boarding in the ED worsens inpatient overcrowding. Applied to national data the effect is over 2 million bed days and 27,000 deaths per year in the UK. Minimising medical boarding would improve outcomes, hospital and ambulance efficiency and public satisfaction with the NHS.