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This study aimed to examine the factors associated with increased length of stay (LOS > 24 hours) in the pediatric emergency observation unit (OU) of an urban tertiary children’s hospital in China.This study was a retrospective cohort study. We retrieved and examined all the records of patients (age, 0–16 years) who were admitted to the OU (n = 10,852) during July 1, 2008, to June 30, 2009. The primary outcome was LOS and prolonged stay (LOS > 24 hours). We also performed a sensitivity analysis by using LOS of 3 days or greater and LOS of 6 days or greater as dependent variables in logistic regression and compared with LOS of greater than 24 hours regression to examine the robustness of the associations.The overall mean (SD) LOS was 24.0 (24.4) hours; 31.3% had LOS of greater than 24 hours, of which the mean (SD) LOS was 50.2 (28.6) hours. The following factors were associated with LOS of greater than 24 hours: age, 28 days to 3 months (odds ratio, [OR], 1.87; 95% confidence interval, 1.36–2.59) and older than 3 months to 12 months (OR, 1.83; 95% CI, 1.35–2.50) compared with age 0 to 28 days; neurologic diseases (OR, 1.50; 95% CI, 1.31–1.72), infectious diseases (OR, 2.00; 95% CI, 1.61–2.49), and visits for non–respiratory-related signs and symptoms (OR, 2.00; 95% CI, 1.61–2.49); acuity level of emergent (OR, 1.79; 95% CI, 1.57–2.04); procedures (OR, 7.09; 95% CI, 4.16–12.10); emergency transfusions (OR, 1.33; 95% CI, 1.01–1.75); staffed by residents (OR, 1.12; 95% CI, 1.01–1.24); and patients living in low–annual gross domestic product districts (OR, 1.14; 95% CI, 1.01–1.29). Arrival at evening (OR, 0.54; 95% CI, 0.49–0.60) and overnight (OR, 0.43; 95% CI, 0.38–0.49) were less likely to have LOS of greater than 24 hours than arrival during day shifts.We identified some risk factors for prolonged stay in an OU. These factors are the starting points in understanding issues related to prolonged stay and are needed to assess efficiency and quality of care in pediatric emergency department and OU. Our results have provided information basis for making improvements in the system and may be important considerations for similar institutions, which encounter similar challenges.