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Background: Anemia affects up to 25% of emergency department (ED) patients. Restrictive red blood cell (RBC) transfusion strategies are recommended for stable patients, but ED transfusion practices often remain liberal. Benefits of ED transfusion remains unclear., Objective: To evaluate the impact of ED transfusion on death-adjusted in-hospital length of stay (LOS) in stable anemic patients requiring hospitalization., Methods: This single-center retrospective propensity-matched study included patients ≥ 18 years admitted to the ED of Nîmes University Hospital in 2022 with hemoglobin levels between 70 and 90 g.L - 1 . Patients with hemorrhagic shock or requiring emergent hemostatic procedures were excluded. Propensity score matching was conducted on variables including age, comorbidities, hemoglobin levels, and diastolic blood pressure. Primary outcome was adjusted in-hospital LOS. Secondary outcomes included ED LOS and RBC transfusion volumes., Results: Among 564 patients, 118 (21%) were propensity-matched: 59 (50%) ED-transfused, 59 (50%) non-ED-transfused. Adjusted in-hospital LOS 13 [8-32] for ED-transfused patients and 12 [6-24] days for non-ED-transfused patients (median difference = 0; 95%CI: -10-7; p = 0.52). Median difference in ED LOS was 7:13 (95%CI: 1:00-11:25; p < 0.001) between ED transfused and non-ED-transfused patients. Median difference in number of RBC transfused during in hospital stay was 2 (95%CI: 1-3); p < 0.01) between ED transfused and non-ED-transfused patients., Conclusion: In stable anemic patients with 70 to 90 g.L - 1 hemoglobin level, ED transfusion did not reduce adjusted in-hospital LOS but prolonged ED LOS. Identifying patients who may safely defer transfusion could improve ED efficiency and safety., Competing Interests: Declarations. Ethics approval and consent to participate: The local ethics committee of Nimes’ university hospital approved the study (Nîmes University Hospital IRB 23.05.02) and waived the consent in accordance with French law (Law no. 2012 − 300 of 5 March 2012 on research involving the human person). A non-opposition letter was sent to patients or their relatives if patients died during hospitalisation, explaining the aims of the study and the possibility of refusing data collection. The authors did not receive any refusals. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Clinical trial number: not applicable., (© 2025. The Author(s).)