Aim We aimed to investigate prehospital factors associated with difficulty in hospital acceptance among elderly emergency patients. Methods We reviewed ambulance records in Osaka City from January 2013 through December 2014, and enrolled all elderly emergency patients aged ≥65 years who were transported by on‐scene emergency medical service personnel to a hospital that the personnel had selected. The definition of difficulty in hospital acceptance was to the requirement for ≥4 phone calls to hospitals by emergency medical service personnel before receiving a decision from the destination hospitals. Prehospital factors associated with difficulty in hospital acceptance were examined through logistic regression analysis. Results During the study period, 72 105 elderly patients were included, and 13 332 patients (18.5%) experienced difficulty in hospital acceptance. In the simple linear regression model, hospital selection time increased significantly with an increasing number of phone calls (R2 = 0.774). In the multivariable analysis, older age (P for trend <0.001), calls from a healthcare facility (adjusted odds ratio [AOR] 1.23, 95% confidence interval [CI] 1.15–1.32), night‐time (AOR 2.17, 95% CI 2.08–2.26) and weekend/holidays (AOR 1.43, 95% CI 1.38–1.49) were significantly associated with difficulty in hospital acceptance. A positive association was observed between gastrointestinal emergency‐related symptoms and difficulty in hospital acceptance among elderly patients with symptoms of internal disease (AOR 1.71, 95% CI 1.53–1.91). Conclusions In Japan, which has a rapidly aging population, a comprehensive strategy for elderly emergency patients, especially for advanced age groups or nursing home residents, is required. Geriatr Gerontol Int 2017; ••: ••–••.