Every day, emergency departments across the United States absorb a steady stream of patients who need hospital care but have nowhere to go. Ambulances continue arriving, waiting rooms fill, and treatment spaces become occupied by people who have already been accepted for admission. This prolonged delay, known as emergency department boarding, is usually measured by the time patients spend waiting for an inpatient bed. A new study in JAMA examines a less visible interval: how long admitted patients wait before an inpatient team actually begins managing their care, even when they remain physically in the emergency department. The findings suggest that the quality and safety of boarding may depend not only on how crowded a hospital is, but also on how it organizes the transfer of clinical responsibility.
Researchers analyzed electronic health record data from 56 hospitals belonging to 17 health systems, focusing on adults admitted to general medical units rather than intensive care, surgical services, or discharge from the emergency department. The investigators defined the transition to inpatient management using evidence that hospital-level care had begun, including medication management, therapy evaluations, diagnostic follow-up, and discharge planning. Their analysis found that 23 percent of emergency department boarders waited at least four hours after the emergency phase of their care had concluded before inpatient-quality management began. At some hospitals, the delay stretched to 12 or 24 hours. These patients were no longer simply waiting for an admission decision: they had been accepted for hospital care, yet the team responsible for coordinating the next stages of treatment had not consistently assumed responsibility.
The four-hour threshold was chosen because the Joint Commission has identified emergency department boarding lasting more than four hours before transfer to an inpatient bed as a critical patient safety concern. However, the researchers emphasize that the handoff interval studied here is not identical to total boarding time. A patient might spend many hours in the emergency department but receive active inpatient management during that period, or might be transferred rapidly to a bed after waiting several hours for an inpatient team to begin work. This distinction matters because emergency and inpatient medicine operate according to different clinical rhythms. Emergency physicians are structured to rapidly evaluate undifferentiated illness, stabilize life-threatening conditions, and remain available for newly arriving patients. Inpatient teams, by contrast, coordinate longitudinal treatment, refine diagnoses, adjust complex medication regimens, involve consultants and therapists, and prepare patients for discharge or post-acute care.
“Great care requires both,” said study co-first author Alex Janke, M.D., M.Sc., M.H.S., an assistant professor of emergency medicine at the University of Michigan Medical School and a member of the U-M Institute for Healthcare Policy and Innovation. But when responsibility remains blurred between the two settings, important tasks can be delayed. A patient with multiple chronic illnesses may need medication reconciliation, renal-dose adjustments, anticoagulation decisions, or monitoring for adverse drug interactions. A frail older adult may require physical and occupational therapy assessments to determine whether returning home is safe. Someone whose admission is driven partly by the absence of a caregiver or a safe home environment may need documentation and evaluations for skilled nursing placement or professional home care. Those processes are often central to inpatient medicine, yet they can be difficult to complete when emergency teams are still managing a department full of new and unstable patients.
The study identified substantial differences between hospitals. Boarders at larger institutions, hospitals serving a greater proportion of Medicaid patients, and teaching hospitals were more likely to experience waits of 12 hours or longer before inpatient management began. Patients older than 65, those covered by Medicare, and those with greater illness acuity were also more likely to face prolonged delays. The researchers caution that these patterns do not prove that hospital size, insurance status, or teaching activity directly causes slower handoffs. They may reflect differences in patient complexity, staffing, bed distribution, local referral patterns, or the way hospitals record clinical activity in electronic health records. Even so, the variation is striking: some hospitals consistently moved patients into inpatient management within four hours, while others took more than a day. That range suggests that operational design may be as important as absolute bed capacity.
The investigators are part of the Research in Emergency Systems and Quality Using EHRs Network, known as RESQUE-NET, a collaborative group founded by Janke, Adrian Haimovich, M.D., Ph.D., of Beth Israel Deaconess Medical Center, and senior author Ari Friedman, M.D., Ph.D., of the University of Pennsylvania. By pooling electronic records across health systems, the network aims to study emergency care at a scale that individual hospitals cannot easily achieve. Electronic records can reveal when admission orders were placed, when medications were reconciled or administered, when inpatient clinicians documented care, and when therapy or discharge-planning processes began. Yet such data also have limitations: documentation may occur after care was delivered, clinical responsibility may be shared among teams, and different hospitals may use different workflows or timestamps. The authors describe the current findings as a starting point for further research rather than a complete national portrait of boarding practices.
The safety implications are especially important for patients who remain in emergency departments for prolonged periods. Emergency rooms are designed for rapid assessment and stabilization, not for extended inpatient stays. They may lack quiet spaces, appropriate mobility equipment, dedicated medication-management workflows, and the staffing model needed for repeated reassessment over several days. At the same time, emergency clinicians must continue prioritizing patients with immediately life-threatening problems. Without a deliberate system for assigning inpatient responsibility, a boarder’s care can become vulnerable to omission: a medication may not be reviewed after kidney function changes, a therapy referral may be postponed, or a discharge barrier may remain undiscovered until the eventual bed transfer. Janke said hospitals need explicit plans for resourcing clinical teams to care for boarders, particularly older adults, people with multiple chronic conditions, and patients taking high-risk medications.
Some hospitals have responded by sending hospitalists, general internal medicine physicians, or family medicine inpatient teams to the emergency department when beds are unavailable. At University of Michigan Health’s University Hospital, Janke said these teams may take over care for patients who remain downstairs, even while maintaining responsibilities on inpatient floors. That approach can allow diagnostic work, medication decisions, consultations, therapy assessments, and discharge planning to proceed before a physical bed opens. It also creates a demanding staffing problem: an inpatient team must divide its attention between patients upstairs and patients waiting elsewhere in the hospital. Hospitals therefore may need broader strategies, including dedicated boarding teams, pharmacist support, mobile therapy services, standardized handoff protocols, and real-time coordination of beds across units. U-M’s Michigan Medicine Command Center, or M2C2, is one example of an operational hub designed to optimize inpatient bed use across a medical campus.
The findings arrive as federal policy begins placing greater emphasis on measuring the patient’s entire emergency care journey. Starting in January 2027, hospital electronic health record systems are scheduled to begin transmitting anonymous information about emergency patients’ movement through the health system to a federal reporting system. Reporting will be required for all hospitals a year later. Boarding times and related measures are expected to become publicly visible through Medicare’s Care Compare website, and by 2030 certain emergency department performance measures are expected to affect Medicare payment rates. A bill introduced in Congress would seek additional transparency around hospital bed availability and emergency department data. If these systems capture the handoff from emergency care to inpatient management, rather than simply recording the time until a bed becomes available, they could expose a previously hidden dimension of hospital performance. But poorly designed metrics could also encourage superficial documentation instead of meaningful care, making validation and consistent definitions essential.
The authors say measuring time to inpatient management could offer hospitals and policymakers a new way to evaluate how capacity crises affect patients after admission has already been decided. The study does not establish that every prolonged handoff causes harm, nor does it represent every hospital in the country. It does, however, show that the period between an admission decision and genuine inpatient oversight is measurable and highly variable. “Risk concentrates at these moments where one clinical team hands a patient to another,” Janke said, noting that emergency and inpatient teams work on different clocks while facing the same resource constraints. The central message is that a hospital’s response to boarding cannot be judged solely by whether a bed is available. Patient safety may depend just as much on whether responsibility, expertise, and clinical resources follow the patient wherever that patient is waiting.
Subject of Research: People
Article Title: Time to Inpatient Management for Boarding Emergency Department Patients
News Publication Date: 17-Aug-2026
Web References: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2026.13302 ; https://ecqi.healthit.gov/upcoming-emergency-care-access-and-timeliness-ecat-ecqm-hospital-oqr-program ; https://www.medicare.gov/care-compare/ ; https://www.congress.gov/bill/119th-congress/house-bill/2936/text
References: JAMA. “Time to Inpatient Management for Boarding Emergency Department Patients.” DOI: 10.1001/jama.2026.13302.
Keywords: emergency department boarding, hospital capacity, inpatient management, patient safety, emergency medicine, hospital quality, health policy, electronic health records, hospital admissions, care transitions
