Study Measures Time to Inpatient Care for Patients Boarding in Emergency Departments

A new study in JAMA is examining an overlooked interval in hospital care: the time between a patient’s admission to a general medical service and the initiation of inpatient management. The research focuses on how this interval varies from one patient to another and from one hospital to another, raising a fundamental question about the reliability of care after the decision to admit has already been made. While emergency departments often receive intense attention for delays, crowding, and waiting times, the transition from admission decision to active inpatient treatment can be less visible. Yet during this period, patients may still be experiencing worsening symptoms, uncertainty about their treatment plan, or delays in receiving therapies, monitoring, consultations, and other elements of hospital care.

The study is led by Alexander T. Janke, MD, MHS, MSc, of the Department of Emergency Medicine at the University of Michigan. Its central subject is not simply whether patients eventually receive inpatient treatment, but how long they wait before that care begins and why the interval differs. Such timing is clinically important because hospitalization is not a single event. It is a sequence that can include evaluation in the emergency department, a decision to admit, assignment to a medical service, transfer to a hospital bed, communication between teams, medication reconciliation, diagnostic planning, and the first physician or advanced-practice assessment on the inpatient unit. Each handoff introduces opportunities for delay, and the cumulative effect may be difficult to detect without carefully defined time measurements.

The researchers’ focus on both patient-level and hospital-level variation is especially significant. Patient-level differences may include illness severity, the complexity of medical problems, the need for specialized consultation, the availability of prior records, or changes in clinical status after admission. Hospital-level differences may reflect staffing models, bed availability, workflow design, electronic health record practices, communication systems, service organization, and local policies governing admissions. Separating these sources of variation is a technical challenge: a patient who waits longer may have more complicated needs, but a pattern affecting many patients at the same hospital could indicate a system-level process rather than individual clinical complexity. Understanding that distinction is essential before hospitals can determine where improvement efforts should be directed.

In health-services research, time to treatment is often treated as a measurable signal of system performance. The clock can begin at different points, however, and the choice of starting point changes the meaning of the result. Measuring from arrival at the hospital captures the entire front-end experience, while measuring from the admission decision isolates a later phase of care. The study’s emphasis on initiation of inpatient management therefore draws attention to a specific transition that may be obscured when all hospital delays are combined into one figure. A precise definition of the interval can help researchers compare institutions more fairly and identify whether delays occur before admission, during transfer to an inpatient service, or after the patient has formally entered the hospital’s medical-care pathway.

The topic also intersects with the growing use of large-scale clinical data to study hospital operations. Electronic health records contain timestamps for orders, bed requests, service assignments, medication administration, vital-sign documentation, notes, and other events. These data can make it possible to reconstruct the sequence of care at a level of detail that was previously difficult to obtain. But timestamps are not identical to clinical actions. An order may be entered before it is carried out, a note may be signed after an assessment has occurred, and an automatically generated record may not reflect a meaningful change in treatment. Any analysis of time to inpatient management must therefore contend with measurement quality, inconsistent documentation, and differences in how hospitals use their digital systems.

The consequences of delayed inpatient management may not be uniform. For some patients, a delay could have limited clinical importance if they are stable and awaiting routine evaluation. For others, even a relatively short interval could matter if symptoms are evolving or if time-sensitive therapies, monitoring, or diagnostic decisions are needed. Delays may also affect the patient experience by prolonging uncertainty and creating confusion about who is responsible for care. At the operational level, slow transitions can contribute to emergency department crowding, impede bed turnover, and increase pressure on clinicians working across multiple locations. The study’s patient- and hospital-level perspective is designed to examine this complexity rather than assume that every delay has the same cause or consequence.

The research arrives as hospitals face increasing pressure to improve throughput without reducing safety. Expanding capacity is one possible response, but capacity alone may not resolve delays created by fragmented workflows or unclear responsibility during handoffs. Hospitals may instead need to examine how admission decisions are communicated, when inpatient teams become accountable, how early assessments are prioritized, and whether electronic systems support or hinder rapid coordination. If substantial variation is found between hospitals after accounting for patient characteristics, that would suggest that organizational design and local practice patterns may play an important role. If variation is mainly concentrated among particular groups of patients, more targeted clinical pathways could be appropriate. The value of the study lies in helping distinguish these possibilities.

The findings could ultimately influence how hospitals measure quality after admission. Current performance indicators often emphasize mortality, readmissions, length of stay, or emergency department waiting times. These outcomes remain important, but they can be too distant from the process that produced them to identify the first point of failure. A measure of time to inpatient management could serve as an earlier operational signal, particularly when paired with information about illness severity and the type of care initiated. Such a metric would need careful interpretation: faster action is not automatically better if it produces unnecessary testing, premature treatment, or poorly coordinated decisions. The goal would be timely, clinically appropriate management, supported by reliable communication and accurate documentation.

By placing the hospital’s internal clock at the center of analysis, the JAMA study highlights a part of the patient journey that is easy to overlook precisely because the patient has already been accepted for admission. The admission decision may feel like the end of a wait, but it is also the beginning of a new phase in which delays can continue. The researchers’ examination of patient- and hospital-level variation may provide a clearer picture of where those delays occur and whether they are driven primarily by clinical complexity, institutional processes, or both. As hospitals search for ways to make care more responsive, understanding this hidden interval could become an important step toward turning admission from an administrative milestone into a prompt and coordinated start to treatment.

Web References: DOI: 10.1001/jama.2026.13302

References: Janke AT, et al. Study published in JAMA. DOI: 10.1001/jama.2026.13302