Estimated reading time: 5 minutes
Nearly one in four patients boarding in hospital emergency departments wait at least four hours after being accepted for admission before an inpatient team assumes responsibility for their care, according to a new study that highlights potential risks during a critical transition in hospital care.
The study, published in JAMA, found wide variation among hospitals in how quickly patients transition from emergency care to inpatient management while boarding in the ED.
Researchers found that 23% of ED boarders admitted to general medical care waited at least four hours for that transition. Some patients waited 12 hours, 24 hours, or longer.
This distinction matters because inpatient management can involve medication adjustments, ongoing diagnostic work, physical and occupational therapy assessments, and discharge planning. Delays can postpone those aspects of care even after the emergency phase of treatment has concluded.
ED Boarding Creates Another Critical Transition
Emergency department boarding occurs when a patient has been admitted to the hospital but remains in the ED because an inpatient bed is unavailable.
The new research examines a less-studied part of that problem: how long patients wait for an inpatient team to assume their care after the emergency phase of treatment has concluded.
“Emergency departments don’t control who arrives or when. Ambulances keep coming, and waiting rooms fill. Emergency care is organized around that reality: rapid assessment, stabilization of life- and limb-threatening illness and injury, and the first hours of treatment, with attention always available to new patients as they come in the door,” 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 member of the U-M Institute for Healthcare Policy and Innovation. “Inpatient care runs on a different clock, orchestrating clinical resources, pursuing diagnoses, adjusting medications, and discharge planning over days. Great care requires both, and delays in the transition from emergency care to inpatient management can be dangerous.”
The researchers distinguished the time to inpatient management from a patient’s total ED boarding time. They used four hours as a key threshold based on the Joint Commission standard identifying ED boarding for more than four hours before transfer to an inpatient bed as a critical patient safety issue.
Older and Higher-Acuity Patients Faced Longer Delays
The researchers pooled electronic health record data from 56 hospitals in 17 health systems participating in the Research in Emergency Systems and Quality Using EHRs Network, or RESQUE-NET.
They found that ED boarders at some hospitals were more likely to wait 12 or even 24 hours after the emergency phase of their care concluded before inpatient management began. Longer delays were more common at larger hospitals, hospitals serving more Medicaid patients, and hospitals that train physicians.
Patients older than 65, Medicare beneficiaries, and those with higher illness acuity were also more likely to experience prolonged delays before an admitting team assumed care.
Those delays may be particularly important for medically complex patients. Patients taking multiple medications can require medication management involving physicians and hospital pharmacists, while physical and occupational therapy assessments can influence decisions about whether a patient can safely return home or needs additional care after discharge.
“Hospital boarding in emergency departments is endemic across the U.S. right now. Health systems must have a plan for resourcing clinical teams to keep patients safe while they board,” Janke said. “This is especially important for older patients, those with multiple chronic conditions, and those taking high-risk medications.”
Hospitals Are Bringing Inpatient Management Into the ED
Some hospitals have responded to prolonged boarding by having inpatient teams assume responsibility for patients before they physically leave the emergency department.
That approach allows diagnosis, treatment, and discharge planning to continue while patients wait for beds. According to the researchers, however, these workflows have received relatively little research or regulatory attention.
At U-M Health’s University Hospital, hospitalists and general internal medicine and family medicine inpatient teams assume care for some admitted patients while they remain in the ED.
“Our hospitalist teams come down to the ED and take over care for patients who are still physically with us,” Janke said. “That’s not a small thing to ask of a team that already has a full service upstairs, and it’s the reason boarding here is safer than it would otherwise be.”
When inpatient teams cannot assume care promptly, hospitals need to ensure ED teams have the tools and clinical support to manage complex patients who may remain in the department well beyond the emergency phase of their care, Janke said.
Could ED Handoffs Become a Hospital Quality Measure?
The researchers suggest that measuring the time between the conclusion of emergency care and the start of inpatient management could offer another way to evaluate how hospitals are managing the inpatient capacity crisis.
The issue is growing more important as federal reporting requirements for emergency department care expand.
Beginning in January 2027, hospital electronic health record systems will start sending anonymous data about ED patient flow to the federal government’s reporting system. Reporting will become mandatory for all hospitals a year later.
The federal government’s Care Compare system will make boarding times and other information publicly available. By 2030, hospital performance on certain ED measures will also factor into Medicare payment rates.
The study included patients admitted from emergency departments to general medical inpatient units. It did not include patients admitted for surgery or intensive care or those treated and discharged from the ED. The 56 participating hospitals are not representative of all U.S. hospitals.
Still, the wide variation found among hospitals suggests that capacity may not be the only factor determining how quickly patients transition to inpatient management.
“Risk concentrates at these moments where one clinical team hands a patient to another. Emergency and inpatient teams work on different clocks, and they’re doing this under resource constraints. What our data show is that some hospitals consistently manage that transition in under four hours, and others take more than a day, which suggests it comes down to how a hospital organizes the work, not just how full it is,” said Janke. “Where this goes well, the work has been assigned, with emergency and inpatient teams given the resources to manage these patients wherever they happen to be.”
