ED patients can wait hours for inpatient team takeover

Clinical takeaway: Patients 65 and older made up more than half of every delay tier, and high-acuity patients were also overrepresented. The interval falls hardest on those least able to tolerate unwritten orders or a missed reassessment. 

The decision to admit and the start of inpatient management are two separate events. Most of the time they occur in rapid succession. But when they don't, a patient with an active order set and no responsible service can sit in a hallway bed while deterioration goes unattributed and the plan of care stalls. 

Boarding has become more common and more prolonged across US hospitals over the past several years, and it now sits on the regulatory agenda, including a proposed national quality measure focused on emergency care access. But those measures count time to a staffed bed, not time to an inpatient clinician. A retrospective cross-sectional analysis of electronic health record data examined that second interval across almost a half-million adults admitted to general medical services from 56 hospital-based emergency departments. 

Overall, 17.3% of admitted patients passed four hours or more after the admission decision with no inpatient team assuming care. Further out, 4.7% passed 12 hours and 0.9% passed 24 hours. Boarding itself was far more common: 53.6% of admitted patients waited at least four hours for a bed. A meaningful share of that time ran without the receiving service involved. 

At the median hospital, 0.4% of admitted patients passed 12 hours without inpatient management and 0.1% passed 24 hours. But at three of 56 hospitals, more than one in 20 crossed the 24-hour threshold, and those three sites accounted for 61% of every such patient in the study. 

Site characteristics tracked with delay more strongly than patient characteristics. Academic hospitals had roughly 3.6 times the rate of four-hour delays compared with community sites, with similar gradients for larger hospitals (above 718 beds) and those with the largest share of Medicaid patients. Within any given hospital, the patient-level differences were narrow, on the order of 3% to 14% higher risk. 

The 17 participating systems belong to a voluntary research network of hospital-based EDs and contributed data from June 2024 through May 2025. Each system set its own marker for when inpatient management began, usually an admission order set or a covering clinician assuming care. That variability is the study's main constraint, since the interval is not measured identically across sites. The analysis captured no patient outcomes, so it establishes the gap without measuring what it costs. 

The authors call for patient safety measures that hold hospitals accountable for timely relocation to inpatient care rather than bed availability alone, and for resourcing the teams expected to absorb that work. 

"This analysis detected meaningful hospital-level variation in the timeliness of transition from ED to inpatient management, a latent safety risk not captured by current quality measures," the authors conclude. "Despite the critical role of inpatient teams in addressing boarding, initiation of inpatient management often lagged far beyond the admission decision." 

Source: Janke AT, et al. (2026 Aug 17) JAMA. Time to Inpatient Management for Boarding Emergency Department Patients