Admitted patients boarding in the emergency department often wait hours, and sometimes more than a day, for an inpatient team to take over their care, well after the decision to admit them, according to a study published Aug. 17 in JAMA.
The retrospective analysis points to a safety gap current boarding metrics do not capture: a patient can be waiting for a bed with no inpatient physician managing the case.
Seven things to know:
1. The study separates two problems often lumped together. Boarding measures how long a patient waits for a staffed, inpatient bed. This study measured something different — the interval from the admission decision to when an inpatient team actually assumed care. The two don’t always move together, and a patient can board for hours with no admitting physician in charge.
2. Researchers reviewed EHR data from 56 EDs across 17 health systems from June 2024 through May 2025. Of nearly 492,000 patients admitted to general medical services, 53.6% boarded at least four hours awaiting an inpatient bed.
3. Handoff delays were common and sometimes ran a full day. More than 17% of admitted patients, or about 85,000, went at least four hours with no inpatient team managing their care. Nearly 23,000 waited 12 hours or more, and about 4,500 waited 24 hours or longer.
4. The problem seems to be concentrated in a handful of hospitals. At just three hospitals, more than 1 in 20 admitted patients went 24 hours or more without inpatient management — and those three sites accounted for 61% of all patients in the study who waited that long.
Academic medical centers, larger hospitals and those serving more Medicaid patients saw prolonged delays far more often; admissions at academic hospitals were more than three times as likely to hit the four-hour mark and more than seven times as likely to reach 12 hours, versus community hospitals.
“Risk concentrates at these moments where one clinical team hands a patient to another,” Alex Janke, MD, the study’s co-first author and an emergency medicine professor at the University of Michigan in Ann Arbor, said in a news release. It “suggests it comes down to how a hospital organizes the work, not just how full it is.”
5. Older and sicker patients waited longest. Patients 65 and older made up roughly 55% of those who went four hours or more without inpatient care. Medicare patients and the most acutely ill also faced prolonged delays more often.
6. A new CMS metric will soon put boarding on the record. The Emergency Care Access and Timeliness measure, finalized in the 2026 outpatient payment rule, includes tracking extended boarding. CMS placed a four-hour threshold for the time from the decision to admit to ED departure. Reporting is voluntary in 2027 and becomes mandatory in 2028, tied to 2030 payment.
The study’s authors called for measures that hold hospitals accountable for timely inpatient handoffs and that resource the teams responsible.
“Health systems must have a plan for resourcing clinical teams to keep patients safe while they board,” Dr. Janke said.
7. The study builds on a worsening national trend. Boarding has shifted from an episodic winter problem to a year-round operational bottleneck, Becker’s reported in December. A Health Affairs analysis of 46 million ED visits found more than 25% of patients waited at least four hours for an inpatient bed in recent years — rising to 35% during peak winter months — and nearly 5% waited 24 hours or more at the 2024 peak.
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