Almost a quarter of emergency department patients accepted for a general hospital bed waited at least four hours before an inpatient team took over their care, according to a study of 56 emergency departments published in JAMA. Some waited more than 24 hours.
The measure matters because it is not the same as boarding time, and much of the coverage of this study has blurred the distinction between the two. Boarding is the total time an admitted patient physically remains in the emergency department while waiting for an upstairs bed. What the researchers examined is narrower and, for patient safety, arguably more consequential: the point at which responsibility for that patient formally shifts from the emergency team to an inpatient team that can manage medications, order therapy assessments, and begin discharge planning.
For families, the practical translation is this. A relative can be lying on a gurney in a hallway and still be receiving active inpatient-level care, or lying on the same gurney with no team yet assigned to manage the next phase. Those are very different situations, and from the hallway, they look identical.
Two Numbers, Two Denominators, and the Difference Between Them
Published figures on this study differ, and the difference is not an error. Michigan Medicine, whose faculty co-led the work, reports that 23 percent of boarding patients accepted for general hospital care waited at least four hours for the handoff. The Center for Infectious Disease Research and Policy reports that 84,936 patients, or 17.3 percent, experienced a delay of four hours or longer before receiving inpatient care.
Both are drawn from the same paper. The 17.3 percent uses all 492,135 patients admitted to general medical care as its denominator. The 23 percent covers only those who actually boarded. Since not every admitted patient boards, the same numerator produces a larger share.
The underlying dataset is substantial. Researchers examined electronic health record data from more than three million adult emergency department visits between June 2024 and May 2025 across 17 health systems. Among those admitted to general medical care, which covers internal medicine, family medicine, and geriatrics, 263,666 patients, or 53.6 percent, waited at least four hours for an inpatient bed. Beyond the four-hour handoff figure, 22,905 patients, or 4.7 percent, went 12 hours or longer without inpatient management, and 4,497, or 0.9 percent, went 24 hours or more.
The four-hour threshold was not chosen arbitrarily. It reflects the Joint Commission standard that identifies boarding for more than 4 hours before an inpatient transfer as a critical patient safety issue.
Older Patients on Medicare Waited Longest
The delays were not evenly distributed. Between 54 and 55 percent of patients experiencing delayed inpatient care were 65 or older. Patients covered by Medicare and those with higher illness severity were also more likely to face a prolonged wait before an admitting team assumed responsibility.
That pattern is why clinicians treat this as a safety question rather than a comfort question. Complex patients on multiple medications benefit from pharmacist review and physician medication management. Physical and occupational therapy assessments, which typically happen on inpatient units and often determine whether someone can safely go home, may be delayed during a long board.
Hospital characteristics mattered too. Larger hospitals, those serving more Medicaid patients, and teaching hospitals were more likely to have patients waiting 12 or 24 hours after emergency care concluded.
Alex Janke, an assistant professor of emergency medicine at the University of Michigan Medical School and a co-first author, put the stakes plainly, saying that "delays in the transition from emergency care to inpatient management can be dangerous." The other co-first author is Adrian Haimovich of Beth Israel Deaconess Medical Center, and the senior author is Ari Friedman of the University of Pennsylvania. The three founded the multi-site network behind the analysis, which pooled records from hospitals across the country.
Some Hospitals Manage the Handoff in Under Four Hours
The finding the authors emphasize is variation rather than uniform failure. Janke has said that some hospitals consistently complete the transition in under four hours while others take more than a day, which he argues suggests the difference comes down to how a hospital organizes the work rather than only how full it is.
That distinction has a practical consequence. Occupancy pressure is largely outside any single hospital's short-term control. Assigning an inpatient team to come down to the emergency department and assume care is a staffing and workflow decision. At the University of Michigan, hospitalist and general medicine teams do exactly that, though Janke noted it is a substantial ask of teams already carrying a full service upstairs.
Several limitations accompany the headline number. The 56 participating hospitals do not constitute a representative national sample, and the analysis covers only general medical admissions, excluding surgery, intensive care, and patients who were treated and discharged. The study also measures timing rather than outcomes, so it cannot say how many patients were harmed.
Federal Reporting Rules Arrive in January 2027
Public accountability on this is about to change. Beginning in January 2027, hospital electronic health record systems will start feeding anonymized emergency care timing data to federal reporting systems, with participation required for all hospitals a year later. Boarding times and related measures will be published through the government's Care Compare site, and by 2030, performance on certain emergency department measures will factor into Medicare payment rates. A separate bill in Congress would expand transparency around bed availability and emergency data tracking.
For households right now, the useful actions are modest. Nobody should avoid an emergency department because of boarding, and anyone with chest pain, stroke symptoms, difficulty breathing or a rapidly worsening condition should seek care immediately. Once a relative is admitted but still in the emergency department, it is reasonable to ask which team is responsible for their care. Bringing a current medication list matters more during a long board, and families of older adults can ask whether a therapy assessment is scheduled, since that evaluation often shapes discharge planning.
Boarding has been worsening for years and peaks in winter. In the coming months, as the respiratory season fills inpatient units, these delays typically lengthen. What remains unknown is whether the coming federal reporting will change hospital behavior and how many patients the handoff gap actually harms.
Key Questions Answered
What exactly did the study measure? The time between the conclusion of emergency care and the moment an inpatient team assumed management of an admitted patient. That is different from total boarding time, which is the time a patient physically spends in the emergency department.
Why do published figures say both 17 percent and 23 percent? The two percentages use different denominators. The lower figure covers all patients admitted to general medical care; the higher figure covers only those who actually boarded.
How large was the study? More than three million adult emergency department visits at 56 emergency departments across 17 health systems between June 2024 and May 2025.
Who waited longest? Patients 65 and older, those covered by Medicare, and those with more severe illness. Delays were also longer at larger hospitals, teaching hospitals, and those serving more Medicaid patients.
Does a long wait mean a patient is receiving no care? No. Emergency teams continue to care for boarding patients. The concern is that inpatient-specific work, such as medication management, therapy assessment, and discharge planning, may not begin until a handoff occurs.
Should anyone delay going to the emergency department because of this? No. Anyone with chest pain, stroke symptoms, breathing difficulty, or a rapidly worsening condition should seek emergency care without delay.
When will this data become public for individual hospitals? Federal reporting begins in January 2027 and becomes mandatory for all hospitals a year later, with results published through Care Compare.
