By: Jashpreet Dhesy & Natalie Houseman
Emergency department (ED) wait times often get treated like a scorecard for the
healthcare system. If the numbers are high, we assume we are failing, if they fall,
we celebrate meeting performance measures. But anyone who has spent any time
on an ED knows that the story is more complicated. Waits aren’t just about how
many people show up or how quickly tests get done. They are shaped by the
realities of people’s lives; whether they have the ability to see a family doctor,
whether their housing is stable, whether they can afford time off work, or how
much stress they are dealing with on a daily basis. These social determinants of
health (SDoH) are not widely studied but they play a key role in the use of ED’s all
over Canada (Haggerty et al.,2007; Kushel et al.,2006; McDonald et al., 2020).
Classic explanations for long waits still matter. High acuity patients, especially
those who need admission tend to wait the longest because their care requires
more resources and often stalls due to capacity challenges (Dinh et al., 2016). Low
acuity patients usually don’t add time per person when looking at “wait times” but
their sheer volumes can stall flow and increase workload for staff (Dinh et al., 2016;
McDonald et al., 2020). Despite similarities with respect to volumes and acuity,
emergency departments show varying wait times. This gap points to an upstream
problem from the ED, more complex issues related to who uses the ED and how
sick they are when they do (Horwitz et al., 2010).
For many people the ED is the only avenue they can take because they have no
other open door to them. For many who are juggling many responsibilities such as
multiple jobs, childcare issues, proximity of residence to where primary care is
available, the ED becomes the only option. Other issues such as issues with trust
due to previous traumas related to negative experiences with healthcare, lack of
stable housing, transportation issues also may cause delays in seeking help. This
leads to worsening health and higher need to needing emergency services
(McDonald et al., 2020). Access to primary care matters, especially timely, after-
hours, culturally safe care. Studies suggest that low income and low education are
often stronger predictors of ED use than physician availability alone, which tells us
that material hardship drives health needs in ways access alone cannot fix (Harris
et al., 2011; McDonald et al., 2020).
The social gradient in ED use is striking. In Ontario, people living in the most
socioeconomically deprived neighborhoods make nearly twice as many ED visits as
those in the least deprived neighborhoods, and that pattern holds regardless of
urgency (Tozer et al., 2014). More than one quarter of ED visits come from the most
deprived populations, and about half of those are low acuity. Young adults aged
20-30 from those communities are noted to have increased ED usage for low acuity
issues. In Ontario’s busiest ED’s this translates to dozens of low acuity encounters
each day from the most marginalized groups, which may be small on their own, but
when combined become very significant (Vanstone et al., 2014). Often the
marginalized are seen as the problem, however the system that fails these
populations needs to bear more of the responsibility.
Canada has had long standing wait time challenges that exist not solely because
hospitals are busy. Differing responsibilities between federal and provincial
governments create uneven policies and performance across provinces and those
variations often land hardest on people who already face barriers to care
(Hajizadeh et al., 2025). Long waits are not just inconvenient; they are harmful and
pose great risk. They are linked to worse health outcomes, higher costs of
treatment, longer periods living with a disability and lost income for patients and
families (Hajizadeh et al., 2025).
If we map the pathways from marginalization to ED strain, the pattern is sadly
familiar. Delayed care leads to sicker presentations, unstable housing breaks
continuity, limited primary care access pushed people to utilize emergency
pathways and for those with substance use disorders, social and structural barriers
compound health risks and increase ED reliance (Chu et al., 2024). Over time, we
see more emergency department visits, heavier demand, and longer waits,
especially in more disadvantaged communities (Haggerty et al., 2007).
Now that we know that there is a problem, how do we solve it? First, we must look
at the operational issues- flow, staffing at peak utilization times and decreasing
capacity challenges for in-patient beds. The next part, which may play a bigger role,
is the social and community aspect. Expanding accessibility to primary care in high
deprivation neighbourhoods that includes after hour care that is youth friendly,,
has a team base model, exploring AI/virtual options for care, co-locating mental
health and substance use services with primary and urgent care, and investing in
housing stability through supportive housing, eviction prevention and medical
respite (chu et al., 2024; Fitzpatrick et al., 2015). Measuring what matters such as
wait times with equity indicators can help us see the gaps and make efforts to close
them (McDonald et al., 2020). These steps take resources, therefore they should be
guided by careful evidence-based assessments and supported by coordinated
provincial/federal strategies that sustain progress over time (Baicker & Chandra,
2017; Hajizadeh et al., 2025).
In the Ed, wait times are a mirror. They reflect the immediate pressures inside a
department, but they also reflect the stressors outside it- poverty, housing
insecurity, fragmented access, and the quiet but cumulative effects of
marginalization. If we want shorter wait times, safer care, and better outcomes, we
cannot make larger waiting rooms or departments. We have to build stronger,
more equitable communities and design health services that meet people where
they are (McDonald et al., 2020; Tozer et al, 2014).
Themes affecting care and access to care are not overly unique from one Province
to the next, what is more unique is how these overall themes show up in the local
context. We have so far identified the impacts of poverty, marginalization, and
transportation (to name of few) on health care utilization but we have not yet
explicitly addressed the issues of ideological racism, and it’s impacts on care
particularly for our Indigenous populations across Canada.
Healthcare Excellence Canada (2026), highlights health disparities well in their video
Lew’s Story- Two Care Journeys, where Lew identifies disparities in care between his
Indigenous mother, and white wife. It’s a powerful example of how ideological
racism continues to show up in our care systems. “Ideological racism refers to a
belief system that asserts the genetic or cultural inferiority of certain racial groups,
often used to justify social hierarchies and inequalities” (Musolf, 2024). Canadian
history is rooted in colonization of Indigenous peoples and implementation of
systems of oppression including the residential school systems. National and
Provincial governance structures, and systems of education and health are built on
western ideologies. These systems, Canadian history, and ongoing discrimination
within our health systems represent ideological racism and racist structures for
Indigenous populations.
The social determinants of health don’t identify racism as a key determinant.
Phelan and Link (2015), go further to ask if racism is a fundamental cause of
inequities in health. Are we so steeped in ideology we fail to see indigenous peoples
as equals when all social determinants of health are equal? Phelan and Link (2015),
argue despite progression in disease specific health outcomes, people of color
continue to experience more adverse outcomes and conclude that persistent racial
inequities give cause to expect racism may be a fundamental cause of health
inequities.
A clinical outcome of ideological racism can be seen in assessment of indigenous
populations. Vang et al., (2024), state Indigenous people report higher levels of pain
compared to others, but can we as providers confidently say we provide adequate
triage and care to address pain?
Alberta sits within treaty lands for treaties six, seven and eight, the Metis Nations of
Alberta and Inuit populations. Over the years, health care organizations have made
efforts to address the impacts of colonization on Indigenous health and Covenant
Health has prioritized this as a faith-based health care organization with much to
learn about the Indigenous health experience. Currently a project team is engaged
in an improvement collaborative to co-develop an education experience for
employees to learn about the impacts of colonization on our Indigenous peoples
and to identify an approach to improve cultural appropriate care.
Providing culturally appropriate care is difficult to measure in a shorter time span.
Particularly as the impacts of culturally safe care in theory should improve clinical
outcomes, build trust, and impact the severity of chronic disease and life
expectancy. There are some data measures though that can be used to assist in
evaluating the effectiveness of an intervention on improving culturally safe care.
Covenant Health will be looking at measures such as the Canadian Triage and
Acuity Scale (2012) which is used to determine patient acuity when people present
to Emergency Departments. McLane et al (2022), show that in Alberta, First Nations
receive lower acuity scoring amongst some common but serious emergency
department presentations. The lower the score, the less acute you are determined
to be, resulting in risk for longer wait times and worse outcomes. Racism and
unconscious bias affect the determination of acuity, with many Indigenous people
feeling ignored in our emergency departments (Covenant Health, 2025).
References
Canadian Association of Emergency Physicians. (2013). The Canadian Triage and
Acuity Scale: Combined adult/paediatric educational program participant’s manual
(Version 2.5b). https://ctas-phctas.ca/wp-
content/uploads/2018/05/participant_manual_v2.5b_november_2013_0.pdf
Covenant Health. (2025). Indigenous Engagement Sessions [Unpublished raw data].
Chu, C., Khan, B., Thiruchelvam, D., Brual, J., Abejirinde, I. O., Kthupi, A., & Tadrous,
M. (2024). Impact of marginalization on characteristics and healthcare utilization
among people with substance use disorder in Ontario, Canada, before and during
the COVID-19 pandemic: A cross-sectional study. PloS one, 19(10),
e0312270. https://doi.org/10.1371/journal.pone.0312270
Dinh, T. T., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The
effectiveness of the teach-back method on adherence and self-management in
health education for people with chronic disease: a systemic review. JBI database of
systemic reviews and implementation reports, 14(1), 210-247.
https://doi.org/10.11124/jbisrir-2016-2296
Downing, A., Wilson, R. C., & Cooke, M. W. (2004). Which patients spend more than 4
hours in the Accident and Emergency department? Journal of public health (Oxford,
England), 26(2), 172–176. https://doi.org/10.1093/pubmed/fdh141
Fitzpatrick, T., Rosella, L. C., Calzavara, A., Petch, J., Pinto, A. D., Manson, H., Goel, V.,
& Wodchis, W. P. (2015). Looking Beyond Income and Education: Socioeconomic
Status Gradients Among Future High-Cost Users of Health Care. American Journal of
Health Policy and Management, 14, 8986. https://doi.org/10.34172/ijhpm.8986
Haggerty, J., Burge, F., Lévesque, J. F., Gass, D., Pineault, R., Beaulieu, M. D., &
Santor, D. (2007). Operational definitions of attributes of primary health care:
consensus among Canadian experts. Annals of family medicine, 5(4), 336–344.
https://doi.org/10.1370/afm.682
Hajizadeh, M., & Jalili, F. (2025). Addressing Healthcare Waiting Time Challenges in
Canada: Insights From Emerging Initiatives. International Journal of Health Policy and
Management, 14, 8986. https://doi.org/10.34172/ijhpm.8986
Harris, J. M., Patel, B., & Bowen, S. (2011). Primary care access and its relationship
with emergency department utilisation: an observational, cross-sectional, ecological
study. British Journal of General Practice, 61(593).
https://doi.org.10.3399/bjgp11X613124
Healthcare Excellence Canada. (2026). Lew’s Story- Two Care Journeys.
https://www.healthcareexcellence.ca/en/welcome-to-foundations-of-healthcare-
excellence/
Horwitz, L. I., Green, J., & Bradley, E. H., (2010). US emergency department
performance on wait time and length of visit. Annals of emergency medicine, 55(2),
133-141. https://doi.org/10.1016/j.annemergmed.2009.07.023
Kushel, M. B., Gupta, R., Gee, L., & Haas, J. S. (2006). Housing instability and food
insecurity as barriers to health among low-income Americans. Journal of general
internal medicine, 21(10), 71-77. https://doi.org/10.111/j.1525-1497.2005.00278.x
McLane, P., Barnabe, C., Mackey, L., Bill, L., Rittenbach, K., Holroyd, B. R., Bird, A.,
Healy, B., Janvier, K., Louis, E., & Rosychuk, R. J. (2022). First Nations status and
emergency department triage scores in Alberta: A retrospective cohort study. CMAJ,
194(2), E37–E45. https://doi.org/10.1503/cmaj.210779
McDonald, E. J., Quick, M., & Oremus, M. (2020). Examining the Association between
Community-Level Marginalization and Emergency Room Wait Time in Ontario,
Canada. Healthcare policy = Politiques de sante, 15(4),
64–76. https://doi.org/10.12927/hcpol.2020.26223
Musolf, G. R. (2024). Ideological racism. EBSCO Research Starters: Social Sciences and
Humanities. https://www.ebsco.com/research-starters/social-sciences-and-
humanities/ideological-racism
Phelan, J. C., & Link, B. G. (2015). Is racism a fundamental cause of inequalities in
health? Annual Review of Sociology, 41, 311–330. https://doi.org/10.1146/annurev-
soc-073014-112305
Tozer, A. P., Belanger, P., Moore, K., & Caudle, J. (2014). Socioeconomic status of
emergency department users in Ontario, 2003 to 2009, CJEM, 16(3), 220-
225. https://doi.org/10.2310/8000.2013.131048
Vang, Z. M., Chau, S., Kobayashi, K. M., Owen, M. J., McKenzie-Sampson, S.,
Mayrand-Thibert, J., & Brass, G. M. (2024). Pain and functional limitations among
midlife and older Canadians: The role of discrimination, race, and sense of
belonging. Journals of Gerontology: Psychological Sciences, 79(4), 1–12.
https://doi.org/10.1093/geronb/gbab137
Vanstone, N. A., Belanger, P., Moore, K., & Caudle, J. M. (2014). Socioeconomic
composition of low-acuity emergency department users in Ontario, Canadian family
physician Medecin de famille canadien, 60(4), 335-
362. https://pubmed.ncbi.nlm.nih.gov/247333328/M. (2014). Socioeconomic composition
of low-acuity emergency department users in Ontario, Canadian family
physician Medecin de famille canadien, 60(4), 335-
362. https://pubmed.ncbi.nlm.nih.gov/247333328/