Why do the marginalized wait longer in our ED’s?
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 various responsibilities, such as multiple jobs, childcare issues, and proximity of residence to where primary care is available, the ED becomes the only option. Other issues, such as issues with trust due to earlier traumas related to negative experiences with healthcare, lack of stable housing, and transportation issues, also may cause delays in seeking help. This leads to worsening health and a higher need for 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 EDs, 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; the system that fails these populations needs to bear more of the responsibility.
A Systems Problem, Not Just a Queue Problem
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 a 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 pushes 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).
Systemic Racism & Trust
This systemic issue is gaining more traction. Evidence from Canadian Emergency Departments has become increasingly visible through various media lenses. Reports have highlighted that Indigenous and Black patients often end up waiting longer than others, and because of that, frustration, as well as the long history of mistrust they carry into the healthcare system, they are more likely to leave against medical advice (AMA), even when they have more complex health needs (Canadian Broadcasting Corporation, 2025). Broader analysis has shown that systemic racism plays a major role in how people experience care, shaping everything from how they are spoken to, how seriously their symptoms are taken and managed, to whether they feel safe enough to stay and complete treatment (CBC, 2020).
More conversations are happening nationally to help us face these truths. Educational sessions, public lectures, and learning series are starting to give language to what marginalized communities have been saying for years (Canadian School of PS, 2024; Healthcare Excellence Canada, 2024). These resources challenge us to reflect on our assumptions, name the biases we might not have noticed, and think differently about how to deliver care that is both safe and equitable.
Operational Levers & Community Solutions: We need both.
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 inpatient 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; 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).
Expanding the Team
When solving the problem, expanding resources often means looking at things differently and improving our pool of resources. Nurse practitioners (NP’s) and Physician Assistants (PA’s) can assist with seeing patients in rural areas or assisting physicians in high acuity or high volume ED’s. Based on the scope of practice and practice guidelines, they may be able to see and effectively treat low acuity patients. Studies found that visits managed by NP’s and PAs involved fewer diagnostic tests, shorter visits (physician in attendance metrics), reduced length of stay, left without being seen rates (LWBS), and at times more efficient care as well as improved patient satisfaction rates (Fowler et al, 2019; Kurtzman et al., 2023). Systemic reviews also show that use of NP’s and PAs in fast track or triaging areas improves metrics and reduces overcrowding in community hospitals with large populations (Lartey et al., 2024). Improving these initiatives would help provide culturally competent care while addressing social determinants and navigating complex health system barriers. By doing so, we can shift the focus from previously determined KPI’s (Key performance indicators) that look at LOS, wait times, door to physician attendance & LWBS indicators to ones that focus on cultural sensitivity, culturally competent care, and improved patient satisfaction. By improving the bottlenecks, we can gain a higher quality of care, improved patient safety, and overall equity of care (Nunez et al, 2018).
Wait times are a mirror in emergency departments. 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).
If you’d like to broaden your knowledge on this topic, I have included some links to videos below:
https://www.cbc.ca/player/play/video/9.6801609
References
Canadian Broadcasting Corporation. (2025, June 17). Indigenous, Black people face longer ER wait times, Winnipeg study finds. https://www.cbc.ca/player/play/video/9.6801609
Canada School of PS/Ecole de la FP du Canada. (2024, June, 21). 2024. A Discussion on the Canadian Healthcare Polycrisis with Dr. Alika Lafonataine. YouTube. https://www.youtube.com/watch?v=X1IinjIvjOA
CBS New: The National. (2020). Tackling systemic racism in Canada’s health-care system. https://www.youtube.com/watch?v=MVdKURnP6_Y
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
Fowler, L. H., Landry, J., & Nunn, M. F. (2019). Nurse practitioners improving emergency department quality and patient outcomes. Critical care Nursing Clinics, 31(2), 237-247.
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
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
Healthcare Excellence Canada. (2024, July 3). Approaches and Theories to Understanding Black Health and Systemic Anti-Black Racism (Part 2). YouTube. https://www.youtube.com/watch?v=ouX8-tVTowk
Lartey, S. A., Douma, M., Cummings, G., Pooler, C., & Montgomery, C. (2024). The impact of nurse practitioners role in emergency departments: A mixed studies review protocol. Canadian Journal of Emergency Nursing, 47(1), 6-13.
Kurtzman, E. T., Barnow, B. S., & Deoli, A. (2023). A comparison of practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistant. Nursing Outlook, 71(6). Article 102062
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
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
Nunez, A., Neriz, L., Mateo, R., Ramis, F., & Ramaprasad, A. (2018). Emergency departments key performance indicators: A unified framework and its practice. The International Journal of Health Planning and Management, 33(4), 915-933. https://doi.org/10.1002/hpm.2548
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
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/