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).
References
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
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