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CADTH Delivers New Evidence and Guidance on Emergency Department Overcrowding

November 28, 2023

CADTH has published new evidence and guidance on the issue of emergency department (ED) overcrowding. The guidance comes as EDs in Canada continue coping with persistently higher patient volumes, staffing shortages and burnout, and as they brace for a potential influx of visits during respiratory virus season.

CADTH’s new evidence reports and guidance from its Health Technology Expert Review Panel (HTERP) aim to support government and health system decision-making on alleviating the systems-wide issue of ED overcrowding in Canada. This work offers decision-makers a road map to identifying the factors contributing to ED overcrowding in their particular context and selecting appropriate interventions and strategies to help alleviate it.

ED overcrowding in Canada contributes to a deteriorating standard of care as health care providers and staff become overworked and burned out. When treatment needs in the ED exceed the available resources and expand the scope of practice required to address them, the health and lives of patients are put at risk.

Given the strain ED overcrowding puts on health systems in Canada and the need for objective advice, CADTH set out to obtain expert input and take an objective look at the scientific literature on the issue. To inform the guidance, CADTH engaged researchers, ED staff and practitioners, health care providers, patients, caregivers, and senior administrators who could bring diverse perspectives and deliver practical and actionable advice.

CADTH adapted an existing and widely accepted conceptual model to categorize the contributing factors and interventions that can alleviate ED overcrowding. The 4 categories are:

input (arrival to the ED)
throughout (flow through the ED)
output (leaving the ED), and
systems and contextual (outside of the ED).

What the Guidance Says

Noting that health system capacity is not aligned with and has not kept pace with the growing and changing needs of the country’s population, HTERP identifies a priority order of the most relevant factors contributing to ED overcrowding in Canada:

misalignment between acute care bed capacity within the hospital and population needs
misalignment between the number of long-term care beds within the community and population needs
misalignment between care available in the community and population needs, including care outside of regular business hours.

Based on the evidence and expert opinion, HTERP asserts that output factors, followed by input factors, are the main contributors to ED overcrowding in Canada. While all contributing factors play a role in ED overcrowding, to have the most significant impact on the issue, the panel advises health systems to prioritize implementing strategies that improve patient flow in and out of the ED over interventions that enhance efficiencies within the ED.

In its guidance, HTERP also emphasizes that ED overcrowding occurs because of interconnected and interdependent factors in the ED, in the broader hospital, within health authorities, and in the community. Because of this, solutions will need to involve all health system partners and not rest solely within the ED and its operations. With no one solution that will fix overcrowding, the guidance provides information and advice for decision-makers on how to:

determine what is contributing to ED overcrowding in context
select evidence-based interventions that align with the context
implement and evaluate selected interventions
uphold transparency and accountability with regards to data collection and reporting.

The guidance includes an accompanying Evidence Navigation Guide to help decision-makers identify and implement appropriate interventions. Within this guide, users have direct access to categorized and relevant studies and interventions identified by our experts and included in CADTH’s assessment of the effectiveness of different interventions (with a rating to indicate the quality of evidence).

The panel also makes strong recommendations around the consistent and comprehensive collection, analysis, use, and reporting of health system data to help align population needs with health system capacity. It calls for each province and territory to mandate consistent and comprehensive reporting by all hospitals to the National Ambulatory Care Reporting System (NACRS) database that the Canadian Institute for Health Information manages. At the time of publication, only 4 jurisdictions (Alberta, Ontario, Quebec, and Yukon) were mandated to submit data to NACRS.

While acknowledging the challenge of comprehensive data collection and analysis, HTERP notes that automation and integrated technology systems may help reduce the burden. Further, reporting most data elements to NACRS may be automated with minimal technology and included in the implementation of ED information systems.

Changing Health Care Needs in Canada Add Additional Strain to Emergency Services

Although ED overcrowding is not a new phenomenon, data shows it is worsening nationwide. Trends show that health care needs in Canada are changing and more complex, which in part can be attributed to a growing, aging, and more culturally diverse population. At the same time, administrative data shows that resources critical to support health services demand have not increased proportionally with population growth, resulting in overcrowded EDs:

EDs are seeing higher proportions of patients who need resuscitation, rapid medical intervention, or urgent care (as measured by their Canadian Triage and Acuity Scale level).
Median wait times for inpatient beds for admitted patients are increasing, while the proportion of patients discharged after an ED visit is decreasing.
From 2016 to 2023, Canada’s population estimates increased by 11.1% from nearly 36 million to just over 40 million people, with permanent and temporary immigration being the main contributors. At the same time, the number of people aged 65 and older rose 18.3% to 7 million.

Final CADTH Reports

CADTH’s series of reports and expert guidance on ED overcrowding includes:

Last Updated : November 28, 2023