Canada’s emergency departments (EDs) had no summer reprieve.
In July, Global News reported that Montreal EDs were operating above 200 per cent capacity. In British Columbia, CityNews reported eight overnight interruptions at Mission Memorial’s ED in two weeks because of physician shortages. By August, 100 Mile House had recorded its 36th ED closure of 2026, with patients directed to a hospital 95 kilometers away.
In addition, a CMAJ study of 410 emergency physicians found that 10 per cent had left the specialty, 48 per cent had reduced their clinical hours and 20 per cent had taken time off. The authors wrote that the prevailing theme was that “the healthcare system is broken.” The Canadian Association of Emergency Physicians calls worsening overcrowding a public health emergency. Nationally, one in 10 admitted patients waited more than 36 hours for an inpatient bed in 2024-25, a 45 per cent increase since 2018-19.
Canada enters autumn with EDs struggling to stay open, move admitted patients to more appropriate care and retain physicians before the predictable winter surge of influenza and other respiratory viruses. This makes addressing this crisis urgent.
In search of a solution, B.C. has announced $210 million for Burnaby Hospital, including 16 emergency treatment spaces. The project also expands the surgical department to 10 operating rooms and adds 17 perioperative bays. Without first removing the inpatient bottleneck, it may buy a larger traffic jam.
Many people occupying emergency stretchers no longer need emergency care. They have been admitted and are waiting for hospital beds (a practice called boarding). Their obstacle is not the ED size but the inability to move through the hospital. A larger ED is not greater inpatient capacity. When wards remain blocked, it is greater capacity to hold the queue. Peter Viccellio, senior author of our New York statewide study, put it bluntly: “One cannot alleviate constipation by building a bigger colon.”
Expansion can lengthen that queue. New bays require scarce nurses, while more operating rooms can increase scheduled admissions. When elective surgery clusters early in the week, it creates peaks in demand for beds and nursing just when emergencies need them. This is like adding lanes before a blocked tunnel: more vehicles reach the obstruction, but none pass faster.
In a peer-reviewed study, an academic medical centre expanded its ED to 53 beds from 33. Patients leaving without treatment did not improve significantly, while boarding rose from 160 to 180 hours per day. After adjustment for elective surgical admissions, hospital occupancy and other factors, increased boarding remained independently associated with the expansion. The authors called it an unintended consequence.
Years ago, when a hospital considered a $10-million ED expansion, I told its president: “How about you give me $5 million and you do nothing and both of us will benefit?” I explained that money spent on patient flow would create more capacity while construction at the wrong point would make matters worse.
The alternative is practical. Before approving expansion, provincial governments should require hospitals to publish boarding hours; nurse-staffed inpatient capacity; the distribution of scheduled admissions and discharges; and the expected effect of added operating room volume. Hospitals should first distribute elective admissions more evenly, align operating schedules with beds and nurses and protect capacity for emergencies.
The Ottawa Hospital redesigned its patient flow, which allowed it to significantly reduce waiting time for emergent and urgent surgeries, thereby saving 40 lives and $9 million annually. Cincinnati Children’s increased surgical activity and avoided a hospital expansion costing more than $100 million.
Some hospitals need new facilities or inpatient beds. But no government should fund a larger emergency department as a boarding remedy until avoidable peaks are removed and a physical bottleneck is proven. Hospitals should stop measuring commitment by square footage. Otherwise, it will spend scarce money and scarce nurses to build a larger queue – and call it progress.
