ED Overcrowding: The Ontario Approach


  • Howard Ovens MD, FCFP(EM)

    1. From the Schwartz/Reisman Emergency Centre, Mount Sinai Hospital, and the Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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  • This article represents a component of the 2011 Academic Emergency Medicine Consensus Conference entitled “Interventions to Assure Quality in the Crowded Emergency Department (ED)” held in Boston, MA.

  • Funding for this conference was made possible (in part) by 1R13HS020139-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. This issue of Academic Emergency Medicine is funded by the Robert Wood Johnson Foundation.

  • Dr. Ovens acts as an advisor on health policy to the Government of Ontario. He has no other conflicts of interest or disclosures to report.

  • Supervising Editor: James Miner, MD.

Address for correspondence and reprints: Howard Ovens MD, FCFP(EM); e-mail: howard.ovens@utoronto.ca.


ACADEMIC EMERGENCY MEDICINE 2011; 18:1242–1245 © 2011 by the Society for Academic Emergency Medicine


Ontario is Canada’s most populous province, with approximately 12 million people and 130 emergency departments (EDs). Canada has a national single-payer universal health care system, but provinces are responsible for administration. After years of problems and failed attempts to address chronic ED overcrowding, in April 2008 Ontario embarked on an ambitious program to improve system performance through targeted investments (initially CAN$500 million over 3 years) and realigned incentives. Supporting the program were requirements for hospitals to submit timely data and targets for length of stay (LOS) and annual improvements; results are publicly reported. The program has been continued this year. While not all our provincial level targets have been met as yet, major improvements have been made, especially in access to care and LOS in the ED for patients eventually discharged home. The greatest improvements were made among the cohort of mainly urban, high-volume EDs that had the worst performance at baseline. This presentation will highlight some of the controversies and challenges and key lessons learned. Overall, the Ontario experience suggests ED overcrowding is a soluble problem, but requires a system-level intervention.