Episode Details

Date: February 13, 2026 Reference: Lang et al. Factors associated with emergency department length of stay in Alberta: a study of patient-, visit-, and facility-level factors using administrative health data. CJEM. 2026 Jan 29. Guest Skeptic: Dr. Paul Parks is an emergency physician from Medicine Hat, Alberta. He has been the President of the Alberta Medical Association (AMA) Section of Emergency Medicine for many years, the AMA Board of Directors for 9 years, and the Previous President of the Alberta Medical Association.  Paul has won the Canadian Association of Emergency Physicians (CAEP) National Teacher of the Year Award and the CAEP Alan Drummond National Advocacy Award. Case: A 78-year-old man with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) arrives at the emergency department (ED) by ground emergency medical services (EMS) at 15:30 with dyspnea and hypoxia. He’s triaged Canadian Triage and Acuity Scale (CTAS) 2, needs non-invasive ventilation (NIV), diuresis, labs, chest x-ray, and likely admission. The department is packed; multiple admitted patients are boarded in hallway spaces because inpatient beds are unavailable, and nursing assignments are stretched. The patient is placed in the “EMS-PARK” area, which is an extension of the waiting room, and part of a mandatory EMS offload policy. Workup is done while the patient is still technically in the waiting room. The workup and disposition decision happen within a few hours, but transfer to an inpatient bed doesn’t occur until 2-3 days later. Background: ED length of stay (LOS) can be considered a vital sign of ED operations and the broader acute-care system. When LOS rises, it often signals that the ED is no longer functioning as a short-stay diagnostic and stabilization unit but is serving as a buffer for upstream demand and downstream capacity issues. The consequences are not just operational (hallway beds, delayed assessments, delayed analgesia, delayed imaging), but also human. We covered a study that showed for older patients, one overnight stay in the ED waiting for an inpatient bed was associated with a 4% absolute increase in mortality (SGEM#424). In addition, increasing LOS can lead to clinician burnout and moral injury. LOS is also tricky because ED crowding is rarely a single-point failure within the ED. Modern crowding frameworks (often summarized as input–throughput–output) remind us that while ED processes matter, some of the most powerful determinants are output constraints. This is especially true when there is access block and inpatient bed scarcity. In other words, you can run an efficient front-end, but if admitted patients cannot be moved to inpatient beds, the system backs up, and ED LOS climbs. As one concrete example of the output challenges many provinces struggle with, in Alberta, 1/3 of our acute hospital capacity, or about 30%, can be occupied by Alternate Level of Care patients. These alternative level of care (ALC) patients have had their acute care needs met, but they cannot be safely discharged from the hospital without specific continuing care resources – home care, assisted living, or long-term care. We’ve talked about ED crowding on an SGEM Xtra. It covered some of the Zombie Ideas that have been circulating around for decades. The classic one is to blame non-urgent patients for using the ED. They are not responsible for ED crowding. Diverting non-urgent patients away can be dangerous and won’t solve the underlying problem. CAEP published a position statement on emergency department overcrowding in 2013. CAEP argued for nationally standardized performance benchmarks. The statement also called for system-level solutions to improve flow while recognizing that ED optimization alone cannot solve crowding without hospital-wide and community-wide action. While CAEP’s advocacy has influenced awareness, policy discussion, and accountability framing, significant problems continue into 2026. Clinical Quest