Highlights
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• RAIN Clinic provides reliable, rapid and effective neurosurgical assessment for patients to reduce ED burden.
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• RAIN Clinic model provides safe disposition for patients with low number of patients requiring return to ED for assessment.
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• Patients seen in RAIN Clinic describe finding the clinic visit valuable.
Introduction
The Canadian healthcare system is currently grappling with several crises, including unprecedented wait times for specialized surgical consultations and critical overcrowding within emergency departments (EDs). These delays represent a significant barrier to care that impacts patient outcomes and quality of life. In the field of neurosurgery, where timely intervention can be the difference between recovery and permanent deficit, the current landscape of access is particularly challenging. With limited resources and an aging and growing population, we need to find more effective and efficient methods to assess patients and provide neurosurgical care. Furthermore, it has been shown that a large portion of patients (45%) where neurosurgical consultation was requested by the ED were sent for outpatient clinic follow up rather than seen in the ED.Reference Tunç, Uzlu and Şahin1 This can lead to delays and prolonged unnecessary ED stays.
Recent national data underscore the severity of the referral bottleneck. According to the Fraser Institute’s 2025 report, neurosurgery currently faces some of the longest wait times in the country. The median wait time from a primary care referral to a neurosurgical consultation has reached 39.7 weeks, contributing to a total median wait of 49.9 weeks from referral to treatment.Reference Moir and Esmail2 These figures represent a nearly 300% increase over the last three decades, leaving patients waiting almost one year for assessment and surgical care. Furthermore, nearly 36% of Canadians seeking a specialist consultation report waiting three months or more just for the initial assessment.3 The caveat for this data is that the Fraser study does not look at referrals from ED to outpatient settings, especially for more urgent cases, and, on review of the existing literature, we could not find any data to indicate the current wait times for this specific population.
As traditional outpatient channels fail to provide timely access, the ED has increasingly become a default entry point for patients with subacute neurological issues. This shift further strains an already overburdened system:
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• ED Volumes: In the 2024–2025 fiscal year, over 16.1 million unscheduled ED visits were seen in Canada, an increase from the previous year.
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• Prolonged Boarding (Long ED stays awaiting inpatient beds or testing): For patients requiring admission, 90% spent up to 48.5 hours in the ED before a bed became available.
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• Left Without Being Seen: High wait times have led to approximately 500,000 Canadians leaving EDs without being assessed by a physician in 2024, a figure that has climbed steadily since 2019.4
Background
The challenges of surgical access and ED overcrowding are not unique to the Canadian landscape. In the United Kingdom, the National Health Service has pioneered the “HOT” clinic model for general surgery – an acute, consultant-led ambulatory service designed to provide rapid assessment for patients who require urgent specialist review but do not necessarily mandate immediate hospital admission. These clinics serve as a “pressure valve” for the ED, allowing for high-acuity diagnostic workups and management plans to be executed in an outpatient setting.
The efficacy of this model has been demonstrated across various surgical disciplines. Abbas Dhahri et al. in the UK evaluated the Hybrid Surgical Hot Clinic model,Reference Dhahri, Ahmad and Shaikh5 which combined telephonic and face-to-face consultations. Their service evaluation revealed that nearly 58% of their patients were referred directly from Accident & Emergency, with only 6.7% ultimately requiring hospital admission. This highlights the model’s significant capacity to divert patients from inpatient beds and streamline acute surgical flows, even during the resource-strained conditions of the COVID-19 pandemic.
Furthermore, the “HOT” clinic model has shown profound clinical and operational benefits in specialized surgical fields. Khan et al. investigated the impact of a dedicated “hot clinic” for critical limb ischemia, a high-stakes vascular condition requiring timely intervention to prevent permanent deficit, much like neurosurgical emergencies. Their results were striking:Reference Khan, Hughes and Ting6
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• Reduced Length of Stay: The median hospital stay for the “hot clinic” cohort was only 3 days compared to 17 days for those admitted through traditional emergency channels (p < 0.001).
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• Improved Clinical Outcomes: Patients seen in the “hot clinic” were six times more likely to experience freedom from reintervention and 2.5 times less likely to undergo major amputation.
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• System Efficiency: The clinic saved a total of 441 bed days over the study period, directly addressing the “access block” that currently plagues Canadian tertiary centers.
In the United States, similar models have been successfully implemented to address the bottleneck between the ED and specialist care. The UCLA Fast Neuro modelReference Roy, Keselman and Nuwer7 was established to provide rapid outpatient neurology access within one week for patients who would otherwise require an ED consult or inpatient admission for subacute issues.
Key outcomes from the UCLA model include:
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• Reduction in Wait Times: Average wait times for an appointment dropped by 82.5% (from 40 days to 7 days).
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• ED Decanting: The volume of non-emergent neurologic consults in the ED was reduced by 60%, allowing ED staff to focus on life-threatening emergencies.
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• Clinician Satisfaction: 92% of attending physicians endorsed the model, noting that it did not detract from traditional clinic operations while improving patient throughput.
The success of these UK and US models provides a robust proof of concept for the Rapid Access in Neurosurgery (RAIN) clinic. By adopting an ambulatory, high-velocity triage system, the RAIN clinic applies these established principles to the neurosurgical context, aiming to replicate the reductions in bed occupancy and improvements in patient outcomes seen internationally. Similarly, in the Canadian landscape, an urgent care Neurology clinic in Calgary showed decreased ED neurological assessment by 35.7% and a decrease in admissions for investigation by 50%.Reference Wile, Warner, Murphy, Lafontaine, Hanson and Furtado8
The RAIN Clinic: a paradigm shift in triage
To address these systemic inefficiencies, the RAIN Clinic was established across the three major academic adult sites in Toronto, the initial one being at Toronto Western Hospital, University Health Network. The RAIN model represents a focused intervention designed to bridge the gap between community-based referrals and acute hospital care. Patients are referred from Toronto hospital ED’s as well as more distant and rural ED’s up to 300 km away.
By providing a dedicated stream for rapid neurosurgical evaluation within 1 to 2 weeks, the clinic aims to:
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1. Divert Stable Patients from the ED: Providing ED physicians with a high-speed alternative to prolonged ED waits for non-emergent but urgent cases (e.g., stable cranial lesions, progressive radiculopathy). Patients seen in ED can be safely discharged home with rapid referral to the clinic.
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2. Optimize Resource Allocation: Reducing “access block” by ensuring that ED resources are reserved for true neurosurgical emergencies while subacute patients are managed in an efficient outpatient setting.
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3. Expedite Definitive Care: Streamlining the transition from initial assessment to surgical intervention or specialized multidisciplinary management.
Through this centralized and expedited triage system, the RAIN Clinic seeks to alleviate the burden on Toronto’s emergency services while ensuring that neurosurgical patients receive expert care within a clinically appropriate timeframe. The current model is run by two neurosurgeons who run clinic 2–3 days per week depending on scheduling and referral volumes. There is a dedicated nurse for the clinic who assists with intake, patient coordination and data collection, as well as a dedicated administrative assistant for the clinic. All referrals are triaged and reviewed by one of the neurosurgeons. We have highlighted the current eligibility criteria in Table 1 as well as the current pathway for referrals in. Figure 1
Current eligibility criteria for the Rapid Access in Neurosurgery clinic at the University Health Network
Table 1. Long description
The table titled ‘Patient eligibility for Rapid Access in Neurosurgery Clinic’ has two columns and eight rows, including the header row. The columns are labeled ‘Condition’ and ‘Pre-imaging required from (from emergency departments)?’. The table lists various conditions and specifies whether pre-imaging is required, along with the type of imaging needed. Row 1: Any intracranial blood (subdural hematoma), YES, CT head. Row 2: Tumors (non-acute), YES, CT head. Row 3: Trauma (concussion, sub-arachnoid hemorrhage), YES, CT head. Row 4: VP shunt malfunction, YES, CT head, Shunt series (x-ray skull, c-spine, chest and abdominal). Row 5: Non-fragility fractures without neurology, YES, CT spine. Row 6: Myelopathy/radiculopathy/neurogenic claudication (arm/leg dominant symptoms) with stable or functional neurologic deficit; intractable pain failing medical/interventional pain management, YES, MRI or CT scan.
VP = Ventriculo-Peritoneal
Current pathway for referrals to the Rapid Access in Neurosurgery clinic defining the process by which patients are referred and the triage pathway for patients.
Methods
To evaluate the efficacy and impact of the RAIN Clinic model at the initial site, University Health Network, data are prospectively collected and maintained in a secure clinical database. The clinic started in April of 2024 and data have been collected since inception. The data used for this analysis are from April 1, 2024, to Dec 31, 2025, covering a 21-month period. The following metrics are analyzed:
1. Clinical and Temporal Metrics
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• Referral-to-Consultation Interval: The primary outcome measure, defined as the number of calendar days between the receipt of the referral and the date the patient is seen in the clinic.
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• Diagnosis: Classification of the neurosurgical condition/pathology to identify the highest-volume referral streams.
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• Disposition: Tracking the clinical outcome of each consultation to determine the subsequent care pathway. Disposition categories include:
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○ Surgical Intervention: Patient added to the elective surgical waitlist.
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○ Sent to ED for admission and urgent surgery
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○ Further Investigation and follow up: Requirement for advanced or repeat imaging (e.g., MRI, PET, functional MRI)
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○ Neurosurgical Subspecialist consultation (e.g., vascular neurosurgeon, spine surgeon, neurosurgical oncologist).
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○ Discharge to Primary Care: Reassurance and return to the primary healthcare provider for routine monitoring and conservative management.
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2. Patient Experience
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• Patient Feedback: Customized patient experience measures are used to assess the quality of care. Patients are asked to rate their satisfaction regarding the wait time for their appointment, the clarity of the consultation and their overall experience with the RAIN model compared to previous specialist encounters.
Data analysis and utilization
The collection of disposition data is critical for validating the Rapid Access model. By analyzing the ratio of patients moving to surgery versus those managed conservatively, we can quantify how many patients were successfully diverted from unnecessary ED visits or urgent inpatient admissions. Descriptive statistics are used to summarize patient demographics and clinical diagnoses. Wait times are expressed as medians with interquartile ranges (IQR) to account for non-normal distribution.
Results
A total of 2979 patients (142/month) were referred to and assessed through the RAIN Clinic at University Health Network during the study period. The following data outline the clinical demographics, wait times and subsequent care pathways established by the rapid access model. We also analyzed the patient satisfaction surveys and present the results below.
Patient demographics and diagnostic distribution
The patient cohort represented a diverse range of neurosurgical pathologies presented below. With the majority of patients presenting with a radiculopathy or myelopathy (41.32%), brain tumors were the second most common diagnosis (13.39%) followed by musculoskeletal back pain (10.34%).
Referral-to-consultation wait times
The primary objective of the RAIN Clinic to provide neurosurgical assessment within 14 days was consistently met. There was some variation owing to patient preference, waiting for imaging, or, in some cases, difficulty in reaching the patients.
The median interval from the receipt of the referral to the initial consultation was 9 days (6–15 days IQR) with a mean wait time of 13.5 days (±20.99 days). This represents a significant reduction compared to the national median wait time of 39.7 weeks for neurosurgical consultation reported in current Canadian health indices.Reference Tunç, Uzlu and Şahin1
Clinical disposition and care pathways
Following the initial assessment, clinical disposition was tracked to determine the necessity of surgical vs. non-surgical management. The breakdown of patient outcomes was as follows:
Of the patients requiring subspeciality assessment, the wait time for an appointment was 36.65 days [7–55.5 days]. Notably, 79.96% of the total cohort were managed conservatively (with follow up imaging or conservative management/follow up with the primary health care provider), successfully avoiding the need for an ED visit for symptom management. Only 0.54% of patients needed to be sent down to the ED for reassessment and admission indicating that these patients can safely and effectively be managed as an outpatient.
We surveyed all patients coming into clinic and had 268 responses. Wait times were minimal: 67.9% reported their appointment started on time or early, and 20.9% were seen within 15 minutes. Patient experience ratings were highly favorable. Most respondents reported that staff completely or mostly explained the purpose of the visit (87.0%), felt comfortable asking questions (89.2%) and felt their questions were answered clearly (89.6%). The majority (79.9%) did not feel rushed. Overall, 79.5% rated the visit as very or extremely valuable. In addition, 51.2% of patients indicated they would go back to ED without the availability of the RAIN Clinic. These findings demonstrate high patient satisfaction, timely access to care and potential ED diversion associated with the RAIN Clinic model.
Discussion
The implementation of the RAIN Clinic across Toronto neurosurgical sites represents a targeted structural response to the pervasive issue of healthcare access block in Canada. By significantly compressing the timeline between referral and specialist assessment, the RAIN model addresses two of the most critical vulnerabilities in the current system: the prolonged specialist waitlist and the over-reliance on EDs for subacute surgical triage.
Addressing the “wait for the wait”
The most striking finding of this study is the referral-to-consultation interval to a range of 6–15 days. This stands in stark contrast to the national median of nearly 40 weeks for neurosurgical consultation from primary care providers reported by the Fraser Institute,Reference Tunç, Uzlu and Şahin1 One limitation, however, is the lack of available data regarding urgent referrals from the EDs. One perceived benefit would be the centralized referral system that would allow ED providers to refer without concern about trying to identify the surgeon on call or without having to call the surgeon on call to ensure the referrals do not get missed.
In neurosurgery, the wait is not merely an administrative delay but creates significant psychological distress for patients and a risk factor for clinical deterioration. For conditions such as progressive radiculopathy or stable but symptomatic cranial tumors, the 14-day window provided by the RAIN Clinic ensures that patients are triaged within a clinically relevant timeframe, preventing the progression of neurological deficits that might occur during a longer wait.
The ED diversion effect
Historically, the ED has served as the only reliable fast track for patients whose symptoms were too urgent for a standard 10-month waitlist but not yet emergent. This study’s data on clinical disposition highlight the clinic’s role as a vital relief for hospital emergency services.
A significant portion of our cohort was managed via conservative pathways or discharged back to primary care with a definitive management plan. Without the RAIN Clinic, many of these patients (51.2%) would have likely sought care in an ED to gain access to imaging or specialist reassurance. Though one limitation is that we do not have a historical control group that could be used as a baseline to compare this to. We do anticipate, though, that by providing an expedited outpatient alternative, the RAIN model preserves ED resources like beds, nursing staff and imaging throughput for true emergencies like acute trauma or stroke, thereby indirectly improving ED boarding times and hopefully reducing the number of patients who leave without being seen4.
Resource optimization and surgical efficiency
The RAIN Clinic also functions as a highly efficient screening tool for surgical candidates. By ensuring that patients arriving for consultation already have the necessary imaging and a clear clinical indication, the clinic optimizes the surgeon’s time. The results indicate that a substantial percentage of patients were triaged directly to a surgical waitlist or further specialized investigations. This streamlining of the pre-operative phase reduces the total time from initial presentation to definitive surgical treatment, a metric that has traditionally been a point of failure in the Canadian system.
Limitations and future directions
While the RAIN model shows success in an urban academic setting, its scalability depends on the availability of neurosurgical human resources and integrated electronic referral systems. Future iterations of this study should investigate:
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• Cost-Utility Analysis: Quantifying the cost savings associated with diverted ED visits versus the operational costs of the RAIN Clinic.
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• Long-term Outcomes: Tracking whether rapid initial assessment leads to better long-term functional recovery compared to standard waitlist cohorts.
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• Geographic Expansion: Evaluating the feasibility of a hub-and-spoke RAIN model to serve more rural or underserviced areas through a mix of virtual and in-person rapid assessments, as well as expansion to other neurosurgical centers across the province or country.
Despite its success, the scalability of the RAIN model faces structural hurdles, primarily regarding human resource sustainability. The integration of high-velocity clinics into the already demanding schedules of neurosurgical faculty necessitates a strategic reassessment of clinical workflows. Future viability may depend on the recruitment of additional neurosurgeons or Advanced Practice Providers (APPs) and dedicated funding to offset the operational burden on consultant staff.
Furthermore, triage precision remains a frontier for improvement. We observed instances where complex spinal fractures or revision cases requiring specialized multi-disciplinary resources were directed to the RAIN Clinic. Refining referral criteria and implementing a more robust pre-clinic screening process will be essential to ensure the clinic remains a high-velocity stream for general neurosurgical pathology rather than a catch-all for complex tertiary cases. In future directions, we hope to be able to recruit APPs to help with clinic triage and seeing patients as well as working with our stakeholders (ED providers, neurosurgeons/spine surgeons and hospital leadership) to further refine referral criteria.
Example Scenarios
Scenario 1 – pre-RAIN
Kate is a healthy 36-year-old lawyer with 6 weeks of horrible right leg pain refractory to physiotherapy and analgesics. She gets so frustrated she attends a local emergency room one evening. They do an MRI showing a large L5S1 disc herniation and send her home with a prescription for pregabalin 25 mg bid. They also copy the note to her family doctor and put in a referral to a neurosurgeon. The patient does not hear for three months and then the appointment is two months hence.
Scenario 2 – post-RAIN
Kate is a healthy 36-year-old lawyer with 6 weeks of horrible right leg pain refractory to physiotherapy and analgesics. She gets so frustrated she attends a local emergency room one evening. They do an MRI showing a large L5S1 disc herniation and send her home with a prescription for pregabalin 25 mg bid. They refer her to the RAIN Clinic at a downtown hospital and Kate is seen 10 days later and referred expediently to an operating surgeon.
Conclusion
The RAIN Clinic model proves that specialized surgical care can be delivered within a timeframe that respects both clinical urgency and patient well-being. By bridging the gap between community medicine and acute neurosurgery, the clinic provides a scalable blueprint for reducing ED congestion and restoring timely access to surgical expertise in the Canadian healthcare landscape.
Author contributions
MS – Conceptualization, Methodology, Investigation, Analysis, Writing, Review and Editing.
JN – Investigation, Analysis, Review and Editing.
MB – Conceptualization, Methodology, Investigation, Review and Editing, Supervision.
Competing interests
The authors have no conflicts of interest or competing interests to declare.
Funding statement
There is no funding to report for this manuscript.
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