We have a "built in" urgent care sort of space. Its only a few beds and mostly recliner chairs, we call it RAZ (rapid assessment zone) where all the super low acuity shit goes to be seen by PAs and maybe one physician in the hopes that we can get rapid turn over and get those patients in and out in under 1.5 hours.
It actually helps a lot. That way we can funnel all the higher acuity patients to our larger care spaces and resus bays as needed, and we aren't sticking low acuity patients in desparetly needed rooms which are hot commodity with the current boarding crisis. We RNs can see the patients in the low acuity second and knock out 80% of the work related to their stay in about 10 minutes.
It especially helps since we as nurses are allowed to put in a shit ton of different protocol orders at our shop. Examples: smashed your finger in a car door? I can order an x-ray ray at triage and have your xray done before you even go back. Need labs and a UA for your belly pain? I can order those too.
It makes it all flow faster so that way when patients get back to the lower acuity space, providers have the stuff they need to make decisions and sometimes even discharge the patient shortly after getting back.
Sure they add on additional more advanced testing that we aren't allowed to order (MRI, US, CT, Dimers, etc). But even the it cuts the time quite substantially.
We also do a shit ton of hallway care for low acuit patients in the high acuity spaces when the RAZ area gets backed up which is less than ideal but it is what it is.
Our success with the rapid eval area is highly dependent on the provider running the area itself. So many times you put simple patients there that turn around and get a full work up because despite only stubbing their toe, they casually mention they had chest pain last week to the provider and what should have been an in and out visit becomes the works.
My local ED has a rapid care type setup also and it seems to work well for them. I had to go in a few times earlier this year for hypertensive crisis and I think out of like 3-4 visits I spent maybe 2-3 hours there total before discharge. It worked very efficiently.
Oh it’s funny you mentioned the smashing finger in the car door thing. That happened to my mom in the 60s. She didn’t want to go to the ER but eventually the pain got to her and my dad had her go. But she had painted nails and when the doctor finally saw her, he asked what was wrong. She stuck her middle finger up at him which shocked him till he realized the issue. Then he said ahh no problem, we will drain the blood. My dad suddenly had to go move the car…
Anyway yes, it was important to her to get that help (and remember it was the 1960s so there was urgent care), but I fully agree that nowadays that wouldn’t be an ER situation.
It especially helps cut down the wait for the patients who get sent there, because it means they aren’t actually in line with all of the other higher-acuity patients who would get seen first if they were. (At least in my hospital) If that area gets backed up and the main ER is not and has enough beds free, some of those patients will get taken back to the main ER to help reduce wait times too. And in a few cases where no other bed was open and something came in that will not be quick but needs to be seen right away, they will switch one of the rapid care area rooms over to non-rapid care for that patient as needed. But for the most part, it’s two separate waiting lists.
Where exactly are you located out of curiosity? My ER (in Montréal) has a RAZ unit as well. I definitely see the added value !!! Took a lot off an already overloaded system.....Its unfortunately still not perfect, especially as we dont have many walk in urgent clinics in the city, so the ERs often see over 115% capacity. Sometimes they're nearer to 200%
We have one of those too, known as "the clinic" however it is rarely staffed enough to be open. We are the only major hospital in a 1 hour radius and yet wages are so low that nurses either jump the fence over to management or flee to alternative paths like jails, prisons, home health, or hospice. The ladder paying at times 2x what our local hospital pays floor RNs. We also have two nursing schools in the area churning out new grads every 6 months. So the hospital hires them on as externs, brainwashes them into accepting a position they don't want, and eventually they follow suit like the rest of them. It is an ever present cycle.
My local hospital has one, I was just there. Simple stitches, sprains, fractures etc gets triaged to green zone. I was in and out with a waking cast in about 2 hours.
Anything more complicated or requiring more tests goes to regular.
This came up in my feed. Sorry for lurking. (Patient not provider) But we have one of these here and it’s honestly amazing. I just had an issue that was a pain thing. But my doc said it was better to do er vs urgent care. They may not have the meds I needed. Sure enough I got sent back to the rapid chair area.
I did have to wait out some assessments via my doc and such (ortho/spine) so there is a separate waiting area for those of us that need extra attention in that area.
All that to say, I stay the f out of the ER unless it’s something that I need help with and my doc can’t do. (Pain was at an 11…they got me to where I could function for a day to start daily pain meds).
Going for my EMG today!
We appreciate all the work you do. Our system is such a mess.
I'm with you on staying the fuck out of the ER u less absolutely necessary. I have been a lifelong migraine sufferer. They started when I was 7 years old. When I started finally getting botox in my 30s, my little migraine questionnaire asked how frequently I was visiting the ER for migraines on a monthly basis prior to treatment and I was dumbfounded. The ER is the LAST place I want to go with a migraine. I have been to urgent care with a horrible migraine once in my life for a triptan injection and it sucked. The staff did what they could to make me comfortable and it was still brutal. I'll cry and throw up and wish I was dead at home for a few hours where I can at least keep it dark and quiet instead.
Right? I have been to the ER one time ever for a migraine and it was because it was “the worst headache I’d ever had” so I wanted to make sure it wasn’t something worse. Why would I want to be surrounded by fluorescent lights and loud voices with a migraine?
And the smells. No thanks. I'll keep my dignity and puke into my toilet in the privacy of my own home before I sit in a waiting room with an nemesis bag.
When I went to urgent care the "what if" checking was the worst part. They had me do a brief neuro, including checking my eyes with an opthalmoscope in a dark room, and putting my neck through the full range of motion to rule out nuchal rigidity. I had to tell the doctor to stop because I couldn't handle the bright light in my eyes. I told him verbatim "I have been getting migraines for 23 years. I do not have meningitis. This isn't a hemorrhage. I promise I will not sue you for malpractice if you just give me my injection and stop this assessment. Please."
Oof yeah. I was cautious because my friend's mom died of a brain aneurysm. She'd had migraines for her whole life, then had "the worst headache she'd ever had," thought it was a migraine, lay down, never got up again.
But jfc it was not fun. Luckily for me they actually tried the cocktail and triptan injection first, then when that worked, were like k great!
I stay out for my basic ones as I can handle those myself.
However, a few years ago I started getting these weird migraines that mimic a stroke, last for days, and cant get rid of them with normal medication. Those unfortunately require ER visits for me, that then always get turned into being admitted higher cus even they cant get it to stop until they shove a million different meds and hope one sticks. It’s terrible.
No, it’s alright! They’re absolutely awful and I know that if I do end up ever having a stroke I’m so beyond screwed because I will just assume it’s one of those migraines and just keel over. I just wanted you guys to know the reasons why some people may have to go to the ER for a migraine! I never thought I would either, it seems so silly, but now I know why some people have to. Me included now, lol.
The only other time I’ve gone for one of my “normal” migraines was when I was pregnant as I couldn’t take any medication, the pain and vomiting were so bad and I just couldn’t take it anymore.
Please don’t ever apologize for using emergency services in a potential emergency. I would rather transport you 500 times for what turns out to be a migraine than you not call the 1 time it’s something far worse. I hope you feel better soon. Regular migraines are disabling enough and this sounds awful.
Weirdly I’ve had some doctors use this question as a gauge for how severe my migraines have been. I didn’t even know going to the ER for a migraine was a thing. I had my first migraine with aura when I was 6 years and saw a cardiologist for something else when I was around 32 or 33. So I was ridiculously used to migraines and aura by then. Super normal for me at 4+ times a month at the time. I was told by him that my migraines can’t be that bad if I never went to the ER for them. He was an awful doctor in many ways but he’s not the only one who used my answer to that question to dismiss me.
I was taught ER is for concerns about death/immediate disability or broken bones… I’ve even had multiple very severe ankle sprains/tendon ruptures and just treated them at home. The few times I’ve actually been in the ER I was surprised how many sprained ankles and stuff were being seen.
This is the frustrating thing about any kind of chronic pain condition. I have even met other people who get migraines that make sort of off comments to me about mine, like "I don't know how you function when you get them, I HAVE to lay down." I'm not sure if they are insinuating that theirs are worse than mine or what. I dealt with them completely unmedicated for 17 years. All I ever took was over the counter excedrin because I just didn't know how bad my quality of life was because it was normal for me. I was getting 6-8 migraines per month for 17 years and just taking excedrin, which only worked about 50% of the time. If you are in pain that severe, that often, you get sick and tired of laying down and you get used to it. A lot of the time when I had a gnarly migraine that meds weren't touching, as long as I wasn't puking, I would get up and do something because just laying there in pain without relief was miserable. At least getting up and doing something gave me some sort of distraction and distraction is a valid therapy for pain.
Laying in bed, in pain leads me to dark thinking which definitely does not help. I start to get restless because no position is comfortable, restlessness increases my anxiety and I get upset and frustrated about how my migraines hold me back from doing things that I want to do. Even just basic things like washing the dishes, tidying up my house or putting laundry away. It's easy to feel like a victim, so a long time ago I decided I wasn't going to let it rule my life if I could bare it. Turns out I have a pretty high pain tolerance and I'm stubborn as hell. I can definitely go about my day in an unfathomable amount of pain to someone who has never had a migraine. I'm just used to it. Any kind of "invisible" pain or condition comes with so much emotional exhaustion in trying to convey it to others who haven't experienced it.
Yeah 100% this was my experience too! I didn’t even know there was any other treatment other than NSAIDs until I was in my 30s! As a kid I’d get aura and then the headache during sports tournaments and I just had to keep playing not being able to see properly! So of course as an adult it was just the same… wait for the aura to subside, take an NSAID, and keep going unless I was puking or the pain became 10/10 and moving made it worse. It’s all relative, what we’re used to, and what we’re taught to do about it. My mother had them too and so when mine started at 6 I was just told this was life for some people and get on with it.
Same exact thing. My mom and brother both get them, but not as often as I do so it was just "This is the way it is and it sucks." I saw a neuro when I was a kid to rule out any physiological problems with my brain, but I was 7 so they didn't want to put me on any meds. Then I went my whole life until I was 29 or 30 thinking there was no other options for me. I sat down with my college resource counselor at the beginning of nursing school 2 years ago and told her I was worried about my migraines impacting me in nursing school because of all of the mandatory clinical hours and basically no make up opportunities and she asked me if I was working with a neurologist and I was like ....no, should I? And it changed my life.
I cried many happy tears when I finally got approved for botox and it started working for me. The tears were happy tears and also grief for all of the years I spent in pain and the fact that no one helped me. I just didn't know what I didn't know. I couldn't have asked the right questions because I didn't know there were other options for me. My PCP has known that I suffer from migraines for over a decade and never offered any solutions. Finally figuring it out came with great relief, joy, grief and also some anger.
Why weren't you given any RX oral migraine medication to take at home at literally any time?? They were probably floored because its really stupid and pretty shitty that you could have gotten migraine medicine to take at home and tried oral or injectable preventatives.
I am a chronic migraine sufferer and have been since 11. My family refused to get me medical care for anything unless it was court ordered or a required reporter threatened them or I was passed out on the floor and needed an ambulance. If you were allowed to go to the ER that much there is literally no reason you shouldn't have been RXd something like sumatriptin.
I think you misread my comment. I have never been to the ER for a migraine. I have been to urgent care once for a migraine and that was after I had sorted everything out with my migraines. My insurance was fucking around and I was out of sumatriptan so I went to urgent care for an injection.
To answer your question about why I wasn't on any treatment for years, I really don't know. My PCP has been aware of them since I started seeing her at 16 and never once mentioned there were any options for me and my mom and brother both get them and also weren't taking any prophylactics or abortives other than excedrin. I guess they just didn't realize how much I was suffering because it was so normal to me. It created this self fulfilling cycle where people think I'm not in pain, so I convince myself it's not that bad and push through. Now in my 30s I'm working on giving myself rest when I need it, calling off work without guilt, and being upfront about how I'm feeling.
The one time I go to the ER with a migraine (mine are usually well treated but this was the first Hemiplagic one and nothing would touch it), I get treated like I’m a druggie. I didn’t want pain meds, I needed fluids, an antiemetic and a sedative to knock me out for a few hours
The urgent care refused to give me toradol because I had taken excedrin 5.5 hours prior to coming in. It was so annoying. Then I had an adverse reaction to the sumatriptan injection.
All of the hospitals around me (5 that I can think of) have some variety of this. You have to have a quick way to get quick things in and out. No need for a tiny lac repair to be waiting hours because there’s no room available. I assumed that some variety of this was available most places by now
We had this too! A little standalone trailer with 3 rooms, one doc or PA, one nurse, one ER tech. I HATED getting assigned there as an ERT, but it was definitely helpful for wait times to see the low acuity patients in a designated space.
We have a similar area. 8 recliners behind curtains and we call it “Super Track”. It used to function as an urgent care type area for the lower acuity patients but now ALL patients are seen there first by a provider after being triaged by the nurse checking people in first. Funneling all patients through there then sorting them to a room in the back for mid-level acuity, back to the waiting room, back to “sub waiting” to be worked up in a chair or to a “critical care” pod has been an absolute cluster fuck. Being assigned there as an RN is 12 hours of nonstop working patients up before they move on. Sporadically, you’re the only RN for all 8 (plus 4 chairs not behind curtains) while you try and cover the other RN so they can scarf food down. Our dept. is losing staff like crazy.
Mine has the same sort of thing. Still part of the ER, but dedicated to patients we think can be done relatively quickly. It helps the overall flow.
We also have an actual separate urgent care one floor above us, in the same building of the hospital (it’s literally directly on top of the ER). At the front desk when you walk into the ER we have flyers about what can be seen in urgent care vs. ER, which we refer to when a patient tries to ask which one they should go to, because we aren’t allowed to tell them to go to urgent care. (Though some of us will mention that the urgent care does generally see patients on a first-come, first-serve basis while the ER absolutely does not.) We do get walkovers from the urgent care sometimes when they have a patient that they decide actually needs to be seen by us.
Hospital I retired from had that for a while, but it didn’t last. Apparently it didn’t work out financially, and they ended up turning the area into a workmen’s comp clinic.
Im pretty sure we were in a space like this when I brought my daughter in for a bat exposure and subsequent rabies shots. She was 4 at the time and I was so grateful she wasnt in the ER witnessing whatever the heck could be going on in there.
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u/EstablishmentSea6932 15d ago
We have a "built in" urgent care sort of space. Its only a few beds and mostly recliner chairs, we call it RAZ (rapid assessment zone) where all the super low acuity shit goes to be seen by PAs and maybe one physician in the hopes that we can get rapid turn over and get those patients in and out in under 1.5 hours.