Specialist care in rural hospitals: From Emergency Department consultation to hospital discharge

In urban and rural hospitals, congested Emergency Departments (EDs) are filled with patients boarding in the ED awaiting admission to inpatient wards. We study this problem beyond the walls of the ED, examining the multi-departmental process managed by specialists. In rural hospitals, an Internal Medicine Specialist (Internist) commonly serves simultaneously as both the Intensive Care Unit (ICU) physician and Internist on call. We develop a stochastic dynamic programming framework for specialists' workflow decisions and apply it to data sets developed from two rural hospitals. One uses the dual role approach and the other, similar to urban hospitals, staffs the ICU with another physician, each with a single role. Our empirical results show that, excluding an overnight batch, arrivals of ED consultation requests for rural specialists follow a homogeneous Poisson process. Our models help identify better policies and determine how much better off a hospital is with two rather than one Internist on call. Although current guidelines suggest an early inpatient discharge strategy, we find that specialists should give higher priority to ED consultations unless a threshold number of patients are boarding in the ED or until a threshold time of day when specialists should give higher priority to inpatient discharges.