Abstract

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.

摘要

在城市和乡村医院，急诊科（ED）中挤满了急诊室的病人，等待入院。我们研究了教育署之外的问题，研究了由专家管理的多部门流程。在农村医院中，内科专家（Internist）通常同时担任重症监护室（ICU）医师和应召唤的Internist。我们为专家的工作流程决策开发了一个随机动态编程框架，并将其应用于从两家乡村医院开发的数据集。一种使用双重角色方法，另一种类似于城市医院，将ICU配备另一位医生，每位医生都担当单一角色。我们的经验结果表明，除隔夜批次外，急诊部针对农村专家的咨询请求的到来遵循泊松过程。我们的模型有助于确定更好的政策，并确定有两个而不是一个Internist值班的医院情况更好。尽管当前的指南建议了较早的住院治疗策略，但我们发现，专家应优先考虑急诊咨询，除非有一定数量的患者登上急诊室或直到一天中的某个阈值时间才应优先考虑住院治疗。