As shown in Table 2, we identified a total of 59 cost objects for EDs. A particular ED may provide all the services listed in Table 2 or a subset of them.
Table 2: List of Cost Objects for EDs.
N°
|
Services
|
Description
|
1
|
Administration of drugs by subcutaneous or intravenous injection
|
Administration of injectable medications of medications that can be administered to the patient without an additional approval process or paperwork because they are not controlled drugs.
|
2
|
Administration of non-injectable drugs
|
Administration either oral, buccal or other enteral route for non-injectable medications
of medications that can be administered to the patient without an additional approval process or paperwork because they are not controlled drugs.
|
3
|
Administration of non-injectable prescribed drugs
|
Administration either oral, buccal or other enteral route for prescribed non-injectable medication of medications that cannot be administered to the patient without an additional approval process or paperwork because they are controlled drugs.
|
4
|
Administration of prescribed drugs by subcutaneous or intravenous injection
|
Administration of injectable medications of medications that cannot be administered to the patient without an additional approval process or paperwork because they are controlled drugs.
|
5
|
Alcohol screening test
|
Application of validated screening tools for alcohol misuse and alcohol use disorder.
|
6
|
Application of a larger orthopedic medical cast
|
Procedure in which a large orthopedic cast is used to treat a trauma condition.
|
7
|
Application of a shorter orthopedic medical cast
|
Procedure in which a short orthopedic cast is used to treat a trauma condition.
|
8
|
Arterial blood gas sample
|
Arterial blood gas (ABG) sampling to obtain information on a patient's respiratory status (blood oxygen and carbon dioxide levels), as well as the patient's acid-base balance.
|
9
|
Black braided silk suture
|
Procedure for approximation and/or litigation of soft tissue in which a black braided silk suture is used. This type of surgical suture is a non-absorbable multifilament composed of an organic protein.
|
Table 2: List of Cost Objects for EDs (continue).
10
|
Bladder instillation
|
Bladder instillation is a combination drug therapy to help painful bladder or cystitis type symptoms including frequency, urgency, burning pain or stinging sensations when passing urine. It works by reducing inflammation and discomfort within the bladder.
|
11
|
Blood culture sample
|
Blood culture collection to test for foreign invaders like bacteria, yeast, and other microorganisms in the blood.
|
12
|
Blood glucose test
|
Procedure to test the amount of glucose in blood.
|
13
|
Blood sampling
|
Blood specimen collection to obtain blood for laboratory testing.
|
14
|
Burn wound dressing
|
Procedure to dress a dermal burn to absorb fluid, avoid maceration and seal the wound from the outside environment to reduce pain and infection.
|
15
|
Catgut suture
|
Surgical suture procedure in which a catgut suture is used. This type of suture is naturally degraded by the body's own proteolytic enzymes. It is used for surgical procedures such as general closure, ophthalmic and orthopedics.
|
16
|
Complex foreign body extraction
|
Complex localization, incision and removal of foreign bodies because of the location of the foreign body inside the patient’s body and the material or shape of the foreign body.
|
17
|
Complex wound dressing
|
Procedure to dress a complex wound that requires specialist wound care intervention. Complex wound dressing often is a result of the treatment of any number of other conditions, including cardiac, pulmonary, neuromuscular and renal diseases.
|
18
|
Diagnostic and therapeutic puncture
|
Medical diagnostic and therapeutic puncture for sample and treatment purposes.
|
19
|
Diagnostic puncture
|
Medical diagnostic puncture for sample purposes.
|
20
|
Discharge of deceased patients
|
It involves all the administrative processes the ED needs to follow to discharge deceased patients.
|
21
|
Electrocardiogram
|
Test provided at the ED to evaluate whether the patient’s heart is beating at a normal rate and strength.
|
22
|
Endotracheal intubation
|
Endotracheal intubation is a medical procedure in which a tube is placed into the trachea, usually through the mouth, to assist breathing.
|
23
|
Enema
|
Procedure used to stimulate stool evacuation.
|
24
|
Feeding tube insertion
|
Technique in which a nasogastric tube is inserted into the patient’s nose, reaching first the back of the throat and then pushed down the esophagus until it reaches the stomach.
|
25
|
Histoacryl
|
Procedure in which histoacryl is applied for closing skin wounds.
|
26
|
Intramuscular drugs administration
|
Technique used to deliver medications deep into the muscles through an injection of medications that can be administered to the patient without an additional approval process or paperwork because they are not controlled drugs.
|
27
|
Intramuscular prescribed drugs administration
|
Technique used to deliver medications deep into the muscles through an injection of medications that cannot be administered to the patient without an additional approval process or paperwork because they are controlled drugs.
|
28
|
Installation of a removable cast walker boot
|
Procedure in which a removable cast walker boot is placed to treat trauma conditions such as severe sprains, fractures, and tendon or ligament tears in the ankle or foot.
|
29
|
IV fluid change
|
Procedure in which the IV fluid bag is change for another one based on the needs of the patient.
|
30
|
Life risk care management
|
It involves all the administrative processes the ED needs to follow to admit a patient with a life-threatening condition regardless of their ability to pay.
|
31
|
Management of imaging tests
|
It involves all the administrative processes the ED needs to follow to ensure that an ED patient is scheduled (if an appointment is required) for the imaging tests prescribed and transported from the ED to the Imaging Unit and back to the ED.
|
32
|
Medical attention of patients arrived by ambulance
|
It involves all the administrative processes the ED needs to follow to admit a patient arriving by ambulance.
|
33
|
Medical consultation
|
It includes the administrative process required to admit the patient into the ED, as well as the physician’s evaluation.
|
34
|
Medical interconsultation
|
It includes the administrative process required to ask a specialist to further evaluate the patient, in order to correctly diagnose the patient, as well as the specialist’s evaluation.
|
35
|
Medium-complex foreign body extraction
|
Medium-complex localization, incision and removal of foreign bodies because of the location of the foreign body inside the patient’s body or the material or shape of the foreign body.
|
36
|
Monofilament nylon suture
|
Procedure for approximation and/or litigation of tissue in which a monofilament nylon suture is used. This type of suture is non-absorbable by the body.
|
37
|
Nebulization
|
Procedure in which a nebulizer is used to treat a person with asthma or another respiratory condition to administer medication directly and quickly to the lungs.
|
38
|
Observation day
|
It involves all the procedures required to monitor the patient’s status while the patient remains under observation.
|
39
|
Orthopedic trauma medical attention
|
It includes the administrative process required to admit the patient into the ED, as well as the evaluation of the patient’s condition by an orthopedic trauma specialist.
|
40
|
Oxygen therapy
|
Procedure in which oxygen is provided if oxygen saturation on a patient is below the threshold defined as desirable for the patient’s condition in order to reach the targeted oxygen saturation level.
|
41
|
Phleboclysis
|
It corresponds to the administration of fluids intravenously drop by drop, by the drip method, through a peripheral catheter.
|
42
|
Polypropylene suture
|
Procedure for approximation and/or litigation of tissue in which a polypropylene suture is used. This type of suture is non-absorbable by the body.
|
43
|
Preparation of patients for hospitalization
|
It includes the administrative process, preparation and transference of patients to be hospitalized.
|
44
|
Preparation of patients for surgery
|
It includes the administrative process, preparation and transference of patients for surgery.
|
45
|
Reduction
|
Procedure to repair a fracture or dislocation to the correct alignment without surgery.
|
46
|
Referral
|
It includes all the administrative processes required to transfer a patient to another hospital, primarily because the hospital currently treating the patient has not all the resources required to successfully treat the patient’s condition.
|
47
|
Resuscitation
|
A life-saving procedure performed when someone has stopped breathing or the heart has stopped beating, as in cardiopulmonary resuscitation (CPR).
|
48
|
Secretion clearance
|
Technique aiming to remove sputum (the combination of mucus and saliva) from the patient’s lungs.
|
49
|
Simple foreign body extraction
|
Simple localization, incision and removal of foreign bodies because the foreign body is located in a place of the body easy to reach and the material or shape of the foreign body are not likely to cause harm while the extraction process is conducted.
|
50
|
Simple wound dressing
|
Procedure to dress a simple wound. This type of wound is defined as a dry dressing, apply to viable skin which does not require specialist wound care intervention.
|
51
|
Skin suture
|
Procedure for approximation and/or litigation of tissue using cutaneous suture.
|
52
|
Splinting
|
Procedure to apply a rigid or flexible device that maintains in position a displaced or movable part; also used to keep in place and protect an injured part.
|
53
|
Stomach pumping
|
Procedure of cleaning out the contents of the stomach through a gastric lavage.
|
54
|
Stool sample
|
Stool specimen collection to obtain stool (feces) for laboratory testing.
|
55
|
Teaching activities
|
It includes all the teaching and research activities carried out within the ED.
|
56
|
Urethral sounding
|
Procedure that involves inserting a sound into the urethra for dilatation of strictures or for obtaining access to the bladder.
|
57
|
Urine specimen collection
|
Urine specimen collection to obtain urine for laboratory testing.
|
58
|
Verify injuries
|
Procedures requested by a judicial order or the police to verify type and severity of injuries.
|
59
|
Vicryl suture
|
Procedure for approximation and/or litigation of tissue using vicryl suture. This type of suture is absorbable, synthetic, and normally braided.
|
Below we present the costs for all the cost objects identified in the ED from Hospital 1, using the ABC method. We calculated the cost of 54 out of the 59 cost objects that this ED provided within a calendar year. We identified and costed 6 processes and 73 activities. Figure 1 shows the indirect costs of the processes that took place in the selected ED.
As shown in Figure 1, the medical care process has the higher proportion (36.9%) of indirect costs whereas the administrative and logistic processes consume more than half (52.1%) of the indirect resources. The indirect resources included in this ABC application can be categorized as: salaries, depreciation of equipment and infrastructure, utilities and medical supplies, office supplies, maintenance, outsourced services and internal services provided by other units. In order to carry out ABC, we need to recognize the tasks that make up these processes, i.e. the activities. To assign indirect resources to the activities, we define resource drivers such as time, number of procedures, number of employees/ time, usage percentage, and square meters/time. The internal services provided by other units or overhead costs from the hospital were proportionally assigned to the ED. Most of them were allocated to the management of the unit activity. The others were identified and assigned to a specific activity. For example, resources from the department of supply chain management were assigned to the storage control activity.
Once activity costs were calculated, then activities were assigned to the cost objects. To allocate the cost of the activities we use the following cost drivers: time, number of procedures, and consumption index. Table 3 presents the eight most expensive activities from this ED.
According to Table 3, the most expensive activities are medical evaluation ($146,054,786 chilean pesos, equivalent to US$225,000) and re-evaluation ($152,047,070 chilean pesos, equivalent to US$234,000). The main reasons for the elevated costs of these activities are the physicians’ salaries and equipment and infrastructure costs.
Table 3: Eight most expensive activities (CLP).
Ranking
|
Activity name
|
Process name
|
Annual Cost (CLP)
|
1
|
Medical re-evaluation
|
Medical care
|
$ 152,047,070
|
2
|
Medical evaluation
|
Medical care
|
$ 146,054,786
|
3
|
Record indications to the patient
|
Administrative process
|
$ 88,170,350
|
4
|
Patient management for imaging examination
|
Logistic process
|
$ 54,408,062
|
5
|
Management of the unit
|
Administrative process
|
$ 37,020,211
|
6
|
Clinical admission
|
Administrative process
|
$ 36,199,886
|
7
|
Withdraw supplies for procedures, meds administration and sample taking
|
Logistic process
|
$ 34,493,631
|
8
|
Take vital signs
|
Diagnosis support procedures
|
$ 29,179,405
|
The next step of ABC is to allocate the cost of the activities to the cost objects. The cost objects are the 54 services provided by the ED. Table 4 shows the final allocation of direct and indirect costs to these services. The services with the highest total costs are medical consultation ($487,445,524 chilean pesos, equivalent to US$750,000), phleboclysis ($97,601,148 chilean pesos, equivalent to US$150,000) and preparation of patients for hospitalization ($93,013,711 chilean pesos, equivalent to US$143,000). Eighty percent of the medical consultation costs come from three activities: medical evaluation, re-evaluation and filling health records for patients. Similarly, 80% of the phleboclysis services’ cost relates to four activities: intravenous (IV) installation, withdraws of supplies for procedures, medication administration and sample taking activities, registering medical supply consumption, and storage control. For preparation of patients for hospitalization the highest costs (78%) are associated with three activities: filling nursing and medical records for hospitalization activities, and preparing patients for transporting. However, if the unit cost is considered, the most expensive services correspond to referral ($134,507 chilean pesos, equivalent to US$207), resuscitation ($131,859 chilean pesos, equivalent to US$203), and diagnostic and therapeutic puncture ($ 43,526 chilean pesos, equivalent to US$67).
Table 4: Total Costs for ED Cost Objects (CLP) including direct and indirect costs
Ranking
|
Services
|
Indirect Costs
|
Direct Costs
|
Total Costs
|
Unit Costs
|
1
|
Medical consultation
|
$ 487,445,524
|
|
$ 487,445,524
|
$ 11,710
|
2
|
Phleboclysis
|
$ 67,044,073
|
$ 30,557,075
|
$ 97,601,148
|
$ 7,426
|
3
|
Preparation of patients for hospitalization
|
$ 91,101,584
|
$ 1,912,126
|
$ 93,013,711
|
$ 17,007
|
4
|
Management of imaging tests
|
$ 71,325,226
|
|
$ 71,325,226
|
$ 5,689
|
5
|
Resuscitation
|
$ 37,052,388
|
|
$ 37,052,388
|
$ 131,859
|
6
|
Blood sampling
|
$ 30,124,604
|
$ 392,805
|
$ 30,517,409
|
$ 5,795
|
7
|
Urine specimen collection
|
$ 18,900,132
|
$ 56,725
|
$ 18,956,857
|
$ 4,180
|
8
|
Electrocardiogram
|
$ 10,555,702
|
$ 150,097
|
$ 10,705,798
|
$ 4,603
|
9
|
Preparation of patients for surgery
|
$ 8,932,030
|
$ 438,436
|
$ 9,370,466
|
$ 7,472
|
10
|
Life risk care management
|
$ 9,080,651
|
|
$ 9,080,651
|
$ 9,053
|
11
|
Referral
|
$ 7,801,401
|
|
$ 7,801,401
|
$ 134,507
|
12
|
Administration of prescribed drugs by subcutaneous or intravenous injection
|
$ 7,655,239
|
$ 80,933
|
$ 7,736,172
|
$ 7,130
|
13
|
Administration of noninjectable prescribed drugs
|
$ 7,451,112
|
|
$ 7,451,112
|
$ 5,714
|
14
|
Monofilament nylon suture
|
$ 6,892,450
|
$ 290,026
|
$ 7,182,476
|
$ 24,265
|
15
|
Simple wound dressing
|
$ 6,744,059
|
$ 333,805
|
$ 7,077,865
|
$ 7,327
|
16
|
Complex wound dressing
|
$ 6,889,495
|
$ 122,572
|
$ 7,012,068
|
$ 23,530
|
Table 4: Total Costs for ED Cost Objects (CLP) including direct and indirect costs (continue)
Ranking
|
Services
|
Indirect Costs
|
Direct Costs
|
Total Costs
|
Unit Costs
|
17
|
Administration of drugs by subcutaneous or intravenous injection
|
$ 6,201,138
|
$ 112,933
|
$ 6,314,072
|
$ 4,170
|
18
|
Teaching activities
|
$ 6,225,455
|
|
$ 6,225,455
|
-
|
19
|
Administration of noninjectable drugs
|
$ 5,515,973
|
|
$ 5,515,973
|
$ 3,032
|
20
|
Nebulization
|
$ 4,330,711
|
$ 1,005,900
|
$ 5,336,612
|
$ 4,202
|
21
|
Arterial blood gas sample
|
$ 5,286,625
|
|
$ 5,286,625
|
$ 3,876
|
22
|
Splinting
|
$ 2,187,641
|
$ 2,262,020
|
$ 4,449,661
|
$ 15,135
|
23
|
Blood glucose test
|
$ 2,945,942
|
$ 147,546
|
$ 3,093,488
|
$ 4,701
|
24
|
Application of a shorter orthopedic medical cast
|
$ 1,904,884
|
$ 955,495
|
$ 2,860,379
|
$ 11,173
|
25
|
Installation of a removable cast walker boot
|
$ 289,805
|
$ 2,509,500
|
$ 2,799,305
|
$ 26,660
|
26
|
Orthopedic trauma medical attention
|
$ 2,348,362
|
|
$ 2,348,362
|
$ 6,452
|
27
|
Black braded silk suture
|
$ 2,212,104
|
$ 80,069
|
$ 2,292,173
|
$ 24,128
|
28
|
Intramuscular prescribed drugs administration
|
$ 1,848,525
|
$ 20,737
|
$ 1,869,262
|
$ 6,724
|
29
|
Medical interconsultation
|
$ 1,724,532
|
|
$ 1,724,532
|
$ 1,342
|
30
|
Intramuscular drugs administration
|
$ 1,476,210
|
$ 28,942
|
$ 1,505,152
|
$ 3,879
|
31
|
Application of a larger orthopedic medical cast
|
$ 622,032
|
$ 855,619
|
$ 1,477,650
|
$ 24,628
|
32
|
Stool sample
|
$ 1,461,081
|
$ 4,253
|
$ 1,465,334
|
$ 4,310
|
33
|
Skin suture
|
$ 1,280,692
|
$ 29,963
|
$ 1,310,655
|
$ 23,830
|
34
|
Stomach pumping
|
$ 983,161
|
$ 92,603
|
$ 1,075,764
|
$ 12,225
|
35
|
Vicryl suture
|
$ 745,130
|
$ 35,083
|
$ 780,212
|
$ 24,382
|
36
|
Histoacryl
|
$ 528,726
|
$ 10,882
|
$ 539,608
|
$ 12,549
|
37
|
Endotracheal intubation
|
$ 478,748
|
$ 23,326
|
$ 502,074
|
$ 12,246
|
38
|
Diagnostic puncture
|
$ 453,459
|
$ 21,398
|
$ 474,857
|
$ 29,679
|
39
|
Diagnostic and therapeutic puncture
|
$ 390,482
|
$ 44,779
|
$ 435,261
|
$ 43,526
|
40
|
Alcohol screening test
|
$ 375,863
|
|
$ 375,863
|
$ 19,782
|
41
|
Medical attention of patients arrived by ambulance
|
$ 254,133
|
|
$ 254,133
|
$ 12,707
|
42
|
Catgut suture
|
$ 209,568
|
$ 9,610
|
$ 219,178
|
$ 24,353
|
43
|
Blood culture sample
|
$ 207,715
|
$ 8,157
|
$ 215,873
|
$ 6,349
|
44
|
Polypropylene suture
|
$ 186,282
|
$ 19,626
|
$ 205,909
|
$ 25,739
|
Table 4: Total Costs for ED Cost Objects (CLP) including direct and indirect costs (continue)
Ranking
|
Services
|
Indirect Costs
|
Direct Costs
|
Total Costs
|
Unit Costs
|
45
|
Discharge of deceased patients
|
$ 146,451
|
|
$ 146,451
|
$ 9,763
|
46
|
Urethral sounding
|
$ 118,086
|
$ 12,822
|
$ 130,908
|
$ 32,727
|
47
|
Complex foreign body extraction
|
$ 117,215
|
$ 590
|
$ 117,806
|
$ 16,829
|
48
|
IV fluid change
|
$ 95,742
|
$ 5,622
|
$ 101,364
|
$ 2,981
|
49
|
Reduction
|
$ 95,091
|
|
$ 95,091
|
$ 5,283
|
50
|
Oxygen therapy
|
$ 36,802
|
$ 23,757
|
$ 60,558
|
$ 3,785
|
51
|
Verify injuries
|
$ 51,283
|
|
$ 51,283
|
$ 4,274
|
52
|
Medium-complex foreign body extraction
|
$ 16,662
|
|
$ 16,662
|
$ 16,662
|
53
|
Simple foreign body extraction
|
$ 16,579
|
|
$ 16,579
|
$ 16,579
|
The proposed cost objects list can also be used to accumulate costs at different levels, such as patient or diagnoses. Table 5 shows an example of how the costs objects proposed can be aggregated at a diagnosis level, using the Pneumonia due to Streptococcus pneumoniae diagnosis (code J13 in the ICD-10 coding system).
Table 5: Example of costing at a diagnosis level (CLP).
Cost Objects
|
ICD-10 Code
|
J13: Pneumonia due to Streptococcus pneumoniae
|
Medical consultation
|
$11,710
|
Arterial blood gas sample
|
$3,876
|
Blood sampling
|
$5,795
|
Management of imaging tests
|
$5,689
|
Intramuscular prescribed drugs administration
|
$6,724
|
Administration of non-injectable prescribed drugs
|
$5,714
|
Nebulization
|
$4,202
|
Total Cost
|
$43,710
|
As shown in Table 5, treating a patient diagnosed with Pneumonia due to Streptococcus pneumoniae costs $43,710. This cost includes only the services provided by the Emergency Department. However, the revenue linked to those services could be imputed to the ED or to another unit at the hospital, given the classification of the services for billing purposes. In this particular case, the total revenue imputed to the ED corresponded to $19,050. Hence, the ED had losses for an average of $24,660 per patient treated for that diagnosis in the time period included in the analysis.
The results are discussed in the next section.