CG 1 Critical Care

CG 1.1 Scope

CG 1.1.1 This Costing guideline provides the scope of critical care services and a guideline on the approach to cost activity within a Critical Care Unit.

CG 1.1.2 This Costing guideline also provides practical steps and examples to guide staff on the patient costing process for this activity.

Critical care scope

CG 1.1.3 For patient level costing purposes, the following units will be included in critical care:

  • Intensive care,
  • Coronary care,
  • Cardiothoracic intensive care,
  • Psychiatric intensive care,
  • Paediatric intensive and
  • Neonatal intensive care.

CG 1.1.4 High dependency, special care nurseries and other close observation units either located within general wards or stand alone will be costed as general wards.

CG 1.1.5 Where close observation unit’s costs are integrated with Critical Care Units, these will be treated as critical care, recognising the difficulty in disaggregating Critical Care services from High Dependency services in combined units.

CG 1.1.6 Special Care Nurseries (SCN) attached to either a Neonatal Intensive Care Unit or in another combined unit, will be treated as critical care. Where the SCN can be identified as a separate ward or cost centre will be treated as clinical care area.

CG 1.2 Objective

CG 1.2.1 The objective of this Costing guideline is to guide costing practitioners on the end to end steps required to ensure that all Critical Care activity and expense contributing to the day to day production of final Critical Care products are included in the patient costing process to determine the full cost of production.

CG 1.3 Costing guideline

Step 1: Stakeholder identification and service scale and scope

CG 1.3.1 Costing practitioners should meet with the appropriate stakeholders within the Critical Care Department and Finance Department to identify both the expense and activity related to Critical Care. Critical Care stakeholders may include the:

  • Director of Critical Care (or local equivalent), the
  • Critical Care Nursing Manager; and
  • Cost Centre Manager.

CG 1.3.2 Stakeholders will explain the operation of the Critical Care Unit. This information is required to understand the configuration of the unit, the scope of expenses, the activities and what drives costs within the unit.

CG 1.3.3 In some hospitals, the expense associated with a Critical Care Unit may not be aligned to each critical care service such as ICU or High dependency. For example, the Critical Care Unit cost centre may include bed expenses that are classified as high dependency (i.e. not Critical Care). When meeting with relevant stakeholders these issues require clarification as the cost model will need to be developed to reflect practice. The meeting should also discuss the available critical care feeder systems and the most appropriate way to allocate expenses and the appropriate RVUs that should be applied at the intermediate product level.

Step 2: Align expense to the service department and define overhead and direct expenses, including overhead allocation methods

CG 1.3.4 Costing practitioners should work with Critical Care Department stakeholders to define the expense within the Critical Care Department that relates to final products. This includes obtaining agreement on the cost centre/s to map to Critical Care for costing purposes.

CG 1.3.5 – Where the general ledger has consolidated expenses for both Critical Care and High Dependency beds within the one cost centre, costing practitioners must work with the Critical Care stakeholders to define and agree on the methods and assumptions to be used (for example, staff rosters, FTE, timesheets, occupied bed days and/or other relevant data) to transfer expenses to other intermediate products.

CG 1.3.6 Costing practitioners should then use stakeholder insights to move expenses appropriately between the Critical Care and High Dependency activity.

CG 1.3.7 Costing practitioners should seek to access staff rosters to understand the level of rotations of residents and junior staff to Critical Care. This information can be used to demonstrate the medical resources used to support Critical Care (or High Dependency) patients from other hospital units as these expenditures are held outside Critical Care cost centre.

CG 1.3.8 This approach enables the cost practitioner to consider the medical resource costs for Critical Care patients are represented not only by critical care medical staff (where expenses are held within Critical Care cost centres), but the activity for medical staff rostered to critical care where associated expenses are held outside Critical Care cost centres.

CG 1.3.9 Detailed documentation should be made on key decisions, including:

  • which expenses have been summarised and classified into the Critical Care final cost centre;
  • what expenses have been summarised into the Critical Care and High Dependency final cost centres;
  • the stakeholders who were consulted and the date of consultation; and
  • a date for future review with these stakeholders.

Step 3: Identify patient level activity and feeder data and perform quality assurance checks

CG 1.3.10 The main feeder system used for the allocation of Critical Care is generally the ward transfer file as this provides data related to the time a patient spends in Critical Care.

CG 1.3.11 Other data may be used for the cost allocation process – for example; the episodic dataset may record whether the patient was ventilated and how long. Ideally, the Critical Care feeder system (and other datasets) will include some or all of the following fields:

  • the patient’s unique identifier;
  • the patient unique episode identifier;
  • unit code (e.g., ICU, NICU, CCU);
  • the time into and out of the unit;
  • hours of mechanical ventilation;
  • campus/site; and
  • Other relevant information.

CG 1.3.12 Costing practitioners should perform quality assurance checks on the Critical Care datasets prior to the costing process. For example, checks should be made on:

  • the date of service (check error dates, relevancy to costing period);
  • time into and out of the Critical Care Department (check for negative values – i.e., where start time is after finish time).

Step 4: Creating and mapping critical care costing products or intermediate products

CG 1.3.13 The most widely used method for allocating Critical Care expenses to patients includes the use of patient duration in the Department, which may also be combined with a Relative Value Unit (RVU).

CG 1.3.14 Intermediate products created for Critical Care will depend on the fields available in the ward transfer feeder systems and the availability of other data (e.g., from nursing dependency systems and the episodic dataset). Usually, the intermediate product will include at a minimum the unit code of the Critical Care Department, but may also include other factors such as the Critical Care level, admission and discharge from the unit, time of day (e.g., am, pm, and night) and patient specialty.

CG 1.3.15 Where Critical Care intermediate products are created in the costing system, they will also need to be mapped to the relevant final cost centre (i.e., Critical Care or High Dependency as appropriate). An example of such a product is: ‘ICU_1_TransfIn_ED’, which denotes the ward (ICU), the acuity level of the patient (1) and the fact that this patient has been transferred into ICU from the Emergency Department. Once the intermediate products are created, costing practitioners will be required to map these in the costing system to the Critical Care final cost centre.

Step 5: Apply Relative Value Units

CG 1.3.16 Patient duration on the Critical Care ward is usually the primary cost driver used to allocate the labour related expenses within a Critical Care Department. Used in isolation, this means that all patients are assumed to have the same nurse/medical staff to patient ratio. Costing practitioners may also wish to discuss with Critical Care stakeholders whether it is possible or feasible to assign RVUs to adjust the cost allocation to account for resource intensity.

CG 1.3.17 For example, patients recently transferred into Critical Care from the Emergency Department or post theatre may require more medical and nursing care than patients who are in a critical condition, but stabilised or ready to be stepped down into high dependency. While the normal nursing staff patient ratio in an intensive adult and paediatric intensive care unit is 1 to 1 there are treatments such as Extra Corporeal Membrane Oxygenation (ECMO) where the staff patient ratio may be higher. Similarly, in Intensive Care areas there may be bed locations such that, as the patient’s condition improves a 1 to 2 or even 1 to 4 ratio may be the norm for that acuity patient.

CG 1.3.18 Where these type of areas or patient types can be readily identified from the electronic data available to the costing team RVU’s should be adjusted to more accurately reflect the relative costliness of patients as they pass through the intensive care unit.

CG 1.3.19 Neonatal Intensive care units normally have one or two rooms with lower acuity patients requiring a lower staff patient ratio and may also include an attached special care nursery area through which the initially sick neonate passes during their overall stay in the NICU. The RVU needs to consider this level of acuity also.

CG 1.3.20 These relative values should be determined in consultation with the Critical Care stakeholders.

Step 6: Create intermediate product costs in final cost centres

CG 1.3.21 Two allocation processes are performed:

  • When overhead costs are allocated to the Production Cost Centre (using an appropriate allocation statistic)
  • When the Production Cost Centre costs (overhead and direct) are allocated to the intermediate products.

Step 7: Match intermediate products and their costs to critical care activity

CG 1.3.22 Activity within the Critical Care Unit will consume resources from other hospital departments, such as imaging, pathology, pharmacy, and allied health on their journey of care and these should be attached to patient activity as these resources contribute to the cost of production.

Step 8: Report costs

CG 1.3.23 Costing practitioners should then perform the required steps to consolidate and report costs at encounter level

Step 9: Cost data review with critical care stakeholders

CG 1.3.24 Costing practitioners should meet with their relevant Critical Care stakeholders to report on costs calculated.

CG 1.3.25 Cost data should be reviewed for, amongst other checks, cost relativity per product and resource completeness per episode to determine if the cost data captures resources that have been provided at encounter level.