Planning and Budgeting

  • Ahmed Taha
  • Gloria Rodríguez-Vega


Planning and budgeting for a critical care unit is as essential as complicated. Critical care requires allocation of resources in a very changing environment and with many unpredictable variables. A significant proportion of the hospital budget is allocated to critical care while only a limited group of patients receive care in the ICU. Fact, critical care does not provide direct financial profits although it might have a positive or negative impact on institutional budget, but given the multiple intervening factors and varied budgetary elements, it becomes very difficult to calculate the return of investment (ROI) for a determined intensive care intervention. Such a challenge in a very demanding healthcare environment require investment in technology, application of costly treatments, and a very much personalized delivery of care. Calculating and justifying costs associated to the delivery of critical care becomes then a challenge. Additional factors need to be considered, including local and regional differences, policies, and beliefs as well as the interaction among different professionals. Finally, aspects related to the application of new technologies and the delivery of educational programs might also influence the planning and budgeting of an intensive care unit (ICU).


ICU Planning Budgeting Cost-effective analysis Return on investments Resource allocation Healthcare economics Population mix Payer mix 


  1. 1.
    Arrow KJ. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53:941–73.Google Scholar
  2. 2.
    Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38:65–71.PubMedCrossRefGoogle Scholar
  3. 3.
    Doubilet P, Weinstein MC, McNeil BJ. Use and misuse of the term “cost effective” in medicine. N Engl J Med. 1986;314:253–6.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Ward NS, Teno JM, Curtis JR, Rubenfeld GD, Levy MM. Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units: results of a national survey. Crit Care Med. 2008;36(2):471–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life? Am J Respir Crit Care Med. 2002;165(6):750–4.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Bekes CE, Dellinger RP, Brooks D, et al. Critical care medicine as a distinct product line with substantial financial profitability: the role of business planning. Crit Care Med. 2004;32:1207–14.PubMedCrossRefGoogle Scholar
  7. 7.
    Vincent JL, Takala J, Flaaten H. Impact of reimbursement schemes on quality of care: a European perspective. Am J Respir Crit Care Med. 2012;185:119–23.PubMedCrossRefGoogle Scholar
  8. 8.
    Finkler SA. The distinction between cost and charges. Ann Intern Med. 1982;96:102–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Wunsch H, Linde-Zwirble WT, Harrison DA, et al. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med. 2009;180:875–80.PubMedCrossRefGoogle Scholar
  10. 10.
    Gyldmark M. A review of cost studies of intensive care units: problems with the cost concept. Crit Care Med. 1995;23:964–72.PubMedCrossRefGoogle Scholar
  11. 11.
    Audit Commission. Critical to success: the place of efficient and effective critical care services within the acute hospital. London: HMSO Publications Centre; 1999.Google Scholar
  12. 12.
    Noseworthy T, Konopad E, Shustack A, et al. Cost accounting of adult intensive care: methods and human and capital inputs. Crit Care Med. 1996;24:1168–73.PubMedCrossRefGoogle Scholar
  13. 13.
    Seidel J, Whiting PC, Edbrooke DL. The costs of intensive care. Contin Educ Anaesth Crit Care Pain. 2006;6(4):160–3.CrossRefGoogle Scholar
  14. 14.
    Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care. 2012;18(6)PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Williams L, Robinson S, Dickinson H. Rationing in health Care: the theory and practice of priority setting. Bristol: Policy Press; 2012.Google Scholar
  16. 16.
    Angus D, Shorr A, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016–24.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Pheby D, Etherington D. Improving the comparability of cancer registry treatment data and proposals for a new national minimum dataset. J Public Health Med. 1994;16:331–40.PubMedGoogle Scholar
  18. 18.
    Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions, and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113:2386–93.PubMedCrossRefGoogle Scholar
  19. 19.
    Jacobson I, Poordad F, Brown R, et al. Standardization of terminology of virologic response in the treatment of chronic hepatitis C: panel recommendations. J Viral Hepat. 2012;19:236–43.PubMedCrossRefGoogle Scholar
  20. 20.
    Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149:818–24.PubMedCrossRefGoogle Scholar
  21. 21.
    Phua J, Badia J, Adhikari N, et al. Has mortality from acute respiratory distress syndrome decreased over time? Am J Respir Crit Care Med. 2009;179:220–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Offenstadt G, Moreno R, Palomar M, Gullo A. Intensive care medicine in Europe. Crit Care Clin. 2006;22:425–32.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Carr B, Addyson D, Kahn J. Variation in critical care beds per capita in the United States: implications for pandemic and disaster planning. JAMA. 2010;303:1371–2.PubMedCrossRefGoogle Scholar
  24. 24.
    Adhikari N, Fowler R, Bhagwanjee S, Rubenfeld G. Critical care and the global burden of critical illness in adults. Lancet. 2010;376:1339–46.PubMedCrossRefGoogle Scholar
  25. 25.
    Rodwin V. Japan’s universal and affordable health care: lessons for the United States. In: WHG, editor. Making universal health care affordable: how japan does it. New York; 1991.Google Scholar
  26. 26.
    WHO. World Health Statistics 2011; 2011.Google Scholar
  27. 27.
    Rhodes A, Ferdinande P, Flaatten H, et al. The variability of critical care bed numbers in Europe. Intensive Care Med. 2012; An observational study that provides key information on ICU bed provision across Europe.
  28. 28.
    Wunsch H, Angus D, Harrison D, et al. Variation in critical care services across North American and Western Europe. Crit Care Med. 2008;36:2787–93.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Martin J, Hart G, Hicks P. A unique snapshot of intensive care resources in Australia and New Zealand. Anaesth Intensive Care. 2010;38:149–58.PubMedCrossRefGoogle Scholar
  30. 30.
    Wunsch H. Is there a starling curve for intensive care? Chest. 2012;141:1393–9. An editorial that highlights the challenges of identifying the appropriate number of ICU beds for a population and raises the possibility of harm associated with frequent use of intensive carePubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Wunsch H, Angus D, Harrison D, et al. Comparison of medical admissions to intensive care units in the United States and United Kingdom. Am J Respir Crit Care Med. 2011;183:1666–73. A large observational study providing detailed information on differences between ICU patients in the US and UKCrossRefGoogle Scholar
  32. 32.
    Hutchings A, Durand MA, Grieve R, et al. Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis. BMJ. 2009;339:b4353.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Metcalfe A, Sloggett A, McPherson K. Mortality among appropriately referred patients refused admission to intensive-care units. Lancet. 1997;350:7–11.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet. 2000;355:1138–42.PubMedCrossRefGoogle Scholar
  35. 35.
    Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the United States and in England. JAMA. 2006;295:2037–45.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Adhikari NK, Rubenfeld GD. Worldwide demand for critical care. Curr Opin Crit Care. 2011;17:620–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Rapoport J, Teres D, Barnett R, et al. A comparison of intensive care unit utilization in Alberta and western Massachusetts. Crit Care Med. 1995;23:1336–46.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Robert R, Reignier J, Tournoux-Facon C, et al. Refusal of ICU admission due to a full unit: impact on mortality. Am J Respir Crit Care Med. 2012;185:1038–40. An observational study that was able to follow both patients admitted to ICU as well as those who did not receive intensive care to examine the impact of early admission to ICU.CrossRefGoogle Scholar
  39. 39.
    Simchen E, Sprung C, Galai N, et al. Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med. 2004;32:1654–6.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Edbrooke DL, Minelli C, Mills GH, et al. Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis. Crit Care. 2011;15:R56.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Stelfox H, Hemmelgarn B, Bagshaw S, et al. Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration. Arch Intern Med. 2012;172:467–74. An important study from Canada that demonstrates the frequent changes in goals of care that occur when ICU bed availability is limited.PubMedCrossRefGoogle Scholar
  42. 42.
    Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001.Google Scholar
  43. 43.
    Carson SS, Cox CE, Holmes GM, et al. The changing epidemiology of mechanical ventilation: a population-based study. J Intensive Care Med. 2006;21:173–82.PubMedCrossRefGoogle Scholar
  44. 44.
    Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307–11.PubMedCrossRefGoogle Scholar
  45. 45.
    Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research. Ann Intern Med. 1994;120:135–42.PubMedCrossRefGoogle Scholar
  46. 46.
    Imhoff M. Clinical pathways as a tool for “intelligent” rationing in intensive care. In: Vincent JL, editor. Yearbook of intensive care and emergency medicine 2000. Berlin, Heidelberg: Springer; 2000. p. 781–92.CrossRefGoogle Scholar
  47. 47.
    Kohn LT, Corrigan JM, Donaldson M, editors. To err is human. Building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, DC: National Academy Press; 2000.Google Scholar
  48. 48.
    Axene D, Doyle R. Analysis of medically unnecessary inpatient service. Research report. Milliman & Robertson: Seattle, WA; 1994.Google Scholar
  49. 49.
    Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF Jr, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med. 1998;338:232–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Gebhart F. VA Facility slashes drug errors via bar-coding. Drug Topics. 1999;1:44.Google Scholar
  51. 51.
    Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35–43.PubMedCrossRefGoogle Scholar
  52. 52.
    Teich JM, Glaser JP, Beckley RF, Aranow M, Bates DW, Kuperman GJ, et al. The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment. Int J Med Inf. 1999;54:197–208.CrossRefGoogle Scholar
  53. 53.
    East TD. Return on investment (ROI) analysis in the face of uncertainty. Proc AMIA Symp. 2000:A.Google Scholar
  54. 54.
    Baker JJ. Activity-based costing for integrated delivery systems. J Health Care Finance. 1995;22:57–61.PubMedGoogle Scholar
  55. 55.
    Kumar G, Falk DM, Bonello RS, Kahn JM, Perencevich E, Cram P. The costs of critical care telemedicine programs: a systematic review and analysis. Chest. 2013;143:19–29.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Lilly, CM, Cody, S, Zhao, H..., and University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305:2175–83.CrossRefGoogle Scholar
  57. 57.
    Angus DC, Clermont G, Watson RS, Linde-Zwirble WT, Clark RH, Roberts MS. Cost-effectiveness of inhaled nitric oxide in the treatment of neonatal respiratory failure in the United States. Pediatrics. 2003;112:1351–60.PubMedCrossRefGoogle Scholar
  58. 58.
    Edbrooke D, Stevens V, Hibbert C, et al. A new method of accurately identifying costs of individual patients in intensive care: the initial results. Intensive Care Med. 1997;23:645–50.PubMedCrossRefGoogle Scholar
  59. 59.
    Moore JE, Pinsky MR. Faculty development for fellows: developing and evaluating a broad-based career development course for critical care medicine trainees. J Crit Care. 2015;30(5):1152.e1–6.CrossRefGoogle Scholar
  60. 60.
    Zeidel ML, Kroboth F, McDermot S, Mehalic M, Clayton CP, Rich EC. Estimating the cost to departments of medicine of training residents and fellows: a collaborative analysis. Am J Med. 2005;118(5):557–64.PubMedCrossRefGoogle Scholar
  61. 61.
    Patel MB, Laudanski K, Pandharipande PP. An international career development survey of critical care practitioners. Crit Care Med. 2014 Apr;42(4):e300–3.PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    Farley H, Casaletto J, Ankel F, et al. An assessment of the faculty development needs of junior clinical faculty in emergency medicine. Acad Emerg Med. 2008 Jul;15(7):664–8.PubMedCrossRefGoogle Scholar
  63. 63.
    Weinert CR, Billings J, Ryan R, et al. Academic and career development of pulmonary and critical care physician-scientists. Am J Respir Crit Care Med. 2006 Jan 1;173(1):23–31.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Ahmed Taha
    • 1
  • Gloria Rodríguez-Vega
    • 2
  1. 1.Critical Care InstituteSheikh Khalifa Medical CityAbu DhabiUAE
  2. 2.Department of Critical Care and Neurocritical CareHIMA-San PabloCaguasPuerto Rico

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