Ventilator-associated pneumonia – What price does the public health system pay?

ABSTRACT

Background:

Ventilator-associated pneumonia (VAP) is the commonest healthcare-associated infection (HAI) in intensive care units (ICU), especially in trauma patients. VAP imposes a significant cost burden on the healthcare ecosystem. However, there are few data from the developing world.

Methodology:

We conducted this study in the trauma ICU (TICU) of PGIMER, Chandigarh, from October 2021 to December 2022. The incidence, incidence density, and average length of stay (ALOS) of both VAP and non-VAP patients were established. The health system cost was assessed using a mixed (top-down and bottom-up) micro-costing approach. We collected data for all the resources (direct and indirect costs) utilized during service delivery and estimated the health system cost per bed per day.

Results:

In this study, 494 patients were admitted to TICU, of which 484 received Mechanical Ventilation (MV) and 47 developed VAP. We included 41 and 44 patients with and without VAP. The VAP incidence rate was 9.7% and the VAP incidence density was 10.79/1000 MV days. The ALOS for VAP patients was 21 days, and for non- VAP patients was 8.2 days. Our study estimated a total health system cost of INR 25,927 per bed per day. The health system cost of treating a VAP patient was INR 544,467 compared to INR 207,416 for a non-VAP patient.

Conclusion:

Treatment of VAP poses substantial costs for the health system and patients. There is a need to focus on preventing VAP, which would eventually reduce the length of stay and the resultant financial impact on the health system and the patient.

INTRODUCTION

Pneumonia is the second most common healthcare-associated infection (HAI) occurring in critically ill patients, affecting almost 27% of critical care patients. Hospital-acquired pneumonia is a HAI occurring 48 hours after patient admission and not in the incubation period at admission.[1] Ventilator-associated pneumonia (VAP) is pneumonia that occurs 48 hours after endotracheal intubation.[2] VAP remains a significant problem in intensive care units (ICU) and patients on mechanical ventilation (MV).[3] A comparison of the rate of VAP in trauma vs non-trauma cases revealed that there was a steep increase in the rate of VAP (~4 times) in trauma ICU (TICU) patients on MV.[4]

In the United States, the VAP incidence is 4-14 cases/1000 ventilator days and 10-52.7/1000 ventilator days in low and middle-income countries (LMIC).[5] VAP imposes a significant cost burden on health care, both direct health system costs and indirect, intangible costs to healthcare services. VAP prolongs the hospital length of stay (LOS) and increases hospitalization costs.[6,7] There are very few studies that have analysed the cost burden of VAP. Identifying the significant cost drivers involved in VAP is crucial as this analysis would empower hospitals to effectively utilize resources, enhance process efficiency, reduce cost burden and increase patient satisfaction.

We cater to many patient referrals and reliable data on the costs borne by the institute and the patients in managing preventable HAIs; namely, VAP is imperative. It would also help provide the expected cost savings and the number of new patients that could be treated if VAP is prevented. Herein, we assess the cost of tertiary care medical services in a publicly funded hospital. We also assess the incidence of VAP in our institute’s TICU and the additional cost burden on the health system due to VAP.

METHODS

The study was conducted in the TICU of the Advanced Trauma Centre of a tertiary care referral institute catering to patients from six to seven states of Northern India. It was a prospective, longitudinal, observational study conducted between October 2021 and December 2022. The Institute Ethics Committee approved the study. A written informed consent was obtained from all the participants. The TICU has 12 Beds and is equipped with state-of-the-art monitoring and therapeutic facilities for managing critically ill poly-trauma patients.

Inclusion criteria

• All mechanically ventilated patients admitted to the TICU with a hospital stay of at least 48 hours were included in this study (universe).

• The cases included intubated patients with > 2 days of ICU stay, >2 days of MV, and who developed VAP (VAP group). The VAP was defined as per the Centers for Disease Control and Prevention (CDC) guidelines.[8]

• The control group included intubated patients > 2 days of ICU stay, >2 days of MV, and who did not develop VAP (non-VAP group).

Exclusion criteria

• Paediatric cases

• Patients with sepsis or septic shock due to causes other than VAP

• Patients receiving palliative care or in a vegetative state to avoid confounding factors of prolonged stay.

VAP incidence, incidence density, and the average length of stay (ALOS)

[Supplementary Figure A1 ^{(117.6KB, tif)} ]

The study population was identified as per the inclusion and exclusion criteria. They were followed daily during the study period. The parameters like VAP cases, patients on MV, MV days, ALOS, total discharges and deaths were noted.

The VAP incidence rate was calculated as the number of VAP cases divided by the total number of MV patients multiplied by 100.[9]

The VAP incidence density was calculated as the number of VAP cases divided by the total number of MV days multiplied by 1000.[9]

The ALOS for the VAP group was calculated as the total number of patient days of the VAP group divided by the total number of discharges and deaths in the same period. Similarly, the ALOS for the non-VAP group was calculated.

Health system cost

[Supplementary Figure A2 ^{(70.3KB, tif)} ]

The health system cost, namely the cost incurred by the hospital, was assessed using a mixed, i.e., top-down and bottom-up micro-costing approach [Supplementary A3- Costing Tool].

Human resource

Human resources included all the medical and technical staff working in the TICU (full-time and visiting staff), including consultants, residents and fellows, nurses, technicians, physiotherapists, dieticians, hospital attendants (HA), sanitation attendants (SA), security guards and lift operators. The staffing details (including leaves availed) were collected based on their attendance and acquittance registers. The gross annual salaries (including all allowances) of permanent staff were obtained from the accounts department. The salaries of contractual staff were obtained based on the District Collector (DC) rates published by the Office of Deputy Commissioner, Chandigarh, for the year 2021–2022.[10] The medical and technical staff members were interviewed regarding their time on various tasks. These included jobs performed regularly (patient care activities and general administration in TICU and other areas, research, and other activities) and tasks performed at predefined intervals (meetings, teaching, etc.). Additionally, observable data were gathered to support the interview results. A total of four consultants (including the Director of TICU, two Professors, and one Associate Professor), three Resident Doctors (one Fellow and two Residents), four Nurses, two Technicians, one HA and one SA were interviewed and subsequently observed. In addition, cross-consultations from other departments, such as personnel from neurosurgery, orthopaedics, hospital administration, physiotherapy and dietetics, were also noted. The weightage of services in terms of time spent in each activity was calculated based on these factors. The salaries of all personnel were finally apportioned to arrive at the overall human resource cost of TICU.

Physical space

The hospital facility maps were obtained from the hospital engineering and planning department, which were used to calculate the total floor area of the rooms used for patient care and common area use (such as waiting areas). According to the opportunity costs, the price of a building is estimated by its subsequent best alternative use, i.e., the amount the building is generating if it is not being used. This foregone income was the cost of the building. The annual rental estimate of space was derived using guidelines/formulae as per the Central Public Works Department (CPWD) Works Manual 2021[11] and the Schedule of Collector’s rates of the Union Territory of Chandigarh 2021.[12] The rental rate, which arrived through this method, was INR 237 per square foot. This rental rate was multiplied by the area of TICU, i.e., 6692 sq ft, to arrive at the annual rent for the study area [Supplementary Table A4].

Supplementary Table A4.

Rental Rate Calculation of the Institute

Sr. No.	LAND AREA
1.	100 sq.yd (@ INR 3,08,880/sq. yd)	INR 3,08,88,000
2.	Rental Value @ 8%	INR 24,71,040 {A}
	COVERED AREA
3.	83.6 sq. mtr @ INR 28455 (PAR of Construction)	INR 23,788/sq. mtr
4.	Water Supply and Sanitation Internal @ 10%	INR 2,379 (Rounded off)
5.	External Services @ 5%	INR 1,189
6.	Electrical Installation Services @ 12.50%	INR 2,973.5
7.	Power Plug @ 4%	INR 951.5
8.	TOTAL (Add 3to7)	INR 31,281
9.	Cost Index @110%	INR 3,128
10.	TOTAL (8+9)	INR 34,409/sq. mtr {C}
11.	Depreciated Cost of Building D=0.94x [(CxA)/(A+R)]	INR 28,032 {D}
12.	Year of Construction	2012
13.	Rental Value @ 8%	INR 2,243
14.	Maintenance Charges @ 12%	INR 3,364
15.	Land Marked {A} above	INR 24,710
16.	Sinking Funds [D x 0.06/(1+0.06)-1]	INR 270
17.	Rent per annum/sq.mtr	INR 30,587/sq.mtr
18.	Rent per month/sq.mtr	INR 25,48/sq. mtr
19.	Rent per month/sq. ft	INR 237/sq. ft

Equipment

For equipment cost, the first step in the analysis was to determine the completeness of data and ensure the presence of essential information about the equipment, such as unit price, average life and annual maintenance charges from the procurement department. Capital resources, such as equipment, are bought in 1 year but used over several years, and their cost needs to be spread over their useful life. This correction is known as annualization. The yearly cost of equipment was derived using an annualization factor (AF), calculated using the average life (AL) and the standard discount rate (DR) of 3% per the Department of Health Research, India guidelines. The AF is calculated as

Where DR is 0.03, and AL is variable according to the item. The annual capital expense on each item was then calculated by multiplying the total amount with the AF. The maintenance charges for each piece of equipment were already included in the cost; hence, they were not considered separately.

Drugs, consumables and diagnostics

The data regarding total annual drugs and consumables used in the TICU was collected from the yearly indent record book. The cost was the one at the time of purchase by the institute obtained from the central store. Diagnostics are integral to hospital usage charges and, hence, not tracked separately.

Non-consumable items, furniture and fixtures

Data on non-consumables or furniture items was collected for each section in the TICU. The first step was to calculate the total cost of each line-listed item. This was performed by multiplying the unit cost and quantity of the item. As before, the total amount for each line-listed item was then annualized using the AF.

Overheads and other utilities

This includes electricity, water, maintenance, telephone, repairs, manifold, diet, laundry and biomedical waste. The water and electricity cost of TICU was calculated from the total cost incurred by the institute based on the proportion of TICU’s area. The actual telephone bills for outgoing-enabled telephone lines were collected. The cost involved by the indirect cost centres, such as laundry services, was derived from a previous study. Inflation index was used to arrive at the present cost, and the cost of washing dirty linen per kg was taken.[13]

The Central Sterile Supply Department cost could not be tracked separately as the data was unavailable. The annual health system cost was determined based on these values. We used apportioning statistical methods for allotting shared and joint resources of TICU. The unit cost, i.e., the per bed day cost, was derived by summating all health system costs annually and dividing it by the total number of beds in TICU throughout the reference period. Thus, we derived the health system costs for treating VAP and non-VAP patients along with incremental costs.

Statistical methods

We used MS Excel, version 2016, to collect the data. The data was assessed for logical error. A commercial statistical package (IBM SPSS software version 22.0) was used for data analysis.

RESULTS

During the study period, 494 patients were admitted to TICU, of which 484 received MV and 47 developed VAP. Comorbidities were higher among non-VAP patients (65%) than VAP patients (48%). More than 75% of patients in both groups reported to have received prior healthcare from public sector facilities. The total number of MV days during the reference period was 4356 days. The incidence of VAP in TICU was 9.7%, and the VAP incidence density was 10.79/1000 MV days.

VAP incidence, incidence density and ALOS

A total of 85 patients from this universe were included in this study. The demographic details of the study sample are summarized in Table 1.

Table 1.

Sample characteristics

Variable	Categories	VAP n (%)	non-VAP n (%)
Total sample		41 (100)	44 (100)
Age (years)	15-25	8 (19.5)	18 (40.9)
	26-35	11 (26.8)	11 (25)
	36-45	10 (24.4)	8 (18.2)
	>45	12 (29.3)	7 (15.9)
Sex	Male	35 (85.4)	36 (81.8)
	Female	6 (14.6)	8 (18.2)
Residence	Urban	21 (51.2)	17 (38.6)
	Rural	20 (48.8)	27 (61.4)
Education	Less than or upto primary education	11 (26.8)	10 (22.7)
	Upto secondary education	15 (36.6)	10 (22.7)
	Senior secondary or higher education	15 (36.6)	24 (54.5)
Occupation	Self employed	12 (29.3)	6 (13.6)
	Daily wager	11 (26.8)	9 (20.5)
	Regular salaried/Employee	8 (19.5)	6 (13.6)
	Unpaid family member	10 (24.4)	23 (52.3)
Insurance enrollment	Insured	23 (56.1)	27 (61.4)
	Non-insured	18 (43.9)	17 (38.6)
Payment profile for current hospitalization	Poor free (funded by hospital)	10 (24.4)	13 (29.5)
	Paid (paid fully by patient)	20 (48.8)	17 (38.6)
	AB-PMJAY (Govt Financed Health Insurance)	11 (26.8)	14 (31.8)
Religion	Hindu	29 (70.7)	29 (65.9)
	Muslim	2 (4.9)	4 (9.1)
	Sikh	10 (24.4)	11 (25)
Social group	SC (Scheduled Caste)/ST (Scheduled Tribe)	15 (36.6)	6 (13.6)
	OBC (Other Backward Castes)	4 (9.8)	7 (15.9)
	Unreserved	22 (53.7)	31 (70.5)
Comorbidities	Comorbidities present	20 (48.8)	29 (65.5)
	No comorbidities	21 (51.2)	15 (34.1)
Previous healthcare providers	None	1 (2.4)	11 (25)
	One	33 (80.5)	27 (61.4)
	Two or more	7 (17.1)	6 (13.6)
Type of previous healthcare provider*	Public	31 (75.6)	34 (77.3)
	Private	10 (24.4)	8 (18.2)

*Information not available for two patients

The ALOS of patients with VAP (n = 41) was 21 days, while the ALOS of the non-VAP (n = 44) group was 8.2 days and was significantly different (0.001). Similarly, the ALOS on ventilator was 18 days in VAP cases versus 5.6 days in patients without VAP (P = 0.0001).

Health system cost

The unit cost, i.e., the average total health system cost per bed per day, was calculated for both VAP and non-VAP groups. The per bed per day cost in TICU was INR 25,927 at 90% bed occupancy (current utilization), while the unit cost was INR 23,923 at 100% bed occupancy. The contribution of different cost centres to total health system cost at the current utilization is shown in Table 2.

Table 2.

Annual health system unit cost of TICU at 90% (current) and 100% utilization

TICU utilization
Cost head	Annual cost (in INR) at 90% (Current) utilization	Annual cost (in INR) at 100% utilization
Human resource	46206386	46206386
Building/infrastructure	19032048	19032048
Furniture	181215	181215
Equipment	15640059	15640059
Drugs	5371841	5953610
Consumables	14711258	16304482
Overheads	1320116.3	1463084
Total cost	102462924	104780883
Unit cost	25927	23923

We found the highest contribution to our total health system cost was the human resource cost (INR 4,62,06,386 per annum), which was 45% of the total cost. The infrastructure cost was INR 1,90,32,048 (19% of the total cost). The equipment and consumables cost were INR 1,56,40,059 and INR 1,47,11,258, respectively [Figure 1].

Figure 1.

Contribution of different cost centres to total health system cost at current utilization. A detailed analysis of the different cost heads in our study revealed that the highest contributor to our total health system cost is the human resource cost (INR 4,62,06,386 per annum), taking a 45% share in this costing pie

The per bed per day cost in TICU was INR 25,927. The VAP group had an ALOS of 21 days. Thus, the health system cost of treating a VAP patient admitted to TICU was found to be INR 5,44,467. In comparison, the health system cost of a non-VAP patient was INR 2,07,416. Thus, results showed that the hospital incurred an incremental cost of INR 3,37,051 in the treatment of every patient admitted to TICU who developed VAP as compared to every patient who did not develop VAP.

DISCUSSION

We found that the VAP incidence rate and the VAP incidence density of 9.7% and 10.79/1000 MV days in our ICU. Previously, the VAP rate was estimated at 3 percent per day during the first seven days of MV, two percent per day in the second week, and 1 percent per day thereafter.[14,15] The pooled cumulative incidence densities of VAP in developed and developing countries have been reported as 7.9 and 23.9/1000 MV days.[16] In another study conducted in seven Polish ICUs, the VAP incidence rate was 8.0%, and the VAP incidence density was 12.3 per 1000 MV days.[17] In a study from India, the VAP incidence rate was 57.14%, while the VAP incidence density was 31.7 per 1000 MV days.[5] A literature search revealed a substantial burden of VAP in India.[18,19,20,21,22,23,24]

[Supplementary Table A5: Epidemiological burden of VAP in India].

Supplementary Table A5.

Epidemiological burden of VAP in India

Epidemiological burden of VAP in India
Author (Year)	Type	Time period/ duration of study	Setting	Sample Size	Relevant findings from the study
Noyal Mariya Joseph et.a1 (2009)	Prospective observational study	15 months	MICU*	200	VAP positive cases - 35
			CCU**		Mortality due to VAP - 16.2%
Shalini et al (20 I 0)	Prospective observational study	18 months	ICU	355	VAP positive cases - 35
Mythri H et al. (2014)	Retrospective Analytical study	10 months	MICU*	130	VAP positive cases - 3
Binila Chacko et al. (2017)	Prospective observational study	1 year	MICU*	499	VAP positive cases - 50
					Mortality due to VAP - 26%
Chanaveerapa Bammigatti et al. (2017)	Prospective observational study	2.5 years	MICU*	364	VAP positive cases - l 64
Tuhina Banerjee et al. (2018)	Prospective Analytical study	5 years	ICU	2984	V AP positive cases - 683
M. Dwivedi et al. (2019)	Prospective observational study	2 years	ICU	200	V AP positive cases - 63
					Length of ICU stay due to HAI - 10 (2-76) days

The VAP incidence ranges from 5 to 67%, contingent on the diagnostic criteria. Our VAP rates are comparable to results in developed economies of the world.[17]

The hospital LOS has a direct and significant impact on the cost burden on both the hospital and the patient. The longer the hospital stay, the higher the number of hospital resources/services being utilized, leading to increased cost burden.[25] A comparison of the ALOS for VAP v/s non-VAP patients in our study showed that the ALOS was almost three times higher among VAP patients than the non-VAP patients (21 days vs. 8.2 days). Similarly, the ALOS on ventilator significantly differed among the two groups, with 18 days in VAP cases compared to 5.6 days in controls. The North American Silver-Coated Endotracheal Tube study, which was carried out at 54 medical facilities across the United States from 2002 to 2006, revealed that the median duration of overall hospitalization was 26.5 days for VAP vs. 14.0 days for non-VAP patients.[25] A study among shock TICU patients in the USA demonstrated that there was a significant increase in LOS between VAP and those without VAP (21.6 versus 6.4 days) and the number of MV days (17.7 versus 5.8).[26]

An ICU treatment typically costs 1700-4500 USD/day.[27] Providing ICU care is more affordable in low and middle-income countries (LMICs), given the lower staffing costs. For instance, a study conducted in our institute in 2013 estimated the average daily cost of ICU treatment of INR 12,697. Our study showed the ICU treatment’s average cost is INR 25,927. The increased cost in our study is due to the more exhaustive cost analysis tool and the additional building maintenance costs. Our institute bears an average cost of INR 5,44,467 for treating every patient admitted to TICU with VAP compared to INR 2,07,416 for those who did not develop VAP. The other estimates provided by various other Indian studies showed costs ranging from INR 11,000 to INR 15,500/bed/day [Supplementary Figure A6 ^{(50.7KB, tif)} : ICU cost comparison of per bed per day].

Analysis of the different cost heads in our study revealed that the highest contributor to the total health system cost is the human resource cost (INR 4,62,06,386 per annum), taking a 45% share in this costing pie. Similar studies across India also estimated 37-58% as human resource costs [Supplementary Figure A7 ^{(66.2KB, tif)} : Summary of cost heads from various studies in India].

García et al.[28] estimate the cost of human resources of 82% of the ICU budget. In another study conducted in 51 German ICUs, the staff expenditure accounted for 30–69% of the overall cost per patient.[29] The other major cost drivers in our study were the infrastructure cost of (capital cost of INR 1,90,32,048 at 19% share), equipment (INR 1,56,40,059 at 15%) and consumables (INR 1,47,11,258 at ~15%). While we attempted to measure the cost determinants in a tertiary care government institution, the daily cost of ICU treatment in the private sector would be around 100 times the per capita income in our nation as per the cost audit of intensive care conducted by Kulkarni et al.[30]

Finally, our study has a few limitations. We could not capture the cost of extra investigations and procedures exclusive to VAP. We did not match cases and controls as the sample size is very small and we did not have a pre- and post-test kind of methodology. The cost of medicines and consumables was apportioned as a whole. This was considered appropriate since there were no fixed criteria for the issue of drugs/consumables specifically for VAP. Subsidy calculation was not carried out.

CONCLUSION

In summary, we found that the VAP incidence rate and the VAP incidence density were 9.7% and 10.79/1000 MV days in our ICU. A unit bed per day cost for tertiary-level medical care in ICU was INR 25,927 at 90% bed occupancy and INR 23,923 at 100% bed occupancy. The hospital incurred an additional cost of INR 3,37,051 on the treatment of each patient admitted to TICU who developed VAP versus those who did not develop VAP. The hospital stays of patients who develop VAP have also increased substantially. Our study results indicate strict enforcement of infection control measures, which require authorities to allocate resources for focused changes in infection control, antibiotic stewardship and other relevant practices. These steps would eventually reduce the length of stay and the resultant financial impact on the health system and the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplementary Figure A1

Study Methodology Flow Chart

Supplementary Figure A2

Health System Costing

Supplementary Figure A6

ICU Cost Comparison of per bed per day

Supplementary Figure A7

Summary of Cost Heads from Various Studies in India

SUPPLEMENTARY A3- COSTING TOOL

1. Cost Data Collection Tool for Health System Costs-Trauma Intensive Care Unit (TICU)

Cost data collection tool: Human resource

Facility type: Tertiary Care

Interview Date: __________________ State Name: _______________________ Institute Name: ____________________

Department Name: _____________________

Section 1: Interview with the head of the facility or person In-charge

1. Please tell me how many days per week this facility is closed?: __________ (Days per week)

2. Please tell me how many hours per day this facility is open?: _________ (Hours per day)

3. If the facility remains closed on Public holidays, then mention total public holidays in last year: _________ (Days in year)

Section 2.

Human Resource-Salary and fringe benefits details (Details for each person separately using codes given below) It includes all the staff involved in OPD/IPD-ICU/OT i.e., doctor (Specialist), senior resident, junior resident, staff nurse, technician, data entry operator, pharmacist, helper, etc.

Serial No.	Job title (Doctor/Resident/Staff Nurse/Technician, etc.)	Speciality	Utility (OPD/IPD/ICU/Operation theatre)	Monthly gross salary (inclusive of all allowances or deductions)	Annual Incentive received for trainings (TA/DA received for trainings)	Period/days of posting in the reference year	Days of absence from this health facility in the period of posting in the reference year

Section 3.

Details of annual allowances received (Interviews and record review)

Staff No. Code	Government residence			Transport facility		Uniform provided/allowance			Any other allowance or Special allowance
	Square feet of the house building, or rooms provided i.e., covered area (Do mention the unit of data collection	Square feet of the open area in the accommodation provided (Do mention the unit of data collection)	Amount paid in a year or How much would you pay if you would rent this house i.e., monthly rental price*12?	Amount paid in a year	Vehicle name and year of make, if provided free	Times per year (a)	Unit cost of uniform (b)	Amount incurred on uniform (a*b) or If unit cost not available ask, “For how much it will be available from market, if bought on its own?”

Section 4.

Physical infrastructure (Interview and record review)

Table 1: Particulars	Specify
Area of the building (Total area in Sq. ft.) (Covered + open space)
What is the rental price of 100 sq. ft place where this Public Health centre is located?
Was there any expense on construction of building or renovation during the period of data collection

Section 5.

Details of stationary/sanitary items (considering whole of the department) (Record review for billed amounts of purchased stationary)

Item	Quantity	Expenditure

Section 6.

Utilities (Overall for whole of the department)

	Expenditure (Annual)
1. Building
Electricity
Water
Maintenance
Telephone
Other
Total (If available)
2. Equipment
Maintenance
Repairs
Other
Total (If available)
Others

Section 7.

Utilisation of funds and grants

Amount spent in the reference year	List services for which it is used. Write serial number codes from Tables on time sheet allocation

Section 8.

Sources of Revenue

		Amount collected during the reference year
1	Procedure fee
2	Others (specify)
3	Total user fee from the reference year

Section 9.

Time allocation sheet Staff Member Code (Enter Code as entered in Section 1)

Service code no	Activity name	Type of activity		Fixed schedule activity			Routine activity
		Fixed schedule	Routine schedule	Frequency (once in a week/once in month/twice a week etc.)*	Hours per day of activity	Days for which the activity was done during the reference year	Time per person (in minutes) (a)	Number of beneficiaries on a routine day (b)	If not (a) and (b) then how much time to do the activity
1	OPD
2	IPD
3	Operation Theatre
4	General Administration
5	Teaching/Training
6	Workshop/Conference
7	Outreach
8	Meetings
9	Research
10	Others (Specify)

*‘1’ for once a year participation, ‘2’ for twice a year, 3 for thrice a year participation, 4 for quarterly participation, 5 for once every two months, 6 for monthly participation, 7 for fortnightly participation, 8 for weekly participation, 9 for twice a week participation, 10 for thrice a week participation

COST DATA COLLECTION TOOL

Facility type: Tertiary Care

Interview Date: __________________ State Name: __________________ Institute Name: __________________

Department Name: __________________ Cost centre: TICU

Section 1.

Human resource (List the number of consultants/residents from other departments visiting the inpatient ward of the selected department)

S. No.	Designation	Speciality	Monthly gross salary	Average visits per week in the inpatient ward of the selected department	Average time per visit (in minutes)
1
2

Section 2.

Annual service detail

S. No.	Number of patients admitted in the inpatient ward/ICU of the department	Specific reason of admission (if any)
1
2

Section 3.

Room wise dimensions: TICU

S. No.	Room Name	Dimension (in sq. feet)
1
2

Section 4.

Details about non-medical items (Observation` and record review) (Do ask for any items that are there in stock register and are stored due to non-utilisation or non- functionality)

Name of the non-medical equipment or furniture	Quantity of functioning items in each room
	ICU no. 1	ICU no. 2	ICU no. 3	ICU no. 4	ICU no. 5	ICU no. 6	ICU no. 7	ICU no. 8	ICU no. 9	ICU no 10	Corridor

Section 5.

Details of Equipment (Observation cum record review of stock registers)

Room No.	Equipment	Quantity	Year of purchase	Unit price	Expected/useful life of the equipment
ICU room

Section 6.

Details of drugs consumed in cost centre (Consumption data to be taken and not the supply data) (Review the stock- register and list the quantity of drugs in drug list sheets)

S. No.	Name of Drug	Quantity consumed	Quantity expired	Unit price

Section 7.

Details of Consumable consumed in cost centre during the reference period. (Material and Supplies consumed in the facility)

S. No.	Consumables	Quantity	Price

Section 8.

Utilities Diet & Laundry

	Quantity or expenditure (Annual)
Different types of laundry items washed
Total
Different types of diets served
Total