hospitals in Canada spent $1.8 billion on their emergency departments (EDs). In the same year, more than one million patients were admitted via EDs. (This rate excludes hospitalizations in Quebec and hospitalizations for woman admitted for childbirth and infants born in hospital.) Based on analyses included in the Canadian Institute for Health Information (CIHI) Understanding Emergency Wait Times: Access to Inpatient Beds and Patient Flow (2007), we know that the majority of emergency patients

more »

... dmitted to hospital via an ED wait in the ED for access to an in-patient bed. Half the patients in our study waited for at least two hours, and one quarter of admitted patients waited more than 24 hours to be moved from the ED to an acute care bed. In this article, we have explored the proportion of ED spending that is dedicated to patients waiting for a bed. We have found that 6.5% of ED spending in Ontario (or $51 million) was dedicated to these patients in Ontario. It is generally agreed that there have been few studies of the costs of ED services (Bamezai et al. 2005; Williams 1996) . Studies that have looked at ED costs for admitted patients compared with those discharged home have found higher costs associated with admitted patients, particularly those who are older and those who visit large EDs located in urban areas (Bennett et al. 2007; Higginson and Guly 2007) . The intent of this article is to describe a method that can be used to determine the proportion of hospital spending and an estimated dollar value of spending in the ED that is associated with admitted patients waiting for access to an in-patient bed. Estimates at the provincial and Local Health Integration Network (LHIN) levels are provided. The method is based on financial and nursing workload reporting; it does not take into consideration issues external to the hospital that could impact costs such as availability of family physicians near the ED. Additional questions that need to be considered to more fully examine and understand ED costs are proposed in our conclusion. Data Sources and Methods All analyses reflect fiscal year 2005-2006. Pan Canadian rates of h o s p i t a lization via the ED (excluding those in Quebec) w e r e d e t e rmined from CIHI's Discharge Abstract Database. The Canadian Management Information Systems (MIS) Database (CMDB) holds financial and statistical data reported by healthcare organizations across Canada (including Quebec). Through the ability to use CMDB to link data from hospitals' clinical and financial databases, total spending on EDs, average cost per ED visit and the proportion of spending on admitted patients waiting in the ED were determined. Because data are submitted using the MIS standards chart of accounts, they are comparable across jurisdictions. ED volumes in Ontario were determined from CIHI's National Ambulatory Care Reporting System (NACRS). Hospital costs reported in the ED include salaries for nurses and other staff, medical supplies and drugs and maintenance and operation of ED equipment. The cost of non-salaried physicians working in the ED and costs associated with laboratory tests and other diagnostics have not been included. For provinces/territories outside of Ontario, cost per visit was estimated by dividing the costs charged directly to EDs by the number of ED visits as reported in the CMDB. For Ontario, costs per ED visit represents costs charged directly to EDs in the CMDB divided by the number of ED visits as reported in the NACRS. The portion of ED costs for patients who were admitted but waited in the ED for an in-patient bed were estimated by using nursing workload reported the hospitals. Workload in the ED is reported for both inpatients and outpatients and it is this split that allows the estimation of the cost associated with patients waiting for a bed. The estimates are only In