Disparities in adult critical care resources across Pakistan: Findings from a national survey and assessment using a novel scoring system

Background: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan\u27s baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities.Methods: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles.Results: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p \u3c 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks.Conclusion: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities

Delivering critical care in remote and resource-limited settings through a neoteric tele-ICU service: A COVID-19 experience from Pakistan

Background: Since February 2020, there have been 825,519 confirmed COVID-19 cases and 17,957 fatalities across Pakistan. The number of ICU beds in Pakistan is approximately 2166, a ratio of 0.7 beds per 100,000 population. Critical care resources are concentrated in metropolitan cities with limited availability in rural areas. These gross shortages have escalated during the COVID-19 pan[1]demic, leaving large parts of the country without access to skilled personnel or ICU beds. The Aga Khan University established a free 24/7 teleICU consultation service to rapidly increase access to trained personnel during the COVID-19 pandemic.Methods: The tele-ICU service adheres to a Scheduled and Responsive Care Model delivered through a centralized and decentralized structure. Using two-way audio-visual technology, the tele-ICU lever[1]ages critical care expertise and connects to clinical teams in rural and remote hospital settings. End[1]to-end encrypted Zoom and WhatsApp applications or telephone calls are utilized. Initially, only COVID-19 patients were consulted; however, coverage was broadened to include surgical and medical patients requiring intensive care.Results: Between June 2020 and April 2021, 1709 teleconsultations have been conducted on 404 patients. These include 339 COVID-19 patients, 231 of which were severe and critically ill. An esti[1]mated 20,394 minutes of consultative services have been provided covering 26 hospitals across 4 provinces. The mean call duration of each teleconsultation was 13.29 (1-60) minutes. The major mode of communication was Zoom (45.58%) followed by Telephone (43.30%) and WhatsApp (11.12%). The overall hospital discharge outcome for the teleICU is 58.27% with a mortality rate of 29.13%. The remaining patients (12.60%) were transferred or left against medical advice.Conclusion: To combat the insufficient critical care capacity, Aga Khan University implemented a novel tele-ICU service to provide an innovative solution for coordination of care and increase avail[1]ability of intensivists in remote settings across Pakistan

166: Clinical outcomes of critically ill covid-19 patients seen through tele-ICU services in Pakistan

Introduction: As the surge of COVID-19 continues, low resource settings such as Pakistan have encountered an acute shortage of ICU facilities and trained intensivists. The dearth of resources is apparent in the remote region of Northern Pakistan. Therefore, we established a tele-ICU consultation service model to address these concerns and leverage critical care capacity in these remote settings.Methodology: This study was conducted in Gilgit and Chitral secondary care hospital in Northern Pakistan. Gilgit is a 46-bedded hospital with 6 ventilators, and Chitral is a 25-bedded hospital with 3 ventilators in their ICU. The study duration is 1 year from July 2020 till June 2021. This is a centralised and decentralised hub-and-spoke tele-ICU model. The main hub is located in Aga Khan University Hospital (AKUH) in the metropolitan city Karachi. The distance from the main hub to the remote facilities is approximately 1800km. The tele-ICU followed a 24/7 Scheduled Care Model (periodic consultations on a predetermined time) and Responsive Care Model (unscheduled teleconsultations prompted by an alert) to provide care. The mode of communication is teleconference calls, video calls, and text messaging. This service is provided by 24/7 AKUH trained intensivists. Patient information such as demographics, clinical course, teleconsultation interventions, and management were obtained from these remote ICUs.Results: A total of 157 patients presented to the tele-ICU from Pakistan’s remote regions of Gilgit and Chitral. Of these, 60% were male (n=95). 86% (n=135) patients presented with COVID-19. 64% (n=97) patients had comorbidities with hypertension (47%, n=46) being the most common. Invasive mechanical ventilation was provided to 12% (n=18) of the tele-ICU patients, while 62% patients (n=98) received non-invasive mechanical ventilation interventions. Average length of stay of patients in the tele-ICU was 9 days with a range of 1-41 days. 72% (n=113) patients were discharged home from the hospital. Tele-ICU mortality was 29% (n=44).Conclusion: We utilized a peer-to-peer tele-consult model to support critical care services in Northern Pakistan. The survival rate achieved by this model is comparable to national and international hospital published data. This was possible through use of multimodal information technology in Pakistan

Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system

Abstract Background In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan’s baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. Methods To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. Results A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public–private and metropolitan–rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. Conclusion Pakistan has an underdeveloped critical care network with significant inequity between public–private and metropolitan–rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities