Commentary: Challenges and Priorities for Pediatric Critical Care Clinician-Researchers in Low- and Middle-Income Countries

Pediatric Critical Care in Resource Limited Settings-Lessening the Gap Through Ongoing Collaboration, Advancement in Research and Technological Innovations

Pediatric critical care has continued to advance since our last article, "Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned" was written just 3 years ago. In that article, we reviewed the history, current state, and gaps in level of care between low- and middle-income countries (LMICs) and high-income countries (HICs). In this article, we have highlighted recent advancements in pediatric critical care in LMICs in the areas of research, training and education, and technology. We acknowledge how the COVID-19 pandemic has contributed to increasing the speed of some developments. We discuss the advancements, some lessons learned, as well as the ongoing gaps that need to be addressed in the coming decade. Continued understanding of the importance of equitable sustainable partnerships in the bidirectional exchange of knowledge and collaboration in all advancement efforts (research, technology, etc.) remains essential to guide all of us to new frontiers in pediatric critical care.

Addressing the information deficit in global health: lessons from a digital acute care platform in Sri Lanka

Lack of investment in low-income and middle-income countries (LMICs) in systems capturing continuous information regarding care of the acutely unwell patient is hindering global efforts to address inequalities, both at facility and national level. Furthermore, this of lack of data is disempowering frontline staff and those seeking to support them, from progressing setting-relevant research and quality improvement. In contrast to high-income country (HIC) settings, where electronic surveillance has boosted the capability of governments, clinicians and researchers to engage in service-wide healthcare evaluation, healthcare information in resource-limited settings remains almost exclusively paper based. In this practice paper, we describe the efforts of a collaboration of clinicians, administrators, researchers and healthcare informaticians working in South Asia, in addressing the inequality in access to patient information in acute care. Harnessing a clinician-led collaborative approach to design and evaluation, we have implemented a national acute care information platform in Sri Lanka that is tailored to priorities of frontline staff. Iterative adaptation has ensured the platform has the flexibility to integrate with legacy paper systems, support junior team members in advocating for acutely unwell patients and has made information captured accessible to diverse stakeholders to improve service delivery. The same platform is now empowering clinicians to participate in international research and drive forwards improvements in care. During this journey, we have also gained insights on how to overcome well-described barriers to implementation of digital information tools in LMIC. We anticipate that this north-south collaborative approach to addressing the challenges of health system implementation in acute care may provide learning and inspiration to other partnerships seeking to engage in similar work.

Pakistan Registry of Intensive CarE (PRICE): Expanding a lower middle-income, clinician-designed critical care registry in South Asia

Introduction

In resource-limited settings - with inequalities in access to and outcomes for trauma, surgical and critical care - intensive care registries are uncommon.

Aim

The Pakistan Society of Critical Care Medicine, Intensive Care Society (UK) and the Network for Improving Critical Care Systems and Training (NICST) aim to implement a clinician-led real-time national intensive care registry in Pakistan: the Pakistan Registry of Intensive CarE (PRICE).

Method

This was adapted from a successful clinician co-designed national registry in Sri Lanka; ICU information has been linked to real-time dashboards, providing clinicians and administrators individual patient and service delivery activity respectively.

Output

Commenced in August 2017, five ICU's (three administrative regions - 104 beds) were recruited and have reported over 1100 critical care admissions to PRICE.

Impact and future

PRICE is being rolled out nationally in Pakistan and will provide continuous granular healthcare information necessary to empower clinicians to drive setting-specific priorities for service improvement and research.

Experiences of ICU survivors in a low middle income country- a multicenter study

Background

Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC.

Methods

This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors’ experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright.

Results

Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%).

The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be “very satisfactory” (93.8%, n = 411) with none of the survivors stating they were either “dissatisfied” or “very dissatisfied”.

Conclusion

In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0494-8) contains supplementary material, which is available to authorized users.