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