Establishing a critical care network in Asia to improve care for critically ill patients in low- and middle-income countries

When undertaking quality improvement (QI) initiatives, one of the greatest burdens is repeated data collection. Intensive care registries, such as those commonly used in high-income countries (HICs), have enabled systematic capture of routine information needed to measure intensive care unit (ICU) performance [1]. Once considered unfeasible in resource-limited settings, newer cloud-based platforms are gaining increasing traction. Collaborative surveillance platforms, such as NICS-MORU and PRICE, which have mobile and desktop applications, have established methods for daily capture of individual patient-level information and have shown that—even in resource-limited settings—the systematic evaluation of patient care throughout the hospital journey is feasible at scale using coalesced minimal data sets [2, 3].

Poor quality of care has resulted in an estimated additional five million deaths, and six trillion US dollars in economic losses worldwide [4, 5]. In South and South-East Asia, a region which accounts for over 25% of the world’s population, poor quality health care is one of the biggest drivers of excess morbidity and mortality [4]. Recent recommendations from the Lancet Global Health Commission have called for greater investment in systems that strengthen evaluation and improvement, and a focus on healthcare that is reflective of and sensitive to the diverse needs of communities [5].

Critical care is expensive and complex. Many barriers impede the optimal care of critically ill patients, especially in resource-restricted settings [6]. Basic equipment for monitoring, treatment and diagnosis is often unavailable and maintenance is suboptimal [7]. Supplies of laboratory consumables and essential medications can be unpredictable and the provision of basic commodities, such as oxygen, electricity and running water, unreliable. Despite these challenges, demand for these services continues and with it the need to establish systems by which quality of care can be continually improved.

Supported by a Wellcome Innovations Flagship Programme grant, our group of multidisciplinary healthcare professionals predominantly based in Asia, is establishing a locally led collaborative network: Collaboration for Research, Implementation and Training in intensive CARE in ASIA (CRIT CARE ASIA). The collaboration will improve patient outcomes using near real-time high-quality data to drive improvement and strengthen the health system through a system of audit and feedback. Delivered over 3 years and extendable beyond this period, the programme will establish an Asian ICU network across 42 units in nine countries and implement a setting-adapted electronic cloud-based registry co-designed and developed by clinicians in the region (Fig. 1). Using the registry, plus qualitative and quantitative research methods, CRIT CARE ASIA will evaluate the quality of critical care, which will then lead into locally led QI interventions to improve ICU performance and patient outcomes driven by the priorities of stakeholders.

The network will enable the implementation and evaluation of innovative LMIC technologies and provide opportunity for data linkage with the registry [14]. The ICU network, supported by the electronic registry, will facilitate epidemiological and clinical research. CRIT CARE ASIA uses a Common Data Model and standard nomenclature and coding, which will facilitate comparison of data with globally relevant health data networks such as ISARIC and LOGIC. Many critically unwell patients are cared for outside of the ICU [6]. Many of the strategies to improve the quality of processes of care will therefore need to extend beyond the ICU to encompass surgical, emergency medicine and community-based services as already demonstrated in Sri Lanka [15].