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

February 2018 | Volume 6 | Article 381
published: 27 February 2018
doi: 10.3389/fped.2018.00038
Frontiers in Pediatrics |
Edited by:
Srinivas Murthy,
University of British
Columbia, Canada
Reviewed by:
Ericka L. Fink,
University of Pittsburgh,
United States
Amelie von Saint Andre-von Arnim,
University of Washington,
United States
Rashan Haniffa
Specialty section:
This article was submitted to
Pediatric Critical Care,
a section of the journal
Frontiers in Pediatrics
Received: 10January2018
Accepted: 09February2018
Published: 27February2018
BeaneA, AthapattuPL, DondorpAM
and HaniffaR (2018) Commentary:
Challenges and Priorities for Pediatric
Critical Care Clinician–Researchers in
Low- and Middle-Income Countries.
Front. Pediatr. 6:38.
doi: 10.3389/fped.2018.00038
Commentary: Challenges and
Priorities for Pediatric Critical Care
Clinician–Researchers in Low- and
Middle-Income Countries
Abigail Beane1, Priyantha Lakmini Athapattu2, Arjen M. Dondorp3,4 and Rashan Haniffa1*
1 Network for Improving Critical Care Systems and Training (NICST), Colombo, Sri Lanka, 2 Ministr y of Health, Nutrition and
Indigenous Medicine, Colombo, Sri Lanka, 3 Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine,
Mahidol University, Bangkok, Thailand, 4 Centre for Tropical Medicine, Medical Sciences Division, University of Oxford,
Oxford, United Kingdom
Keywords: low- and middle-income countries, low resource settings, researchers, pediatric critical care, support
of research, surveys and questionnaires, intensive care unit
A commentary on
Challenges and Priorities for Pediatric Critical Care Clinician–Researchers in Low- and Middle-
Income Countries
by Von Saint Andre-Von Arnim AO, Attebery J, Kortz TB, Kissoon N, Molyneux EM, Musa NL, etal.
Front Pediatr (2017) 5:277. doi: 10.3389/fped.2017.00277
Von Saint Andre-Von Arnim and colleagues noted that LMIC clinicians should be empowered to
inuence local and global research agendas for critically unwell children (1). We too can report
that clinicians trained in LMIC acknowledge the need for systematic gathering of outcome data in
improving services and endorse the role that non-LMIC collaborators can play in contributing to
training, surveillance, and research (2). Interestingly, these perceptions were more strongly held
when compared to High Income Country (HIC) counterparts with experience in LMIC settings.
ese ndings perhaps point to untapped opportunities to upskill LMIC clinicians to build equitable
research and training partnerships with their non-LMIC counterparts.
Network for Improving Critical Care Systems and Training (NICST) is an LMIC-based organiza-
tion working collaboratively, since 2012, with clinical teams to build capacity for research, train-
ing, and continuous audit to improve patient outcomes (3). A collaboration between clinicians,
researchers, and educational experts based in HICs and LMIC, the network, funded in part by a UK
grassroots charity of the same name, links over 110 state and private sector hospitals and has trained
over 4,500 nurses and doctors in acute and critical care skills.
e NICST platform, a clinician-led mobile electronic health information initiative, is an example
of a setting-adapted national registry for critically unwell adults, children, and neonates in Sri Lanka
and beyond. Output from the registry supports a critical care bed availability system that facilitates
access to and utilization of resources and provides information on post-hospital outcomes (4).
Mobile applications linked to the platform improve the availability of information essential for the
care of individual patients and enable practical training for nurses and doctors (5). Partnered with
institutions based in HIC (UK and the Netherlands), it is creating educational opportunities (MSc,
PhD pathways) (6, 7) and undertaking frontline quality improvement projects in Sub-Saharan Africa
and South Asia.
Creating sustainable partnerships that harness the power of the existing LMIC-based network
enables equitable exchange of expertise and fosters greater understanding of setting-specic research
priorities. We anticipate that these successful collaborations coupled with rising awareness of the
importance of high-quality surveillance systems in LMIC will somewhat help address the challenges
Beane et al. NICS: Novel LMIC-Based Network
Frontiers in Pediatrics | February 2018 | Volume 6 | Article 38
currently experienced by LMIC-based researchers approaching
traditional funding streams. We believe our model provides a
template for promoting setting-relevant research, which can
enable successful south-to-south (and perhaps south-to-north!)
RH and AB wrote the rst dra of the manuscript. AD and PA
approved and improved the manuscript. All the authors approved
the contents.
1. Von Saint Andre-Von Arnim AO, Attebery J, Kortz TB, Kissoon N, Molyneux EM,
Musa NL, etal. Challenges and priorities for pediatric critical care clinician-
researchers in low- and middle-income countries. Front Pediatr (2017) 5:277.
2. Hania R, De Silva AP, de Azevedo L, Baranage D, Rashan A, Baelani I, etal.
Improving ICU services in resource-limited settings: perceptions of ICU work-
ers from low-middle-, and high-income countries. J Crit Care (2017) 44:352–6.
3. Network for Improving Critical Care Systems and Training (NICST). Available
from: (accessed February, 2018).
4. Rathnayake S. Smart Content for Smart People Best Practices of Sri Lankan
e-Content and Applications of 2014. (2014). p. 28–30. Available from:le/upload/1/Document/1503/Smart Content for Smart
5. De Silva AP, Harischandra PL, Beane A, Rathnayaka S, Pimburage R,
Wijesiriwardana W, et al. A data platform to improve rabies prevention, Sri
Lanka. Bull World Health Organ (2017) 95(9):646. doi:10.2471/BLT.16.188060
6. Hania R, Mukaka M, Munasinghe SB, De Silva AP, Jayasinghe KS, Beane A,
etal. Simplied prognostic model for critically ill patients in resource limited set-
tings in South Asia. Crit Care (2017) 21(1):250. doi:10.1186/s13054-017-1843-6
7. Beane A, Padeniya A, De Silva AP, Stephens T, De Alwis S, Mahipala PG, etal.
Closing the theory to practice gap for newly qualied doctors: evaluation of
a peer-delivered practical skills training course for newly qualied doctors
in preparation for clinical practice. Postgrad Med J (2017) 93(1104):592–6.
Conict of Interest Statement:e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
Copyright © 2018 Beane, Athapattu, Dondorp and Hania. is is an open-access
article distributed under the terms of the Creative Commons Attribution License
(CC BY). e use, distribution or reproduction in other forums is permitted, provided
the original author(s) and the copyright owner are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice. No
use, distribution or reproduction is permitted which does not comply with these terms.
... Patient expectations regarding ICU care in Sri Lanka may be different to those of high income countries due to a multitude of factors, including, the fierce competition for scarce critical care services [24][25][26][27] relatively lowstaffing, overcrowding and low resources in non-critical care wards to which patients are discharged to, and originate from [27,28], and conversely the relatively well staffed ICU environment [29,30]. In addition, cultural beliefs regarding critical illness [31] may further influence patient perspectives and need further exploration in this setting [32]. ...
... Patient expectations regarding ICU care in Sri Lanka may be different to those of high income countries due to a multitude of factors, including, the fierce competition for scarce critical care services [24][25][26][27] relatively lowstaffing, overcrowding and low resources in non-critical care wards to which patients are discharged to, and originate from [27,28], and conversely the relatively well staffed ICU environment [29,30]. In addition, cultural beliefs regarding critical illness [31] may further influence patient perspectives and need further exploration in this setting [32]. ...
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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.
... NICST has trained over 4,500 nurses and doctors in acute and critical care skills. Beyond the clinical training this "collaborative of clinicians, researchers, and educational experts linked through continuous audit is designed to improve patient outcomes" (16). NICST research focuses on improving quality and access of acute and critical care services by combining "clinical medicine with health informatics, epidemiological and social science, along with health systems and improvement science" (17,18). ...
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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.
... Motivated by an ambition to address the need for data-driven healthcare improvement that empowers users, the platform was developed using a cycle of implementation, co-evaluation and feedback. 13 To support evaluation of adoption, qualitative enquiry founded in technology adoption frameworks were utilised to guide understanding of potential social and behavioural influences of the team. 17 design Working directly in partnership with the Ministry of Health, clinicians and administrative end users, a minimal data set was derived based on previous work undertaken by the collaboration. ...
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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.
... 3 In South Asia, a region encompassing eight countries and a population of 1.87 billion (24.6% of the world's population), only Sri Lanka has a national intensive care registry. 4,5 Investment in registries remains limited with ambiguity and concern over cost, sustainability and feasibility. Experiences from HICs have demonstrated that registries can be difficult to implement; requiring specialist and expensive information technology. ...
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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.
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This book is a review of 49 white papers which were selected through e-Swabhimani 2014, Best e-Content and Application award of Sri Lanka. White papers are normally used in two main spheres, government and business-to-business marketing. The main objective of this book is to benchmark the best e-content and applications developed in Sri Lanka in year 2014 and take them to a national and international level. It has been identified that most of e-content and applications are innovative in answering a problem in today’s world. For example, the white paper on iHelmet is a good solution for ordinary motorbike riders. It’s an application developed for smart phones and ordinary helmets which uses Bluetooth, wireless and sensor-based technology to provide convenience and safety for motorbike riders. This book discussed ICT innovation in nine categories, namely, e-Government & Institutions, e-Health & Environment, e-Learning & Education, e-Entertainment & Games, e-Culture & Heritage, e-Science & Technology, e-Business & Commerce, e-Inclusion & Participation and m-Content.
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Introduction There is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high. Materials and methods To inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis. Results The majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation. Conclusion LMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success.
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Background Current critical care prognostic models are predominantly developed in high-income countries (HICs) and may not be feasible in intensive care units (ICUs) in lower- and middle-income countries (LMICs). Existing prognostic models cannot be applied without validation in LMICs as the different disease profiles, resource availability, and heterogeneity of the population may limit the transferability of such scores. A major shortcoming in using such models in LMICs is the unavailability of required measurements. This study proposes a simplified critical care prognostic model for use at the time of ICU admission. Methods This was a prospective study of 3855 patients admitted to 21 ICUs from Bangladesh, India, Nepal, and Sri Lanka who were aged 16 years and over and followed to ICU discharge. Variables captured included patient age, admission characteristics, clinical assessments, laboratory investigations, and treatment measures. Multivariate logistic regression was used to develop three models for ICU mortality prediction: model 1 with clinical, laboratory, and treatment variables; model 2 with clinical and laboratory variables; and model 3, a purely clinical model. Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer-Lemeshow C-Statistic; higher values indicate poorer calibration). Comparison was made with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II models. Results Model 1 recorded the respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), blood urea, haemoglobin, mechanical ventilation, and vasopressor use on ICU admission. Model 2, named TropICS (Tropical Intensive Care Score), included emergency surgery, respiratory rate, systolic blood pressure, GCS, blood urea, and haemoglobin. Model 3 included respiratory rate, emergency surgery, and GCS. AUC was 0.818 (95% confidence interval (CI) 0.800–0.835) for model 1, 0.767 (0.741–0.792) for TropICS, and 0.725 (0.688–0.762) for model 3. The Hosmer-Lemeshow C-Statistic p values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, when APACHE II and SAPS II were applied to the same dataset, AUC was 0.707 (0.688–0.726) and 0.714 (0.695–0.732) and the C-Statistic was 124.84 (p < 0.001) and 1692.14 (p < 0.001), respectively. Conclusion This paper proposes TropICS as the first multinational critical care prognostic model developed in a non-HIC setting. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1843-6) contains supplementary material, which is available to authorized users.
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Problem: In Sri Lanka, rabies prevention initiatives are hindered by fragmented and delayed information-sharing that limits clinicians' ability to follow patients and impedes public health surveillance. Approach: In a project led by the health ministry, we adapted existing technologies to create an electronic platform for rabies surveillance. Information is entered by trained clinical staff, and both aggregate and individual patient data are visualized in real time. An automated short message system (SMS) alerts patients for vaccination follow-up appointments and informs public health inspectors about incidents of animal bites. Local setting: The platform was rolled out in June 2016 in four districts of Sri Lanka, linking six rabies clinics, three laboratories and the public health inspectorate. Relevant changes: Over a 9-month period, 12 121 animal bites were reported to clinics and entered in the registry. Via secure portals, clinicians and public health teams accessed live information on treatment and outcomes of patients started on post-exposure prophylaxis (9507) or receiving deferred treatment (2614). Laboratories rapidly communicated the results of rabies virus tests on dead mammals (328/907 positive). In two pilot districts SMS reminders were sent to 1376 (71.2%) of 1933 patients whose contact details were available. Daily SMS reports alerted 17 public health inspectors to bite incidents in their area for investigation. Lessons learnt: Existing technologies in low-resource countries can be harnessed to improve public health surveillance. Investment is needed in platform development and training and support for front-line staff. Greater public engagement is needed to improve completeness of surveillance and treatment.
Purpose: To evaluate perceptions of intensive care unit (ICU) workers from low-and-middle income countries (LMICs) and high income countries (HICs). Materials and methods: A cross sectional design. Data collected from doctors using an anonymous online, questionnaire. Results: Hundred seventy-five from LMICs and 43 from HICs participated. Barriers in LMICs were lack of formal training (Likert score median 3 [inter quartile range 3]), lack of nurses (3[3]) and low wages (3[4]). Strategies for LMICs improvement were formal training of ICU staff (4[3]), an increase in number of ICU nurses (4[2]), collection of outcome data (3[4]), as well as maintenance of available equipment [3(3)]. The most useful role of HIC ICU staff was training of LMIC staff (4[2]). Donation of equipment [2(4)], drugs [2(4)], and supplies (2[4]) perceived to be of limited usefulness. The most striking difference between HIC and LMIC staff was the perception on the lack of physician leadership as an obstacle to ICU functioning (4[3] vs. 0[2], p<0.005). Conclusion: LMICs ICU workers perceived lack of training, lack of nurses, and low wages as major barriers to functioning. Training, increase of nurse workforce, and collection of outcome data were proposed as useful strategies to improve LMIC ICU services.
Purpose: The Good Intern Programme (GIP) in Sri Lanka has been implemented to bridge the 'theory to practice gap' of doctors preparing for their internship. This paper evaluates the impact of a 2-day peer-delivered Acute Care Skills Training (ACST) course as part of the GIP. Study design: The ACST course was developed by an interprofessional faculty, including newly graduated doctors awaiting internship (pre-intern), focusing on the recognition and management of common medical and surgical emergencies. Course delivery was entirely by pre-intern doctors to their peers. Knowledge was evaluated by a pre- and post-course multiple choice test. Participants' confidence (post-course) and 12 acute care skills (pre- and post-course) were assessed using Likert scale-based questions. A subset of participants provided feedback on the peer learning experience. Results: Seventeen courses were delivered by a faculty consisting of eight peer trainers over 4 months, training 320 participants. The mean (SD) multiple choice questionnaire score was 71.03 (13.19) pre-course compared with 77.98 (7.7) post-course (p<0.05). Increased overall confidence in managing ward emergencies was reported by 97.2% (n=283) of respondents. Participants rated their post-course skills to be significantly higher (p<0.05) than pre-course in all 12 assessed skills. Extended feedback on the peer learning experience was overwhelmingly positive and 96.5% would recommend the course to a colleague. Conclusions: A peer-delivered ACST course was extremely well received and can improve newly qualified medical graduates' knowledge, skills and confidence in managing medical and surgical emergencies. This peer-based model may have utility beyond pre-interns and beyond Sri Lanka.