Background: COVID-19 emerged as a global health crisis with multiple waves of infection ranging from asymptomatic to critical cases requiring intensive care. In Pakistan, dearth of ICU data limit understanding of critical care admissions and outcomes, making it difficult to understand critical care admissions and outcomes. This study aims to describe demographics, clinical characteristics, and outcomes of patients with SARS-CoV-2 infection admitted to 69 intensive care units (ICUs) during five waves of pandemic in Pakistan.
Methods: This study analyzed prospectively collected data of adult COVID-19 patients admitted to Pakistan Registry of Intensive Care (PRICE) ICUs from April 2020 to March 2022.
Results: 9,102 ICU admissions were reported during the study period, with highest in Wave 1 (n=2,704) and Wave 2 (n=2,563). Most admissions were male, and predominant age group was 60-79 years. Patients aged>80 years increased from 8.9% in Wave 4 to 18.6% in Wave 5. Common presenting symptoms were shortness of breath, fever, and cough with no sputum. Highest mortality was recorded during Waves 3 and 4 (41%). Among patients requiring organ support, mortality increased from 50% in Wave 1 to 65% in Wave 4. Cox regression showed younger age, low
oxygen saturation, and cardiovascular disease were associated with higher risk of invasive mechanical ventilation (IMV).
Conclusion: Mortality was highest during Waves 3 and 4, particularly among patients requiring organ support. Younger patients, those with low oxygen saturation, and individuals with cardiovascular diseases were at increased risk for IMV.
Background: The Collaboration for Research, Implementation, and Training in Critical Care in Asia (CCA) is implementing a critical care registry to capture real-time data to facilitate service evaluation, quality improvement, and clinical studies.
Objective: The purpose of this study is to examine stakeholder perspectives on the determinants of implementation of the registry by examining the processes of diffusion, dissemination, and sustainability.
Methods: This study is a qualitative phenomenological inquiry using semistructured interviews with stakeholders involved in registry design, implementation, and use in 4 South Asian countries. The conceptual model of diffusion, dissemination, and sustainability of innovations in health service delivery guided interviews and analysis. Interviews were coded using the Rapid
Identification of Themes from Audio recordings procedure and were analyzed based on the constant comparison approach.
Results: A total of 32 stakeholders were interviewed. Analysis of stakeholder accounts identified 3 key themes: innovation-system fit; influence of champions; and access to resources and expertise. Determinants of implementation included data sharing, research
experience, system resilience, communication and networks, and relative advantage and adaptability.
Conclusions: The implementation of the registry has been possible due to efforts to increase the innovation-system fit, influence of motivated champions, and the support offered by access to resources and expertise. The reliance on individuals and the priorities
of other health care actors pose a risk to sustainability.
The COVID-19 pandemic has revealed limitations in real-time surveillance needed for responsive health care action in low- and middle-income countries (LMICs). The Pakistan Registry for Intensive CarE (PRICE) was adapted to enable International Severe Acute Respiratory and emerging Infections Consortium (ISARIC)–compliant real-time reporting of severe acute respiratory
infection (SARI). The cloud-based common data model and standardized nomenclature of the registry platform ensure interoperability of data and reporting between regional and global stakeholders.
Inbuilt analytics enable stakeholders to visualize individual and aggregate epidemiological, clinical, and operational data in real time. The PRICE system operates in 5 of 7 administrative regions of Pakistan. The same platform supports acute and critical care registries in eleven countries in South Asia and sub-Saharan Africa. ISARIC-compliant SARI reporting was successfully implemented by leveraging the existing PRICE
infrastructure in all 49 member intensive care units (ICUs), enabling clinicians, operational leads, and established stakeholders with responsibilities for coordinating the pandemic response to access real-time information on suspected and confirmed COVID-19 cases (N=592 as of May 2020) via secure registry portals. ICU occupancy rates, use of ICU resources, mechanical ventilation,
renal replacement therapy, and ICU outcomes were reported through registry dashboards. This information has facilitated coordination of critical care resources, health care worker training, and discussions on treatment strategies. The PRICE network is now being recruited to international multicenter clinical trials regarding COVID-19 management, leveraging the registry
platform. Systematic and standardized reporting of SARI is feasible in LMICs. Existing registry platforms can be adapted for pandemic research, surveillance, and resource planning.
Pakistan Registry of Intensive Care (PRICE) is a platform that has enabled standardized COVID19 clinical data collection based on ISARIC/WHO Clinical Characterization Protocol. The near real-time data platform includes epidemiology, severity of illness, microbiology, treatment and outcomes
of patients admitted with suspected or laboratory confirmed COVID19 infection to 67 intensive care and high dependency units across the country. Data has been extracted and analysed at regular intervals to inform stakeholders and improve care practices. This is our 28th report including all patients with suspected or confirmed COVID-19 from 26th March 2020 to 26th December 2021.
The Randomized Embedded Multifactorial Adaptive Platform (REMAPCAP) adapted for COVID-19 trial is a global adaptive platform trial of hospitalised patients with COVID-19. We describe implementation in three countries under the umbrella of the Wellcome supported Low and Middle Income Country (LMIC) critical care network: Collaboration for Research, Implementation and Training in Asia (CCA).
The collaboration sought to overcome known barriers to multi centre-clinical trials in resource-limited settings.
Methods described focused on six aspects of implementation: i, Strengthening an existing community of practice; ii, Remote study site recruitment, training and support; iii, Harmonising the REMAP CAP- COVID trial with existing care processes; iv, Embedding REMAP CAP- COVID case report form into the existing CCA registry platform, v, Context specific adaptation and data management; vi, Alignment with existing pandemic and
critical care research in the CCA. Methods described here may enable other LMIC sites to participate as equal partners in international critical care trials of urgent public health importance, both during this pandemic and beyond.
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.
