Spotlight - Senior Travelling Fellow 2018, Madiha Hashmi

In January 2018, Dr Madiha Hashmi received the Intensive Care Society’s Senior Travelling Fellowship which helped her to realise the ambition of establishing the Pakistan Registry of Intensive CarE (PRICE). In this blog she shares highlights of how the fellowship  enabled the evaluation of existing critical care services, identified opportunities for critical care research, training and capacity building within the international critical care community.   

Dr Madiha Hashmi is the founding CEO of South East Asian Research in Critical care Health (SEARCH) and leading the Pakistan Registry of Intensive CarE (PRICE). Dr Hashmi is also the President of Pakistan Society of Critical Care Medicine (PSCCM), a member of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) and InFACT. She is the Secretary of the Faculty of CCM at the College of Physicians and Surgeons Pakistan (CPSP) that assists the Department of Medical Education develop curricula, accredits and appoints supervisors and examiners.

She was Assistant Professor, Department of Anaesthesiology at the Aga Khan University (AKU), Karachi Pakistan and the university’s Director of Critical Care Medicine Fellowship Training Programme (CCMF), which is one of the eight training programmes recognized by the CPSP to train candidates for sub-specialty training (FCPS) in Critical Care Medicine (CCM). She is the winner of the Global Sepsis Award (Seoul 2015) for her outstanding awareness raising initiatives in Pakistan. Building on the successful project  started during the ICS fellowship, Madiha continues her collaboration with NICST-MORU as she embarks on a PhD pathway focused on improving quality of critical care in Pakistan.  

The goal of the fellowship

My journey started in September 2017, when my colleagues and I in Pakistan sought to understand the provision of existing critical care services and identify priorities for improving care. To do this we used a methodology designed and successfully implemented in Sri Lanka, by a research collaboration of Network for Improving Critical Care Systems and Training (NICST) and Mahidol Oxford Tropical Medicine Research Unit (MORU), Thailand. The aim of the fellowship was to support implementation of PRICE - an electronic real time surveillance platform which uses routine information to enable evaluation of critical care services and enables clinicians and policy makers to harness the information to identify opportunities for quality improvement, research and capacity building within the international critical care community.   

Rising pressures on critical care in Pakistan

Pakistan is a developing country with a population of nearly 200 million people with rising demands for critical care services. Increasing incidence of trauma following road traffic and construction incidents, infectious diseases resulting in organ dysfunction and a growing epidemic of non-communicable diseases and their related complications, all place considerable burden on the limited and disparate critical care services that currently exist nationally.  

Why we need to provide a mechanism to benchmark and evaluate existing care and plan for the future

Having trained in Anaesthesia (1991-1996) and Intensive care (2005), I returned to Pakistan with a desire to build capacity for education and research in the region. My role, first as an anaesthetist and later as a full time intensivist has seen me help to establish a dedicated burns critical care service in a densely populated area of Karachi and help to establish critical care as an independent speciality through a dedicated speciality training programme.  

With a growing interest in acute and critical care, Pakistan’s doctors and allied healthcare professionals now have the opportunity to practice critical care in Pakistan, with postgraduate training opportunities established nationally. With rising demand on critical care services, increasing demands for resource investment and growing interest from professional bodies in how to strengthen the quality of critical care systems, the next natural step seemed to be to help provide a mechanism through which existing care could be benchmarked, quality of care evaluated and priorities for future investment in infrastructure, human resource and training be identified.  

What we did

Building on the successful co-implementation methods used in Sri Lanka, the registry of intensive care services was piloted in 5 ICU’s in 3 cities of Pakistan (Karachi, Islamabad and Lahore).  The data collection platform was adapted to reflect the priorities of local clinicians. Implementation, data collection, and technical support for the registry adaptation and scale up was provided by NICST-MORU (with a seed fund awarded by the Wellcome Trust Institutional Translational Partnership Award).

In Pakistan the project is locally supported by SEARCH (South East Asian Research in Criticalcare Health, a charity to promote investigator led research in the region. The 14th International Conference on Anaesthesia, Pain and Intensive Care in Pakistan held in Bhurban, a small hill station 100 km from the capital city of Islamabad, provided a forum through which the aims of the collaboration could be shared with the wider anaesthesia and critical care community in Pakistan. The idea of the registry was well received by the Pakistan Society of Critical Care Medicine (PSCCM) and senior colleagues within the clinical and scientific community.
Our achievements over the last year
Over 12 months and in collaboration with clinical colleagues, I worked alongside stakeholders in Pakistan, NICST, MORU, ICS and PSCCM to achieve the following milestones:

Implementation of the registry - we now have over 25 centres (and growing) from 5 administrative regions of Pakistan as part of the network and have reached a milestone of providing information on over 10,000 patient episodes. Focus of the collaboration is now on supporting individual sites to utilise the registry to identify priorities for quality improvement, measure the burden of critical care and provide a foundation for future research. 

Service review of existing critical care provisions in Pakistan,
systematically mapping ICUs in the country and documenting existing organisational structures, provision of training and infrastructure within institutions recognised for critical care training. We hope to disseminate the findings of this National Survey through peer review publication in the coming months.  

Established SEARCH, an independent registered research organisation in Pakistan through which a governing body, core standard operating procedures relevant to the daily governance, data management and information sharing within the registry are possible.

Progress of the registry, and our experiences of implementation have been published in the ICS’s peer reviewed journal JICS (Journal of the Intensive Care Society 2018 0(0) 1–6)

Top two tips:

Collaborations and partnership: Starting a registry from scratch has been a daunting task. The success we have so far achieved has been made possible with the collaboration, guidance and supervision of colleagues and from building on the expertise of partner organisations.

Harnessing routine information to enable the critical care community to start to evaluate services at facility level is the first step towards improving the quality of care of patients in Pakistan.


Next steps

We hope the momentum created by the fellowship will prove a springboard to support the first Pakistan based PRICE-NICST-MORU fellowship - giving opportunities for trainees in critical care to undertake research and professional development opportunities, through which they will  develop research, quality improvement and health informatics skills, strengthening partnerships between South Asian, and UK critical care professional bodies.  

The next steps will be to:
- Evaluate outcomes for patients following ICU and to understand quality of recovery, health and well-being following hospital discharge.
- Understand the burden of sepsis in ICUs and build educational links with community based acute care providers to prevent admission to ICU and identify patients at risk of deterioration.
- Identify indicators of quality to help provide contextualised evaluation of critical care services in Pakistan


Madiha Hasmi: