Background: Limited critical care subspecialty training and experience is available in many low- and middleincome countries, creating barriers to the delivery of evidence-based critical care. We hypothesized that a
structured tele-education critical care program using case-based learning and ICU management principles is an
efficient method for knowledge translation and quality improvement in this setting.
Methods and interventions: Weekly 45-min case-based tele-education rounds were conducted in the recently
established medical intensive care unit (MICU) in Banja Luka, Bosnia and Herzegovina. The Checklist for Early
Recognition and Treatment of Acute Illness (CERTAIN) was used as a platform for structured evaluation of critically
ill cases. Two practicing US intensivists fluent in the local language served as preceptors using a secure two-way
video communication platform. Intensive care unit structure, processes, and outcomes were evaluated before and
after the introduction of the tele-education intervention.
Results: Patient demographics and acuity were similar before (2015) and 2 years after (2016 and 2017) the
intervention. Sixteen providers (10 physicians, 4 nurses, and 2 physical therapists) evaluated changes in the ICU
structure and processes after the intervention. Structural changes prompted by the intervention included
standardized admission and rounding practices, incorporation of a pharmacist and physical therapist into the
interprofessional ICU team, development of ICU antibiogram and hand hygiene programs, and ready access to
point of care ultrasound. Process changes included daily sedation interruption, protocolized mechanical ventilation
management and liberation, documentation of daily fluid balance with restrictive fluid and transfusion strategies,
daily device assessment, and increased family presence and participation in care decisions. Less effective
(dopamine, thiopental, aminophylline) or expensive (low molecular weight heparin, proton pump inhibitor)
medications were replaced with more effective (norepinephrine, propofol) or cheaper (unfractionated heparin, H2
blocker) alternatives. The intervention was associated with reduction in ICU (43% vs 27%) and hospital (51% vs 44%)
mortality, length of stay (8.3 vs 3.6 days), cost savings ($400,000 over 2 years), and a high level of staff satisfaction
and engagement with the tele-education program.
Conclusions: Weekly, structured case-based tele-education offers an attractive option for knowledge translation
and quality improvement in the emerging ICUs in low- and middle-income countries.
