Assessing acceptability, feasibility, and utilization in a peer-to-peer tele-critical care model: a mixed-methods analysis to inform scalable remote ICU models

Introduction Critical care in low- and middle-income countries (LMICs) like Pakistan, particularly in remote areas, is constrained by limited infrastructure and expertise. Telemedicine can bridge this gap by connecting frontline ICU physicians with remote critical care experts. While tele-ICU models have been evaluated in high-income settings, limited evidence exists from LMICs. This study evaluated the acceptability, feasibility, and utilization of a peer-to-peer tele-ICU consultation service launched by Aga Khan University in Pakistan. Methods We conducted a cross-sectional mixed-methods study using 145 survey responses and 10 in-depth interviews of physicians who had utilized a national Tele-ICU consultation service. Quantitative data were collected using a structured survey. Qualitative data were obtained through open-ended survey responses and 10 in-depth interviews. Survey data were analyzed using descriptive statistics while qualitative data underwent thematic analysis by two independent reviewers to identify key themes related to service use, quality, and feasibility. Results Of 219 physicians, 145 (66.2%) responded. Consultations primarily occurred via voice (77.2%) and text (43.4%). Respondents reported high satisfaction across clinical (mean 4.50), process (3.82), and technical (4.18) domains. Key benefits included knowledge enhancement, support for complex cases, and ease of access. The Net Promoter Score was 40.7, indicating favorable satisfaction. Thematic analysis confirmed high satisfaction but highlighted utilization barriers, including administrative hurdles and the difficulty of implementing standardized recommendations within local resource constraints. Conclusion The peer-to-peer Tele-ICU model was perceived as highly acceptable and clinically useful by bedside physician physicians. However, infrastructure resource and workflow limitations might affect its implementation. These finding highlight the potential of remote critical care consultation while identifying the barriers that must be addressed to support wider implementation in resource-limited settings. Clinical trial number Not applicable.