Real-world implementation challenges in low-resource settings

Postoperative mortality is disproportionately high in low-income and middle-income countries (LMICs). In 2019, the African Surgical Outcomes Study (ASOS) collaborative prospectively followed 11 422 patients 25 showed that postoperative morality this setting twice as global average.1Biccard BM Madiba TE Kluyts HL et al.Perioperative patient outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Summary Full Text PDF PubMed Scopus (222) Google Scholar As reported The Lancet Global Health, ASOS-2, cluster-randomised controlled trial, developed earlier work to assess an intervention aimed at reducing mortality.2The ASOS-2 InvestigatorsEnhanced surveillance versus standard of care reduce among adult surgical Africa (ASOS-2): trial.Lancet Glob Health. 2021; (published online Aug 18.)https://doi.org/10.1016/S2214-109X(21)00291-6Google A package five interventions were applied risk on basis clinical concept failure rescue—ie, complications require active hospitals with rates fail rescue deteriorating patients.3Ghaferi AA Birkmeyer JD Dimick JB Variation hospital associated inpatient surgery.N Engl J Med. 2009; 361: 1368-1375Crossref (944) This included admitting higher ward, increasing frequency nursing observations, assigning bed view station, allowing family members say placing guide visible position bedside. Although trial recruited 28 892 from 332 countries, it did not meet its target recruitment size. Additionally, findings show difference 30-day in-hospital between group (169 [1·3%] 12 970) control (193 15 242). Most tellingly, 160 allocated struggled implement package, only 40·0% (64 hospitals) able include bedside plus one additional component, 59·4% (95 two or more items package. Despite negative findings, study has made three major contributions. First, shows large-scale, multi-country, randomised trials led by investigators populations are feasible, but continue be woefully underfinanced. Second, pragmatic stress local health-care systems providers. data collection was limited 100 consecutive per maximum 4 weeks collection, forms page minimise their impact constrained resources, asked comply simple resource-neutral less than half initially enrol patients. reason for observation inability obtain ethical review provide evidence Good Clinical Practice (93 failed stakeholder engagement (49 hospitals). third finding well known challenge implementation. Even solutions, such putting close proximity station providing bedside, could implemented uniformly, fifth delivered all components enhanced risk. An implementation science approach essential resource-limited settings leverage effective, novel solutions under resource variability. Implementation challenges tend fall into concrete categories: specifics intervention; material, intellectual, administrative support implementation; knowledge behaviours required enact change; measurement, oversight, feedback mechanisms identify progress; how systematised.4Weiser TG Forrester JA Negussie T innovation surgery.Br Surg. 2019; 106: e20-e23Crossref (10) Scholar, 5WHOImproving infection prevention health facility: interim practical manual supporting WHO guidelines core programmes. World Helalth Organization, Geneva2018Google acknowledge limitation paucity input co-ownership design. though agreed experts, some interventions, sleeping stations, always strong. Did reduction because themselves effective them? Were these comprising impactful, would full have reduced mortality? These questions hard answer given incomplete. Nevertheless, situation entirely surprising particular systems: even studies focus select number hospitals, across numerous unlikely.6Allegranzi B Aiken AM Zeynep Kubilay N al.A multimodal safety site infections Africa: multicentre, before-after, study.Lancet Infect Dis. 18: 507-515Summary (48) 7Forrester Starr al.Clean Cut (adaptive, programme) low-resource settings: quality improvement study.Br 108: 727-734Crossref (0) 8Haynes AB Edmondson L Lipsitz SR al.Mortality trends after voluntary checklist-based collaborative.Ann 2017; 266: 923-929Crossref (62) Both power strategy must considered effect improvements care. Fixed budgets, overwhelmed weak LMIC settings. setbacks, there urgent need real-world LMICs improve study, powerful breadth scope, should serve wakeup call clinicians interested improving quality. Collaborators willingness apparent; however, resources scarce desperately inadequate. KMC reports grants UK Academy Science Challenges Research Fund, National Institute Health Research, South Foundation, outside submitted work, board membership One Africa, Consortium Universities Médecins Sans Frontières—South Africa. TGW UBS Foundation consulting fees Lifebox work. Enhanced trialThis decrease morbidity mortality. Further research needed develop prevent death Full-Text Open Access