Pilot Implementation Projects in Low-and Middle-Income Countries to Guide Surgical Quality Improvement using Best Practice Recommendations Running head: LMIC Implementation of Best Practices

Lye-Yeng Wong^1,2*Saad Hussain³Michael Labib³Richard Alynn Henker⁴Chizoba Efobi⁵Igunma Jeremiah⁵Seye Mesfin Minas⁶Tsegazeab Laeke⁷Mark K Ferguson⁸Cheng-Har Yip⁹Andrew Hill¹⁰Jaymie Claire Henry¹¹

• ¹Stanford Healthcare, Stanford, United States
• ²Oregon Health and Science University, Portland, Oregon, United States
• ³Royal College of Surgeons in Ireland, Dublin, County Dublin, Ireland
• ⁴University of Pittsburgh, Pittsburgh, Pennsylvania, United States
• ⁵University of Benin Teaching Hospital, Benin City, Nigeria
• ⁶Mekelle University, Mekelle, Tigray Region, Ethiopia
• ⁷Addis Ababa University, Addis Ababa, Addis Ababa, Ethiopia
• ⁸University of Chicago Medicine, Chicago, Illinois, United States
• ⁹University of Malaya, Kuala Lumpur, Malaysia
• ¹⁰Faculty of Medical and Health Sciences, The University of Auckland, Auckland, Auckland, New Zealand
• ¹¹Baylor College of Medicine, Houston, Texas, United States

Background: Adherence to Best Practice Recommendations (BPRs) has been shown to improve morbidity and mortality in surgical healthcare delivery in low and middle-income countries (LMICs). Methodology: Three LMIC healthcare centres in Laos, Nigeria, and Ethiopia were chosen to participate in the implementation pilots through existing cross-collaborative partnerships. Local teams were assembled to conduct needs assessment analyses prior to implementation study design. The projects are ongoing, and preliminary results are presented using descriptive analysis. Results: The BPRs chosen for each site were: hand hygiene in Laos, antimicrobial stewardship in Nigeria, and trauma in Ethiopia. The World Health Organization (WHO) hand hygiene observation tool was used to determine baseline hand hygiene compliance in a children’s hospital in Laos, revealing that 56.1% of hand hygiene opportunities were missed. A gap analysis was conducted in an academic Nigerian hospital to investigate antibiotic use in surgical patients, which found that 81.2% of antibiotic use was for prophylactic versus empiric indications. Lastly, the emergency medical technician national curriculum as set by the Ethiopian Ministry of Health was reviewed by local experts and a 15-module supplemental curriculum was developed to include additional topics such as managing large-scale events, transport of emergency patients, advanced life support, and establishing quality standards. Conclusion: Through international collaboration spearheaded by local stakeholders, we initiated baseline needs assessments in 3 countries to identify pillars on which to build-up implementation projects based on BPRs. These scalable pilot projects can be used as a framework to promote further optimization and standardization of safe and quality surgical care in LMICs.