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Background The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low‐income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. Methods This study had a longitudinal embedded mixed‐methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty‐six hospitals received 3‐day multidisciplinary training and 4‐month follow‐up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR‐derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. Results At 12–18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high‐fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12–18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6–9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. Conclusion This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.

Background As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. Methods 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. Results From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. Conclusions This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

Background High-quality surgical lighting is often lacking in low-resource settings. Commercial surgical headlights are unavailable due to high cost and supply and maintenance challenges. We aimed to understand user needs of a surgical headlight for low-resource settings by evaluating a preselected robust but relatively inexpensive headlight and lighting conditions. Methods We observed headlight use by ten surgeons in Ethiopia and six in Liberia. All surgeons completed surveys about their lighting environment and experience using headlight, and were subsequently interviewed. Twelve surgeons completed logbooks on headlight use. We distributed headlights to 48 additional surgeons, and all surgeons were surveyed for feedback. Results In Ethiopia, five surgeons ranked operating room light quality as poor or very poor; seven delayed or cancelled operations within the last year and five described intraoperative complications due to poor lighting. In Liberia, lighting was rated as ''good'', however fieldnotes, and interviews noted generator fuel-rationing, and poor lighting conditions. In both countries, the headlight was considered extremely useful. Surgeons recommended nine improvements, including comfort, durability, affordability and availability of multiple rechargeable batteries. Thematic analysis identified factors influencing headlight use, specifications and feedback, and infrastructure challenges. Conclusion Lighting in surveyed operating rooms was poor. Although conditions and need for the headlights differed between Ethiopia and Liberia, headlights were considered highly useful. However, discomfort was a major limiting factor for ongoing use, and the hardest to objectively characterise for specification and engineering purposes. Specific needs for surgical headlights include comfort and durability. Refinement of a fit-for-purpose surgical headlight is ongoing.

T he protection of healthcare workers is vitally important during the coronavirus pandemic. 1 In addition to delays in availability of vaccines for low-and middle-income country (LMIC) providers, 2 there are ongoing deficits in COVID-19 mitigation and provider protection efforts, particularly with respect to personal protective equipment (PPE). 3 Pandemic-related supply chain disruptions have resulted in severe shortages of PPE, including gloves, masks, and eye protection used routinely in patient care by surgical and anesthetic providers. Furthermore, continued development and implementation of policies and procedures for the safe donning, doffing, and use of PPE is essential. This includes protocols for managing COVID-19þ patients on the wards and in the operating theatre. We conducted a global survey of surgical facilities and perioperative providers to assess the availability of materials and safety processes, including provider training, for preventing transmission of SARS-CoV-2 in the perioperative setting.An online facility-level survey was distributed to contacts of Lifebox, Smile Train, and Jhpiego who work at partner hospitals. A second online survey aimed at individual providers was disseminated widely through our networks and via social media. Both surveys were translated into 9 languages (English, Bahasa, French, Spanish, Khmer, Hindi, Mandarin, Portuguese, Vietnamese), to align with common organization partner languages. Responses were collected in October 2020 and all data were anonymized. Participation was voluntary, ethical approval was obtained, and data were analyzed using Stata v.15.1. Primary outcomes of interest were provider-reported PPE availability and self-purchasing, COVID-19 related training and protocol usage, and surgical facility COVID-19 testing, viral filter and pulse oximeter availability as reported by a senior level single facility respondent.A total of 230 facility and 507 provider surveys, representing 52 LMICs, were included in the analysis. Provider and facility surveys were similar in regional, hospital type, and hospital level distribution. We stratified data by income classification, grouping low-and lower-middle income countries (LIC/L-MICs) as compared to upper-middle income countries (UMICs) to better elucidate where the largest gaps in training and material resources were located.Providers in LIC/L-MICs reported less training in COVID-19 protocols for the operating room (51.2% vs 81.8%), PPE donning and doffing (67.2% vs 86.4%), and COVID-19 surgical patient checklist (40.0% vs 59.8%) than those in UMICs (Table 1). Actual use of protocols followed the same pattern, with LIC/L-MIC providers reporting less COVID-19 protocol implementation (48.5% vs 78.8%).In LIC/L-MICs, providers did not have routine access to N95s (37.1%), surgical masks (29.1%), gloves (21.6%), or eye protection (30.9%). Shortages were present but less severe in UMICs. Clinicians also reported reusing PPE; some were reusing PPE without decontamination (7.7% in LIC/L-MICs vs 6.8% in UMICs). Other prov...