Implementing Surgical Interventions as a Triad Care Bundle

The landscape of surgical care has evolved substantially in the last 3 decades and continues to advance at an unprecedented pace. Among the innovative changes three stand out: (i) laparoscopic surgery, (ii) the surgical safety checklist (SSC) and, (iii) the enhanced recovery after surgery (ERAS) program, all of which have had a significant and sustained positive impact on the quality and safety of surgical care [1, 2]. The benefits of these interventions include a decrease in mortality, a reduction in surgical site infections and other complications, a shorter length of hospital stay (LOS), lower in-hospital costs, and improved patient experience [1-3]. Uptake of these innovations have occurred predominantly in high-income countries (HIC's) with slower uptake in low- and middle-income countries LMIC's [4-6]. In the majority of countries these innovations have been implemented at individual institutions rather than at a national level. For more than 2 decades laparoscopic surgery has been the standard approach in HICs for cholecystectomy and appendectomy. Over the past decade its use has expanded to include most elective and emergency abdominal procedures. However, in most LMICs these procedures are still performed predominantly as open procedures. For example, in SA, although the first laparoscopic cholecystectomy was done 32 years ago, the procedure remains inaccessible to the majority of the population. Rwanda only performed its first laparoscopic cholecystectomy as recently as 2015. The adoption of the SSC, introduced by the World Health Organization in 2009, is low in LMICs (20%–40%) [4]. Similarly, the ERAS program, available for more than 10 years and implemented in over 120 countries worldwide, includes very few LMIC's. Encouragingly, LMICs institutions that have implemented the SSC and the ERAS program have achieved results comparable to HIC's [5]. The authors of “Implementation and Outcomes of an Enhanced Recovery After Surgery (ERAS) pathway for Laparoscopic Cholecystectomy in East and Central Africa: A Prospective Non-Randomized Controlled Trial in Rwanda's Tertiary Teaching Hospital,” in this edition, are commended for their work in implementing laparoscopic cholecystectomy, the SSC, and the ERAS program as a care bundle [6]. The study achieved a significant reduction in the length of LOS (3 vs. 1 day, p = 0.0001) without an increase in complications or readmissions. The study by Nyundo M et al. adds to the existing body of knowledge from LMICS on proof of concept for these interventions. Modifying the ERAS guidelines to be contextually relevant, measuring the in-hospital cost and describing the socio-cultural barriers to pain management, and early discharge are important contributions to the field and will assist in informing implementation in LMIC's. However, some of the ERAS guidelines implemented in their study are intended for major surgery rather than laparoscopic cholecystectomy, for example the use of a preoperative carbohydrate drink, routine glucose monitoring and preoperative warming. This would have added to time and cost with limited benefit to patient outcomes. Prioritizing and shifting from institutional interventions to national level is crucial to effect change at scale. This will require substantial resources and commitment by all stakeholders. Additional challenges that will need to be addressed include the increasing clinical workload and skills shortage. Despite these challenges, there is a strong opportunity for transformative change. Developing a global platform to implement elective and emergency laparoscopic surgery, the SSC, and ERAS as an integrated triad care bundle could significantly enhance patient outcomes and standardize best practices worldwide. Such a platform would facilitate collaboration between established laparoscopic surgical and ERAS institutions and those wishing to introduce the “triad care bundle.” It could shift the current fragmented siloed approach to one that is cohesive, advocates for change, supports the standardization of laparoscopic skills training, facilitates access to affordable instruments, contextualizes the current ERAS perioperative care guidelines and simplify evaluation tools and support relevant research. Further emerging technologies, for example artificial intelligence tools, could also be integrated into the platform. Implementing the “triad care bundle” as part of a global platform is an opportunity to accelerate the reach of these and other advancements, shift from implementation at individual institutions to national level and achieve a more efficient, equitable and effective healthcare system that enhances patient care and outcomes, worldwide. Ravi Oodit: conceptualization, writing – original draft, writing – review and editing. Michael M. Mwachiro: writing – review and editing.