DISCUSSIONWe designed a surgical drill for scale by designing specifically for end users in low-resource settings. The Drill Cover system provides surgeons a device that is durable, affordable, and safe, whereas current alternatives are inadequate for users in low-resource settings in at least one of these criteria area (new surgical drills are not affordable; donated surgical drills are not durable; manual drills or nonsterile hardware drills are not safe). The current Drill Cover has been well received by surgeons and nurses because it creates an improved sterile barrier between the operating room and drill, uses a hardware drill carefully selected for safe bone-drilling speeds, and is sized for easy loading of the drill into the bag. Each of these features represent significant improvements over previous drill cover designs.

This Drill Cover system provides a proof-of-concept for a product that can scale globally which will increase access to safe surgical drills in low – and middle-income countries (LMICs). Development of this Drill Cover system can now progress towards meeting the standards of Health Canada (our group’s home country regulatory agency).

A key strength of the Drill Cover approach is that multiple covers can be provided with a single drill in a “kit”, meaning that a hardware drill can be used in back-to-back surgeries by changing drill covers, eliminating the need for immediate sterilization. A kit of 5 Drill Covers and a single drill provides capacity for an operating theater to complete 5 surgeries per day, before sterilization is needed. Furthermore, because of its low cost, hospitals with limited access to sterilization devices can stockpile Drill Covers in order to reduce dependence on same-day sterilization.

One limitation of the Drill Cover system is that it uses a drill that is not cannulated, making it difficult to use some reaming attachments, and challenging to grip Kirschner wires using a collet in the same manner as a modern surgical drill. To overcome these limitations, future Drill Cover designs will pursue compatibility with reaming attachments and an affordable cannulated drill. Another limitation is that battery-powered drills are not be as widely available as corded drills in some countries. One potential solution is to form partnerships with hardware drill suppliers so that battery-powered hardware drills (safe for bone drilling) are widely accessible in LMICs at affordable prices.

To maximize the positive impact of this Drill Cover system, the design must be optimized for safety and efficacy in order to meet medical device standards and regulations, and production growth must be sustained by product sales. Development of a sustainable model requires the use of “Integrated Innovation” 10. the combination of scientific, business, and social innovation to scale using a sustainable business model and maximize impact by improving access to safe surgery for patients throughout LMICs.

If made widely available, the Drill Cover system can play a contributing role in improving surgical outcomes and efficiency in LMICs. For example, in Uganda (where we have focused our work), long bone fractures account for over 15% of hospital admissions. 11 Nearly all patients should receive surgical care in a timely fashion, but in reality, a lack of resources—occasionally specific to the lack of a powered surgical drill—means that patients will long wait times or not receive surgery at all. 12 Long wait times lead to extended periods of disability, reduced income, and a significant socioeconomic trickle-down effect on families and dependents. 12 A widely available Drill Cover system can eventually eliminate surgical inefficiencies because of manual drill use and reduce infections because of the nonsterile hardware drill use. Next steps in the development of this Drill Cover system include a clinical study at Mulago Hospital that will track surgical site infections and surgical drilling time using both currently available tools and the Drill Cover system.


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