Improving timing to open cranial surgery following traumatic brain injury in Lima, Peru using implementation science - Project Summary Candidate: Roxanna Garcia, MD, MS, MPH is a neurosurgeon and fellowship trained neuro-critical intensivist serving as Assistant Professor of Neurological Surgery at Northwestern University. Dr Garcia’s long-term career goal is to be an independent physician-scientist who uses expertise in implementation research to improve adoption of evidence-based practice in neurosurgical disease, with a focus on traumatic brain injury (TBI) globally. Background: TBI is a public health crisis that disproportionately affects low- and-middle income countries (LMICs), where the risk of mortality is 3 to 4-fold greater than compared to high-income countries. The incidence of TBI represents the leading cause of neurologic disease globally, with approximately 69 million incident cases every year. Moderate TBI (Glasgow Coma Scale[GCS] scores 9-12) and severe TBI (GCS scores 3-8, msTBI) can produce lifelong disability, and is estimated to contribute to over 30% of deaths caused by trauma. Timing to surgery is an important factor, especially among patients with structural lesions. A four- hour timeframe from event to surgical decompression can improve survival. Health system factors delaying timing to intervention have not evaluated, especially in LMICs. Training Plan: In order to achieve research independence, Dr Garcia will need to strengthen skills in (1) applying implementation science methodologies, (2) learning mixed methods to develop (3) expertise in clinical trials research design. Dr Garcia will be mentored by an outstanding multinational team including primary mentor Dr Andrew Naidech (Northwestern University), and Dr Patricia Garcia (Universidad Peruano Cayetano Heredia). Her co-mentors Dr Lisa Hirschhorn (Northwestern University) and Dr Fizan Abdullah (Northwestern University). This team represents experts in health systems and services research, as well implementation science and global health and surgical research. Research Plan: With guidance from her mentor team, Dr Garcia will apply the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to understand to open cranial surgical intervention for msTBI in the acute emergency setting among health providers in Lima, Peru at high volume trauma centers. The study will continue to build upon an existing prior NIH related post-doctoral research fellowship experience. Dr Garcia will (1) explore the current clinical practices, and define the barriers, and facilitators influencing timing to open cranial surgery for patients suffering from msTBI. She will then apply (2) mechanistic mapping through a co-creation process to create codesign strategies for addressing critical barriers and leveraging facilitators among key stakeholders; and (3) conduct a feasibility implementation pilot to improve timing of open cranial surgery for msTBI. The study will utilize mixed-methods including semi- structured interviews, surveys and focus groups to inform an implementation research logic model and plan, and inform an R01 proposal focused on implementation and sustainment.
