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Introduction <p>Emerging data suggest Brain Injury Guidelines (BIG) can be used to manage patients with mild to moderate traumatic brain injury (TBI) without neurosurgical consultation. However, many Level 3 trauma centers without neurosurgical specialists continue transferring these patients to higher-level facilities. This study aimed to evaluate the transfer outcomes of TBIs and contribute to the discussion on the feasibility of observing mild TBI patients and evaluate barriers to BIG adoption at both smaller and larger hospitals.</p> Methods <p>A retrospective chart review was performed on patients transferred to a Level 1 trauma center with confirmed TBI based on computed tomography (CT) between January 2018 and December 2024. Patients were assigned to BIG 1, 2, or 3. The primary outcome was need for neurosurgical intervention. Secondary outcomes included transfer times and mortality. Emergency medicine physicians at a transferring hospital were surveyed regarding obstacles to adopting BIG.</p> Results <p>A total of 301 patients were transferred to our emergency department with a TBI. Of these, 36 were BIG 1, 73 were BIG 2, and 192 were BIG 3. Neurosurgical intervention was required in 5.3% of BIG 2 patients and 18.4% in BIG 3 patients (<i>p</i> &lt; 0.001), while no BIG 1 patients required intervention. Mortality was highest in BIG 3 (2.7% vs. 6.7% vs. 17.1%, <i>p</i> = 0.009). BIG 3 independently predicted the need for neurosurgical intervention on multivariate analysis. On survey, emergency physicians reported discomfort with use of BIG criteria without neurosurgical consultation.</p> Discussion <p>BIG 1 patients with mild traumatic brain injury can be safely managed without neurosurgical consultation, however adoption of BIG criteria remains limited in some areas. Our findings highlight that barriers exist at both referring and receiving hospitals including provider discomfort, medicolegal concerns, and staffing limitations at smaller centers, as well as institutional caution and conservative admission pathways at larger centers. Successful implementation will require system-wide cultural change and a staged approach, potentially beginning with retention of BIG 1 patients at smaller centers and subsequently expanding implementation as provider comfort increases.</p>

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Adoption of brain injury guidelines in mild traumatic brain injury: challenges at both referring and receiving trauma centers

  • 期刊论文

  • 发表日期：

    2025年11月14日

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  • Grace Hwang,
  • Daniel Margain,
  • Connor Fewel,
  • Danielle Vanderet,
  • Esther Lee,
  • Albert Kazi,
  • Bryan Love,
  • Mallory Jebbia,
  • Kevin Morrow

摘要

Introduction

Emerging data suggest Brain Injury Guidelines (BIG) can be used to manage patients with mild to moderate traumatic brain injury (TBI) without neurosurgical consultation. However, many Level 3 trauma centers without neurosurgical specialists continue transferring these patients to higher-level facilities. This study aimed to evaluate the transfer outcomes of TBIs and contribute to the discussion on the feasibility of observing mild TBI patients and evaluate barriers to BIG adoption at both smaller and larger hospitals.

Methods

A retrospective chart review was performed on patients transferred to a Level 1 trauma center with confirmed TBI based on computed tomography (CT) between January 2018 and December 2024. Patients were assigned to BIG 1, 2, or 3. The primary outcome was need for neurosurgical intervention. Secondary outcomes included transfer times and mortality. Emergency medicine physicians at a transferring hospital were surveyed regarding obstacles to adopting BIG.

Results

A total of 301 patients were transferred to our emergency department with a TBI. Of these, 36 were BIG 1, 73 were BIG 2, and 192 were BIG 3. Neurosurgical intervention was required in 5.3% of BIG 2 patients and 18.4% in BIG 3 patients (p < 0.001), while no BIG 1 patients required intervention. Mortality was highest in BIG 3 (2.7% vs. 6.7% vs. 17.1%, p = 0.009). BIG 3 independently predicted the need for neurosurgical intervention on multivariate analysis. On survey, emergency physicians reported discomfort with use of BIG criteria without neurosurgical consultation.

Discussion

BIG 1 patients with mild traumatic brain injury can be safely managed without neurosurgical consultation, however adoption of BIG criteria remains limited in some areas. Our findings highlight that barriers exist at both referring and receiving hospitals including provider discomfort, medicolegal concerns, and staffing limitations at smaller centers, as well as institutional caution and conservative admission pathways at larger centers. Successful implementation will require system-wide cultural change and a staged approach, potentially beginning with retention of BIG 1 patients at smaller centers and subsequently expanding implementation as provider comfort increases.