Transfer Outcomes of Traumatic Brain Injuries – What Will it Really Take to Adopt BIG at a Level 3 Trauma Center?

Transfer Outcomes of Traumatic Brain Injuries – What Will it Really Take to Adopt BIG at a Level 3 Trauma Center? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Transfer Outcomes of Traumatic Brain Injuries – What Will it Really Take to Adopt BIG at a Level 3 Trauma Center? Grace Hwang, Daniel Margain, Connor Fewel, Danielle Vanderet DO, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7059382/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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 at smaller 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 This study supports similar studies showing BIG 1 patients can be safely observed without neurosurgical consultation. However, implementing BIG at smaller hospitals requires a large culture shift, along with adequate staffing and resources to observe patients for six hours. traumatic brain injury brain injury guidelines trauma Background Traumatic brain injury (TBI) is a significant public health concern in the United States, accounting for approximately 2.8 million emergency department visits, hospitalizations, and deaths each year ( 1 ). These injuries contribute to considerable morbidity, mortality, and long-term disability, often resulting in difficulty reintegrating into the workforce and significant socioeconomic burdens to patients ( 2 ). In fact, one study found that patients have decreased cognition and quality of life and increased depression for up to 10 years following TBI ( 3 ). To help standardize management of TBIs, the Brain Injury Guidelines (BIG) were developed to stratify patients based on the severity of their injuries, using both clinical and radiographic findings. Categories are BIG 1, 2 and 3 from least to most severe ( 4 ). These guidelines were subsequently validated, demonstrating that selected patients (BIG 1 and BIG 2) could be safely managed without neurosurgical consultation ( 5 ). In 2022 Khan et al validated the modified BIG criteria which made changes to the type of intracranial hemorrhage in certain categories, particularly the management of epidural hematomas ( 6 ). Trauma centers in the United States are categorized by the American College of Surgeons (ACS) as Level I through V based on their resources and capabilities. ( 7 ) Level I and II trauma centers are required to have neurosurgical services available, while Level III-V centers are not mandated to maintain neurosurgical specialists on staff but instead established transfer protocols for patients requiring higher levels of care ( 8 ). Previous standard practice mandates patients with any severity of TBI get transferred to Level I or II for neurosurgical evaluation. However, more recently level III trauma centers have begun implementing BIG criteria into their management algorithms ( 9 ). Some are looking at the feasibility of not transferring patients with BIG 1 or BIG 2 TBIs ( 10 , 11 ). This study aimed to evaluate the transfer outcomes of TBIs and contribute to the discussion on the feasibility of observing mild TBI patients at smaller hospitals. Methods After institutional review board approval was obtained, a retrospective chart review was performed at our Level 1 trauma center. We included all adult trauma patients age 18 years and older who were transferred to our emergency department from a level III trauma center between January 2018 and December 2024 with a traumatic brain injury diagnosed on computed tomography (CT). Head CTs, anticoagulation use, and blood alcohol levels were reviewed and patients were assigned to modified BIG 1, 2 or 3. The modified BIG criteria was used to determine patient classification ( 6 ). The primary outcome was need for neurosurgical intervention. Secondary outcomes included transfer times, length of stay (LOS) and mortality. Transfer times were calculated as the time from initial CT imaging at the transferring hospital to the time of arrival at our emergency department. Ground transport time from the transferring hospital to our facility is 30–45 minutes on average. Demographic data points that were collected included age and sex. The injury data collected included mechanism of injury, traumatic brain injury type, abbreviated injury scale of the head (AIS head), the injury severity score (ISS) and initial vitals. Additional outcomes evaluated were intensive care unit (ICU) admission, ICU length of stay (LOS), hospital LOS and mode of transport between hospitals. All bivariate analyses were performed with IBM SPSS Statistics for Windows (Version 29, IBM Corp., Armonk, NY). A Mann-Whitney-U test was used to compare continuous variables and a chi-square was used to compare categorical variables in the bivariate analysis. Categorical data was presented as percentages while continuous data was presented as a mean with standard deviation. We then performed a multivariable logistic regression analysis to determine the risk of neurosurgical intervention for patients with traumatic brain injury. We adjusted for potential confounders, which were selected based on discussion among coauthors, review of the literature and identifying univariate statistically significant differences between proposed confounding variables. These included age, ISS, and severe AIS (AIS > 3) for the head. P-values were defined as statistically significant if < 0.05. Emergency medicine physicians from the transferring hospital were then anonymously surveyed by email about their comfort level in adopting BIG criteria, and about their perception on the feasibility of BIG adoption at their institution (Full survey questions listed in Table 5 ). Results A total of 301 patients were transferred to our facility with confirmed traumatic brain injury. Of those, 36 were BIG 1, 73 were BIG 2, and 192 were BIG 3. There was no difference in average age among the three groups (57.9 vs 57.4 vs 57.5, p = 0.993). Patients in the BIG 3 group were more likely to be male (44.4% vs 69.9% vs 70.3%, p = 0.009) and had higher ISS scores (10.7 vs 12.4 vs 14.4, p = 0.003). The AIS head score trended towards higher mean scores in the BIG 3 group (2.8 vs 3.0 vs 3.1, p = 0.052). The most common mechanism of injury in all three groups was ground level fall (61.1%, 50.7%, and 54.2%). 33.4% of BIG 3 patients were on anticoagulation at the time of their trauma. Loss of consciousness was more common in BIG 3 patients (50% vs 69.9% vs 82.8%, p < 0.001). The presenting GCS was lowest in the BIG 3 group (15 vs 14.2 vs 10.8, p < 0.001). BIG 3 patients tended to have a lower systolic blood pressure on arrival (141 vs 133 vs 131, p = 0.041) but there was no difference in presenting heart rate (92 vs 84 vs 88, p = 0.102). (Table 1 ) A total of 7 (9.6%) patients in the BIG 2 category had non-displaced skull fractures while 22 total BIG 3 patient has skull fractures, 9 (4.7%) were non-displaced and 13 (6.8%) were displaced. 11 (30.6%) BIG 1 patients had subdural hematomas (SDH), 18 (50%) had intraparenchymal hemorrhage (IPH) or contusion, and 7 (19.4%) had subarachnoid hemorrhage (SAH). The BIG 2 patients had 27 (37.0%) SDH, 25 (34.3%) IPH/contusion, and 21 (28.8%) SAH. BIG 3 patients had 88 (45.8%) SDH, 10 (5.2%) epidural hematoma (EDH), 48 (25.0%) IPH/contusion, 46 (24.0%) SAH, and 11 (5.7%) intraventricular hemorrhage (IVH). (Table 2 ) The average transfer time was 151 minutes in the BIG 1 group with a range of 48 minutes to 177 minutes. BIG 2 patients had an average transfer time of 156 minutes with a range of 48 minutes to 224 minutes. BIG 3 patients had an average transfer time of 137 minutes with a range of 38 minutes to 185 minutes. A higher percentage of BIG 3 patients were transferred by helicopter (40.1%) compared to BIG 1 (27.8%) and BIG 2 (26.0%) patients. The remaining patients in each group were transported via ground ambulance. In the BIG 1 category, 2 patients (5.6%) were admitted to the floor, 1 (2.8%) was discharged home from the ED and the remainder were admitted to the ICU. In the BIG 2 category 4 (5.5%) of patients were admitted to the floor, no patients were discharged from the ED and the remaining patients were admitted to the ICU. All patients in the BIG 3 category were admitted to the ICU. BIG 1 patients had the shortened average hospital LOS (5.4 vs 5.9 vs 10.0 days, p = 0.010) and shorted ICU LOS (1.8 vs 1.9 vs 4.4 days, p < 0.001). No patients in the BIG 1 category required neurosurgical intervention while 4 (5.3%) of BIG 2 and 37 (18.4%) of BIG 3 required intervention (p < 0.001). There was an increasing trend in progression on repeat head CT from 14.3–31.3% to 37.5% for BIG 1, 2 and 3 respectively, however this did not reach statistical significance (p = 0.290). Mortality increased with BIG category (2.7% vs 6.7% vs 17.1%, p < 0.001) (Table 3 ). On multivariate analysis, BIG 3 was the only independent predictor for the need for neurosurgical intervention (OR 9.25, CI 1.07–80.17, P = 0.044) when controlling for age, ISS and AIS head (Table 4 ). A total of 7 emergency medicine attendings from a level III trauma center responded to the anonymous survey. The average familiarity with the BIG criteria was 2.14/5. When asked about comfort in correctly applying BIG to clinical situations the average score was 1.86/5. They reported 1.57/5 for how often they utilize BIG criteria in clinical decision-making. Comfort in discharging a BIG 1 patient from the emergency department without neurosurgical consultation was reported at 1.43/5. Conversely, a score of 3.71/5 represented how much their comfort level would increase if a neurosurgery telehealth consult was available. When asked how much bed availability and nursing staff availability played a role in their hospital’s ability to observe a BIG 1 patient for 6 hours they reported 3.86/5 and 3.42/5 respectively. (Table 5 ) Discussion Our results are consistent with the growing body of evidence supporting the use of the Brain Injury Guidelines in the triage and management of patients with mild traumatic brain injuries. Consistent with previous studies, we found that none of the BIG 1 patients required neurosurgical intervention ( 4 – 6 ). Despite these findings, survey responses from a level III referring center indicate significant hesitation to retain and monitor TBI patients locally. Our findings reaffirm that BIG 1 patients are safely managed without neurosurgical consultation, aligning with the results of Martin et al who utilized the traditional BIG criteria to assess need for neurosurgical intervention in patients evaluated at a level III trauma center ( 12 ). This was successfully applied to a rural level II trauma center by Morocho et al with no BIG 1 or 2 patients requiring neurosurgical intervention ( 13 ). Khan et al. then demonstrated the safety and effectiveness of the modified BIG criteria in stratifying TBI patients by risk level ( 6 ). In our cohort, BIG 1 patients required no neurosurgical intervention, had stable vitals and there was only 1 mortality that was unrelated to the patient’s mild TBI. In fact the BIG criteria was the only independent predictor of the need for neurosurgical intervention in our patients, suggesting it is a reliable tool for patient prognostication and management. Additionally there was minimal progression of intracranial hemorrhage seen on repeat CT head (only 14%) for BIG 1 patients, similar to other study findings ( 14 ). Yet these BIG 1 patients were still transferred to a tertiary facility, often admitted to the ICU, and subjected to unnecessary resource utilization. These results show that despite growing literature showing the safety of the BIG criteria, hospitals are utilizing additional resources to transfer patients to higher levels of care. The lengthy transfer times, averaging over 2.5 hours for BIG 1 and BIG 2 patients, raise concerns about the practicality and efficiency of current interfacility transfer practices. Transfer time was counted as the time stamp on the patient’s CT head showing a TBI to the arrival time at the receiving emergency department and therefore included calling the receiving facility, providing handoff, coordinating ground or air transfer, and the actual transport time itself. These delays in transfer represent nearly half of the six-hour observation period recommended for mild TBIs, meaning many patients effectively complete half the suggested monitoring period while awaiting transfer to a higher-level facility. In this context, the transfer of BIG 1 patients, who ultimately do not require interventions, represents a potential target for quality improvement and cost reduction. While implementing BIG criteria at smaller hospitals has clear potential benefits such as resource preservation and cost reduction, our survey of physicians from a referring center revealed systemic barriers. These included limited bed capacity, difficulty allocating staff for prolonged neurologic observation, and provider discomfort with managing hemorrhagic injuries without a neurosurgeon on call. Particularly in some of our smaller referring facilities, some of which have only 12-bed emergency departments, these concerns are valid. Owodunni et al found that over 50% of emergency medicine physicians surveyed would still consult neurosurgery for BIG 1 patients despite having an understanding of the BIG criteria. Additionally, they found that over 50% of these physicians would order a repeat CT head for BIG 1 patients despite the guideline recommendations suggesting this is not necessary ( 15 ). This shows that despite several studies demonstrating the efficacy of the BIG criteria and the modified BIG criteria, there is some hesitation in full adoption which the authors suggest could be related to medicolegal concerns or lack of institutional guidance ( 15 ). As a result, rather than proposing immediate adoption of BIG 1 and 2 retention at smaller centers, a more incremental approach may be more feasible. For example, starting with observing BIG 1 patients without transfer, and when comfort improves, addressing retention of BIG 2 patients. This staged strategy could help shift culture while maintaining patient safety and building local confidence in the guidelines. We acknowledge several limitations to this study. It was a retrospective analysis conducted at a single Level 1 trauma center, introducing potential selection and documentation bias. Additionally, the small number of BIG 1 patients in our cohort limits the generalizability of conclusions. Survey responses were limited to a single level III center and may not reflect broader trends across other level III or non-trauma hospitals. Additionally we only received 7 responses, so to provide a more robust analysis a larger scale survey of several centers across the country should be performed. Conclusion Our study supports existing literature that BIG 1 patients with mild traumatic brain injury can be safely managed without neurosurgical consultation or transfer to a higher-level trauma center. Despite this, widespread adoption of BIG criteria remains limited, which may be due to concerns about staffing, liability, and resource constraints at lower-level facilities. While BIG criteria offer a safe and evidence-based framework for triaging TBI, substantial system-level and cultural changes are necessary before it can be broadly implemented in Level III or even non-trauma centers. Declarations Ethics approval and consent to participate: IRB approval was obtained by MetroWest Medical Center IRB. A waiver of consent was granted. Consent for publication: not applicable Availability of data: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: None Author Contribution GH and MJ wrote the main manuscript text. DM and CF prepared the tables.EL and AK helped with project design and edited the manuscript drafts.BL and DV acquired the data.KM helped with conceptualization, manuscript edits and overall supervision.All authors reviewed and approved the final manuscript. References Centers for Disease Control and Prevention. Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States. 2014. Published March 2019. Gaudette É, Seabury SA, Temkin N, et al. Employment and Economic Outcomes of Participants With Mild Traumatic Brain Injury in the TRACK-TBI Study. JAMA Netw Open. 2022;5(6):e2219444. 10.1001/jamanetworkopen.2022.19444 . Grauwmeijer E, Heijenbrok-Kal MH, Peppel LD, Hartjes CJ, Haitsma IK, de Koning I, Ribbers GM, Cognition. Health-Related Quality of Life, and Depression Ten Years after Moderate to Severe Traumatic Brain Injury: A Prospective Cohort Study. J Neurotrauma. 2018;35(13):1543–1551. doi: 10.1089/neu.2017.5404. Epub 2018 Apr 6. PMID: 29343203. Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965-9. 10.1097/TA.0000000000000161 . PMID: 24662858. Joseph B, Aziz H, Pandit V, Kulvatunyou N, Sadoun M, Tang A, O'Keeffe T, Gries L, Green DJ, Friese RS, Lemole MG Jr, Rhee P. Prospective validation of the brain injury guidelines: managing traumatic brain injury without neurosurgical consultation. J Trauma Acute Care Surg. 2014;77(6):984-8. 10.1097/TA.0000000000000428 . PMID: 25423541. Khan AD, Lee J, Galicia K, Billings JD, Dobaria V, Patel PP, McIntyre RC, Gonzalez RP, Schroeppel TJ. A multicenter validation of the modified brain injury guidelines: Are they safe and effective? J Trauma Acute Care Surg. 2022;93(1):106–112. doi: 10.1097/TA.0000000000003633. Epub 2022 Apr 1. PMID: 35358157. American College of Surgeons. Resources for Optimal Care of the Injured Patient. ACS; 2014. American College of Surgeons Committee on Trauma. Statement on trauma center designation based upon system need. Bull Am Coll Surg. 2015;100(1):51–2. PMID: 25626271. Gribbell M, Hsu J, Krech L, et al. Step up to the Brain Injury Guidelines league: Adoption of Brain Injury Guidelines at a Level III trauma center, A pilot study. Trauma. 2022;24(4):294–300. 10.1177/14604086211017374 . Alan N, Kim S, Agarwal N, Clarke J, Yealy DM, Cohen-Gadol AA, Sekula RF. Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14–15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers. J Clin Neurosci. 2020;81:246–51. Epub 2020 Oct 15. PMID: 33222924; PMCID: PMC7560640. Capron GK, Voights MB, Moore HR 3rd, Wall DB. Not every trauma patient with a radiographic head injury requires transfer for neurosurgical evaluation: Application of the brain injury guidelines to patients transferred to a level 1 trauma center. Am J Surg. 2017;214(6):1182–5. Epub 2017 Sep 18. PMID: 28939250. Martin GE, Carroll CP, Plummer ZJ, Millar DA, Pritts TA, Makley AT, Joseph BA, Ngwenya LB, Goodman MD. Safety and efficacy of brain injury guidelines at a Level III trauma center. J Trauma Acute Care Surg. 2018;84(3):483–489. 10.1097/TA.0000000000001767 . PMID: 29251702. Morocho B, Meinert J, Stirpe S, Paramore CG, Behm R. Retrospective Validation of Brain Injury Guidelines in a Rural Level II Trauma Center. J Surg Res. 2024;302:259–62. 10.1016/j.jss.2024.07.044 . Epub 2024 Aug 7. PMID: 39116824. Khan AD, Elseth AJ, Brosius JA, Moskowitz E, Liebscher SC, Anstadt MJ, Dunn JA, McVicker JH, Schroeppel T, Gonzalez RP. Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications. Trauma Surg Acute Care Open. 2020;5(1):e000483. 10.1136/tsaco-2020-000483 . PMID: 32537518; PMCID: PMC7264829. Owodunni OP, Alunday RL, Albright D, George NR, Wang ML, Cole CD, Norii T, Banks LL, Sklar DP, Crandall CS. Emergency physicians' perceived comfort with clinical decision-making for traumatic brain injury: Results from the BIG survey. Am J Emerg Med. 2025;87:177–81. Epub 2024 Sep 2. PMID: 39271400. Tables Table 1 Demographics and injury patterns for patients with traumatic brain injury. BIG 1 BIG 2 BIG 3 p-value Characteristic (n = 36) (n = 73) (n = 192) Age, years, mean 57.9 57.4 57.5 0.993 Male % 44.4% 69.9% 70.3% 0.009 ISS, mean (SD) 10.7 (4.6) 12.4 (5.9) 14.4 (7.4) 0.003 AIS-Head, mean (SD) 2.8 (0.4) 3.0 (0.5) 3.1 (0.7) 0.052 Mechanism % GLF 61.1% 50.7% 54.2% Assault 5.0% 7.0% 7.6% MVC 11.1% 23.3% 15.1% Other 22.8% 19.0% 23.1% Anticoagulant use 0 0 45 (33.4%) LOC, n (%) 18 (50%) 51 (69.9%) 159 (82.8%) < 0.001 Presenting GCS, mean 15 14.2 10.8 < 0.001 Presenting SBP, mean, mmHg 141 133 131 0.041 Presenting HR, mean, bpm 92 84 88 0.102 ISS = injury severity score, SD = standard deviation, AIS = abbreviated injury scale, GLF = ground level fall, MVC = motor vehicle collision, LOC = loss of consciousness, GCS = Glasgow Coma Scale, SBP = systolic blood pressure, HR = heart rate, bpm = beats per minute Table 2 Fracture and bleeding pattern for patients with traumatic brain injury. BIG 1 BIG 2 BIG 3 (n = 36) (n = 73) (n = 192) Skull Fracture Non-displaced 0 7 (9.6%) 9 (4.7%) Displaced 0 0 13 (6.8%) Intracranial Injury Type SDH, n (%) 11 (30.6%) 27 (37.0%) 88 (45.8%) EDH, n (%) 0 0 10 (5.2%) IPH/Contusion, n (%) 18 (50.0%) 25 (34.3%) 48 (25.0%) SAH, n (%) 7 (19.4%) 21 (28.8%) 46 (24.0%) IVH, n (%) 0 0 11 (5.7%) SDH = subdural hematoma, EDH = epidural hematoma, IPH = intraparenchymal hemorrhage, SAH = subarachnoid hemorrhage, IVH = intraventricular hemorrhage Table 3 Outcomes for patients with traumatic brain injury. BIG 1 BIG 2 BIG 3 p-value Outcome (n = 36) (n = 73) (n = 192) Transfer time*, mean, minutes 151 156 137 0.690 Transportation Mechanism 0.059 Helicopter, n (%) 10 (27.8%) 19 (26.0%) 77 (40.1%) Ground Ambulance, n (%) 26 (72.2%) 54 (74.0%) 115 (59.9%) Admitted to Floor, n (%) 2 (5.6%) 4 (5.5%) 0 0.999 Discharged from ED, n (%) 1 (2.8%) 0 0 0.999 LOS, mean days (SD) 5.4 (5.1) 5.9 (5.2) 10.0 (14.1) 0.010 ICU LOS, means days (SD) 1.8 (2.9) 1.9 (2.6) 4.4 (6.5) < 0.001 Need for Neurosurgical Intervention, n (%) 0 4 (5.3%) 37 (18.4%) < 0.001 Progression on repeat CT 14.3% 31.3% 37.5% 0.290 Mortality, n (%) 1 (2.7%) 5 (6.7%) 35 (17.1%) 0.009 ED = emergency department, LOS = length of stay, ICU = intensive care unit *Transfer time represents time from initial CT head at the transferring center to arrival at our facility. Table 4 Multivariable logistic regression analysis for risk of requiring neurosurgical intervention after traumatic brain injury. Risk factor OR CI p-value BIG 3 (versus BIG 1 or 2) 9.25 1.07–80.17 0.044 Age (years) 0.97 0.94-1.00 0.080 Injury severity score 0.94 0.84–1.06 0.310 Severe head injury (AIS 3+) 3.21 0.22–47.51 0.400 BIG = Brain Injury Guidelines, AIS = abbreviated injury scale Table 5 Results of ED physician survey at transferring centers. Each question scored 1–5 with 1 meaning not familiar or not comfortable at all and 5 meaning very familiar or very comfortable. Question Score Average (Range) How familiar are you with the modified BIG criteria used for assessing traumatic brain injuries? 2.14 ( 1 – 3 ) How confident are you in your ability to correctly apply BIG criteria in clinical decision-making? 1.86 ( 1 – 3 ) How often do you currently use BIG criteria in your emergency department practice when evaluating patients with traumatic brain injury? 1.57 ( 1 – 3 ) How comfortable are you discharging a patient who meets BIG 1 criteria without a neurosurgical consultation? 1.43 ( 1 – 3 ) How much would your comfort level increase if a telemedicine neurosurgery consult was available and supported the decision to discharge a BIG 1 patient? 3.71 ( 3 – 5 ) How much do you feel bed availability plays a factor in your hospital’s ability to observe BIG 1 patients for 6 hours with plans for subsequent discharge home? 3.86 ( 3 – 5 ) How much do you feel nursing staff availability affects your hospital’s ability to observe a BIG 1 patient for 6 hours in the emergency department with plans for subsequent discharge home? 3.43 ( 2 – 5 ) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7059382","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489066916,"identity":"75172f2c-3864-4942-b81a-af7bf5f253b7","order_by":0,"name":"Grace Hwang","email":"","orcid":"","institution":"Touro University California, College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"","lastName":"Hwang","suffix":""},{"id":489066917,"identity":"6512d30b-d282-4767-a4e2-20e9fb36f110","order_by":1,"name":"Daniel Margain","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Margain","suffix":""},{"id":489066918,"identity":"01b22973-642d-4a0c-a2a8-b4b50d8cc9ab","order_by":2,"name":"Connor Fewel","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Connor","middleName":"","lastName":"Fewel","suffix":""},{"id":489066919,"identity":"a2b461b5-34f8-429b-947b-88790f71ac32","order_by":3,"name":"Danielle Vanderet DO","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"Vanderet","lastName":"DO","suffix":""},{"id":489066920,"identity":"157a4718-cd9b-4dad-89ec-76c7dec5a9dc","order_by":4,"name":"Esther Lee","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Esther","middleName":"","lastName":"Lee","suffix":""},{"id":489066921,"identity":"a4faa4fe-f041-498a-86a1-5f54c38bbd6b","order_by":5,"name":"Albert Kazi","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Albert","middleName":"","lastName":"Kazi","suffix":""},{"id":489066922,"identity":"89ebae2b-bfee-4132-bca3-bed49f7fbf3d","order_by":6,"name":"Bryan Love","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Bryan","middleName":"","lastName":"Love","suffix":""},{"id":489066923,"identity":"9ebf1f86-30da-4533-ba6f-bfd4b0b65c98","order_by":7,"name":"Mallory Jebbia","email":"data:image/png;base64,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","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Mallory","middleName":"","lastName":"Jebbia","suffix":""},{"id":489066924,"identity":"8b544de1-f03a-4929-8717-8785b81135f5","order_by":8,"name":"Kevin Morrow","email":"","orcid":"","institution":"Desert Regional Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Morrow","suffix":""}],"badges":[],"createdAt":"2025-07-06 18:08:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7059382/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7059382/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90058132,"identity":"20303c70-fc04-4b7b-8dd3-6c204fb05b63","added_by":"auto","created_at":"2025-08-28 02:31:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":556468,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7059382/v1/71447d04-c842-4aff-ba7c-3c239d49a8b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transfer Outcomes of Traumatic Brain Injuries – What Will it Really Take to Adopt BIG at a Level 3 Trauma Center?","fulltext":[{"header":"Background","content":"\u003cp\u003eTraumatic brain injury (TBI) is a significant public health concern in the United States, accounting for approximately 2.8\u0026nbsp;million emergency department visits, hospitalizations, and deaths each year (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These injuries contribute to considerable morbidity, mortality, and long-term disability, often resulting in difficulty reintegrating into the workforce and significant socioeconomic burdens to patients (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In fact, one study found that patients have decreased cognition and quality of life and increased depression for up to 10 years following TBI (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). To help standardize management of TBIs, the Brain Injury Guidelines (BIG) were developed to stratify patients based on the severity of their injuries, using both clinical and radiographic findings. Categories are BIG 1, 2 and 3 from least to most severe (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These guidelines were subsequently validated, demonstrating that selected patients (BIG 1 and BIG 2) could be safely managed without neurosurgical consultation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In 2022 Khan et al validated the modified BIG criteria which made changes to the type of intracranial hemorrhage in certain categories, particularly the management of epidural hematomas (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrauma centers in the United States are categorized by the American College of Surgeons (ACS) as Level I through V based on their resources and capabilities. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Level I and II trauma centers are required to have neurosurgical services available, while Level III-V centers are not mandated to maintain neurosurgical specialists on staff but instead established transfer protocols for patients requiring higher levels of care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Previous standard practice mandates patients with any severity of TBI get transferred to Level I or II for neurosurgical evaluation. However, more recently level III trauma centers have begun implementing BIG criteria into their management algorithms (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Some are looking at the feasibility of not transferring patients with BIG 1 or BIG 2 TBIs (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This study aimed to evaluate the transfer outcomes of TBIs and contribute to the discussion on the feasibility of observing mild TBI patients at smaller hospitals.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e After institutional review board approval was obtained, a retrospective chart review was performed at our Level 1 trauma center. We included all adult trauma patients age 18 years and older who were transferred to our emergency department from a level III trauma center between January 2018 and December 2024 with a traumatic brain injury diagnosed on computed tomography (CT). Head CTs, anticoagulation use, and blood alcohol levels were reviewed and patients were assigned to modified BIG 1, 2 or 3. The modified BIG criteria was used to determine patient classification (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The primary outcome was need for neurosurgical intervention. Secondary outcomes included transfer times, length of stay (LOS) and mortality. Transfer times were calculated as the time from initial CT imaging at the transferring hospital to the time of arrival at our emergency department. Ground transport time from the transferring hospital to our facility is 30\u0026ndash;45 minutes on average.\u003c/p\u003e\u003cp\u003eDemographic data points that were collected included age and sex. The injury data collected included mechanism of injury, traumatic brain injury type, abbreviated injury scale of the head (AIS head), the injury severity score (ISS) and initial vitals. Additional outcomes evaluated were intensive care unit (ICU) admission, ICU length of stay (LOS), hospital LOS and mode of transport between hospitals.\u003c/p\u003e\u003cp\u003eAll bivariate analyses were performed with IBM SPSS Statistics for Windows (Version 29, IBM Corp., Armonk, NY). A Mann-Whitney-U test was used to compare continuous variables and a chi-square was used to compare categorical variables in the bivariate analysis. Categorical data was presented as percentages while continuous data was presented as a mean with standard deviation. We then performed a multivariable logistic regression analysis to determine the risk of neurosurgical intervention for patients with traumatic brain injury. We adjusted for potential confounders, which were selected based on discussion among coauthors, review of the literature and identifying univariate statistically significant differences between proposed confounding variables. These included age, ISS, and severe AIS (AIS\u0026thinsp;\u0026gt;\u0026thinsp;3) for the head. P-values were defined as statistically significant if\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eEmergency medicine physicians from the transferring hospital were then anonymously surveyed by email about their comfort level in adopting BIG criteria, and about their perception on the feasibility of BIG adoption at their institution (Full survey questions listed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 301 patients were transferred to our facility with confirmed traumatic brain injury. Of those, 36 were BIG 1, 73 were BIG 2, and 192 were BIG 3. There was no difference in average age among the three groups (57.9 vs 57.4 vs 57.5, p\u0026thinsp;=\u0026thinsp;0.993). Patients in the BIG 3 group were more likely to be male (44.4% vs 69.9% vs 70.3%, p\u0026thinsp;=\u0026thinsp;0.009) and had higher ISS scores (10.7 vs 12.4 vs 14.4, p\u0026thinsp;=\u0026thinsp;0.003). The AIS head score trended towards higher mean scores in the BIG 3 group (2.8 vs 3.0 vs 3.1, p\u0026thinsp;=\u0026thinsp;0.052). The most common mechanism of injury in all three groups was ground level fall (61.1%, 50.7%, and 54.2%). 33.4% of BIG 3 patients were on anticoagulation at the time of their trauma. Loss of consciousness was more common in BIG 3 patients (50% vs 69.9% vs 82.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The presenting GCS was lowest in the BIG 3 group (15 vs 14.2 vs 10.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). BIG 3 patients tended to have a lower systolic blood pressure on arrival (141 vs 133 vs 131, p\u0026thinsp;=\u0026thinsp;0.041) but there was no difference in presenting heart rate (92 vs 84 vs 88, p\u0026thinsp;=\u0026thinsp;0.102). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eA total of 7 (9.6%) patients in the BIG 2 category had non-displaced skull fractures while 22 total BIG 3 patient has skull fractures, 9 (4.7%) were non-displaced and 13 (6.8%) were displaced. 11 (30.6%) BIG 1 patients had subdural hematomas (SDH), 18 (50%) had intraparenchymal hemorrhage (IPH) or contusion, and 7 (19.4%) had subarachnoid hemorrhage (SAH). The BIG 2 patients had 27 (37.0%) SDH, 25 (34.3%) IPH/contusion, and 21 (28.8%) SAH. BIG 3 patients had 88 (45.8%) SDH, 10 (5.2%) epidural hematoma (EDH), 48 (25.0%) IPH/contusion, 46 (24.0%) SAH, and 11 (5.7%) intraventricular hemorrhage (IVH). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe average transfer time was 151 minutes in the BIG 1 group with a range of 48 minutes to 177 minutes. BIG 2 patients had an average transfer time of 156 minutes with a range of 48 minutes to 224 minutes. BIG 3 patients had an average transfer time of 137 minutes with a range of 38 minutes to 185 minutes. A higher percentage of BIG 3 patients were transferred by helicopter (40.1%) compared to BIG 1 (27.8%) and BIG 2 (26.0%) patients. The remaining patients in each group were transported via ground ambulance. In the BIG 1 category, 2 patients (5.6%) were admitted to the floor, 1 (2.8%) was discharged home from the ED and the remainder were admitted to the ICU. In the BIG 2 category 4 (5.5%) of patients were admitted to the floor, no patients were discharged from the ED and the remaining patients were admitted to the ICU. All patients in the BIG 3 category were admitted to the ICU. BIG 1 patients had the shortened average hospital LOS (5.4 vs 5.9 vs 10.0 days, p\u0026thinsp;=\u0026thinsp;0.010) and shorted ICU LOS (1.8 vs 1.9 vs 4.4 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No patients in the BIG 1 category required neurosurgical intervention while 4 (5.3%) of BIG 2 and 37 (18.4%) of BIG 3 required intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was an increasing trend in progression on repeat head CT from 14.3\u0026ndash;31.3% to 37.5% for BIG 1, 2 and 3 respectively, however this did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.290). Mortality increased with BIG category (2.7% vs 6.7% vs 17.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). On multivariate analysis, BIG 3 was the only independent predictor for the need for neurosurgical intervention (OR 9.25, CI 1.07\u0026ndash;80.17, P\u0026thinsp;=\u0026thinsp;0.044) when controlling for age, ISS and AIS head (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA total of 7 emergency medicine attendings from a level III trauma center responded to the anonymous survey. The average familiarity with the BIG criteria was 2.14/5. When asked about comfort in correctly applying BIG to clinical situations the average score was 1.86/5. They reported 1.57/5 for how often they utilize BIG criteria in clinical decision-making. Comfort in discharging a BIG 1 patient from the emergency department without neurosurgical consultation was reported at 1.43/5. Conversely, a score of 3.71/5 represented how much their comfort level would increase if a neurosurgery telehealth consult was available. When asked how much bed availability and nursing staff availability played a role in their hospital\u0026rsquo;s ability to observe a BIG 1 patient for 6 hours they reported 3.86/5 and 3.42/5 respectively. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our results are consistent with the growing body of evidence supporting the use of the Brain Injury Guidelines in the triage and management of patients with mild traumatic brain injuries. Consistent with previous studies, we found that none of the BIG 1 patients required neurosurgical intervention (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite these findings, survey responses from a level III referring center indicate significant hesitation to retain and monitor TBI patients locally.\u003c/p\u003e\u003cp\u003eOur findings reaffirm that BIG 1 patients are safely managed without neurosurgical consultation, aligning with the results of Martin et al who utilized the traditional BIG criteria to assess need for neurosurgical intervention in patients evaluated at a level III trauma center (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This was successfully applied to a rural level II trauma center by Morocho et al with no BIG 1 or 2 patients requiring neurosurgical intervention (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Khan et al. then demonstrated the safety and effectiveness of the modified BIG criteria in stratifying TBI patients by risk level (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In our cohort, BIG 1 patients required no neurosurgical intervention, had stable vitals and there was only 1 mortality that was unrelated to the patient\u0026rsquo;s mild TBI. In fact the BIG criteria was the only independent predictor of the need for neurosurgical intervention in our patients, suggesting it is a reliable tool for patient prognostication and management. Additionally there was minimal progression of intracranial hemorrhage seen on repeat CT head (only 14%) for BIG 1 patients, similar to other study findings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Yet these BIG 1 patients were still transferred to a tertiary facility, often admitted to the ICU, and subjected to unnecessary resource utilization. These results show that despite growing literature showing the safety of the BIG criteria, hospitals are utilizing additional resources to transfer patients to higher levels of care.\u003c/p\u003e\u003cp\u003eThe lengthy transfer times, averaging over 2.5 hours for BIG 1 and BIG 2 patients, raise concerns about the practicality and efficiency of current interfacility transfer practices. Transfer time was counted as the time stamp on the patient\u0026rsquo;s CT head showing a TBI to the arrival time at the receiving emergency department and therefore included calling the receiving facility, providing handoff, coordinating ground or air transfer, and the actual transport time itself. These delays in transfer represent nearly half of the six-hour observation period recommended for mild TBIs, meaning many patients effectively complete half the suggested monitoring period while awaiting transfer to a higher-level facility. In this context, the transfer of BIG 1 patients, who ultimately do not require interventions, represents a potential target for quality improvement and cost reduction.\u003c/p\u003e\u003cp\u003eWhile implementing BIG criteria at smaller hospitals has clear potential benefits such as resource preservation and cost reduction, our survey of physicians from a referring center revealed systemic barriers. These included limited bed capacity, difficulty allocating staff for prolonged neurologic observation, and provider discomfort with managing hemorrhagic injuries without a neurosurgeon on call. Particularly in some of our smaller referring facilities, some of which have only 12-bed emergency departments, these concerns are valid. Owodunni et al found that over 50% of emergency medicine physicians surveyed would still consult neurosurgery for BIG 1 patients despite having an understanding of the BIG criteria. Additionally, they found that over 50% of these physicians would order a repeat CT head for BIG 1 patients despite the guideline recommendations suggesting this is not necessary (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This shows that despite several studies demonstrating the efficacy of the BIG criteria and the modified BIG criteria, there is some hesitation in full adoption which the authors suggest could be related to medicolegal concerns or lack of institutional guidance (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). As a result, rather than proposing immediate adoption of BIG 1 and 2 retention at smaller centers, a more incremental approach may be more feasible. For example, starting with observing BIG 1 patients without transfer, and when comfort improves, addressing retention of BIG 2 patients. This staged strategy could help shift culture while maintaining patient safety and building local confidence in the guidelines.\u003c/p\u003e\u003cp\u003eWe acknowledge several limitations to this study. It was a retrospective analysis conducted at a single Level 1 trauma center, introducing potential selection and documentation bias. Additionally, the small number of BIG 1 patients in our cohort limits the generalizability of conclusions. Survey responses were limited to a single level III center and may not reflect broader trends across other level III or non-trauma hospitals. Additionally we only received 7 responses, so to provide a more robust analysis a larger scale survey of several centers across the country should be performed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study supports existing literature that BIG 1 patients with mild traumatic brain injury can be safely managed without neurosurgical consultation or transfer to a higher-level trauma center. Despite this, widespread adoption of BIG criteria remains limited, which may be due to concerns about staffing, liability, and resource constraints at lower-level facilities. While BIG criteria offer a safe and evidence-based framework for triaging TBI, substantial system-level and cultural changes are necessary before it can be broadly implemented in Level III or even non-trauma centers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: IRB approval was obtained by MetroWest Medical Center IRB. A waiver of consent was granted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: None\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGH and MJ wrote the main manuscript text. DM and CF prepared the tables.EL and AK helped with project design and edited the manuscript drafts.BL and DV acquired the data.KM helped with conceptualization, manuscript edits and overall supervision.All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths\u0026mdash;United States. 2014. Published March 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaudette \u0026Eacute;, Seabury SA, Temkin N, et al. Employment and Economic Outcomes of Participants With Mild Traumatic Brain Injury in the TRACK-TBI Study. JAMA Netw Open. 2022;5(6):e2219444. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2022.19444\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2022.19444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrauwmeijer E, Heijenbrok-Kal MH, Peppel LD, Hartjes CJ, Haitsma IK, de Koning I, Ribbers GM, Cognition. Health-Related Quality of Life, and Depression Ten Years after Moderate to Severe Traumatic Brain Injury: A Prospective Cohort Study. J Neurotrauma. 2018;35(13):1543\u0026ndash;1551. doi: 10.1089/neu.2017.5404. Epub 2018 Apr 6. PMID: 29343203.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965-9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000000161\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000000161\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 24662858.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoseph B, Aziz H, Pandit V, Kulvatunyou N, Sadoun M, Tang A, O'Keeffe T, Gries L, Green DJ, Friese RS, Lemole MG Jr, Rhee P. Prospective validation of the brain injury guidelines: managing traumatic brain injury without neurosurgical consultation. J Trauma Acute Care Surg. 2014;77(6):984-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000000428\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000000428\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 25423541.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan AD, Lee J, Galicia K, Billings JD, Dobaria V, Patel PP, McIntyre RC, Gonzalez RP, Schroeppel TJ. A multicenter validation of the modified brain injury guidelines: Are they safe and effective? J Trauma Acute Care Surg. 2022;93(1):106\u0026ndash;112. doi: 10.1097/TA.0000000000003633. Epub 2022 Apr 1. PMID: 35358157.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican College of Surgeons. Resources for Optimal Care of the Injured Patient. ACS; 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican College of Surgeons Committee on Trauma. Statement on trauma center designation based upon system need. Bull Am Coll Surg. 2015;100(1):51\u0026ndash;2. PMID: 25626271.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGribbell M, Hsu J, Krech L, et al. Step up to the Brain Injury Guidelines league: Adoption of Brain Injury Guidelines at a Level III trauma center, A pilot study. Trauma. 2022;24(4):294\u0026ndash;300. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/14604086211017374\u003c/span\u003e\u003cspan address=\"10.1177/14604086211017374\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlan N, Kim S, Agarwal N, Clarke J, Yealy DM, Cohen-Gadol AA, Sekula RF. Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14\u0026ndash;15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers. J Clin Neurosci. 2020;81:246\u0026ndash;51. Epub 2020 Oct 15. PMID: 33222924; PMCID: PMC7560640.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCapron GK, Voights MB, Moore HR 3rd, Wall DB. Not every trauma patient with a radiographic head injury requires transfer for neurosurgical evaluation: Application of the brain injury guidelines to patients transferred to a level 1 trauma center. Am J Surg. 2017;214(6):1182\u0026ndash;5. Epub 2017 Sep 18. PMID: 28939250.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartin GE, Carroll CP, Plummer ZJ, Millar DA, Pritts TA, Makley AT, Joseph BA, Ngwenya LB, Goodman MD. Safety and efficacy of brain injury guidelines at a Level III trauma center. J Trauma Acute Care Surg. 2018;84(3):483\u0026ndash;489. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000001767\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000001767\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 29251702.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorocho B, Meinert J, Stirpe S, Paramore CG, Behm R. Retrospective Validation of Brain Injury Guidelines in a Rural Level II Trauma Center. J Surg Res. 2024;302:259\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jss.2024.07.044\u003c/span\u003e\u003cspan address=\"10.1016/j.jss.2024.07.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Aug 7. PMID: 39116824.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan AD, Elseth AJ, Brosius JA, Moskowitz E, Liebscher SC, Anstadt MJ, Dunn JA, McVicker JH, Schroeppel T, Gonzalez RP. Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications. Trauma Surg Acute Care Open. 2020;5(1):e000483. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tsaco-2020-000483\u003c/span\u003e\u003cspan address=\"10.1136/tsaco-2020-000483\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 32537518; PMCID: PMC7264829.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOwodunni OP, Alunday RL, Albright D, George NR, Wang ML, Cole CD, Norii T, Banks LL, Sklar DP, Crandall CS. Emergency physicians' perceived comfort with clinical decision-making for traumatic brain injury: Results from the BIG survey. Am J Emerg Med. 2025;87:177\u0026ndash;81. Epub 2024 Sep 2. PMID: 39271400.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics and injury patterns for patients with traumatic brain injury.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBIG 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBIG 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBIG 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;192)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years, mean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.993\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eISS, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.7 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.4 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.4 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIS-Head, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.8 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.0 (0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.1 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMechanism %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGLF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssault\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMVC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnticoagulant use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (33.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOC, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (69.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e159 (82.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresenting GCS, mean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresenting SBP, mean, mmHg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresenting HR, mean, bpm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eISS\u0026thinsp;=\u0026thinsp;injury severity score, SD\u0026thinsp;=\u0026thinsp;standard deviation, AIS\u0026thinsp;=\u0026thinsp;abbreviated injury scale, GLF\u0026thinsp;=\u0026thinsp;ground level fall, MVC\u0026thinsp;=\u0026thinsp;motor vehicle collision, LOC\u0026thinsp;=\u0026thinsp;loss of consciousness, GCS\u0026thinsp;=\u0026thinsp;Glasgow Coma Scale, SBP\u0026thinsp;=\u0026thinsp;systolic blood pressure, HR\u0026thinsp;=\u0026thinsp;heart rate, bpm\u0026thinsp;=\u0026thinsp;beats per minute\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFracture and bleeding pattern for patients with traumatic brain injury.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBIG 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBIG 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBIG 3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;192)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSkull Fracture\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-displaced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (9.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (4.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisplaced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13 (6.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntracranial Injury Type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSDH, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (30.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (37.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88 (45.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEDH, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10 (5.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIPH/Contusion, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (34.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e48 (25.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSAH, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (19.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (28.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46 (24.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIVH, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eSDH\u0026thinsp;=\u0026thinsp;subdural hematoma, EDH\u0026thinsp;=\u0026thinsp;epidural hematoma, IPH\u0026thinsp;=\u0026thinsp;intraparenchymal hemorrhage, SAH\u0026thinsp;=\u0026thinsp;subarachnoid hemorrhage, IVH\u0026thinsp;=\u0026thinsp;intraventricular hemorrhage\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutcomes for patients with traumatic brain injury.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBIG 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBIG 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBIG 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;192)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransfer time*, mean, minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.690\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransportation Mechanism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHelicopter, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (27.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (26.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77 (40.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGround Ambulance, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (72.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (74.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e115 (59.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdmitted to Floor, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDischarged from ED, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOS, mean days (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.4 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.9 (5.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.0 (14.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU LOS, means days (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.8 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.4 (6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeed for Neurosurgical Intervention, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37 (18.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProgression on repeat CT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.290\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMortality, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (6.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (17.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eED\u0026thinsp;=\u0026thinsp;emergency department, LOS\u0026thinsp;=\u0026thinsp;length of stay, ICU\u0026thinsp;=\u0026thinsp;intensive care unit\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Transfer time represents time from initial CT head at the transferring center to arrival at our facility.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariable logistic regression analysis for risk of requiring neurosurgical intervention after traumatic brain injury.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRisk factor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBIG 3 (versus BIG 1 or 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.07\u0026ndash;80.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.94-1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.080\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInjury severity score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.84\u0026ndash;1.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.310\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere head injury (AIS 3+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.22\u0026ndash;47.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.400\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBIG\u0026thinsp;=\u0026thinsp;Brain Injury Guidelines, AIS\u0026thinsp;=\u0026thinsp;abbreviated injury scale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of ED physician survey at transferring centers. Each question scored 1\u0026ndash;5 with 1 meaning not familiar or not comfortable at all and 5 meaning very familiar or very comfortable.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScore Average (Range)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow familiar are you with the modified BIG criteria used for assessing traumatic brain injuries?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.14 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow confident are you in your ability to correctly apply BIG criteria in clinical decision-making?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.86 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow often do you currently use BIG criteria in your emergency department practice when evaluating patients with traumatic brain injury?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.57 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow comfortable are you discharging a patient who meets BIG 1 criteria without a neurosurgical consultation?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.43 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow much would your comfort level increase if a telemedicine neurosurgery consult was available and supported the decision to discharge a BIG 1 patient?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.71 (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow much do you feel bed availability plays a factor in your hospital\u0026rsquo;s ability to observe BIG 1 patients for 6 hours with plans for subsequent discharge home?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.86 (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow much do you feel nursing staff availability affects your hospital\u0026rsquo;s ability to observe a BIG 1 patient for 6 hours in the emergency department with plans for subsequent discharge home?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.43 (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"traumatic brain injury, brain injury guidelines, trauma","lastPublishedDoi":"10.21203/rs.3.rs-7059382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7059382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003e 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 at smaller hospitals.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA 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\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while no BIG 1 patients required intervention. Mortality was highest in BIG 3 (2.7% vs. 6.7% vs. 17.1%, p\u0026thinsp;=\u0026thinsp;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.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e\u003cp\u003eThis study supports similar studies showing BIG 1 patients can be safely observed without neurosurgical consultation. However, implementing BIG at smaller hospitals requires a large culture shift, along with adequate staffing and resources to observe patients for six hours.\u003c/p\u003e","manuscriptTitle":"Transfer Outcomes of Traumatic Brain Injuries – What Will it Really Take to Adopt BIG at a Level 3 Trauma Center?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-24 16:05:39","doi":"10.21203/rs.3.rs-7059382/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"69d82991-ccdd-47f3-8eba-b707a1469f7d","owner":[],"postedDate":"July 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-28T02:23:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-24 16:05:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7059382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7059382","identity":"rs-7059382","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}