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

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.