Applying an updated brain injury guideline classification to interhospital transfer of patients with traumatic brain injury: Who benefits most?

OBJECTIVE

The Brain Injury Guidelines (BIG) categorize patients with mild, moderate, and severe traumatic brain injuries (TBIs). We examined whether TBI transfer guidelines should be modified to incorporate BIG alongside polytrauma and patient frailty assessments to identify which patients are most likely to benefit from transfer.

METHODS

Patients ≥ 18 years old transferred to our Level 1 trauma center in 2019-2023 with nonpenetrating blunt cranial trauma were identified retrospectively. BIG scores were calculated using presentation, injury, in-hospital, and follow-up characteristics.

RESULTS

Of the 999-patient cohort, 168 patients were considered BIG1, 133 BIG2, and 698 BIG3. BIG1 and BIG2 (compared with BIG3) patients had lower injury severity scores (14.6, 13.8, 19.9, respectively, p < 0.001), no > 1-point decline in Glasgow Coma Scale score during transportation (0, 0, 16.8 %, p < 0.001), shorter hospital stays (4.6 days, 3.6, 8.3, p < 0.001), fewer intensive care unit admissions (31.5 %, 37.6 %, 66.6 %, p < 0.001), rare progression on imaging (1.2 %, 4.6 %, 29.4 %, p) without clinical decline, and minimal neurosurgical interventions (0, 1.5 %, 13.9 %, p < 0.001). BIG2 polytrauma patients had greater risk of neurologic decline (OR 2.13, p = .04), whereas BIG1 patients had no meaningful predictors of neurologic decline. BIG3 classification (OR 5.92), SDH (OR 3.03), and high-velocity injury (OR 2.52) were the greatest risk factors for neurosurgical intervention.

CONCLUSIONS

BIG1 and BIG2 patients without polytrauma may not require transfer, but BIG2 patients with polytrauma and BIG3 patients often required transfer. Frailty and patient age may not require consideration in decision-making. Assessment including BIG and polytrauma may reduce unnecessary transfers, preserve hospital resources, and optimize patient care.