Safe local management of mild traumatic brain injury: Reducing unnecessary transfers to higher-level trauma centers

Patients with mild traumatic brain injury and traumatic intracranial hemorrhage are frequently transferred to higher-level trauma centers despite low rates of neurologic deterioration and operative intervention. Standardized brain injury algorithms prioritize safety but often escalate care for patients with small, nonoperative hemorrhages. In trauma systems with level III and IV centers lacking on-site neurosurgical coverage, identifying patients who can be safely managed locally remains challenging.

We performed a retrospective cohort study of adult patients treated between 2015 and 2025 with isolated mild traumatic brain injury (Glasgow Coma Scale 14-15) and traumatic intracranial hemorrhage. Patients meeting strict clinical and radiographic criteria were either managed locally at a level III trauma center using a standardized monitoring and escalation protocol or transferred to a level I trauma center under standard regional practice. Outcomes included neurosurgical intervention, in-hospital mortality, length of stay, and discharge disposition.

Three hundred thirty-five patients were included (48 level III; 287 level I). No locally managed patients required neurosurgical intervention (0%) compared with 1 transferred patient (0.4%). In-hospital mortality was similar between groups (2.1% vs 2.2%), and the median length of stay was 2 days in both cohorts. A higher proportion of locally managed patients were discharged home (81.3% vs 72.5%).

Selective local management of carefully selected patients with isolated mild traumatic brain injury and traumatic intracranial hemorrhage was associated with outcomes comparable to transfer to a level I trauma center. These findings support risk-based transfer strategies and align with updated Pennsylvania Trauma Systems Foundation standards permitting select patients to remain at level III and IV trauma centers.