Previous literature demonstrates increased mortality for Traumatic Brain Injury (TBI) with transfer to a Level II versus Level I trauma center. Our objective is to determine the effect of the most recent American College of Surgeons-Committee on Trauma (ACS-COT) Resources for the Optimal Care of the Injured Patient resources manual (“The Orange Book”) on outcomes after severe TBI after interfacility transfer to Level I vs Level II center.
Utilizing the Trauma Quality Program Participant Use File (TQP-PUF) of the American College of Surgeons (ACS) admission year 2017, we identified patients with isolated TBI undergoing interfacility transfer to either Level I or Level II trauma center. Logistic regression was performed to determine independent associations with mortality.
There were 10,268 (71.6%) transferred to a level I and 4,025 (28.4%) were transferred to a level II center. They were mostly male (61.4%) with a mean age of 61 ± 20.8 years. Mean Injury Severity Score (ISS) was 16.3 ± 6.3 and most were injured in a single level fall (SLF) (51.5%). Patients transferred to a Level I center were less likely white (82.3% vs 84.7%, 0.002) and more likely to have sustained penetrating trauma (2.7% vs 1.6%, <0.001). The incidence of severe TBI (Glasgow coma scale (GCS) 3-8) was similar (9.3% vs 8.3%, 0.068). On logistic regression, severity of TBI predicted death, however, there was no difference in adjusted mortality outcome with admission to a Level II versus a Level I center [0.998 (0.836 – 1.192), 0.985].
There is no mortality discrepancy in patients with isolated TBI transferred to a Level II versus Level I center despite previous contrary evidence and thus no reason to bypass a Level II in favor of a Level I. This relative improvement potentially relates to the new requirements as defined in the latest version of the ACS-COT’s Resources Manual.

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