Neurosurgery 2026;99(2):391–400
Complicated mild traumatic brain injury often triggers admission, repeat imaging and specialist assessment despite a low probability of intervention in selected patients. The University of Utah introduced a modified Brain Injury Guideline that retained neurosurgical consultation while prioritizing appropriate resource use. This before-and-after study evaluated 977 adults with traumatic intracranial hemorrhage. Implementation increased direct emergency-department and home discharge without reducing follow-up. Fewer patients returned with radiological lesion expansion, although the observational design does not prove that the protocol caused this improvement.
Objective
To determine whether implementing a modified Brain Injury Guideline incorporating neurosurgical consultation could improve resource utilization without compromising follow-up in patients with complicated mild traumatic brain injury.
Methods
A retrospective before-and-after review included patients with mild traumatic brain injury and acute traumatic intracranial hemorrhage treated before UteBIG implementation, from January 2016 through August 2022, or afterward, from September 2022 through December 2023.
The investigators compared direct emergency-department discharge, destination after hospitalization, length of stay, provision of educational material, 3-month follow-up and emergency return with lesion expansion. The study analyzed 977 patients; 63.5% were male, mean age was 58.0 years and 57.6% had a Glasgow Coma Scale score of 15.
Main results
After implementation, direct discharge from the emergency department increased from 0.3% to 7.2% (p<0.001), and discharge home after hospitalization increased from 45.6% to 69.2% (p<0.001).
Mean length of stay decreased numerically from 8.33 to 5.17 days, but the difference was not significant (p=0.27). Receipt of educational material (78.5% versus 83.9%; p=0.06) and 3-month follow-up (67.4% versus 72.7%; p=0.13) were unchanged. Emergency-department return with lesion expansion fell from 6.0% to 2.7% (p=0.02).
Interpretation
A structured pathway that preserves neurosurgical participation may allow more selected patients with complicated mild traumatic brain injury to avoid unnecessary hospitalization or non-home discharge. The findings suggest that resource stewardship and specialist collaboration are compatible, but they should not be interpreted as evidence that every patient with a small traumatic hemorrhage can be safely discharged.
Limitations
This was a retrospective, single-center comparison across two different time periods. Changes in staffing, bed availability, discharge practice and case mix may have influenced the results. The postimplementation interval was shorter, and the study was not designed to demonstrate equivalence for rare deterioration, delayed surgery or mortality.
Clinical takeaway
Protocol-based assessment can reduce avoidable resource use in selected adults with complicated mild traumatic brain injury. Safe implementation requires explicit imaging and clinical criteria, neurosurgical availability, reliable observation and discharge instructions, and a defined route for urgent reassessment.
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