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In 1995, evidence-based guidelines for the management of severe traumatic brain injury (TBI) were published and disseminated. Information regarding their implementation is limited.During 1999 to 2000, we contacted all designated U.S. trauma centers caring for adults with severe TBI to determine the degree of guideline compliance and to identify predictors.Of 924 centers identified, 828 participated (90%). Four hundred thirty-three with intensive care units caring for severe TBI were surveyed. Three hundred ninety-five centers transferring patients were excluded. Full guideline compliance was rare (n = 68 [16%]). In multivariate analyses, treatment protocols (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.9–6.6), neurosurgery residency program (OR, 5.0; 95% CI, 2.6–9.8), and state (OR, 2.7; 95% CI, 0.62–12) or American College of Surgeons (OR, 5.1; 95% CI, 1.1–23) designation increased the likelihood of full compliance versus noncompliance.Although evidence-based guidelines were published and disseminated in 1995, implementation is infrequent. Focus must turn to changing physician practice and transport decisions to provide guideline-compliant care and improve patient outcome.