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Prior surveys of acute medical management of severe traumatic brain injury (TBI) indicate that care is fragmented and inconsistent, although Guidelines for the management of severe traumatic brain injury (guidelines) were distributed and endorsed by the American Association of Neurologic Surgeons. We conducted a survey of US trauma centers to evaluate guideline adherence, to examine predictors of adherence, and to compare our results with similar surveys conducted in 1991 and 2000.A Web-based survey was conducted in 413 designated trauma centers admitting patients with severe TBI. Good adherence was defined as adherence to the median number of guidelines (median = 6, interquartile range 5–7).In adjusted analysis, good adherence was predicted by Level I trauma center designation and presence of treatment protocols. Compared with trauma centers without these predictive factors, the likelihood of good guideline adherence increased 2.4-fold with each additional predictor (95% confidence interval = 1.8–3.3).Routine intracranial pressure monitor use increased from 32.4% in 1991 and 50.8% in 2000 to 77.4% in the current survey (p < 0.0001). Avoidance of steroids in TBI rose from 47.8% in 1991 and 52.4% in 2000 to 86.0% in 2006 (p < 0.0001). Lack of guideline adherence decreased significantly from 67% in 2006 to 34.5%.Adherence to evidence-based guidelines for severe TBI has improved dramatically since 1991. Trauma center level and treatment protocols were associated with good adherence, suggesting that directing patients with severe TBI to Level I and Level II trauma centers with treatment protocols will improve outcome for these patients.