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Background: Prehospital management of traumatic brain injury (TBI) and trauma system development and organization are aspects of TBI care that have the potential to significantly impact patient outcome. This multi-center study was conducted to explore the effect of prehospital management decisions on early mortality after severe TBI., Methods: This report is based on 1449 patients with severe TBI (GCS<9) treated at 22 trauma centers enrolled in a New York State quality improvement (QI) program between 2000 and 2004. The prehospital data collected on these patients include time of injury, time of arrival to the trauma center, mode of transport, type of EMS provider, direct or indirect transport, blood pressure and pulse oximetry values, GCS score, pupillary assessment, and airway management procedures., Results: After exclusion criteria were applied, a total of 1,123 patients were eligible for analysis. The majority of patients were male (75%) with a mean age of 36 years. After controlling for arterial hypotension, age, pupillary status, and initial GCS score, direct transport was found to result in significantly lower mortality than indirect transport. Transport mode, time to admission, and prehospital intubation were not found to be related to 2-week mortality., Conclusions: The present study provides class II evidence that demonstrates a 50% increase in mortality associated with indirect transfer of TBI patients. Patients with severe TBI should be transported directly to a Level I or Level II trauma center with capabilities as delineated in the Guidelines for the Prehospital Management of Traumatic Brain Injury, even if this center may not be the closest hospital.