Factors associated with Parental Knowledge and Attitudes towards Concussions in the Republic of Korea.

Background: This study investigated the status and evaluated factors associated with knowledge and attitudes regarding concussions among Korean parents of children aged 6-18 years. Methods: A cross-sectional online survey was employed to collect data from a panel of parents in the Republic of Korea in 2023. To assess knowledge and attitudes regarding concussions, participants completed a validated questionnaire. The outcome variables of the total knowledge and total attitude scores, which ranged from 0 to 30 and 7 to 49, respectively, were categorized into three levels based on approximately 33% increments. We conducted multivariable ordinal logistic regression analyses with the participants' and their children's demographics and characteristics as covariates. Results: A total of 260 parents responded to the survey and demonstrated moderate concussion-related knowledge (median total score, (Inter Quartile Range (IQR) 18-22.5)). The respondents exhibited favorable attitudes toward concussions (median total score, 39 (IQR 34-43)). Multivariate ordinal regression analysis for outcomes revealed that, except for the careers of healthcare providers (adjusted odds ratio (AOR) 3.15, 95% confidence interval (CI), 1.13-8.75), no factors were associated with parental concussion-related knowledge. Among the factors, none exhibited a statistically significant association with concussion-related parental attitudes. Conclusion: Our results confirmed the knowledge-attitude gap regarding concussions among Korean parents and novel strategies are warranted to improve parental knowledge and attitudes.

Efficacy and safety of ketamine alone and ketamine-dexmedetomidine combination for sedation for brain computed tomography in paediatric patients with head injuries: A retrospective study.

OBJECTIVE: To compare the efficacy and safety of ketamine alone with those of ketamine-dexmedetomidine combination for sedation during brain CT in paediatric patients with head injuries. METHODS: We retrospectively analysed the data of paediatric patients who underwent sedation for brain CT at the ED. We included patients aged 6 months to 6 years with American Society of Anesthesiologists physical status I or II. The sedative protocol involved the administration of intramuscular (IM) ketamine 3 mg/kg (K), ketamine 2 mg/kg with dexmedetomidine 1.5 µg/kg (KD) or ketamine 1.5 mg/kg with dexmedetomidine 1.5 µg/kg (low-KD). The primary and secondary outcomes were sedation failure and adverse events, respectively. RESULTS: We included 77 patients; among them, 28, 23 and 26 were in the K, KD and low-KD groups, respectively. In multivariable analysis, the combination groups (KD and low-KD groups) were significantly associated with a lower possibility of sedation failure compared to the K group (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.56). Moreover, there were no significant differences in adverse events between the groups, and the sedation-related time variables also did not significantly differ among the three groups. CONCLUSIONS: Our findings indicated that a combination of IM ketamine-dexmedetomidine provides effective sedation for paediatric patients undergoing brain CT without significant adverse events. Further research is needed to investigate the potential benefits of using lower doses of ketamine in combination.

Effect of the interval between birth and second dose of hepatitis B vaccine on perinatal transmission of hepatitis B virus.

Preventing perinatal transmission is important for hepatitis B (HepB) elimination. We conducted a retrospective cohort study to assess the interval between HepB birth-dose (HepB-BD) to second-dose (HepB-SD) vaccination on perinatal transmission. Among 39,313 infants born to HepB s-antigen (HBsAg)-positive mothers from a Korean national database 38,411 (97.7%) had completed timely immunophylaxis with HepB-BD 41,572 (99.8%) with hepatitis B immune globulin, and 1027 (2.6%) were HBsAg-positive at ≥ 9 months. Maternal factors (i.e. HepB e-antigen status, age, or nationality) were associated with an increased risk of infection whereas short gestational length decreased it. The HepB-BD - HepB-SD interval (<8 vs. ≥8 weeks) did not alter the risk.

Correction: Evaluation of class participation in non-face-to-face CPR training for medical students.

[This corrects the article DOI: 10.1371/journal.pone.0278273.].

Framework Development of Non-Face-to-Face Training of Basic Life Support for Laypersons: A Multi-Method Study.

The spread of infectious diseases has accelerated the transition from face-to-face (F2F) to non-F2F (NF2F) education. To maintain the effect of successful NF2F education in cardiopulmonary resuscitation, reorganizing the curriculum to suit the NF2F educational environment is necessary. We propose an appropriate learning curriculum for NF2F basic life support (BLS) training for laypersons based on expert surveys and learners' performance outcomes. This study included three stages and used multiple methods. A draft curriculum was created through a literature review and three-round Delphi approach, and then applied as a test for actual education. After the training, the final curriculum of the NF2F BLS training for laypersons was proposed by reflecting on the performance outcomes of learners and expert opinions. NF2F theoretical education was simplified into five content items: concept of chain of survival, legal protection for first aiders, importance of bystander cardiopulmonary resuscitation, how to recognize a patient in cardiac arrest and activate the emergency medical services system, and reduced training time. In the hands-on skills session, it was recommended to practice chest compressions using a simple intuitive feedback device and to use automated external defibrillators step-by-step more than in F2F training. In conclusion, NF2F training is a suitable option for BLS training methods in situations where F2F training is difficult.

Area-Level Socioeconomic Inequalities in Intracranial Injury-Related Hospitalization in Korea: A Retrospective Analysis of Data From Korea National Hospital Discharge Survey 2008-2015.

BACKGROUND: Although inequality in traumatic brain injury (TBI) by individual socioeconomic status (SES) exists, interventions to modify individual SES are difficult. However, as interventions for area-based SES can affect the individual SES, monitoring or public health intervention can be planned. We analyzed the effect of area-based SES on hospitalization for TBI and revealed yearly inequality trends to provide a basis for health intervention. METHODS: We included patients who were hospitalized due to intracranial injuries (ICIs) between 2008 and 2015 as a measure of severe TBI with data provided by the Korea National Hospital Discharge Survey. Area-based SES was synthesized using the 2010 census data. We assessed inequalities in ICI-related hospitalization rates using the relative index of inequality and the slope index of inequality for the periods 2008-2009, 2010-2011, 2012-2013, and 2014-2015. We analyzed the trends of these indices for the observation period by age and sex. RESULTS: The overall relative indices of inequality for each 2-year period were 1.82 (95% confidence interval, 1.5-2.3), 1.97 (1.6-2.5), 2.01 (1.6-2.5), and 2.01 (1.6-2.5), respectively. The overall slope indices of inequality in each period were 38.74 (23.5-54.0), 36.75 (21.7-51.8), 35.65 (20.7-50.6), and 43.11 (27.6-58.6), respectively. The relative indices of inequality showed a linear trend for men (P = 0.006), which was most evident in the ≥ 65-year age group. CONCLUSION: Inequality in hospitalization for ICIs by area-based SES tended to increase during the observation period. Practical preventive interventions and input in healthcare resources for populations with low area-based SES are likely needed.

Analyzing willingness for extracorporeal cardiopulmonary resuscitation in refractory ventricular fibrillation.

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia in out-of-hospital cardiac arrest has recently been recommended for selected patients with favorable prognostic features. We aimed to identify factors affecting the willingness of emergency physicians to implement extracorporeal cardiopulmonary resuscitation (ECPR). We conducted a factorial survey with nine experimental vignettes by combining three different scene time intervals and transportation time intervals. Emergency physicians reported willingness to implement ECPR (1-100 points). Respondent characteristics that could affect the willingness were studied. Multilevel analysis of vignettes and respondent factors was conducted using a mixed-effects regression model. We obtained 486 vignette responses from 54 emergency physicians. In the case of longer scene time intervals, there was a significant difference in the willingness scores at 9 and 12 min transportation time intervals. When the pre-hospital time interval was > 40 min, emergency physicians demonstrated lower willingness to implement ECPR. Clinical experience of 15-19 years showed a significant favorable effect on willingness to implement extracorporeal membrane oxygenation (ECMO). However, the mean willingness scores of EPs for ECMO implementation were more than 75 across all vignettes. In ECPR, the prehospital time interval is an important factor, and the willingness of emergency physicians to implement ECMO could be mutually affected by scene time intervals, transportation time intervals, and total prehospital time.

Evaluation of class participation in non-face-to-face CPR training for medical students.

BACKGROUND: Cardiopulmonary resuscitation (CPR) education requires that learners practice key skills to promote mastery. Our aim in this study was to evaluate differences in post-education performance and class participation during CPR training between face-to- face (FF) and non-face-to-face (NFF) learning formats. METHODS: This was a randomized controlled study of third-year medical students from two university hospital, allocated to either the FF or NFF format for CPR education. The learning scenario addressed single-person CPR, consisting of chest compression only, and excluded breathing. The Kahoot! application was used for NFF. Between-group comparisons for class participation and CPR skills were based on video recordings. RESULTS: Seventy students participated in our study, with 35 randomly allocated to the FF and NFF groups. There were no between-group differences in terms of age, sex, previous basic life support training, and willingness and confidence in performing CPR. Compared to the FF group, the NFF group demonstrated significant differences during CPR, including fewer calling for assistance and using of defibrillator (p = 0.006), as well as fewer checking for breathing (p = 0.007), and fewer counting during chest compression (p = 0.006). Additionally, < 30% of learners in the NFF group completed rhythm analysis after the last defibrillator shock delivery and resumed immediate chest compression (p < 0.001). All students in both groups passed the post-training assessment. CONCLUSION: Class participation in NFF learning was lower than that in FF learning. Although the post-education evaluation in the NFF group was not inferior, efforts on promoting active participation in NFF learning are required.

Extremity Injuries during Sporting Activities According to Life Course: Focusing on Fractures.

Background: The increased participation in sports has led to an increased number of sports-related injuries. We aimed to identify the incidence of sports-related injuries by life course and the risk factors for sports-related extremity fractures. Methods: We analyzed data of patients with sports-related extremity injuries from Emergency Department-based national injury surveillance systems, obtained from Jan 2013 to Dec 2016. A multiple logistic regression analysis was performed to identify risk factors of extremity fracture by life course after adjusting for sex, injury season, injury time, injury place, sports type, and mechanism of injury. Results: Overall, 23385 patients met our inclusion criteria. Soccer injuries were most common in the 5-14-year (32.4%), 15-24-year (43.0%), and 25-44-year groups (32.7%), and hiking injuries were most common in the 45-64-year (23.6%) and ≥65-year age groups (38.0%). The upper extremity injury and fracture rates were higher in the younger-age group; nevertheless, the injury and fracture rates of the lower extremities increased with increasing age. Moreover, the rate of hip and thigh injuries and fractures increased significantly in the ≥65-year age group. Conclusion: The incidence and severity of sports injuries are affected by player factors and the sports activity itself. The age of players is a major determinant that affects their medical and physiologic conditions and the sport of choice. The strategy for preventing sports injuries should be structured based on age.

Incidence and outcomes of adverse drug reactions to first-line anti-tuberculosis drugs and their effects on the quality of life: A multicenter prospective cohort study.

BACKGROUND: In tuberculosis (TB) treatment, adverse drug reactions (ADRs) can interrupt treatment and decrease the quality of life (QoL). We aimed to prospectively investigate the incidence of ADRs to first-line anti-TB drugs and related outcomes and QoL. METHODS: Adult patients with TB who had been treated with first-line anti-TB drugs in five Korean hospitals were enrolled. ADR questionnaire surveys and blood tests were performed four times serially, and QoL was assessed on the fourth TB treatment week (±2 weeks). RESULTS: Of 410 enrolled patients with TB (males, 62%; mean age, 52.1 ± 18.1 years [those aged ≥65 years, 26.6%]), 67.8% experienced any ADRs (≥ grade 2) to TB drugs. The most common ADR was fatigue (53.2%), followed by itching (42.7%) and anorexia (41.7%). Older adult patients experienced relatively more ADRs, including anorexia, dyspepsia, rash, dizziness, anemia, abnormal hepatic/renal function tests, and increased uric acid levels (p < 0.05). Treatment regimens changed for 9.5% of patients owing to ADRs to anti-TB drugs. Patients with any ADRs and older adult patients had significantly lower QoL than their counterparts (p < 0.05). Old age (odds ratio [OR], 1.02) and being male (OR 2.65) were independently associated with ADRs, whereas active smoking (OR 4.73) and a relatively long treatment phase (OR 5.13) were independently associated with hepatotoxicity. CONCLUSION: ADRs to first-line anti-TB drugs were common and related to relatively low QoL, especially among older adults. Although 9.5% of patients had ADR-related regimen changes, most patients with ADRs completed treatments successfully.

Emergency Transport Refusal during the Early Stages of the COVID-19 Pandemic in Gyeonggi Province, South Korea.

We analyzed the changes in patients' clinical characteristics and transport refusal pre- and post-COVID-19 and identified the reasons for transport refusal using emergency medical services run sheet data from pre-COVID-19 (April−December 2019) and post-COVID-19 (April−December 2020) in Gyeonggi Province, South Korea. We included patients aged ≥18 years. Univariate and multivariate logistic regression analyses were performed to identify the relationship between patients' personal factors and clinical characteristics and emergency transport refusal. During the control and study periods, 612,681 cases were reported; the transport refusal rates during the control and study periods were 6.7% and 8.2%, respectively. Emergency transport refusal was associated with younger age, the male sex, a normal mental status, a shock index < 1, and trauma in both the pre- and post-COVID-19 periods. Although fever prevented transport refusal during the pre-COVID-19 period (aOR, 0.620; 95% CI, 0.567−0.679), it became a significant risk factor for transport refusal during the post-COVID-19 period (aOR, 1.619; 95% CI, 1.534−1.709). The most common reason for transport refusal by critically ill patients was "because it was not accepted within the jurisdiction and remote transport was required." It is necessary to expand the response capacity of patients with fever in the community to reduce the refusal of transport by critically ill patients.

Nurse evaluation of stress levels during CPR training with heart rate variability using smartwatches according to their personality: A prospective, observational study.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a very critical phenomenon, and to prepare for it, most nurses undertake simulation training, during which learners' stress levels should be managed. This study aims to evaluate nurses' stress levels during CPR simulation training using heart rate variability (HRV) measured with a smartwatch and to determine the correlation between individual personality traits and stress levels. METHODS: This prospective observational study was conducted from July 2020 to December 2021. For nurses participating in advanced life support training with more than six months of clinical experience, their stress levels while performing as a CPR team leader were measured. Regarding stress levels, heart rate data measured with a smartwatch were processed using Kubios HRV Standard software to generate HRV parameters. The personality of participants was evaluated using the Big Five personality test. The degree of stress according to personality was determined using HRV parameters. Consequently, the correlation between personality and stress according to the clinical experience of cardiac arrest was analyzed. RESULTS: Of the 132 participants, 91.7% were female, and the median age of the sample was 27 years. Agreeable personality had the highest score (32.84±3.83). LF power (r = 0.18, p = 0.04) and HF power (r = 0.20, p = 0.02) showed a significant positive correlation with the agreeableness trait. In subgroup analysis according to the cardiac arrest experience, the agreeableness trait had a positive correlation with a standard deviation of NN intervals (r = 0.24, p = 0.01), root-mean-square of successive differences (r = 0.23, p = 0.02), LF Power (r = 0.26, p = 0.01), and HF power (r = 0.23, p = 0.02), but a negative correlation with mean HR (r = -0.22, p = 0.03). CONCLUSION: The clinical experience in cardiac arrest and agreeableness were related to acute stress during training. In the future, it is necessary to apply a scenario of a level suitable for individual personality and experience, and evaluate the level and achievement of students.

Unintended beneficial effects of COVID-19 on influenza-associated emergency department use in Korea.

BACKGROUND: Non-pharmaceutical interventions, including hand hygiene, wearing masks, and cough etiquette, and public health measures such as social distancing, used to prevent the spread of coronavirus disease 2019 (COVID-19), could reduce the incidence rate of respiratory viral infections such as influenza. We evaluated the effect of COVID-19 on the incidence of influenza in Korea. METHODS: This retrospective study included all patients who visited five urban emergency departments (EDs) during the influenza epidemic seasons of 2017-18, 2018-19, and 2019-20. Influenza was defined as ICD-10 codes J09, J10, and J11, determined from ED discharge records. The weekly incidence rates of influenza per 1000 ED visits during the 2019-20 season, when COVID-19 became a pandemic, were compared with those of 2017-18 and 2018-19. The actual incidence rate of the 2019-20 season was compared with the predicted value using a generalized estimation equation model based on 2017-18 and 2018-19 data. RESULTS: The weekly influenza incidence rate decreased from 101.6 to 56.6 between week 4 and week 5 in 2020 when the first COVID-19 patient was diagnosed and public health measures were implemented. The weekly incidence rate during week 10 and week 22 of the 2019-20 season decreased most steeply compared to 2017-18 and 2018-19. The actual influenza incidence rate observed in the 2019-20 season was lower than the rate predicted in the 2017-18 and 2018-19 seasons starting from week 7 when a COVID-19 outbreak occurred in Korea. CONCLUSIONS: The implementation of non-pharmaceutical interventions and public health measures for the COVID-19 epidemic effectively reduced the transmission of influenza and associated ED use in Korea. Implementing appropriate public health measures could reduce outbreaks and lessen the burden of influenza during future influenza epidemics.

Effect of Designating Emergency Medical Centers for Critical Care on Emergency Medical Service Systems during the COVID-19 Pandemic: A Retrospective Observational Study.

During the coronavirus disease 2019 (COVID-19) pandemic, prehospital times were delayed for patients who needed to arrive at the hospital in a timely manner to receive treatment. To address this, in March 2020, the Korean government designated emergency medical centers for critical care (EMC-CC). This study retrospectively analyzed whether this intervention effectively reduced ambulance diversion (AD) and shortened prehospital times using emergency medical service records from 219,763 patients from the Gyeonggi Province, collected between 1 January and 31 December 2020. We included non-traumatic patients aged 18 years or older. We used interrupted time series analysis to investigate the intervention effects on the daily AD rate and compared prehospital times before and after the intervention. Following the intervention, the proportion of patients transported 30-35 km and 50 km or more was 13.8% and 5.7%, respectively, indicating an increased distance compared to before the intervention. Although the change in the AD rate was insignificant, the daily AD rate significantly decreased after the intervention. Prehospital times significantly increased after the intervention in all patients (p < 0.001) and by disease group; all prehospital times except for the scene time of cardiac arrest patients increased. In order to achieve optimal treatment times for critically ill patients in a situation that pushes the limits of the medical system, such as the COVID-19 pandemic, even regional distribution of EMC-CC may be necessary, and priority should be given to the allocation of care for patients with mild symptoms.

Trends in hospital visits and healthcare costs of gout and seropositive rheumatoid arthritis in Korea from 2010 to 2017 using National Healthcare Claims.

BACKGROUND/AIMS: We examined temporal trends in the rate of gout and seropositive rheumatoid arthritis (RA) hospital visits and healthcare costs in Korea. METHODS: We conducted a serial cross-sectional analysis of Korean national healthcare claims. We calculated the annual increase in hospital visits (emergency department [ED] visits, outpatient visits, and hospitalizations) and total healthcare costs per visit. RESULTS: From 2010 to 2017, the annual rates of ED visits, outpatient visits, and hospitalizations for gout increased from 6.28 to 21, from 638.38 to 1059.55, and from 12.37 to 15.6 per 100,000 persons, respectively. Before 2013, ED visits for gout were most common in patients over 70 years old, but they were most common in those aged between 30 and 49 years after 2013. The number of patients with ED visits, outpatient visits, and hospitalizations for RA from 2010 to 2017 increased from 1.25 to 1.87, from 219.04 to 307.49 and from 8.44 to 12.32 per 100,000 persons, respectively. However, there was no increase in the prevalence of ED visits for RA in any age group except for those older than 70 years. The cost per ED visit for gout significantly decreased from 496.3 to 273.6 US dollar during the study period. There was no significant change in the cost per ED visit for RA between 2010 and 2017. CONCLUSION: There was a large increase in ED visits for gout during the study period. Further studies are needed to analyze the reason behind increased ED visits for gout and suggest ways on how to improve gout care.

Risk Factors for Intracranial Injury Caused by Falls at Home in Korea Using Data from the Emergency Department-based Injury In-depth Surveillance (2011-2018).

BACKGROUND: Most unintentional injuries that occur at home are preventable. However, it may be difficult to sufficiently reduce the number of falls occurring at home by only identifying risk factors focused on specific age groups. Therefore, this study aimed to identify the risk factors (especially age and places where injuries occurred at home) for intracranial injury (ICI) caused by unintentional falls at home. METHODS: Using the Emergency Department (ED)-Based Injury In-depth Surveillance, we analyzed the data of patients who visited the ED due to unintentional falls at home. Risk factors were identified using multivariable logistic regression according to age groups and interactions between place of injury occurrence and age groups, and sex and age groups were assessed. RESULTS: In total, 232,124 patients were included in the analysis; older adults had a higher adjusted odds ratio (aOR) 14.05 (95% confidence interval [CI], 12.74-15.49) of ICI than infants. The corridor was associated with ICI in the male pediatric group (aOR, 2.71; 95% CI, 1.08-6.84) and the balcony with the female pediatric group (aOR, 2.04; 95% CI, 1.03-4.04). In the adult group, aOR of kitchen was 1.38 (95% CI, 1.02-1.88) in females and 0.56 (95% CI, 0.48-0.66) in males. CONCLUSION: In this study, we identified the risk factors of ICI caused by falls at home using ED-based injury surveillance data. The risk of ICI was different among places of occurrence in the home depending on the age groups and sex.

Association between Survival and Time of On-Scene Resuscitation in Refractory Out-of-Hospital Cardiac Arrest: A Cross-Sectional Retrospective Study.

It is estimated that over 60% of out-of-hospital cardiac arrest (OHCA) patients with a shockable rhythm are refractory to current treatment, never achieve return of spontaneous circulation, or die before they reach the hospital. Therefore, we aimed to identify whether field resuscitation time is associated with survival rate in refractory OHCA (rOHCA) with a shockable initial rhythm. This cross-sectional retrospective study extracted data of emergency medical service (EMS)-treated patients aged ≥ 15 years with OHCA of suspected cardiac etiology and shockable initial rhythm confirmed by EMS providers from the OHCA registry database of Korea. A multivariable logistic regression analysis was conducted for survival to discharge and good neurological outcomes in the scene time interval groups. The median scene time interval for the non-survival and survival to discharge patients were 16 (interquartile range (IQR) 13-21) minutes and 14 (IQR 12-16) minutes, respectively. In this study, for rOHCA patients with a shockable rhythm, continuing CPR for more than 15 min on the scene was associated with a decreased chance of survival and good neurological outcome. In particular, we found that in the patients whose transport time interval was >10 min, the longer scene time interval was negatively associated with the neurological outcome.

Effects of positive dispatcher encouragement on the maintenance of bystander cardiopulmonary resuscitation quality.

BACKGROUND: Implementation of dispatcher-assisted cardiopulmonary resuscitation (DACPR) has increased the likelihood of bystander CPR upon cardiac arrest. However, the quality of CPR has been found to be very low. In this study, we aimed to compare CPR quality between the current DACPR practices and the interventional instruction of adding verbal encouragement from the dispatcher. METHODS: In this randomized controlled trial, we recruited adult (age ≥18) laypersons who were non-health care providers and had never received any previous verified CPR training. They were randomly selected to perform DACPR using metronome sounds (mDACPR) as per the standard protocol, or DACPR with metronome sounds along with human encouragement (mheDACPR). The ratio of accurate compression rate, depth, and complete release for each CPR phase was examined. RESULTS: Sixty nine records (34, mDACPR; 35, mheDACPR) were taken. The median proportion of accurate chest compression rate was initially 29.5% with mDACPR, and significantly increased to 71% after 2 minutes of CPR administration (P = .046). However, the median ratio of accurate chest compression depth was 61.5% in the first phase, and significantly decreased to 0% in the last phase (P < .001). In contrast, for the mheDACPR group, a high accurate compression rate was maintained throughout the 2 minutes of CPR administration (91%, 100%, 100%, 100%). CONCLUSION: To maintain the quality of CPR administered by bystanders, continuous feedback and repeated human encouragement should be provided during DACPR. Active dispatcher intervention reduces the time required to reach an appropriate CPR rate and allows for the maintenance of accurate compression rates.

Association between Area-Level Socioeconomic Deprivation and Prehospital Delay in Acute Ischemic Stroke Patients: An Ecological Study.

We analyzed the associations between area-level socioeconomic status (SES) and prehospital delay in acute ischemic stroke (AIS) patients by degree of urbanization with the use of an ecological framework. The participants were 13,637 patients over 18 years of age who experienced AIS from 2007 to 2012 and were admitted to any of the 29 hospitals in South Korea. Area-level SES was determined using 11 variables from the 2010 Korean census. The primary outcome was a prehospital delay (more than three hours from AIS onset time). Multilevel logistic regression was conducted to define the associations of individual- and area-level SES with prehospital delay after adjusting for confounders, which includes the use of emergency medical services (EMS) and individual SES. After adjusting for covariates, it was found that the area-level SES and urbanization were not associated with prehospital delay and EMS use was beneficial in both urban and rural areas. However, after stratification by urbanization, low area-level SES was significantly associated with a prehospital delay in urban areas (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 1.04-1.47) but not in rural areas (aOR 1.04, 95% CI 0.78-1.38). Therefore, we posit that area-level SES in urban areas might be a significant barrier to improving prehospital delay in AIS patients.