Social Vulnerability and Out-of-Hospital Identification of Neurologic Emergencies

Timely out-of-hospital recognition and management of neurologic emergencies-including status epilepticus, stroke, intracerebral hemorrhage, and traumatic brain injury-are critical to improving patient outcomes. However, the influence of social risk factors on the delivery and quality of emergency medical services (EMS) care in these time-sensitive conditions remains poorly understood and may contribute to long-term morbidity and mortality. This study examines the association between community-level social vulnerability and out-of-hospital identification of neurologic emergencies.

This retrospective cohort study used data from the ESO Data Collaborative research dataset from January 2019 through December 2022. The dataset covers EMS agencies across the United States that participated in the ESO Data Collaborative research dataset, which includes a health data exchange linking EMS and emergency department encounters. EMS encounters initiated via 911 calls for patients of all ages diagnosed in the emergency department with status epilepticus, stroke, intracerebral hemorrhage, or traumatic brain injury, as determined by primary International Classification of Diseases-10 codes, were included for analysis. Social vulnerability was measured at the census tract level using the Social Vulnerability Index, categorized in quintiles. Our primary outcome was EMS identification of the neurologic emergency, defined as an out-of-hospital impression or treatment protocol consistent with the emergency department diagnosis.

Among 69,842 EMS encounters, 35,729 (51.2%) were for stroke, 23,607 (33.8%) for traumatic brain injury, 5,911 (8.5%) for intracerebral hemorrhage, and 4,595 (6.6%) for status epilepticus. Patients in the most socially vulnerable census tract quintile had a 33% greater risk of EMS not identifying the neurologic emergency (risk ratio [RR] 1.33; 95% confidence interval [CI] 1.23 to 1.43) compared to the least vulnerable quintile. Condition-specific analyses showed social vulnerability was associated with an increased risk of not identifying stroke (RR 1.31; 95% CI 1.22 to 1.41) and traumatic brain injury (RR 1.17; 95% CI 1.03 to 1.32). No significant association was found for status epilepticus (RR 0.90; 95% CI 0.73 to 1.10) or intracerebral hemorrhage (RR 1.09; 95% CI 0.99 to 1.20).

Higher neighborhood social vulnerability was associated with lower rates of out-of-hospital neurologic emergency identification, particularly stroke and traumatic brain injury. Targeted strategies are needed for equitable out-of-hospital recognition and response for time-sensitive neurologic conditions.