Abstract Body: Introduction
Acute telestroke connects stroke experts with rural or under-resourced hospitals to aid in emergent stroke decision-making. Few studies have evaluated subacute inpatient telestroke programs that focus on subsequent stroke management. We evaluated the implementation of the Veterans Health Administration (VHA) subacute telestroke consult service launched in 2022 by the National Telestroke Program (NTSP).

Methods
Program implementation was assessed using mixed-methods with key informant semi-structured interviews that included 1) N=36 clinical providers from the 11 selected VHA sites (Table 1) where inpatient telestroke consults are initiated, including emergency medicine (EM) physicians, internal medicine (IM) hospitalists, neurologists, and nursing staff and 2) N=8 NTSP telestroke providers, including tele-neurologists, physician assistants (PAs), and nurse coordinators. Semi-structured interview guides were used along with Likert (scaled 1-7) ratings of acceptability. We analyzed interviews using Rapid Qualitative Analysis methods, with a matrix guided by the RE-AIM framework with extracted key concepts and themes related to the adoption, reach, effectiveness, and implementation. All interviews were discussed by team members to achieve consensus on identified concepts/themes.

Results
Providers reported high acceptability of the subacute telestroke consult service (84.2% rated usefulness ≥6/7). Key facilitators of the subacute telestroke service included: filling a critical need, on-site champions, and reduction in interhospital transfers. Ongoing barriers included: confusion between the acute/subacute services, site-level infrastructural barriers, and program awareness (Table 2). EM physicians (N=5) rated the usefulness of the service numerically higher than IM physicians/hospitalists (N=10; mean score 7 vs 6.3), a difference apparent in some interviews. Inpatient local neurology coverage led to unique implementation challenges, with historical practice patterns and differences of recommendations noted (Table 3). However, usefulness ratings were similar between sites with/without local neurology.

Discussion
Implementing an inpatient subacute telestroke consult service filled a critical gap in stroke care within the VHA. Addressing confusion between acute/subacute telestroke consults, efforts to maintain site awareness, and sensitivity to working with local neurology may be helpful implementation strategies for subacute telestroke programs.