Introduction: Nebraska Mission: Lifeline Stroke is a 4-year initiative to increase guideline-based treatment of acute stroke across the continuum of care. Guidelines advise post-stroke assessment by a multi-disciplinary team to guide discharge process and select ideal rehab setting. Purpose: To develop resources to facilitate the transition of Nebraskans with stroke to the most appropriate level of post-acute care. Methods: Healthcare Providers (HCPs) from various settings completed two surveys: hospital stroke rehab referral strategies and practices (N=23), and individual experiences related to stroke rehab (N=260). In addition, a literature review was conducted to find published guidelines and research on clinical decision making. Lastly, a focus group consisting of social worker/case managers was held to provide input on resources developed. Results: Hospitals (N=23) believe higher numbers of stroke patients should be referred to IRFs (42%) and stated that patients’ “health status” (91%), “opinions from hospital team members” (87%), and “opinions from patient, family, or caregivers” (78%) are most relevant in the decision process. Factors that impact referral process include: HCPs may not be familiar with all options for post-acute rehab care (17%) and patient or family/caregivers are not educated about options (30%). Most (57%) of HCPs surveyed and all focus group participants indicated discharge referral process could be improved with a standardized decision-making tool. Based on this input, two discharge planning guides were developed. The first assists HCPs in determining appropriate level of post-acute stroke care by comparing various types and settings in an easy-to-read format. The second is patient/caregiver focused and includes information to assist in decision-making process and a table comparing rehab settings. These guides have been disseminated through conference presentations, direct mailings, and web-based resources. Conclusions: Discharge tools with clear descriptions of options are necessary to assist HCPs and patients/caregivers in matching appropriate care with patient’s rehab needs. These care choices are key to patients achieving their highest level of independence.

Introduction: Urban and rural stroke care disparities are pervasive for post-acute stroke rehabilitation. Mission:Lifeline Stroke conducted a needs assessment to identify needs and gaps in care for stroke rehabilitation throughout rural Nebraska (NE). Purpose: The assessment included surveys of healthcare providers (HCPs) and stroke survivors to inform a robust understanding of stroke rehabilitation needs across NE, addressing barriers and facilitators to care, including outpatient therapy, social support, equipment, and patient-facing resources. Methods: HCPs were recruited through the Nebraska Stroke Advisory Council to complete a 17-question online survey. Survivors in NE were recruited through social media and existing stroke support groups to complete a 26-question online survey. Results: Respondents of the HCP survey (N=260) identified the top barrier to providing care to survivors as lack of insurance (62%), lack of caregiver support (42%), and lack of specialized services (42%). Respondents of the survivor survey (N=30) identified top barriers as lack of insurance (74%), financial burden (64%), and lack of caregiver/social support (50%). Both HCPs’ and survivors identified lack of caregiver and social support as resources missing from their community, and survivors identified communication about support groups or sources of emotional support (n=4) as the top missing resource. In addition, 39% of survivors indicated an interest in attending a support group. HCPs indicated missing resources primarily include specialized rehab equipment, technology, and services (52%), and professional opportunities for staff (37%). Regarding resources provided to survivors, most HCPs indicated community resources (94%) are provided, proceeded by follow-up/continued outpatient therapy (88%). In slight contrast, survivors indicated the top resources they learned of when discharged were outpatient physical therapy (82%), outpatient occupational therapy (70%), and outpatient speech therapy (56%). Conclusion: Although both healthcare providers and survivors identified outpatient therapies are made available, there is a need for more communication about support groups and physical resources such as rehab equipment, technology, and services.

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

Introduction: Mission: Lifeline Stroke Nebraska was a 4-year program to enhance stroke systems of care in Nebraska. With 68% of hospitals in Nebraska participating in GWTG-Stroke, analysis of stroke treatment data can be accomplished on disparities across the state. Methods: De-identified data was accessed through AHA GWTG-Stroke registry to assess stroke outcomes of patients at 49 participating NE hospitals in 2020. Data were analyzed based on AHA specified Mission: Lifeline reporting, achievement, and pre-hospital measures. The purpose of analysis was to describe patient characteristics and determine differences in IV thrombolytic treatment and mean patient NIH stroke score (NIHSS) upon admission. Percentages and counts were reported for categorical variables. The mean, standard deviation (SD) and median were reported for continuous variables. The Kruskal-Wallis rank sum, Wilcoxon sign rank, T-tests, chi-square and one-way ANOVA tests were used, where appropriate, to assess differences in stroke outcomes by age, gender, and race/ethnicity. Results: Of the 3,952 patient encounters registered in GWTG-Stroke from 01/01/2020 to 12/31/20, 2670 (67.5 %) were patients 18+ at time of admission with clinical diagnosis of ischemic stroke. Statistically significant differences in age, NIHSS at admission, and treatment with thrombolytics by gender were observed. Compared to males, females were older (72.7 vs. 68.1 years), had a lower mean NIHSS at admission (5.8 vs. 6.0), and a smaller proportion of females received thrombolytic treatment (42% vs. 58%). Conclusions: Overall, females were less likely to receive IV thrombolytic treatment compared to males. Women in the study were older with lower NIHSS than males. Results from this analysis align with those from the study “The Impact of Sex and Gender on Stroke” (Rexrode, et al.,2022) indicating that females may present different signs of a stroke than males. Our data showed the NIHSS scores to be lower for females possibly leading to lower frequency of treatment. As a part of the Mission: Lifeline initiative, this information was shared with hospitals and providers across the state. These results led to public awareness and education targeted to women, including a local podcast and social media.

Introduction: Mission: Lifeline Stroke Nebraska (NE) is a four-year project which aims to improve stroke systems of care within the state through various interventions, including education of healthcare providers. Timely in-hospital treatment of stroke patients is key to reducing death and disability in stroke patients. Methods: An anonymous survey was administered to physicians and advanced practice providers that work in the ED at NE hospitals to assess the comfort/confidence level in administering IV thrombolytics and to learn more about the reasons for giving (and not giving) IV thrombolytics in various scenarios, including when an ischemic stroke is mild (NIHSS <4). A total of 110 providers completed the survey between February and April of 2021. Results: Critical Access Hospital (CAH) providers represented 70% of respondents. Only 50% of providers at certified centers and 29% at CAHs feel comfortable/confident in giving IV thrombolytics to ischemic stroke patients before consulting another provider. After consulting another clinician, this percentage increases to 89.7% in CAH providers but does not change in certified center providers. Overall, only 26.5% of certified center providers and 21.8% of CAH providers stated they are likely to give IV thrombolytic to a mild ischemic stroke patient. Certified center providers indicated that improved feedback on patient outcomes post IV thrombolytic therapy (41.2%) is the top item that would increase their comfort/confidence with administering IV thrombolytic. Qualitative feedback from certified center providers also shows there is hesitancy in administering IV thrombolytics to stroke patients and a desire to see more research showing the benefits. CAH providers identified access to telestroke (78.2%) and annual stroke education including updated guidelines on IV thrombolytic administration (66.7%) as the top items that would increase their comfort/confidence. Conclusions: These results indicate there is hesitancy to use IV thrombolytics to treat mild ischemic stroke patients and a need for more telestroke/neurology consultation options for providers in CAHs. From these conclusions, Mission: Lifeline is catering educational opportunities to the needs of rural and urban providers in NE