Supplementary Online Content

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Sydney Carpenter
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1 Supplementary Online Content Itrat A, Taqui A, Cerejo R, et al; Cleveland Pre-Hospital Acute Stroke Treatment (PHAST) Group. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol. Published online December 7, doi: /jamaneurol etable 1. Role of Team Members on the Mobile Stroke Unit etable 2. List of Medications Available on the Mobile Stroke Unit This supplementary material has been provided by the authors to give readers additional information about their work.

2 etable 1. Role of Team Members on the Mobile Stroke Unit The Mobile Stroke Treatment Unit Team is comprised of the Staff Vascular Neurologist (virtual), Critical Care Transport Nurse, Paramedic, Emergency Medical Technician, and CT Technologist. The roles for each member of the interdisciplinary team are outlined below: Nurse - Assesses patient s hemodynamic status and determine the last known well (LKW) time - Verifies that orders are placed and are being performed - Ensures neuro checks and vital signs are documented every 15 minutes - Follow physician orders as they are given - Administers medications as needed - Reports medications administered to the physician - Anticipates patient s need for IV tpa - Calculates IV tpa dose, mixes and verifies it, then cosigns with paramedic - Obtains blood pressure just prior to starting IV tpa to ensure it is within acceptable parameters - Start thrombolytic therapy as ordered according to IV tpa Protocol - Ensure Vital Signs and neuro assessments are done every 15 minutes for 2 hours from the start of IV tpa, then every 30 minutes for 6 hours, then every 60 minutes for 16 hours. - Monitor for neurological changes over time until care of patient is handed off at final destination - Calls nursing report to accepting facility Paramedic - Places patient on cardiac monitor and obtains vital signs - Initiates IV (#18 gauge) and draws labs and labels them (if not already started) - Obtains a stat blood glucose measurement - Calculates IV tpa dose, mixes and verifies it, then cosigns with nurse - Assists nurse with patient assessment / care - Obtains a stat blood glucose measurement - Calculates IV tpa dose, mixes IV tpa, and verifies dose and cosigns with Nurse - Assists nurse with patient assessment / care Emergency Medical Technician (EMT-Basic) - Provides immediate response of the Mobile Stroke ambulance to the scene - Assists MSTU team in patient assessment / care - Assists family members as needed

3 CT Technologist - Schedules patient in Cleveland Clinic EMR and creates unique medical record number (if not already existing). Provides information via the acute stroke pager. - Notes arrival time and contacts the physician to place orders for imaging and labs - Prepares patient for CT scan of brain - Communicates with the neuro-radiologist regarding patient information and need for STAT read - Transfers images to Cleveland Clinic main campus neuro-radiologist for STAT read - Assists MSTU team in patient assessment / care - Assists family members as needed Vascular Neurologist - Assess patient via telemedicine & determines LKW time and performs NIH Stroke Scale within 15 minutes of MSTU ambulance arrival at scene - Orders POC laboratory testing and CT scan - Verifies past medical history, medications, and allergies of patient - Reviews CT scan and POC laboratory results - Reviews IV tpa inclusion/exclusion criteria - Determines treatment and provides recommendation to patient / family - Discusses risks and benefits of treatment with patient / family - Communicates with MSTU team to provide acute treatment - Determines destination disposition of patient based on triage transfer algorithm - Calls physician report to receiving facility LKW: Last known well; IV: Intravenous; tpa: Tissue plasminogen activator; MSTU: Mobile Stroke Treatment Unit; CT: Computed Tomography; EMR: Electronic Medical Record

4 etable 2. List of Medications Available on the Mobile Stroke Unit Bag 1 Quantity Empty IV Bag 150 ml 3 IV Drip Set 1 Filter Set 2 20 ml Syringe 2 Mannitol 50 grams 2 Blunt Needle 2 IV tpa/altepase 100 mg 2 Sterile Water 100 ml 2 tpa Transfer Device 1 Prothrombin Complex Concentrate (Kcentra) 1000 units 2 Prothrombin Complex Concentrate (Kcentra) 500 units 1 Bag 2 (all medications are intravenous unless stated) Hydralazine 1 fosphenytoin 4 Nicardipine 40mg/200 mg premix 1 Labetalol 100mg 1 Norepinephrine 4 mg 1 ondansetron 4 mg 2 Methylprednisolone 1 Diphenhydramine 50 mg 1 Epinephrine 1: Vasopressin 20 units 2 Nitroglycerin sublingual tablets 1 Amiodarone 150 mg 3

5 Epinephrine 1: Atropine 1mg 2 Lidocaine 100mg 1 Albuterol unit dose (inhaled) 2 Sodium Bicarbonate 50 meq 1 naloxone 2 mg 1 50% Dextrose 25 grams 1 Oral Glucose Gel Tube 1 Racemic Epinephrine (inhaled) 2 Narcotics Pouch 1 Midazolam 2mg 4 Lorazepam 2 mg 4 Etomidate 40 mg 1 Fentanyl 100 mcg 1 Rocuronium 50mg 2 Succinylcholine 200mg 1

PARAMEDIC SCOPE OF PRACTICE

PURPOSE PARAMEDIC SCOPE OF PRACTICE The purpose of this policy is to define the Scope of Practice of a Paramedic accredited in the Yolo County Emergency Medical Services Agency (YEMSA) Region. AUTHORITY