First in Houston to Receive
JCAHO Stroke Certification
By Bryant Boutwell, Dr.P.H.
If you are looking for what’s new in stroke patient
care and research, you’ve come to the right place when you find James
C. Grotta, M.D., and his nationally recognized Stroke Team. Having joined
the faculty of The University of Texas Medical School at Houston in 1979,
Dr. Grotta has emerged as an international leader in stroke, both as a
doctor” in the United States and as a leading researcher who is as
dedicated to educating the public as well as health professionals regarding
new therapies that can improve dramatically the outcome for many patients
if administered quickly.
recipient of the Department of Neurology’s Roy M. and Phyllis Gough
Huffington Distinguished Chair in Neurology and director of the UT’s
Vascular Neurology (Stroke) Program, Dr. Grotta has been on a mission that
starts with an understanding that stroke is a medical emergency that must
be assessed and dealt with quickly. It is one thing to find and demonstrate
the efficacy of new drugs that can reduce the damage to the brain during
those critical first hours of a stroke. It is another to educate and organize
health professionals about the importance of quick response and teamwork
to give patients the benefits of new drugs and treatments.
On both fronts Dr. Grotta has been making a difference. Through his leadership
in 1988, he formed the Medical School’s Stroke Treatment Team, which serves
as Houston’s premier medical team for the treatment of acute stroke emergencies.
Comprised of a broad spectrum of medical expertise numbering more than a dozen,
the Stroke Team pioneers acute stroke treatment and recovery interventions aimed
at preventing or reducing significant disability from stroke.
A commitment to
excellence in research and clinical practice has made the team the most experienced
provider of thrombolysis (clot-dissolving) therapy following acute stroke
in Houston and much of the world.
Funded by the National Institutes
of Health as one of three U.S. centers for the discovery of revolutionary
stroke treatments and translation of basic research from the laboratory
to the bedside, the UT Stroke Team brings state-of-the-science care to
the citizens of Texas.
That expertise has not escaped national attention. In recent months,
the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) began certifying stroke centers based on their excellence
in acute stroke care and prevention. That Memorial Hermann Hospital
received the first certification in the entire region is a testament
to the national and international attention Dr. Grotta and his
colleagues have developed. Needless to say, the certification of
excellence is a great source of pride. It is also a double-edged
sword, he notes, given the capacity of this team to treat the volume
of stroke patients sent to Memorial Hermann is testing the ability
of the team to meet all needs, including the increasing number
of referrals (now around 40 percent) from other hospitals who seek
the expertise and capabilities of Dr. Grotta’s team.
Consider stroke as a “brain attack.” There are two major causes of
stroke: blood clots (about 80 percent of all strokes) and hemorrhages or burst
vessels causing bleeding into the brain. According to the American Heart Association,
every 45 seconds, someone in America has a stroke. About 700,000 Americans will
have a stroke this year alone, making stroke our nation’s number
three killer and a leading cause of severe, long-term disability.
When part of the brain dies from lack of blood flow, the part of the
body it controls is affected. Strokes can cause paralysis and affect
language and vision, making it one of the most debilitating diseases.
“When I started my practice, there was little that could be done for stroke
patients,” Dr. Grotta says. “In most cases, a stroke occurred and
doctors monitored the patient’s progress to determine what kinds of after-stroke
care could be used. We’ve come a long way in understanding the
cascade of events that occur in the brain following stroke and how
to control the resulting damage to the brain.”
The 1990s witnessed a revolution in new therapies. Use of a clot-busting
drug called tissue plasminogen activator, or t-PA, attacked the cause
of strokes by dissolving blood clots that prevented free flow of blood
to the brain. Given that blood clots account for the majority of strokes,
the findings have been significant and mean that a growing number of
stroke victims can have a life after stroke. Dr. Grotta and his team
have made headlines since 1995 as national leaders in these studies along
with their insight that a good drug like t-PA, which is only effective
in the first few hours of stroke, is only as good as the health care
system’s knowledge and appropriate administration of the
drug. Since the remaining 20 percent of strokes are hemorrhagic or
breaks in the blood vessels within the brain, the administration of t-PA
could be life threatening, compounding the problem by encouraging more
bleeding. Thus, quickly identifying the type of stroke is an essential
part of the therapy process.
Dr. Grotta’s team currently sees more than 600 stroke patients a year,
accounting for 46 percent of all acute stroke patents transported by the Houston
Fire Department’s Emergency Medical Services (EMS). Using intravenous t-PA,
more than 20 percent of all stroke patients seen by Dr. Grotta’s
team with ischemic strokes (clots that obstruct blood flow) at Memorial
Hermann Hospital are treated with the drug in less than three hours
from stroke onset, and more than half (53 percent) of these are treated
in less than two hours. Of those, nearly a third (30 percent) have
complete success in breaking up the clot and restoring full blood flow
to the brain. Citywide, thanks to efforts to educate and develop participating
stroke centers at other hospitals in the area, about 70 percent of
all stroke patients transported by EMS travel to designated stroke
centers and citywide use of t-PA is now about 11 percent compared to
a 2 percent national average. In short, these numbers translate into
a significant reduction in stroke deaths and severe disabilities and
an impressive leap forward from a few years ago when physicians could
only wait and see how much of the brain would die following a stroke.
Today Dr. Grotta and his team relentlessly look for ways to make even
more improvements by researching new drugs and combinations of therapies.
Their research is comprehensive and includes both strokes caused by blood
clots and those caused by hemorrhages.
Using t-PA in combination with ultrasound (see Page 12), they’ve
already demonstrated that they can reopen blocked vessels and restore
blood flow to the affected parts of the brain for 49 percent of the
patients, versus 30 percent success when administering t-PA alone within
the same timeframe.
Given that time is critical when one is dealing with stroke and the often
progressive damage to the brain that results if untreated, both public
and professional education is paramount. Through telemedicine (see Page
16) and grant-funded educational programs (see Page 13), Dr. Grotta and
his team are well recognized for their community and professional education
efforts. On their Web site, www.houstonstroke.com, lay public and professionals
alike can find a variety of information from an overview on stroke to
the latest clinical trials.
Taking time out from his busy patient rounds, Dr. Grotta recently addressed
an assembly of faculty, residents, fellows, and students to talk about
the future of stroke research and patient care. Presenting his top 10
questions for stroke researchers to consider, his hourlong presentation
provided a comprehensive overview of the present and future of stroke
therapy. For each question posed, he provided the audience with a review
of current literature and data that demonstrated an uncanny knowledge
of his field that only comes with years of commitment and a passion to
make a difference.
For starters, he said, if drugs like t-PA work, are there combinations
of antithrombotic and lytic therapies that might accelerate the breakup
of clots in the brain event better and prevent those blood vessels from
reocclusion? Are there better ways to apply ultrasound and other energies
to help accelerate the breakup of blood clots in the brain? Are there
mechanical clot-removable devices that can be employed, and when are
they best used and to what result? For each of these questions and many
others, he cited the current state of international research addressing
these questions along with the many research trials in which he and his
team are part of.
While much progress has been made to date, he challenged the audience
of healthcare professionals to think down the road at the molecular level.
What is the role of genetics/proteomics in identifying stroke, predicting
complications, predicting outcomes, and identifying new therapeutic targets?
“This is where much of the funding for future research will be in the next
decade,” he predicted, adding that the answers to these questions
will allow us to fine-tune our understanding of each patient as well
as each new therapy with a precision that will define the next era
of advancement in stroke management and care.
Without a doubt, Dr. Grotta and his team will be at the head of the class
when it comes to continued progress in stroke. Meanwhile, he has to deal
with the challenges that the success of his team to date has created
through his number one question on his top 10 list. That is, how do we
do all this with just two neurology residents, one nurse practitioner,
four stroke fellows and four stroke faculty?