First in Houston to Receive JCAHO Stroke Certification

Stroke Team Excels in Patient Care, Research,
and Education

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 recognized “best 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.

  

As 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?