Setting New Standards of Care

Stroke is the third leading cause of death in America and the nation's No. 1 source of disability, with 750,000 cases annually.

That means a new stroke occurs about every 45 seconds, and close to 29 percent of those are recurrent events, afflicting victims a second or third time, says Kerri Remmel, M.D., Ph.D., director of the Stroke Center at University Hospital.

Statistics like these, however, would improve substantially if victims learned to recognize the early warning signs of stroke and if hospitals did a better job of providing optimal care to patients who seek treatment, Remmel says.

"Time saved really is brain saved," notes Remmel, who also is interim chair of the Department of Neurology in the School of Medicine at the University of Louisville.

"So it's critically important that patients get treatment as soon as they begin to see any of the five major warning signs of stroke -- sudden onset of weakness or numbness on one side of the body, sudden change in vision, sudden difficulty in speaking or understanding words, sudden dizziness and incoordination or sudden headache.

"It's so exciting when I see a patient's stroke symptoms disappear before my eyes after one of our acute stroke treatments.

"But most patients don't come in to the hospital early enough to benefit from acute stroke treatments. They don't recognize the symptoms and they don't act on them by calling 9-1-1."

Some patients even experience transient ischemic attacks (TIAs) -- brief stroke-like events that may occur months or hours before an actual stroke. But the symptoms of TIAs usually dissipate in less than an hour, making it all too easy for victims to ignore the red flags.

"People say, 'Well, I don't know what that was, but I'm fine now,' " Remmel says. "If they had just come in to the hospital for an evaluation, we could have found the cause of that TIA and prevented the stroke."

Compounding the problem is the fact that many hospitals provide what Remmel describes as fragmented care. They don't always adhere to the latest "best practices" for treatment as established in clinical studies, and they may discharge patients with little to no follow up, increasing the likelihood of recurrent stroke.

"Doctor A may follow evidence-based guidelines for patient care at one hospital, while at the same hospital Doctor B may follow his or her own traditional approach that doesn't use evidence-based protocols," Remmel explains. "There also may be no continuity of care after the initial, acute treatment is complete. That is fragmented care."

Remmel and University Hospital have been working aggressively for nearly six years to tackle both problems -- patient education and hospital care -- by conducting extensive research, by developing community-wide awareness programs and by establishing the Stroke Center itself, a benchmark multidisciplinary unit designed to provide patients with the latest in stroke treatment.

Those efforts were recognized this summer when University Hospital was one of just five facilities nationwide to receive the American Stroke Association's "Get with the Guidelines" achievement award, an honor bestowed annually on institutions that implement the highest standards of stroke care. Nearly 750 hospitals vied for the honor.

"Dr. Remmel and her team have done a remarkable job establishing a state-of-the-art Stroke Center at University Hospital," says Mark Pfeifer, M.D., interim dean of the School of Medicine and the hospital's former chief of staff. "The care they provide is among the finest available anywhere in the country.

"The team also has placed a strong emphasis on patient and community education, helping raise awareness of the need for immediate treatment at
the onset of stroke symptoms. These two approaches, taken together, are helping improve patient outcomes dramatically."

Built from the ground up

Remmel joined UofL in 2000 and, with the backing of hospital leaders, began building the Stroke Center and its dedicated, multidisciplinary response team from scratch almost immediately. The Stroke Center's director of nursing, Kari Moore, and the stroke team's nurse practitioner were the first medical team members who were essential to the program's success, Remmel says.

The decision to develop the Stroke Center was prompted by recent studies which showed a substantial improvement in patient care at facilities that instituted dedicated stroke teams.

UofL was no exception.

The average length of patient stays on the stroke service is now 6 1/2 days, and fully 80 percent of those patients are discharged home or to an inpatient rehabilitation facility rather than to nursing homes or hospice care, Remmel says. Both figures are substantially better than national averages.

Equally impressive, well-known stroke complications like deep venous thrombosis or aspiration pneumonia are rare in stroke patients admitted to University Hospital.

Meanwhile, the team continues to refine and improve its system. From 2003 to 2005, for example, mortality rates dropped from an already-low figure of about 10.3 percent to just 9 percent.

Today the University Hospital team offers the region's most comprehensive care for stroke patients, with state-of-the-art diagnostic equipment -- including a 3T MRI that allows routine diffusion and perfusion imaging - and a unique interdisciplinary approach that boasts 24-hour-a-day neurological coverage.

Team members include emergency physicians, neurosurgeons, neurocritical-care physicians and nurses, neurointerventionalists, cardiologists, physical therapists, occupational therapists, speech-language pathologists, nutritionists, stroke nurses, case managers and social workers -- all of whom are dedicated to treating and rehabilitating stroke victims.

"Every member of the team is essential to the care of our patients," Remmel says. "Our approach involves evidence-based protocols for acute care, seamless integration with sub-acute care, and intensive education of the patient and the family about risk factors and the causes of stroke," Remmel notes.

"The entire hospital has really stood behind this effort. For example, the nurses at University Hospital -- the cream of the crop in my opinion -- have been empowered to call a 'stroke code' when they recognize the symptoms of stroke in their patients."

Treatment of a stroke patient begins with a "fast track" assessment, even before the patient arrives in University Hospital's Emergency Department.

"Emergency Medical Service personnel are an important part of our team," Remmel says, "because they are the first responders and call ahead to let us get ready for the stroke patient.

Time is of the essence, Remmel explains, because up to 1.9 million neurons are lost every minute following the most common kinds of stroke. Equally important, the debilitating effects of stroke can be reversed under certain circumstances if the proper treatments are given soon enough.

To properly assess the patient, a CT scan must be completed to determine if the stroke is hemorrhagic -- caused by bleeding in the brain -- or ischemic -- caused by a clot or arteriosclerosis that blocks blood from reaching the brain.

University Hospital's Emergency Department features its own CT scanner, and Stroke Team members are able to observe the scan as it is taking place, saving precious minutes.

Nationally accepted standards call for stroke patients to receive a CT scan within 25 minutes of arriving at the hospital, and for that scan to be interpreted within another 20 minutes, Remmel says.

"But for us," she says, "both events take place simultaneously within a matter of minutes."

Treatment protocols vary depending on the kind of stroke a patient has suffered, but options include endovascular and neurosurgical interventions, vascular surgery and the administration of "clot-busting" drugs.

Because University Hospital is involved in a substantial amount of clinical research, these drugs often include the latest treatments not available from other area hospitals, Remmel says.

For example, the Stroke Center currently is participating in its second multi-center study to determine the effectiveness of a promising new thrombolytic, or clot-busting, drug based on a protein synthesized from the saliva of bats.

The drug, called Desmoteplase, has generated a tremendous amount of interest because it can be administered up to nine hours after the onset of symptoms and still produce excellent patient outcomes. Standard intravenous thrombolytics are typically given within just three hours of the onset of symptoms, Remmel says.

In an earlier study, Desmoteplase was found to have re-opened blocked arteries 70 percent of the time. Current clot-busting drugs open vessels in about 50 percent of the cases.

The Stroke Center also has participated in numerous clinical trials of neuroprotective agents -- drugs that can help prevent tissue death in the brain while doctors work to restore blood flow -- as well as studies of endovascular techniques used to repair a hole between the upper chambers of the heart.

"That hole can potentially lead to a stroke because a blood clot that's formed in the leg can travel across to the left side of the heart, where it may be pumped up to the brain," Remmel says. "This new technique, performed by highly specialized interventional cardiologists, deploys a transcatheter device to repair the hole, which means that open-heart surgery is no longer necessary -- and patients may not need to take blood thinners for the rest of their lives."

Another key component of the Stroke Center team is its approach to rehabilitation and education, which assists patients with all aspects of recovery following their release from the hospital and helps them mediate risk factors that could cause another stroke by teaching healthy lifestyle habits.

"Once a patient is discharged, their primary-care physician can work with us as a team member in an outpatient setting," Remmel adds. "And we'll follow the patient's progress forever in our Stroke Clinic. Some patients come back every three months or so, but we'll see most patients twice a year.

"We're making sure they haven't had any further neurological events. We're also evaluating their risk factors to make sure that the treatments we put them on are effective -- treatments for blood pressure, atrial fibrillation, cholesterol, diabetes, carotid stenosis and smoking cessation.

"Our treatment plan for a stroke patient is individualized -- tailor-made
to the patient's unique set of vascular risk factors and cerebral vascular anatomy. Our hope is that this will become the standard of care, but our approach is fairly unique in this community right now."

Model of excellence

For all this work, the Stroke Center was recognized as a national model of excellence in December 2004 when it became the first organization in Kentucky to receive accreditation as a Primary Stroke Center from the Joint Commission on Accreditation of Healthcare Organizations.

University Hospital also has been recognized for the past two years as one of just a handful of hospitals nationally to meet the American Heart Association/American Stroke Association's quality standards for providing appropriate, evidence-based care to stroke patients at least 85 percent of the time.

Remmel's goal now is to continue improving the Stroke Center at University Hospital. Working with the state health department, she also hopes to raise awareness of stroke prevention across the commonwealth and help other hospitals establish their own dedicated stroke teams.

"I think we've made a tremendous difference in Louisville," she says. "The University Hospital Stroke Center has given the people in the community the health care they deserve -- the best health care the medical community has to offer.

"My hope and belief is that stroke centers will become the standard of care across the state and nation. If we can do it here, other hospitals can do it, too."