Improving Outcomes with a Regionalized Systems of Care For Cardiogenic Shock Treatment

Behnam N. Tehrani, MD, is the Co-Director of Cardiac Catheterization Laboratories for Inova Fairfax Medical Campus and Co-Director of Inova Heart and Vascular Institute’s Cardiogenic Shock Program. He is board certified in interventional cardiology and cardiovascular disease.

Cardiogenic shock is a time-sensitive and challenging condition to treat – the heart suddenly cannot pump blood to the body’s vital organs. As a result, short-term survival rates for patients with cardiogenic shock have historically been low – approximately 50 percent die within 30 days. It’s the most common cause of death in patients hospitalized after a heart attack.

However, a team of specialists working together at Inova Heart and Vascular Institute (IHVI) found a way to improve our patient survival rates using a standardized protocol. This, combined with the expertise of a multidisciplinary team, increased our patient survival rates to more than 70 percent. We then focused on expanding use of our team and care protocol across a regional network of hospitals. We’ve recently published a clinical research paper detailing how our innovative, standardized protocol can improve outcomes for patients.

Challenges of Treating Cardiogenic Shock

Cardiogenic shock requires a quick and complex response with input and expertise across several medical specialties. When the heart is unable to pump blood (and therefore oxygen) to the brain and other vital organs, those organs fail quickly. Patients in cardiogenic shock can progress to the end stages of multiorgan failure, and ultimately death, within hours.

Implementing the correct response and treatment strategy can be tricky. The most common cause of cardiogenic shock is a heart attack. But other diseases (such as chronic congestive heart failure) can also lead to it, sometimes making the diagnosis of cardiogenic shock unclear at its onset. Treating this condition requires advanced knowledge, meticulous care and a coordinated effort among multiple specialists.

Even when physicians stop the progression of multiorgan system failure, patients may require high-level treatments to recover such as organ transplants, ventricular assist devices (which provide mechanical circulatory support) or ECMO (extracorporeal membrane oxygenation), an advanced form of life support. But not all hospitals are equipped to offer the level of therapy and condition-specific expertise that a complex disease like cardiogenic shock requires.

Using a Hub-and-Spoke Model for Cardiogenic Shock

IHVI’s dedicated heart hospital, located on the Inova Fairfax Medical Campus in Falls Church, serves as a regional hub to manage cardiogenic shock. It offers a full spectrum of interventional, surgical and critical care capabilities, with an American Heart Association-designated Level 1 cardiac intensive care unit and a multidisciplinary shock team on call and available around the clock. To improve outcomes across the region’s Level 2 and 3 hospitals, Inova expanded its approach by sharing the protocol with more than 30 hospitals.

The cardiogenic shock team at Inova, which has been in place since 2017, includes specialists in:

• Advanced heart failure
• Cardiovascular critical care
• Cardiac surgery
• Emergency medicine
• Interventional cardiology

The team has developed a protocol that relies on a “hub-and-spoke” approach to provide a network-wide, timely and coordinated multidisciplinary approach to cardiogenic shock. Inova Fairfax Medical Campus is the central hub, serving more than 30 spoke (satellite) hospitals in this network.

All hospitals in the regionalized network of care are encouraged to follow the standardized protocol to identify cardiogenic shock quickly, stabilize patients, manage them in a critical care setting and determine if they need advanced treatments. The spoke hospitals look to the cardiogenic shock team at Inova Fairfax Medical Campus for support and guidance around patient care and transport decisions.

Improved Outcomes for Cardiogenic Shock

Inova is the first site in the world to implement this approach to care and publish the results. Our established protocol has served as a blueprint for healthcare centers around the globe.

Before implementing a standardized, multispecialty approach, Inova’s 30-day survival rates for cardiogenic shock were just below 50 percent, in line with national and worldwide averages. Over the past five years, survival has increased to more than 70 percent. Notably, this survival rate has remained consistent, even as the volume of patients treated at IHVI for cardiogenic shock has tripled.

Critical Factors in Treating Cardiogenic Shock Successfully

The cardiogenic shock team credits three factors with the success of this regional approach:

Collaboration

More than half of patients with cardiogenic shock treated at Inova Fairfax Medical Campus initially present at a spoke hospital before being transferred. The shared protocol guides spoke hospitals in their initial response to cardiogenic shock, which is critical for care transitions and overall patient outcomes. Spoke hospitals can access the entire Inova cardiogenic shock team through a “one call” approach – specialists in all relevant disciplines can be reached 24/7 using one point of contact.

Communication

The new approach requires communication between the cardiogenic shock team and the spoke hospitals. The team welcomes consultations and phone calls from partner hospitals as often as needed to discuss treatment and possible transfer of patients. Check-ins follow the initial consultation at 8, 16 and 24 hours, and in between as needed.

Multidisciplinary Approach

Uniting specialists from multiple disciplines allows for collaborative, expert decision making and a tailored approach to care. The team considers the complexity of each case, along with the patient’s health condition and health values.

Inova’s Impact on Cardiogenic Shock Outcomes

Inova’s cardiogenic shock team is advancing critical care and knowledge by overcoming historical challenges and publishing its accomplishments. Our work is impacting national guidelines and worldwide health protocols. The 2022 American College of Cardiology and the American Heart Association guidelines for the management of heart failure have cited Inova’s work. They now provide a Class IIa recommendation for the employment of multidisciplinary shock teams to care for patients with cardiogenic shock, making this approach the new standard of care in the treatment of patients with advanced cardiovascular disease.

Learn more about Inova’s cardiogenic shock team.