There’s No ‘I’ in Shock Team: Multidisciplinary Approach Seems to Pay Dividends

Getting everybody organized and on the same page when it comes to treating cardiogenic shock in patients with acute MI or acute decompensated heart failure appears to have a major impact on patient outcomes, according to single health system’s experience with implementing a multidisciplinary shock team.

A few years ago, clinicians at Inova Heart and Vascular Institute in Falls Church, VA, took a fresh look at what might be done to improve cardiogenic shock survival in their system, which lingered around 50% in 2016, similar to what has been seen more broadly in other centers and in randomized trials. They identified four areas that could be improved: early recognition of shock, speed of care, access to physicians with needed expertise, and variations in care.

A task force was formed to develop strategies for each of those areas, resulting in the formation of a shock team tapping into representatives from interventional cardiology, cardiac surgery, advanced heart failure, and critical care—which could be activated with a single call—and development of an easy-to-use algorithm to standardize care.

The team-based approach was implemented at the beginning of 2017 and within a year, 30-day survival among patients with cardiogenic shock reached 58%. By the middle of 2018, about 77% of patients with shock treated in the Inova system survived to 30 days, lead author Behnam Tehrani, MD (Inova Heart and Vascular Institute), and colleagues report in a study published in the April 9, 2019, issue of the Journal of the American College of Cardiology.

As you try to develop standards of care, best practices, it becomes critically important that everybody’s on the same page. Behnam Tehrani

Co-author Carolyn Rosner, NP (Inova Heart and Vascular Institute), who serves as the SHOCK/CHIP coordinator, said these efforts were inspired by a paper published in Catheterization and Cardiovascular Interventions by a group of experts recommending a team-based approach to treating cardiogenic shock.

That idea “was really borne out over our experience here,” she told TCTMD. “The team-based approach truly did make a difference and had durable real-world results, and. . . . having algorithms to reduce the variations and to guide care and having easy access to care really showed—in a pretty large number of patients—that there was a huge impact on survival.”

To TCTMD, Tehrani underscored the importance of the team-based approach and said, “We would like for this paper to serve as a road map, if possible, for other centers around the country to develop their own protocols and algorithms to take care of these patients.” He added that it will be important for centers to share meaningful data during that process to help inform the development of pragmatic trials and ultimately clinical guidelines, which are currently lacking for cardiogenic shock.

Commenting for TCTMD, Tanveer Rab, MD (Emory University School of Medicine, Atlanta, GA), who wrote an editorial accompanying the JACC paper, pointed out that the survival rate seen in this study is similar to that seen in the National Cardiogenic Shock Initiative, which also employs a common treatment protocol for patients with acute MI complicated by shock.

“Protocol-based algorithmic care is very, very important, I think, in the management of shock patients if you want to have good outcomes,” he said.

Key Components

The Inova algorithm at the heart of the team-based approach, which can be found in the JACC paper, starts with an assessment of clinical criteria, including lactate levels, to rapidly identify shock. This is followed by activation of the shock team to initiate a multidisciplinary discussion. Depending on the situation, patients are then taken to either the cardiac cath lab or the cardiac intensive care unit (CICU) for further evaluation, which includes right heart catheterization whenever possible. Minimizing use of vasopressors and inotropes is another key aspect.

The team then evaluates hemodynamic criteria, including cardiac power output and pulmonary artery pulsatility index, and determines whether percutaneous mechanical circulatory support (MCS) is needed, with the decision about the specific intervention chosen left to the shock team. Patients are then treated longitudinally in the CICU with continued involvement of the shock team.

Tehrani said one of the major challenges with getting the shock team set up was getting clinicians from diverse fields on board with a standardized care protocol. “Physicians are very independent. They practice medicine in ways that have helped their patients for a long period of time,” he said. “But as you try to develop standards of care, best practices, it becomes critically important that everybody’s on the same page.”

Identifying leaders within specialties who would work to disseminate the protocols to other physicians was key in moving the process forward, Tehrani said, who also stressed the importance of constantly reviewing cases after the fact to see how the effort could be improved.

In concert with the team-based strategy, the researchers also developed a score based on clinical and hemodynamic variables to risk-stratify patients and found that it performed well for predicting 30-day mortality (C-statistic = 0.97). No patients with a low score died, whereas 17.6% and 82.4% of those with moderate or high scores, respectively, did not survive to 30 days.

“A score incorporating demographic, laboratory, and hemodynamic data may be used to quantify risk and guide clinical decision-making for all phenotypes of cardiogenic shock,” the authors say.

Regionalizing Care

In addition to the formation of shock teams, the Inova group also recommends regionalizing care to reduce variations in practice, improve patient outcomes, and facilitate the design of clinical trials to evaluate cardiogenic shock therapies.

“There is precedent for implementing regionalized care systems, resulting in improved survival for other time-sensitive cardiovascular conditions such as cardiac arrest, ST-segment elevation myocardial infarction, aortic dissection, and stroke,” they note. “Pilot studies have shown the feasibility of mobile cardiogenic shock teams that travel to spoke hospitals to initiate MCS, stabilize patients, and then transport them back to the hub institution.

“Although different hypothetical models have been proposed to develop cardiogenic shock hub-and-spoke systems,” they continue, “we believe it is critically important to implement coordinated regionalized systems of care to reduce practice variation and centralize the care of the patient with cardiogenic shock to high-volume tertiary medical centers able to offer early escalation of therapy and full-spectrum, multidisciplinary care.”

Rab agreed that a system to centralize the treatment of cardiogenic shock is important because of the relatively low number of shock cases that most centers see. He estimated that shock patients account for no more than 6% of any given hospital’s PCI population. Thus, Rab said, it’s critical to get patients to hospitals that have access to the expertise and devices needed to manage cardiogenic shock.

Though some health systems have begun implementing hub-and-spoke systems geared toward improving outcomes in patients with shock, Rab said the concept is still in its infancy. That should change, he said.

“I think hospital centers have to create a shock center with a hub-and-spoke pattern,” Rab said. “[They should] create teams of people, a shock team, and have a protocol-based approach. . . . And that’s the only way you can improve survival to above 70% or 75%.”

In his editorial, Rab advocates for the presence of a “shock doc” on every shock team. This would be “a designated ‘shock team’ member who is central to ‘shock team’ alert/activation,” he writes. “The ‘shock doc’ is responsible for coordinating and implementing with other multidisciplinary ‘shock team’ members critical team-based decisions for the patient with cardiogenic shock, such as emergent MCS placement, arrangement of dedicated cardiac intensive care unit bed, and daily management of the patient.”

Where’s the Randomized Data?

Commenting for TCTMD, Emmanouil Brilakis, MD, PhD (Minneapolis Heart Institute – Abbott Northwestern Hospital, MN), said that the apparent benefits seen in the Inova experience should be considered hypothesis-generating because of the observational nature of the study. He added, however that the study “suggests such a systematic approach works and can improve patient outcomes.”

The lack of randomized data has proved to be a touchy subject in the area of cardiogenic shock, especially as it pertains to use of the Impella device (Abiomed).

But that gap should not slow a move toward organizing team-based management of shock, Tehrani said, adding that parallel efforts can be made to both create shock teams and conduct randomized trials.

“Until  we have data from a randomized trial showing a survival benefit with one device or another, we have to rely on a team-based approach to identify who is appropriate for which therapies—and by therapies that could be medical or device-based—and then make a decision to move forward,” he said, stressing that the involvement of the shock team should continue throughout the longitudinal care of patients.

Rosner agreed. “I think the multidisciplinary approach and then the subsequent coordination is really probably as impactful in survival as any one particular device,” she said. “We really try to be well rounded in our approach to this and continue to take data as it comes, but always just try to get the best equipment and technology for our patients.”

Even in the absence of randomized data, Brilakis supported the idea of going ahead with the team concept, noting that a standardized definition of cardiogenic shock will be released by the Society for Cardiovascular Angiography and Interventions (SCAI) and the Heart Failure Society of America at SCAI’s annual meeting next month.

“Like everything else, the more that people are specialized in dealing with this specific group of patients, the better it’s going to be,” Brilakis said.