Implementing Cardiogenic Shock Protocols

January 9, 2020

Cardiogenic Shock Protocol Compliance Associated with Survival

Joseph Parrillo, MD, discusses implementation of a cardiogenic shock committee and cardiogenic shock protocols at Hackensack University Medical Center, where he is chairman of the Heart and Vascular Hospital.

“About 3 years ago, we noticed that there was great variability in the management of cardiogenic shock at Hackensack University Medical Center,” Dr. Parrillo tells interviewer Dr. Dan Raess. “And because of this, we decided to appoint a cardiogenic shock committee.”

Dr. Parrillo explains that this cardiogenic shock committee is chaired by the vice chairman of the Heart and Vascular Hospital, who reviews all the cases. Dr. Parrillo is also part of this committee that includes the directors of the cardiac cath lab, cardiac surgery, advanced heart failure program, and cardiac surgery ICU, as well as a nurse project lead.

The cardiogenic shock committee meets weekly or every other week. In the beginning, they reviewed cases that had not followed the protocol and then followed up with the surgeon or interventional cardiologist who had been involved with the case, suggesting to them that they follow the evidence-based protocol. “Using this technique,” Dr. Parrillo explains, “we went from, initially, a 20% compliance rate up to an 80% compliance rate, and now 100% compliance rate in 2019.”

Dr. Parrillo cites awareness of the protocol as one of the biggest challenges to compliance. Once physicians were educated on the value of the protocol and saw committee leadership behind it, they began to follow it reliably.

Dr. Parrillo explains that the program infrastructure is a critical component to the success of the program. “The most important issue is having a nurse, or some healthcare professional who can review the cases along with a cardiologist who understands the ins and outs of this. And we were very fortunate to have an experienced interventional cardiologist and a nurse work together to screen the cases.”

The protocol implemented at Hackensack University Medical Center recommends that once patients are identified as being in cardiogenic shock, they receive an Impella® and if it is a case of STEMI, the coronary artery is opened. “And the use of right heart catheterization, we found was something that was not routinely being done and we felt was very important,” Dr. Parrillo explains, “particularly to the management of these patients going forward over the next hours to days.”

In addition, escalation is a major part of the protocol. Dr. Parrillo explains that Impella CP® is typically the device of choice. However, if patients don’t turn around hemodynamically within a few hours, surgeons are at the ready to implant Impella 5.0® or, more recently, Impella 5.5™ with SmartAssist­­­®.

In 2018, a year after implementation of the program, data revealed that compliance with the cardiogenic shock protocol was associated with survival. The survival rate was 50% in cases that were compliant with the protocol. Dr. Parrillo emphasizes, “And this was all-comers, including patients with cardiac arrest and other very poor prognostic indicators.” In cases not complying with the protocol, however, mortality was 100%. “So, using that data to educate our clinicians,” Dr. Parrillo states, “it was convincing that the compliant protocol was the better way to go.”

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