Improving Outcomes in Cardiogenic Shock

June 22, 2020

Inova Cardiogenic Shock Program

How can you improve outcomes for cardiogenic shock patients? Here’s an insightful look under the hood of the cardiogenic shock program at the Inova Heart & Vascular Institute. Benham Tehrani, MD, FSCAI identifies how we can improve care for patients with cardiogenic shock. Alexander Truesdell, MD, FACC, FSCAI, FSVM, describes the innovative approach embodied in the Inova cardiogenic shock program. Carolyn Rosner, NP describes the key role of the cardiogenic shock coordinator, and Shashank Sinha, MD, MSc, FACC discusses patient management in the CICU. In addition, Chuck Murphy, MD, Inova Heart & Vascular Institute’s chief safety officer, leads a Q&A with these 4 members of the Inova cardiogenic shock team.

“Over the course of the last 2 decades, despite improvements in early reperfusion, regionalized systems of care, and the advent of robust mechanical circulatory support devices, survival in AMI-shock has been poor, with survival rates hovering about 50%,” explains Dr. Tehrani, co-medical director of Inova cardiogenic shock team and medical director of cardiac catheterization lab at Inova Fairfax. He describes the importance of preventing hemodynamic problems from developing into hemo-metabolic problems, in which patients develop end-organ failure. Dr. Tehrani identifies 4 areas Inova’s shock program targets for improving care for cardiogenic shock: (1) fractured care, (2) late detection, (3) impaired access to care, and (4) variations in care. In addition, he emphasizes the importance of the multidisciplinary heart team in providing patient-centered, coordinated care to improve outcomes.

Dr. Truesdell, interventional cardiologist and co-director of Inova cardiogenic shock team, highlights that the clinical objectives in shock have focused on coronary perfusion and have not focused sufficient attention on circulatory support and ventricular support. “And this is where some of our improvements in outcomes have been realized,” Truesdell explains. He describes how the Inova shock program focuses on multidisciplinary team-based care, emphasizing (1) rapid identification of the shock state, (2) early employment of circulatory support, and (3) hemodynamic assessment to guide decision-making. “You can’t treat what you can’t identify,” Dr. Truesdell states during the Q&A session. “So, if a patient is not identified to be in cardiogenic shock, they’re not going to get timely therapy.”

“I think one of the really important lessons that we’ve learned,” states Carolyn Rosner, RN, coordinator of the Inova shock program, “is it’s critical to continue assessing, reassessing, evolving, growing, and learning.” Rosner identifies her 2 main goals as creating and maintaining infrastructure and ensuring sustainability. “Infrastructure, for the cardiogenic shock team,” she explains, “is essentially hardwiring the process. I want to make sure that when a patient hits our hospital—whether it’s 4 o’clock in the morning or 4 o’clock in the afternoon—that they receive access to the same level of care.” To do this, she focuses on (1) training and education, (2) algorithms, (3) documentation, and (4) order sets. To ensure the continued growth and success of the cardiogenic shock team, she highlights the key element of team meetings, education and training, financial reviews, collaboration (both in reach and outreach), research, and equipment management.

Dr. Shashank Sinha, the medical director of the Inova cardiovascular intensive care unit, discuses best practices and troubleshooting strategies in the CICU. He emphasizes the importance of device management (position assessment, assessing hemolysis, and managing alarms) as well as groin management, and weaning and escalation. Dr. Sinha also talks about the importance of early management of these patients, algorithms, and standardization of care as well as after-action reviews “to review what we’ve learned from our experiences, so that the next patient can be best served by our cardiogenic shock team.”

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