Outcomes of a multidisciplinary shock team utilizing an integrated medical/surgical strategy: The Penn Medicine Shock Model

Abstract

Background Cardiogenic shock (CS) is associated with poor prognosis, with mortality rates in excess of 40-50%. Multidisciplinary shock teams have been created to facilitate early diagnosis and appropriate escalation of support. However, there are varying approaches to implementation, resulting in variable outcomes. We describe our team's approach and outcomes over 18 months. Shock team Approach : The Penn Medicine Cardiogenic Shock Team (PMCST) was established in November 2019 and consists of physicians from Interventional Cardiology, Electrophysiology, Cardiac Surgery, and Intensive Care. The team is led by an Advanced Heart Failure Cardiologist and Cardiothoracic Surgeon, who activate other members of the team by phone for expedited decision-making. The multidisciplinary team evaluates referred patients for a potentially treatable insult and/or an appropriate exit strategy to avoid futile device placement. Accepted patients are then categorized for treatment/escalation of support according to three pathways: 1) acute myocardial infarction (AMI) shock, 2) hemodynamic (non-AMI) shock, 3) post-cardiotomy shock. All PMCST calls are maintained in a data registry. Results Between November 2019 and April 2021, the team received a total of 197 shock calls. Majority of the calls (93%) came from 20 local referring centers and 139 patients (70%) were accepted. Approximately half (53%) were admitted to the Cardiothoracic Intensive Care Unit. Temporary mechanical support devices were used in 84 patients (61%). Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) were the most frequently used single platforms (IABP 29%, ECMO 23%), but the majority of patients (36%) received multiple devices. Escalation of mechanical support was required in 32 patients (38%). Combined Impella and ECMO was the most commonly implemented escalation platform (25%). In total, 39 patients (46%) were evaluated for advanced therapies, with 6 patients (7%) proceeding to durable VAD or transplant. Overall survival rate was 68%. Discussion The PMCST multidisciplinary approach utilizes an integrated medical/surgical team strategy with leadership by Advanced Heart Failure and Cardiothoracic Surgery. This approach prioritizes ongoing community partnership for early recognition and appropriate utilization of therapy, and represents a successful strategy towards implementation of timely, but not futile, mechanical support and advanced therapies. Cardiogenic shock (CS) is associated with poor prognosis, with mortality rates in excess of 40-50%. Multidisciplinary shock teams have been created to facilitate early diagnosis and appropriate escalation of support. However, there are varying approaches to implementation, resulting in variable outcomes. We describe our team's approach and outcomes over 18 months. : The Penn Medicine Cardiogenic Shock Team (PMCST) was established in November 2019 and consists of physicians from Interventional Cardiology, Electrophysiology, Cardiac Surgery, and Intensive Care. The team is led by an Advanced Heart Failure Cardiologist and Cardiothoracic Surgeon, who activate other members of the team by phone for expedited decision-making. The multidisciplinary team evaluates referred patients for a potentially treatable insult and/or an appropriate exit strategy to avoid futile device placement. Accepted patients are then categorized for treatment/escalation of support according to three pathways: 1) acute myocardial infarction (AMI) shock, 2) hemodynamic (non-AMI) shock, 3) post-cardiotomy shock. All PMCST calls are maintained in a data registry. Between November 2019 and April 2021, the team received a total of 197 shock calls. Majority of the calls (93%) came from 20 local referring centers and 139 patients (70%) were accepted. Approximately half (53%) were admitted to the Cardiothoracic Intensive Care Unit. Temporary mechanical support devices were used in 84 patients (61%). Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) were the most frequently used single platforms (IABP 29%, ECMO 23%), but the majority of patients (36%) received multiple devices. Escalation of mechanical support was required in 32 patients (38%). Combined Impella and ECMO was the most commonly implemented escalation platform (25%). In total, 39 patients (46%) were evaluated for advanced therapies, with 6 patients (7%) proceeding to durable VAD or transplant. Overall survival rate was 68%. The PMCST multidisciplinary approach utilizes an integrated medical/surgical team strategy with leadership by Advanced Heart Failure and Cardiothoracic Surgery. This approach prioritizes ongoing community partnership for early recognition and appropriate utilization of therapy, and represents a successful strategy towards implementation of timely, but not futile, mechanical support and advanced therapies.