Cardiogenic Shock Systems of Care Best Practices, Part 3: Regionalization of Care, Organizational Components, and Critical Care Transport Medicine

Abstract

This paper explores the regionalization of care, organizational components, and critical care transport medicine for cardiogenic shock patients. It discusses the establishment of cardiogenic shock centers, interdisciplinary collaboration, and the necessary infrastructure to ensure optimal patient outcomes. Emphasizing the importance of a regionalized treatment algorithm and transfer strategy, the paper builds on the foundational understanding of managing cardiogenic shock, aiming to provide a comprehensive framework for advanced management and regional transfer strategies essential for high-risk patients.

In our previous accompanying papers, ‘Cardiogenic Shock Systems of Care Best Practices. Part 1: Prehospital and Emergency Department Evaluation and Management’ and ‘Cardiogenic Shock Systems of Care Best Practices. Part 2: Shock Team and Inpatient Management,’ we explored identification and management strategies for patients with cardiogenic shock (CS) in the prehospital, emergency department settings, and inpatient settings.1,2 These articles laid the foundational understanding of how to recognize and initially manage this complex and life-threatening condition, emphasizing the importance of timely and appropriate interventions.

In part three of this series, we delve deeper into the regionalization of care (Figure 1), organizational components, and critical care transport medicine for patients with CS. Based on the available data and expert opinion, we discuss the establishment of a CS center (CSC), the necessary interdisciplinary collaboration, and the infrastructure required to ensure optimal patient outcomes. By building on the principles highlighted in the previous parts, this article aims to provide a comprehensive framework for the advanced management and regional transfer strategies essential for high-risk CS patients.

Figure 1: Regional Spoke-and-Hub Cardiogenic Shock Systems of Care Made up of Level 1, 2, and 3 Cardiac Intensive Care Units, and Partner Hospitals.

This figure shows the complex bidirectional communication that occurs for the best care of regional patients. The system includes close coordination with emergency medical services and critical care transport medical services, as depicted through transfers. Level 1 CICUs provide comprehensive, high-acuity care for all acute cardiovascular conditions and major comorbidities, with advanced invasive monitoring, full life-support capabilities, and access to all forms of mechanical circulatory support. Care is led by cardiac intensivists or intensivists working closely with cardiologists, and these units serve as regional referral, research, and education centers. Level 2 CICUs deliver intermediate critical care, with invasive monitoring, short-term life support, primary percutaneous coronary intervention, and select temporary mechanical circulatory support. Staffing may involve high-intensity models or consultative intensivist support, and patients requiring advanced therapies are transferred to Level 1 centers. Level 3 CICUs provide basic critical care in community settings, emphasizing stabilization with non-invasive monitoring, supplemental oxygen, and higher nurse-to-patient ratios, generally without on-site cardiac catheterization, percutaneous coronary intervention, or mechanical circulatory support. Patients are managed primarily by cardiologists with intensivist consultation as needed and transferred to higher-level centers when indicated. CICU = cardiac intensive care unit; ICU = intensive care unit.

Regionalization and Transfer of Care for the Patient with Cardiogenic Shock

CS patients represent a continuum of disease and are often extremely resource-intensive, requiring large, multidisciplinary teams to achieve the best outcome. Although the initial stages of management may be safely performed at local facilities, many patients will require expedient transfer and transport to a high-volume receiving hospital. Improved patient outcomes have previously been linked to operator and institutional volume for high-risk cardiac procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting, mechanical circulatory support (MCS), and heart transplantation, with similar data to support improved outcomes for CS patients at facilities with a high CS volume compared with facilities with lower numbers.3–5 Based on experience with other time-sensitive conditions (e.g. trauma, stroke, ST-segment elevation MI [STEMI]), healthcare and industry leaders have advocated for a regionalized treatment algorithm and transfer strategy for CS patients in order to get the right patient to the right place at the right time.6–8

Programmatic Organization of a Cardiac Shock Center

Based on expert consensus and informed by established models for other time-sensitive cardiovascular conditions, a center with the capability of caring for the most complex and critically ill cardiovascular patients is often referred to as a CS center (CSC). Organized CSCs require interdisciplinary collaboration for clinical and administrative organization. The organized framework for verified STEMI, stroke, cardiac arrest, and trauma centers can provide a template of successful programmatic structures. Programmatic components for a CSC include: a statement of institutional commitment; an organized mission statement; a structured interdisciplinary oversight committee; clear role definitions for key functions (Table 1); a performance improvement process; comprehensive clinical practice guidelines; resources consistent with meeting functional requirements; a registry or database specific to the disease process and outcomes; and routine fiduciary monitoring and reporting.

Table 1: Cardiogenic Shock Centers: Roles and Ability Requirements.

Roles	Abilities
Shock medical director	Receive communications 24/7 and activate the shock team
Shock program manager	24/7 ability to restore cardiac output
Shock surgical director	Maintain dedicated critical care capacity to admit
Shock coordinator	Have a site-specific, evidence-based, tiered activation system
Shock performance improvement coordinator	Declare and document the shock level within a defined time
Liaisons to the shock committee	Maintain organized clinical practice guidelines that are reviewed and updated regularly
Data analyst	Have predefined activation metrics
Educator	Have an organized education plan
CICU director	Participate in a registry database of patients who present with cardiogenic shock
CNO, VP service line, supply chain management	Create a feedback process to follow-up on outcomes with care delivery teams

CICU = cardiac intensive care unit; CNO = chief nursing officer; VP = vice president.

Centers that desire to function as comprehensive CSCs require collaboration from multiple aspects of patient care. These resources need to be aligned to function towards a common goal: improving recognition and timely restoration of cardiac output. At times, competing needs of an institution or system can delay the allocation of these resources, which may adversely affect patient outcomes. A CSC is also a program that will have community impacts outside a facility. CSCs likely will develop outreach programs and provide quality feedback to improve regional outcomes in sudden cardiac death, advocacy for acute MI awareness, and access to bystander cardiopulmonary resuscitation. Institutional leadership should understand the commitments of time, finances, authority, and role delineation that are required to sustain and operate a successful shock program. Executive councils, directors, and chief officers should demonstrate an institutional commitment to this process. This commitment in disease-specific programs is often demonstrated through presentation of the program at an executive level meeting and a resolution of support for the initiative.

A program with intent and focus benefits from a mission statement. A defined mission statement can be a guiding light to aid in decision-making, build consistency in a program and focus the efforts of a team. For example, an MCS program’s mission may be “to provide the timely restoration of cardiac output to allow patients to recover and live meaningful lives.” A shared common mission statement may aid in focusing on response, research, education, care delivery, teamwork, quality, or resource management. Programs may struggle to mature when they attempt to do too much with too little at one time.

A hallmark of an interdisciplinary center is a comprehensive performance improvement program. An institution may be able to integrate shock metrics into pre-existing hospital, departmental, or MCS program metrics. The CS population is unique in several aspects and the interdisciplinary committee members should reflect that unique oversight. Predefined metrics for data collection, registry entry, and review should be consistent and institutionally specific. Metrics may include time to consult/team activation, documentation of Society for Cardiovascular Angiography and Interventions (SCAI) level, consult response time, time to objective measurement of cardiac output, objective measurement of organ dysfunction, resource use (e.g. length of hospital stay, ventilator days, use of renal replacement therapy), the need for the escalation of therapy, the incidence of cardiac arrest, 30-day mortality, and functional level at discharge.

A dashboard of metrics provides a team a consistent method to review a program’s delivery of care and adherence to clinical practice guidelines. A predefined review process by a performance improvement team should allow adjudication of data and escalation of opportunities into the hospital or community quality system. A common part of similar programs is the ability of the quality team to provide feedback to emergency medical systems, emergency department staff, and transferring hospitals in an organized manner that highlights lifesaving outcomes, builds pattern recognition, and identifies opportunities for improvement.

Oversight and development of a CSC should be provided by an engaged and committed group of interdisciplinary team members. A typical construction of this may include an executive committee, an interdisciplinary shock committee, and a performance improvement or quality committee. The executive committee may be tasked with communications with the parent institutional leadership, fiduciary oversight, and advocacy or alignment of resources. This should include the shock medical director, shock surgical director, and program manager. The greater shock committee may include representation from emergency medicine, critical care, advanced heart failure, cardiac surgery, palliative care, nursing, the cath lab, the operating room, perfusion, hospital quality and process improvement, finance, and rehabilitation. Typically, the shock committee will review the programmatic dashboard, develop clinical practice guidelines, and act on performance improvement plans. A separate shock quality committee is a group of experienced clinicians who review quality and outcomes data, perform a secondary review, and develop performance improvement plans.

The resources needed to operationalize a shock center should be able to provide a consistent level of timely care without jeopardizing the current procedural and critical care services. This often means incremental allocation of resources to provide crucial services. A shock center should assess the epidemiological incidence of STEMI, non-STEMI, acute decompensated heart failure, and post-cardiac arrest shock in its served population. Although some systems may be able to integrate services with a shock program, case-by-case incremental investments may be required. Critical systems include an education service to implement the program, communications and triage resources, consult and response staff, medical devices, staff capacity, and procedural spaces.

Large clinical care teams require tools to provide consistency in the care they deliver. The clinical practice guideline (CPG) is a common tool to do this. CPGs for a shock program can be supported by pathways and procedural checklists. Initial shock CPGs may include prehospital communications, patient identification, activation and communication, initial care of the shock patient, reassessment of the patient at risk for shock, procedural team response, optimal care for common clinical conditions, patient transfer, in-hospital shock response, MCS weaning guidelines, and pathways for recovery. Functional CPGs should be concise, easily applicable to most patients, easy to reference in a timely manner, and frequently reviewed and updated.

Role of the Shock Coordinator

The contemporary CS system has grown increasingly complex with evolving treatment modalities and further use of MCS devices. The increasing complexity of CS systems requires significant coordination and a high administrative burden to function at optimal levels. Care for patients with durable left ventricular assist devices, heart transplants, complex arrhythmias, and structural heart interventions has been enhanced by incorporating highly specialized team members, often dubbed program coordinators.9,10

As such, at CSCs, full-time shock coordinators are becoming more commonplace, enhancing patient care for those experiencing CS.11 These coordinators, often experienced former cardiac intensive care unit (ICU) nurses, are integral to the functionality and efficiency of these advanced medical centers. The value proposition for the shock coordinator is to improve the quality of care offered and increase the capture of patients who may benefit from the multidisciplinary care offered at the CSC.

The CS coordinator has multiple roles within the system. The primary role revolves around the clinical care of CS patients, including those supported by MCS devices. The CS coordinator ensures that all institutional protocols, such as those for anticoagulation, purge systems, and weaning of temporary MCS, are followed. By being present during rounds, the CS coordinator inspects the devices and addresses any specific concerns, providing real-time updates to the physician team. This meticulous oversight ensures that patient care is consistent and of the highest quality, reducing the likelihood of complications and improving overall patient outcomes. In addition, shock coordinators monitor patients throughout the system, ensuring that updates and information flow seamlessly between all members of the care team.

Beyond direct patient care, shock coordinators are responsible for managing patient and system logistics. This includes facilitating patient transport, ensuring the availability of necessary devices, coordinating transitions of care, facilitating referrals to post-CS clinics, and maintaining device protocols and staff education. CS coordinators identify high-risk patients, assess those at risk daily, and ensure that known shock patients are coordinated appropriately with the necessary physicians. CS coordinators also develop and manage order sets, provide staff education, maintain data registries, and develop a well-networked and respected presence among their peers. This longitudinal, system-wide approach ensures that patients receive timely and appropriate care, which is vital in the fast-paced environment of cardiac critical care.

Case Study: CentraCare Heart and Vascular Center

CentraCare Heart and Vascular Center is a high-volume community hospital located in central Minnesota. In 2017, the interventional cardiology team was concerned that cardiac surgical consults who were not candidates for a coronary artery bypass graft, but were candidates for MCS-assisted complex PCI (high-risk PCI) were being lost to follow-up. Chart review revealed 20 surgical turn-down patients lost to follow-up who could have benefited from high-risk PCI. This led to patients self-referring to neighboring hospitals, leading to the perception that the program was incapable of caring for high-risk patients. The interventional cardiology team received funding to employ a registered nurse who had previously worked in the cardiovascular ICU and had expertise in high-risk CS patients. Through the evolution of this role, the interventional cardiology team identified five key roles of the shock coordinator: system-wide patient surveillance (the coordinator attends rounds in the cardiovascular ICU and reviews the cardiology list to identify patients who may benefit from high-risk PCI or MCS); order set oversight and management (to develop and update all order sets for MCS devices, shock protocols, and the CS registry); provider and referrer education (to educate nursing staff and provide community outreach education); program coordinator (to coordinate procedures, liaise between cardiology and nursing, and provide quality and outcome tracking); and program management (to plan monthly meetings and contribute to device-specific decision-making based on programmatic-level factors). Since the implementation of the shock coordinator role, the capture of patients who were candidates for high-risk PCI increased, with the annual number of high-risk PCI and acute MI CS (AMI-CS) patients increasing from 31 in 2017 to 107 in 2023 with a 245% increase in revenue for the program.

Transfer of Patients in Cardiogenic Shock

One key role of a shock team coordinator is to help facilitate the timely transfer of CS patients to a CSC. In one example of an implemented hub- and-spoke model of CS systems of care, over 50% of CS patients treated at CSCs arrive via transfer from another hospital.12 In this model, the early recognition and expedited transfer of patients in CS is imperative, because most patients who initially present in the early stages of CS will deteriorate in a time-dependent manner. In one study, patients requiring transfer from a spoke site were more likely to present to hub sites in SCAI D and E stages of CS than patients presenting directly to the hub (72.8% versus 55.3%, respectively).12 The increased SCAI stage and higher acuity of illness following transport likely reflect the outside hospital length of stay prior to transfer. Unfortunately, few evidence-based recommendations exist on the timing and thresholds of transfer for patients with CS from spoke to hub centers.

Although there are many potential indications to transfer a CS patient (Table 2), the impact of transport on patients in CS is unclear. Although a national analysis demonstrated that treatment at a CSC after transport was associated with significantly lower mortality, other studies have demonstrated higher mortality compared with a non-transfer cohort.12,13 However, the increased mortality demonstrated in the study by Garan et al. was associated with patients with heart failure-mediated CS (HF-CS), but was not seen for those with AMI-CS.12 Variables associated with increased mortality rates in HF-CS transfer patients, such as the need for renal replacement therapy, suggest that the transfer of HF-CS patients earlier in their shock course may have improved survival. In the study by Garan et al., all CS patients received treatment intensification or escalation following transport to the CSC, demonstrating the clinical need for transfer, and further reinforcing the need for the early recognition and transport of patients experiencing CS.12 As such, discussion of the best practices for the transport of these patients is imperative.

Table 2: Proposed Expert-based Triggers for Early Transfer to a Cardiogenic Shock Center.

Potential trigger	Rationale/clinical consideration	Example metrics/observations
Progression in SCAI shock stage	Increasing severity of shock predicts higher risk of deterioration and need for advanced therapies	Transition from SCAI B to C, or from SCAI C to D/E
Rising lactate/worsening metabolic profile	Reflects tissue hypoperfusion and escalating shock	Trend of lactate increasing over 2–6 h, lactate >4–5 mmol/l concerning
Escalating vasopressor/inotropic requirements	Indicates worsening hemodynamics despite current therapy	Need for increasing doses or multiple agents to maintain MAP ≥65 mmHg
Worsening end-organ perfusion markers	Early organ dysfunction signals high-risk physiology	Rising creatinine, decreasing urine output, rising bilirubin and elevated liver enzymes
Hemodynamic instability despite support	Suggests the need for advanced mechanical or surgical support	Persistent hypotension (MAP <65 mmHg) despite fluids/ vasopressors; recurrent arrhythmias
Need for MCS	CSCs can initiate or escalate temporary or durable MCS	Impella, ECMO, IABP consideration; failure of current MCS to maintain perfusion
High-risk clinical events/cardiac arrest	Post-arrest CS may require advanced interventions only available at CSCs	Recent SCA, refractory VT/VF, or CPR in progress
Unstable respiratory status/multiorgan failure	Multisystem compromise increases the benefit of tertiary care	Worsening hypoxemia, ventilator dependence, or need for CRRT
Delayed response to initial therapy	Early recognition of therapy failure supports timely transfer	No improvement after 2–4 h of optimized local care
Need for advanced procedures not available locally	Certain interventions require tertiary capabilities	High-risk PCI, urgent cardiac surgery, ECMO initiation, advanced heart failure therapies

This table summarizes potential clinical, laboratory, and hemodynamic features that may prompt consideration for early transfer of patients with CS to a higher-acuity CSC. Although evidence-based thresholds are lacking, these expert-opinion–based triggers aim to standardize escalation decisions, facilitate timely communication between referring and receiving centers, and support the early identification of patients at risk for rapid deterioration. CPR = cardiopulmonary resuscitation; CRRT = continuous renal replacement therapy; CS = cardiogenic shock; CS = cardiogenic shock center; ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump; MAP = mean arterial pressure; MCA = mechanical circulatory support; PCI = percutaneous coronary intervention; SCA = sudden cardiac arrest; SCAI = Society for Cardiovascular Angiography and Interventions; VT = ventricular tachycardia.

Role of the Shock Bed at Cardiogenic Shock Centers

The rapid diagnosis and early treatment of critically ill patients has been shown to decrease morbidity and mortality across multiple disease states, including CS.14–19 Shock beds have been developed to rapidly stabilize and treat all acutely ill patients, whether they originate from the hospital or another facility (e.g. the emergency department, the prehospital environment, or an interfacility transfer). The shock bed is staffed by a critical care-trained interdisciplinary team, typically including an intensivist or cardiac intensivist, bedside critical care nursing, and immediate access to respiratory therapy, pharmacy, and cath lab or procedural teams as needed. Admission criteria are protocolized and include patients with CS or impending shock from any entry point, particularly those requiring invasive monitoring, vasoactive support, mechanical ventilation, or escalation to temporary MCS. By reserving capacity and standardizing activation, the shock bed improves triage and care delivery by eliminating delays related to bed availability, facilitating early multidisciplinary decision-making, and expediting interfacility transfers.

The first documented shock bed was developed by Weil and Shoemaker with the aim of gaining insight into the mechanisms of acute illnesses.20 CSCs should have a shock bed in place, managed by a critical care-trained team, and consistently available for inpatient cardiac patients who deteriorate or for CS patients from outside the CSC. The shock bed can be used to support AMI-CS patients after PCI or to expedite interfacility transfer of the CS patient, because bed availability often affects the triage of critically ill patients.21 Protocols for the management of CS patients in the shock bed should be established and approved by a multidisciplinary team beforehand to provide efficient care of CS patients at all hours of the day.22

Key Points/Best Practices

• There should be a statement of formal institutional commitment to operating an interdisciplinary shock center.

• There should be a written shock performance improvement plan with predefined quality metrics.

• There should be a multidisciplinary organized cardiogenic shock committee with heart team liaisons.

Critical Care Transport Medicine for Cardiogenic Shock Patients

Prehospital Care Versus Critical Care Transport Medicine in Interfacility Transports

Emergency medical service (EMS) systems were initially created to provide care for medical emergencies in the prehospital setting for patients who had not yet been cared for in a healthcare facility. As the capabilities of modern healthcare have advanced, and increased regionalization of care has occurred, patients now often require critical care transport medicine (CCTM), the transport of critically ill patients who have already received inpatient care between two healthcare facilities, to receive a higher level of care and advanced interventions not available at the referring facility (Figure 1). A 2009 study demonstrated that nearly 5% of ICU patients in the US undergo transport by CCTM services at some point in their critical illness.23 As such, the role of traditional EMS systems has evolved, and CCTM systems have been developed with capabilities to transport an increasingly critically ill patient population, including patients with CS.

Critically ill patients requiring interfacility transport can decompensate quickly, mandating explicit planning and a team with significant experience to provide continuation of current care, or a higher level of care, throughout transport. Relying on transport teams trained only in standard prehospital care may result in compromises in care secondary to insufficient training and a lack of specialized equipment. The development of a robust CCTM service, in addition to the existing EMS resources, is essential to regionalization of care. As regionalization of care increases, multi-institutional hub-and-spoke systems of care are increasing and driving the evolution of CCTM. As successful CSCs and their affiliated healthcare networks are developed, they will also require the development of safe CCTM services to facilitate patient movement. The availability of CCTM services with a detailed understanding of the pathophysiology and management of CS is critical.

Current Standards of Critical Care Transport Medicine in the US

The Highway Safety Act of 1966 established the Department of Transportation’s National Highway Transportation Safety Administration (NHTSA) as the governance agency for EMS. CCTM, albeit very different from prehospital EMS, has fallen under the NHTSA regulatory governance of EMS, despite no regulations aligning with interfacility transport.24 Guidelines specific to CCTM interfacility transport have been developed by non-governing professional organizations; however, enforceable regulations within the US remain absent despite efforts by patient advocacy organizations, such as the Association of Critical Care Transport.25,26 As such, governing standards and reimbursement align with the originally intended mission of prehospital EMS and not with the current structure and needs of CCTM organizations and the patients they serve.

In the absence of governing national standards specific to CCTM, the Commission on Accreditation of Medical Transport Systems (CAMTS) provides voluntary accreditation based on an industry standard. The Air and Surface Transport Nurses Association (ASTNA) and the International Association of Flight and Critical Care Paramedics (IAFCCP) defined training recommendations and scope of practice for flight crews.27,28 Unfortunately, despite the standards set forth by CAMTS, ASTNA, and IAFCCP, substantial variability exists, leading to heterogeneity in the quality of care provided in CCTM. Given the vital role CCTM organizations play in CS systems of care, significant effort should be made to provide deliberate standards, linked to governing bodies and reimbursement, to support the resource-intensive training and care mandated by this critically ill population. The importance of regionalization of care is underscored by the UK ARREST trial, which reinforces the role of level 3 centers and CCTM in CS systems of care.29

Ideal Critical Care Transport Medicine System for Cardiogenic Shock Systems of Care

The appropriate and comprehensive care of patients experiencing CS during interfacility transport demands a highly trained CCTM team supported by tertiary or quaternary medical centers (level 1 and level 2 cardiac ICUs; Table 3). Clinical care delivered in the CCTM system should mirror that provided in the ICU at the affiliated CSC, as described in our previous paper, part 2 of this series.2 Nearly 100% of these patients necessitate critical care interventions throughout transport, with adverse events occurring in 5–28% of CCTM interfacility transports, emphasizing the need for meticulous team preparation and quality surveillance.30–32 Equipment malfunction, reported in 15.6% of transport cases, underscores the importance of preparation in case of essential equipment failure and rigorous quality improvement programs.33 The consistently successful transport of patients experiencing CS relies on well-trained team members, pretransport coordination, rigorous standard operating procedures, and standardized guidelines that are supported by governing bodies and reimbursement agencies.

Table 3: Cardiovascular Intensive Care Unit Levels.

Level	Patient Population	Technology	Physician Availability
1	All cardiovascular diagnoses	Full spectrum of MCS, including ECMO and implantable VADs	Care directed by a 24/7 in-hospital intensivist
	All CV surgery patients	Interventional cardiology available 24/7
	Advanced heart failure	Cardiac surgery readily available
	All patient populations from CICU level 2 and level 3	Continuous renal replacement
		All technology from CICU level 2 and level 3
2	STEMI or primary PCI patients	All invasive and noninvasive cardiac monitoring	Intensivists always available and are involved in management
	All patient populations from the CICU level 3	IABP and Impella support
		Coronary angiography availability
		Interventional cardiology availability
		Cardiac surgery on call
		All technology from CICU level 3
3	Initial diagnosis and management of common, stable CV conditions	Non-invasive monitoring and minimally invasive monitoring	Intensivist available at all times
		Mechanical ventilation

CICU = cardiac intensive care unit; CV = cardiovascular; ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump; MCS = mechanical circulatory support; PCI = percutaneous coronary intervention; STEMI = ST-elevation MI; VADs = ventricular assist devices.

The composition of the CCTM team caring for CS patients ideally comprises two providers trained in critical care with significant multidisciplinary experience, reflecting the specific skills required for the complex management of CS and the needs of the transport environment. Where possible, providers should seek training programs with independent professional specialty certification. The inclusion of certified personnel has shown favorable outcomes, significantly affecting pretransport optimization, adverse events, and mortality rates.34,35 Defining the scope of practice for flight crews and implementing standardized training regimens and onboarding programs can reduce variability and ensure the delivery of quality care. Given the current absence of CCTM regulations for caring for CS patients within the CCTM environment, embracing common national baseline training requirements presents an opportunity for standardization and quality improvement within the industry.

Interfacility Critical Care Transport Medicine for the Cardiogenic Shock Patient

CCTM is essential for the optimal caring of patients experiencing CS within modern systems of care (Figure 1), because it includes specialized teams beyond basic life support or advanced cardiac life support services. The primary responsibility of CCTM clinicians is to continue the current level of care and prevent further deterioration during transport. Clinical care delivered in CCTM should mirror that provided in the ICU at the affiliated CSC.

Various transport modalities, including ground and rotor-wing and fixed-wing aircraft, offer distinct advantages and considerations. Selecting the appropriate transport method involves a comprehensive assessment of factors such as the distance between facilities, transport time, personnel availability, vehicle capabilities, weather, terrain, safety, and cost implications. For patients requiring veno-arterial extracorporeal membrane oxygenation support, previous Extracorporeal Life Support Organization (ELSO) guidelines recommended ground transport for distances up to 250–300 miles (~400–485 km), rotor-wing aircraft transport for distances up to 300–400 miles (~485–645 km), and fixed-wing aircraft for any distance.36 However, more recently published ELSO guidelines do not have transport modality recommendations based on transport distance.26 By adhering to standardized protocols and maintaining clinical competency, CCTM teams ensure the safe and efficient transport of patients in CS, ultimately improving patient outcomes and survival rates.

Auto-launch of Critical Care Transport Medicine Teams for Shock Alerts

Auto-launch is a method where the 911 dispatcher can send a CCTM helicopter team directly to the patient’s location based off pre-established criteria, as opposed to waiting for a traditional provider request, to increase rapid access to definitive care for time-sensitive pathologies. A CCTM helicopter team is dispatched simultaneously with the ground-based EMS team to reduce response times and shorten transport times. Historically, trauma services most frequently use auto-launch policies in the prehospital setting, with 44.2% of respondents to a 2005 survey of CCTM providers confirming the routine use of such policies.37 However, contemporary systems of care have used auto-launch protocols to expedite interfacility transports to facilitate time-dependent interventions across multiple disease states such as stroke and STEMI.38,39 CS systems of care should consider auto-launch policies for patients likely experiencing CS to expedite transfer to a CSC.

Transport of Mechanical Circulatory Support Devices

MCS device use is common in patients with CS. As such, when CCTM teams receive a transport request for a patient experiencing CS, we recommend that the transport team routinely ask about the use of MCS devices. Patients supported by MCS will require additional preparation, including additional specialized equipment, appropriately trained personnel, and device-specific adaptations to the transport vehicle. Transport considerations for patients supported by temporary MCS have been described previously.40–42 CCTM services should implement pre-established standardized transfer protocols to ensure high-quality care during transfer and timely access to higher levels of care.43,44 CCTM clinicians should be aware of unique features of the various MCS devices before caring for this complex patient population during transport. Device-specific training and continual education for CCTM clinicians is vital; specific transport recommendations can be found in the Supplementary Material.

Key Points/Best Practices

• The CCTM team for CS patients should consist of two providers trained in critical care with significant multidisciplinary experience.

• CCTM teams need to be strongly supported by tertiary or quaternary medical centers.

• CCTM teams should provide the same level of care as the cardiac ICU at the CSC.

• Transporting patients with MCS devices requires additional preparation, specialized equipment, and device-specific training for CCTM clinicians.

Cardiogenic Shock (Post-intensive Care Unit) Recovery Clinics

Advances in critical care and the widespread use of temporary MCS have improved outcomes in CS, such that most patients now survive to hospital discharge; however, survival is frequently followed by prolonged recovery characterized by post-intensive care syndrome.45–47 After discharge, CS survivors face persistent physical, cognitive, and psychological impairments that reflect both the severity of shock and the complications of critical illness.48 Post-intensive care syndrome may manifest differently depending on the underlying critical illness, and survivors of CS represent a distinct subgroup due to differences in shock pathophysiology, premorbid health status, and exposure to advanced cardiac therapies such as MCS, driving unique patterns of post-ICU impairment.

Post-ICU clinics have been established at many institutions, including clinics focused on cardiac ICU survivors.49,50 These clinics are typically led by intensivists and supported by multidisciplinary teams that include pharmacists, social workers, rehabilitation therapists, and mental health specialists.50 Evidence for post-ICU clinics has been inconsistent secondary to the heterogeneity in pre-ICU health status, the type of critical illness, and ICU exposures.51 Much of the existing evidence is derived from survivors of sepsis or respiratory failure populations who have different comorbidities and ICU therapies than patients with CS. Despite limited CS-specific data, survivors of shock are considered a high-risk group.50 The Society of Critical Care Medicine recommends early post-discharge screening, typically within 2–4 weeks, to identify impairments, with serial reassessment over time and referral to specialized care for detected abnormalities.52 At present, the evidence of CS recovery clinics is evolving, although specialized expertise may offer advantages in coordinating complex care needs and managing sequelae related to advanced critical care interventions.

Conclusion

The organization of regionalized CS systems of care is essential for optimizing patient management. Regionalization facilitates efficient resource allocation and ensures that all patients always receive the highest level of care necessary. Coordinated networks of CS centers and community hospitals have the potential to improve outcomes through timely diagnosis, rapid treatment initiation, and seamless patient transfers.

The successful interfacility transport of patients experiencing CS is a key component of CS systems of care. This requires a team of highly trained CCTM professionals, supported by tertiary or quaternary medical centers. Effective clinical care during transport should mirror that provided in the ICU at the affiliated CS center, necessitating meticulous team preparation, rigorous standard operating procedures, and quality surveillance to mitigate adverse events. By adhering to standardized protocols and maintaining clinical competency, transport teams ensure the safe and efficient transport of patients experiencing CS, ultimately improving patient outcomes and survival rates across CS systems of care.

This paper discusses the logistics of creating a CS center, the role of a shock coordinator, and the importance of critical care transport. Additional phases of the contemporary CS systems of care are described in the accompanying articles.1,2

Funding Statement

This article was created and funded by a cardiogenic shock advisory board for Abiomed. The authors were compensated for their time as part of the cardiogenic shock advisory board.