John Byrne, MD, and Mandeep Mehra, MD

John Byrne, MD, chief of  BWH Cardiac Surgery, and Mandeep Mehra, MD,
executive director of BWH Center for Advanced Heart Disease

When a patient experiences cardiogenic shock, a state in which the heart is too weak to pump enough blood to the patient’s organs, timing is everything.

The most common cause of cardiogenic shock is lasting damage to the heart muscle after a heart attack. Only about 7 percent of people who have suffered a heart attack end up experiencing cardiogenic shock, but when it does occur, it is extremely dangerous.

Such patients may arrive at BWH though the Emergency Department or Cardiac Catheterization Lab, or may be transferred from another hospital. From there, they require immediate identification and appropriate triage to an Intensive Care Unit within the Shapiro Cardiovascular Center, where a series of consultations about next steps in the patient’s care plan happen, says Mandeep Mehra, MD, executive director of the Center for Advanced Heart Disease at BWH.

“This is the toughest heart and vascular situation to treat because outcomes are highly variable,” said Mehra. “The multidisciplinary experts needed are spread across the division, and convening everyone for the decision-making process can sometimes take days. The mortality rate of someone coming to the center with cardiogenic shock is 50/50.”

But as of late August, the BWH center began an innovative, experimental program to greatly speed up the decision-making process and attempt to enhance the clinical care of cardiogenic shock patients. It established a strategic approach called Cardiogenic Shock Team Page Activation and the organization of a “Shock Team,” which brings rapid, shared decision-making to the bedside.

The “Shock Team”

The principle of the Shock Team involves a “golden hour of decision-making that is integrated and immediate,” said Mehra. “A patient comes to the Levine Cardiac Intensive Care Unit (LCU) in the Shapiro Cardiovascular Center, and a convergence of consultation between four experts—a critical care cardiologist, an advanced heart failure specialist, a cardiac surgeon with expertise in ECMO and ventricular assist device (VAD) insertion, and an interventional cardiologist capable of acute short-term intervention in the Cath Lab—takes place. It is a vital period of shared decision-making about triaging the patient to the next step that happens immediately.”

As part of the program, when a patient gets transferred to the LCU, a critical care attending will immediately activate a virtual beeper to notify the critical experts of the Shock Team. The four clinicians either come to see the patient directly or consult instantly by phone to discuss next steps. This may lead to sending the patient to the Cardiac Cath Lab for support with a temporary device, or to the operating room for surgery. Ultimately, the system seeks to avoid delays in care and improve care coordination.

Formalizing the Informal

The concept of the Shock Team has been in place at BWH for months. Leading up to August, a team comprised of the Cardiovascular Division’s Ben Scirica, MD, MPH; David Murrow, MD, MPH; Michael Givertz, MD; and Pinak “Binny” Shah, MD, has been working to create standard operating procedures and protocols. Mehra and BWH Chief of Cardiac Surgery John Byrne, MD, oversee all aspects of the program.

“We’ve been working to formalize this multidisciplinary approach for patients with cardiogenic shock that we’ve been practicing informally at the Brigham for the past couple of years,” said Scirica. “Now, it is protocol that all of these physicians come together immediately to discuss these critically ill patients. The Shock Team is an opportunity to bring each of the key clinical specialists into an organized method of consultation in order to provide optimal care for these patients.”

As patient data is gathered, the team hopes to record and track outcomes to continue to improve the quality of care for this population of critical patients.

“Our goal is that if a patient comes here in cardiogenic shock, we will act swiftly and completely change the outcome for him or her,” said Mehra.

Added Scirica: “It will take several months to start seeing patterns and overall utilization of the Shock Team. We’re very interested in understanding how these patients arrive at the Brigham in order to help us improve our outreach to community providers, who send these patients to us. We’re thrilled to be able to provide a more focused, timely and efficient triage and management of critically ill cardiac patients.”