A Standardized and Regionalized Network of Care for Cardiogenic Shock

Abstract

Background: The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood.

Objectives: The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network.

Methods: The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascular events.

Results: Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascular events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44).

Conclusions: Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation.

Keywords: cardiogenic shock; hub and spoke networks; systems of care.

Figure 1:

Consort Flow Diagram and Study Design

Figure 2:. The Inova Health System Regionalized Care Network for Cardiogenic Shock.

Map depicting regionalized cardiogenic shock network spanning Northern/Central Virginia, Maryland, the District of Columbia and West Virginia.

Figure 3:. Short-Term Clinical Outcomes

Bar graph depiction of 30-day mortality and associated short-term outcomes based on initial site of clinical presentation.

Central Illustration:. Standardized Systems of Care Network for Cardiogenic Shock.

Schematic representation of the Inova Health System’s regionalized cardiogenic shock network. Key components include early recognition and stabilization, comprehensive shock phenotyping, and coordinated transfer to the Level 1 center. Following multivariate regression analysis, no differences in 30-day mortality and associated short-term outcomes were noted based on initial site of clinical presentation and management.