Shock Centers Definitions

Consortium Position Statement

The STL Shock Consortium has established a tiered framework to define institutional capability for the recognition, stabilization, treatment, and escalation of cardiogenic shock across the regional system of care.

These definitions support:
• consistent communication across institutions
• coordinated transfer and escalation pathways
• regional quality improvement and education
• future data reporting and registry development

Note: Final designation is determined by the STL Shock Consortium Steering Committee following capability review and periodic reassessment.

Patients should be stabilized at the nearest capable center and escalated through the regional network based on clinical severity, mechanical circulatory support needs, and institutional capability.

Levels of Care

  • Level I — Comprehensive Shock Centers
    • I-A: Advanced HF & Transplant
    • I-B: Comprehensive Shock Center
  • Level II — Advanced Shock Centers
  • Level III — Stabilization Shock Centers
  • Level IV — Shock Recognition & Transfer Centers

Regional Cardiogenic Shock System of Care

Patients should be stabilized at the nearest capable center and escalated through the regional network based on clinical severity, mechanical circulatory support needs, and institutional capability.

Level I — Comprehensive Shock Centers
I-A: Comprehensive Advanced HF & Transplant
I-B: Comprehensive Shock Center
↑
Level II — Advanced Shock Centers
High-level capability but limited surgical/MCS spectrum
↑
Level III — Stabilization Shock Centers
Stabilize and transfer model
↑
Level IV — Shock Recognition & Transfer Centers
Recognition • Stabilization • Rapid Transfer

Summary of Designations

Level Designation Core Role
I Comprehensive Shock Centers Full spectrum shock management
I-A Advanced HF & Transplant Destination therapy (LVAD + transplant)
I-B Comprehensive Shock Center Advanced acute shock care without transplant
II Advanced Shock Centers Early MCS + stabilization + escalation
III Stabilization Shock Centers Stabilize and transfer
IV Recognition & Transfer Centers Identify, stabilize, rapidly transfer

Level I — Comprehensive Shock Centers
Highest level of cardiogenic shock capability in the region

Core Capabilities
  • Highest level of cardiogenic shock capability
  • 24/7 Interventional Cardiology (primary PCI capable)
  • 24/7 Cardiac Surgery
  • Full spectrum Advanced Mechanical Circulatory Support (MCS):
  • pLVAD/pRVAD
  • Surgical pVAD
  • VA-ECMO (and various configurations – structural IC for septostomy/LAVA)
  • Structured shock protocol (SCAI staging integrated)
  • Dedicated Shock Team activation system
  • Cardiac ICU with shock expertise
  • Advanced ICU hemodynamic monitoring (Swan, lactate protocols, etc.)
  • 24/7 ancillary consultative services (Vascular surgery, NSGY, etc.)
  • Multidisciplinary team:
    • Advanced HF
    • Cardiac surgery
    • ECMO specialists
    • Perfusion support
    • Ability to accept regional transfer
Regional Role
  • Data reporting to consortium registry
  • Regional referral hub
  • Escalation center
  • Lead education & quality initiatives

Level I-A — Advanced HF & Transplant
Highest level of cardiogenic shock capability in the region

Must Have
  • Highest regional capability
  • Required Capabilities
  • 24/7 Interventional Cardiology
  • 24/7 Cardiothoracic Surgery
  • Full Mechanical Circulatory Support (MCS) spectrum:
  • All tiers pVAD (including surgical pVAD e.g. impella 5.5)
  • VA-ECMO
  • Durable LVAD implantation program
  • Active Heart Transplant (HTX) program
  • Advanced Heart Failure team onsite
  • Dedicated Shock Team activation protocol
  • Cardiac ICU with advanced shock expertise
  • ECMO specialists and perfusion support
  • Advanced hemodynamic monitoring protocols
  • Ability to accept regional transfers 24/7
Regional Role
  • System Role
  • Regional referral hub
  • Destination therapy center
  • Transplant and durable MCS decision center
  • Consortium leadership, education, and registry participation

Level I-B — Comprehensive Shock Center
Advanced acute shock management without transplant capability

Must Have
  • 24/7 Interventional Cardiology
  • 24/7 Cardiothoracic Surgery
  • All tiers pVAD (including impella 5.5)
  • VA-ECMO initiation (and management onsite preferably)
  • Structured Shock Team activation protocol
  • Cardiac ICU capable of advanced MCS management
  • Formalized transfer pathway to Level I-A for transplant/LVAD
May Not Have
  • Durable LVAD program
  • Heart transplant program
Regional Role
  • Full acute stabilization center
  • ECMO initiation and management
  • Regional escalation partner to Level I-A

Level II — Advanced Shock Centers
High-level capability with early advanced support, but limited full-spectrum MCS

Must Have
  • 24/7 PCI capability
  • pVAD capability (pLVAD/RVAD)
  • Structured shock protocol
  • Shock team activation (formal or informal)
  • Cardiac surgery(limited surgical MCS e.g. initiate ECMO)
  • Cardiac ICU capability
  • Established transfer pathway to Level I center
May Not Have
  • 24/7 ECMO
  • 24/7 cardiac surgery
  • Advanced HF/transplant capability
Regional Role
  • Initial stabilization
  • Early MCS initiation
  • Rapid escalation/transfer if needed
  • Participation in regional protocol alignment

Level III — Stabilization Shock Centers
Stabilize-and-transfer model

Must Have
  • Emergency department recognition protocols
  • 24/7 PCI Capability
  • Ability to initiate:
  • Vasopressors/inotropes
  • Limited pMCS(e.g. pLVAD or IABP)
  • Defined transfer agreement with Level I/II center
May Not Have
  • No expectation of advanced MCS capability
Regional Role
  • Early recognition
  • Initial stabilization
  • Early SCAI staging
  • Rapid transfer activation

Level IV — Shock Recognition & Transfer Centers
Focused on early identification and rapid escalation

Core Function
  • Recognize → Stabilize → Transfer
Core Capabilities
Recognition
  • Early recognition
  • SCAI shock staging protocol implemented
  • Lactate and shock biomarker protocol
  • ED and ICU shock screening pathway
  • STEMI/NSTEMI recognition pathway
Stabilization
  • Vasopressors/inotropes
  • Arterial line + central access
  • Ventilator support
Escalation
  • Defined transfer agreements
  • 24/7 activation pathway
Regional Role
  • Early identification
  • Immediate stabilization
  • Rapid transfer to higher-level centers

Governance

Center designation is assigned by the STL Shock Consortium Definitions Workgroup and Steering Committee based on:

  • institutional capability
  • operational readiness
  • participation in the regional system

Designations are dynamic and reassessed periodically.