Letter to the Editor

After Action Reviews

Dear Editors:

Cardiogenic shock (CS) has a persistently high mortality rate with limited improvement in survival over several decades. Patients in shock present in extremis and deteriorate rapidly. Successful diagnostic and therapeutic decision making must therefore be both timely and effective. Since 2017, our single-center “shock team of teams” progressively increased local CS survival rates quarter by quarter, from <50% at the start of our initiative in 2017, to >75% in 2018.1-3 Our local experience suggests that some potential keys to success include: teamwork; rapid collaborative decision making; standardized protocols and care pathways; and after action reviews (AARs).

Our CS team schedules recurring multidisciplinary meetings with 100% case review of each patient’s clinical presentation, initial treatment, hospital course, and clinical outcomes.1 Team meetings occur every 2-4 weeks with alternating sessions dedicated to process and research discussions. Attendees include representatives from nursing, pharmacy, emergency medicine, critical care, interventional cardiology, cardiac surgery, heart failure, safety, and often hospital administration. Our roundtable format assesses compliance with our protocols, determines the effectiveness of our interventions, and facilitates regular incremental changes to our care pathways and protocols as part of a continuous “unblinking eye” quality-assurance and process-improvement program.1,3 Meetings close with clear due-outs, responsible parties, and timelines for completion.

We modified the validated military AAR model, which was designed to critique training and combat events and answer four key questions: (1) What was planned? (2) What really happened? (3) Why did it happen? (4) What can we do better next time?4,5 The AAR is a dynamic method of evaluation that connects past experiences with future actions, provides a forum to discuss and dissect root causes of both team failures and successes, and links past performance to future training.5,6

To be efficient and successful, AARs require broad participation, a structured process, the availability of objective data, attention to information recording and dissemination, and a climate of openness and candor.7 At its core, the AAR is a problem-solving process designed to discover strengths and weaknesses, propose concrete and actionable solutions and recommendations, and identify tasks and topics requiring leadership attention. When conducted correctly, AARs promote inclusiveness, spark creativity, reduce siloing of care, facilitate a continuous learning process, and enable effective decision making.

In our institutional AARs, we continuously review our patient- and operator-level data with a focus on: timely identification of the shock state; appropriate shock team activation; team member participation in both in-person and “virtual” shock team discussions; adherence to our recommended treatment protocols; right heart catheterization utilization; accurate clinical and hemodynamic characterization of the shock state (acute myocardial infarction or acute decompensated heart failure phenotype with right, left, or biventricular involvement); mechanical circulatory support device use and appropriateness; vascular complication rates and etiologies; and patient morbidity and mortality. These open-forum meetings have allowed us to capture and share knowledge from each team member’s perspective at every level, become a learning organization, and reduce unwanted variations in care. They have also proven effective for team building and esprit de corps among historically parallel-working groups.

Two years into our shock team and AAR process, we are now focusing our attention on developing a regional hub-and-spoke shock network by exporting our local hub lessons learned to affiliated spoke medical institutions. We hope that our multidisciplinary team’s hard-earned and AAR-derived best practices may be of use to others as we all work together to end preventable death from CS. 


Alexander G. Truesdell, MD; Behnam Tehrani, MD; Carolyn Rosner, NP;  Ramesh Singh, MD;  Shashank Sinha, MD; Mehul Desai, MD; Shashank Desai, MD; Glenn Druckenbrod, MD; Charles Murphy, MD;  Wayne Batchelor, MD; Christopher O’Connor, MD

Address for correspondence: Alexander G. Truesdell, MD, Inova Heart and Vascular Institute, 3300 Gallows Road, Falls Church, VA 22042. Email: agtruesdell@gmail.com


1. Truesdell A, Tehrani B, Singh R, et al. ‘Combat’ approach to cardiogenic shock. Interv Cardiol. 2018;13:81-86.

2. Tehrani B, Truesdell A, Sherwood M, et al. Standardized team-based care for cardiogenic shock. J Am Coll Cardiol. 2019;73:1659-1669.

3. McChrystal S, Collins T, Silverman D, Fussell C. Team of Teams: New Rules of Engagement for a Complex World. New York, NY: Penguin Publishing Group; 2015.

4. Truesdell A. War on shock. J Invasive Cardiol. 2017;29:E14-E15.

5. Headquarters Department of the Army. A Leader’s Guide to After-Action Reviews. Fort Leavenworth, KS: Training Management Directorate; 2003.

6. Bray K, Laker S, Ilott I, Gerrish K. After Action Review: An Evaluation Tool. Sheffield, United Kingdom: Collaborations for Leadership in Applied Health Research and Care for South Yorkshire; 2013.

7. Garvin D. Learning in Action: A Guide to Putting the Learning Organization to Work. Boston, MA: Harvard Business School Press; 2000.