Introduction In 2013, the Hospital Specialist Palliative Care (HSPCT) and General Intensive Care Unit (GICU) Teams began a quality improvement initiative in response to the palliative care needs experienced by GICU patients. 'Palliative Critical Care' now involves seamless inter-disciplinary working on an almost daily basis, supported by one session each per week of dedicated Intensivist and Palliative Medicine Consultant time. Here, we detail the impact of this collaboration on HSPCT activity and patient outcomes. Methods Retrospective review of HSPCT records between April 2013 and March 2019. Results Over the last 5 years the HSPCT has received 588 referrals from adult intensive care services (General, Cardiac and Neurological). From a baseline of 6 referrals in 2013/14 we now receive over 130 new referrals per year. Over this time our caseload has evolved; 79% of referrals for non-malignant conditions in 2018/19, compared with 59% in 2014/15. In both years the in-hospital mortality rate of patients seen by the HSPCT was approximately 50%. Key areas of impact include pain control, symptom control, family support in 66%, 81%, and 86% of interactions, respectively. Patients are given psychological support in 48% of interactions. The HSPCT also provide valued support to ICU staff in 32% of interactions and discharge advice in 19%. HSPCT involvement now routinely continues throughout the patient's hospital stay. The average number of contacts per patient has increased from 4.3 to 7.5 (2014/15 vs 2018/19, respectively), each contact lasting 30–40 minutes. Thus, the average total duration of HSPCT time per patient has increased from 139 minutes (2014/15) to 287 minutes (208/19). Conclusion This Quality Improvement Initiative has enabled a flourishing collaboration between our HSPCT and GICU teams resulting in a sustained increase in referral numbers from all adult ICU areas with more time dedicated to support each patient in a continuously evolving cohort.

Introduction Historically, joint-working between our General Intensive Care Unit (GICU) and Hospital Specialist Palliative Care Team (HSPCT) was restricted to occasional complex cases. In 2013 there was shared recognition that patients, families and staff might benefit from a broader, structured, collaborative approach. In 2014, we created four hours dedicated intensivist time and enhanced joint working – ‘Palliative Critical Care’. In 2016, a weekly combined ward round was established. Here, we report the impact of this Quality Improvement Initiative on HSPCT activity and place of care. Methods Retrospective review of HSPCT records between April 2013 and March 2018. Results Over 300 patients have been seen under this collaborative model since April 2013. Initially, referrals increased from six in 2013/14 to 57 in 2014/15. Continuous development has resulted in sustained year on year increase in referrals; 107 in year 5 (2017/18). Collaborative working has promoted recognition and treatment of symptoms, and provided an additional layer of support for patients, families and staff. Staff report increased confidence especially in symptom control of actively dying patients. The in-hospital mortality of this patient group is 46%–74% with an ICU mortality of 23%. Patient preferences have been supported; 61.5% of survivors were discharged home or to a hospice (2017/18). In selected cases discharge has been achieved direct from GICU; seven patients to a hospice and eight to home (2013/14 – 2016/17). Patient, family and staff feedback has been ‘excellent’; one relative said ‘I had no idea that palliative care and intensive care could work together especially for someone who doesn’t have cancer and isn’t dying!’ Conclusion Through this Quality Improvement initiative the relationship between our GICU and HSPCT has been transformed from one of occasional interaction to a regular programme of collaborative working resulting in a sustained increase in referrals and supported patient preferences.

Introduction A collaborative approach between the General Intensive Care Unit (GICU) and the Hospital Specialist Palliative Care Team (HSPCT) can promote optimisation of patient physiology and symptom burden, aid clinical decision making, expedite transfer or discharge plans and provide additional support to patients, families and staff. In 2014 we created 4 hours of intensivist time for palliative care and developed joint working, named ‘Palliative Critical Care’. In 2016 a weekly combined Palliative Medicine and GICU ward round was established. Here, we detail the impact of this intervention on the activity of the HSPCT and associated patient outcomes. Methods A retrospective review of HSPCT records of GICU referrals between March 2013 and March 2017. Results There has been a sustained increase in referrals from GICU to the HSPCT since 2013; 6 in 2013/2014, 57 in 2014/2015, 99 in 2015/16, 89 in 2016/17. Timeliness of referrals has improved. The proportion of patients who died before HSPCT review has reduced, 15.8% in 2014/2015, 7.6% in 2015/16, 10.1% in 2016/2017. Collaborative working has supported patient preferences, enabling direct discharge from GICU to home or hospice in a number of cases (0% prior to intervention, 13.3% in 2014/2015, 2% in 2015/2016, 6.4% in 2016/2017). Over the years, of those transferred to wards 12.5%–22% are discharged home and 13.6%–20.8% to a hospice. The majority of patients seen by the HSPCT are kept under review whilst in hospital, even if discharged from GICU (66.0%–89.7%). Patient and family feedback has been ‘excellent’. Conclusion This intervention has resulted in sustained improvements in collaborative working between the GICU and the HSPCT as indicated by the number and timeliness of referrals. It has supported patient preferences, enabling a significant proportion to be discharged either to home or hospice, including some directly from GICU.

The United Kingdom population is ageing. Half of patients requiring an emergency laparotomy are aged over 70, 20 % die within 30 days, and less than half receive good care. Frailty and delay in management are associated with poor surgical outcomes. P-POSSUM risk scoring is widely accepted, but its validity in patients aged over 70 undergoing emergency laparotomy is unclear. Aims: To assess if P-POSSUM risk stratification reliably predicts inpatient mortality in this group and establish whether those who died within 30 days received delayed care.

The effects of a high carbon dioxide on cerebral perfusion and intracranial pressure are well known. We report the case of a man who presented after with a severe traumatic brain injury including intracranial and extradural haemorrhage. Neuroprotective ventilation was impossible without supramaximal tidal volumes due to a combination of chest trauma and severe bronchospasm. A pump driven Novalung iLA active® system was inserted to achieve both ARDSnet ventilation and a lowering of intracranial pressure. To our knowledge, this is the first time this system has been used to this effect. The patient went on to make a good recovery.