23 From an intensive care unit (ICU) to a hospice; a case study highlighting the need for tailored staff education in response to the increasingly complex case-mix in specialist palliative care

Background Palliative Medicine has expanded rapidly as a specialty to encompass non-cancer patients, with multiple co-morbidities, in a wider range of settings. Adaptation of existing services with ongoing staff training is essential to meet the evolving demographics and demand. Case report An 81-year-old diabetic patient with peripheral vascular disease developed necrosis of the foot. Revascularisation attempts were complicated leading to ICU admission for intravenous antibiotics and haemodynamic support. They were diagnosed with necrotising fasciitis but were not fit for further surgery. Referral was made from ICU to hospice, their preferred place of death. After inotrope withdrawal, the patient was transferred with a bupivacaine spinal line in-situ for pain control. Diabetic control was challenging in the context of variable oral intake and sepsis. Morphine and midazolam syringe drivers were titrated; the patient died peacefully eight days after admission. Evolving case mix: Admissions to the hospice inpatient unit from 2015–2019 were reviewed retrospectively. Although we were unable to identify those patients transferred directly from ICU to hospice, the proportion of patients admitted to the hospice with non-malignant conditions had risen from 11% (2015) to 21% (2018) during this time. Staff training Teaching sessions were provided for staff to highlight key considerations when caring for patients with necrotising fasciitis, including symptoms and infection control advice. Feedback was gathered from staff attending teaching with 82% rating it as ‘useful’ or ‘very useful’ and 90% indicating that they would be interested in future education sessions. Conclusion The breadth of patients referred for inpatient hospice management is growing. The case outlined may represent an emerging patient subgroup; those without a prior palliative diagnosis whereby active treatment of an acute complication has failed. Teaching sessions proved beneficial to hospice staff and should be considered in the future to promote individualised integration of care across disciplines.