Improving the management of high impact users in emergency departments: The SHarED programme

An NIHR ARC West evaluation of a programme to improve how ‘high impact users’ of emergency departments (ED) are managed, has shown the programme to be successful in reducing ED attendance and hospital admissions among these patients.

The high-level results of the evaluation have been published in a West of England Academic Health Science Network (AHSN) infographic, alongside a pre-print paper.

In England, patients who attend emergency departments (A&E) five or more times a year represent 2 per cent of attendees but account for 11 per cent of attendances. These patients are known as ‘high impact users’.

High impact users have often experienced extremely challenging situations in their lives. This can include experiences of violence, exploitation, alcohol and drug abuse, homelessness, chaotic life conditions, chronic pain, complex medical conditions, and, particularly, mental health conditions.

The West of England AHSN programme ‘Supporting high impact users in emergency departments’ (SHarED) supported six emergency departments in the region to introduce personalised care plans for high impact users.

The SHarED programme was based on an approach developed at the Bristol Royal Infirmary. SHarED aimed to reduce emergency department attendance by high impact users by 20 per cent in a year.

The evaluation showed SHarED successfully promoted better and more integrated care for high impact users. It also gave practical support to emergency department staff working in very difficult environments.

Interviews showed the staff involved in the programme felt SHarED was very positive for both emergency department staff and high impact users. They believed care was more appropriate, consistent and person-centred. They also felt patients would experience less stigma if staff were more empowered to help them.

A total of 148 high impact users enrolled in SHarED, but emergency department attendance and hospital admission follow-up data varied from three months (148 patients) to 12 months (33 patients). Data was available for 86% (127/148) of patients for six months before and after being enrolled in SHarED. For these cases, attendance reduced by 33% from 2.1 to 1.4 attendances per month on average. Similarly, hospital admissions reduced by 67% from 0.6 to 0.2 admissions per month on average.

SHarED enabled training on the management of high impact users to be given to 55% of staff (372/671) across the emergency departments.

Dr Hugh McLeod, Senior Lecturer in Health Economics at the University of Bristol and Health Economics Team Lead at ARC West, said:

“SHarED has helped both high impact users, who often have extremely challenging lives, and staff in emergency departments, which can be very difficult workplaces.

“Our evaluation suggests that investing in staff to focus on care plans these patients can both improve the care they receive, while also reducing their impact on the healthcare system overall. Other integrated care systems should consider adopting a similar approach to SHarED.”

Clare Evans from the West of England AHSN said:

“Spreading the high impact user model across the West of England has been an incredible achievement.

“Teams have developed a model that improves the care and experience for those who frequent emergency departments and supports staff to gain the confidence and competence to provide excellent care.”