Improving care for high impact users of hospital emergency departments: a mixed-method evaluation of a regional quality improvement programme Supporting High impact users in the Emergency Department (SHarED)

BackgroundThe need to better manage frequent attenders or high-impact users (HIUs) in hospital emergency departments (EDs) is widely recognised. These patients often have complex medical needs and are also frequent users of other health and care services. The West of England Academic Health Science Network launched its Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme to spread a local HIU intervention across six other EDs in five Trusts. AimSHarED aimed to reduce ED attendance and hospital admissions by 20% for enrolled HIUs. To evaluate the implementation of SHarED, we sought to learn about the experience of staff with HIU roles and their ED colleagues, and assess the impact on HIU attendance and admissions. MethodsWe analysed a range of data including semi-structured interviews with 10 HIU staff; ED staff training; an ED staff experience survey; and ED attendances and hospital admissions for 148 HIUs enrolled in SHarED. ResultsStaff with HIU roles were unanimously positive about the benefits of SHarED for both staff and patients. SHarED contributed to supporting ED staff with patient-centred recommendations and provided the basis for more integrated case management across the health and care system. 55% of ED staff received training. There were improvements in staff views relating to confidence, support, training, and HIUs receiving more appropriate care. The mean monthly ED attendance per HIU reduced over time. Follow-up data for 86% (127/148) of cases showed a mean monthly ED attendances per HIU reduced by 33%, from 2.1 to 1.4, between the six months pre- and post-enrolment (p<0.001). ConclusionSHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff. What is already known on this topicFrequent attendance in hospital emergency departments is a worldwide problem that, despite the national recognition of the rationale for better management of high-impact users, has relied on the local efforts of clinicians to change working practices. What this study addsThe Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme was successful in spreading a model of high-impact user management based on the identification, proactive management, monitoring and review of these patients, with clear benefits to emergency department staff, and potential benefits to patients and resource use. How this study might affect research, practice or policySHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff.