Helping A&E teams manage ‘high impact users’

In England, patients who attend emergency departments (ED) five or more times a year represent 2% of attendees but account for 11% of attendances. These patients are known as ‘high impact users’. High impact users often experienced extremely challenging situations in their lives, such as violence, exploitation, alcohol and drug abuse, homelessness, chaotic life conditions, chronic pain, complex medical conditions, and, particularly, mental health conditions. Rebecca Thorpe, Emergency Medicine Consultant and Associate Medical Director at University Hospitals Bristol and Weston, explains, “‘High impact users’ are vulnerable patients with complex needs who attend emergency departments much more frequently than other people. I felt that, with the right support, clinical advice and risk assessments, staff would be empowered to provide high quality care for these patients, delivered with compassion.”

Improving the management of high impact users

The Health Innovation West of England programme ‘Supporting high impact users in emergency departments’ (SHarED) aimed to improve the management of high impact users. Working with six EDs in the region, SHarED helped staff identify, proactively manage, monitor and review these patients. A key part of the programme was personalised care plans with information about the patient’s situation and health conditions. The plans helped staff engage with patients about their behaviour and needs, and gave recommendations on how to interact with and care for them. The West NIHR Applied Research Collaboration (ARC) evaluation, led by researchers Hugh McLeod and Carlos Sillero-Rejon and clinician Rebecca Thorpe, showed SHarED successfully promoted better and more integrated care for high impact users. The care plans were a practical support tool for ED staff working in very difficult environments. SHarED enabled 55% of ED staff to be trained on how to manage high impact users.

Reduced attendance and admissions

The evaluation showed SHarED was successful in reducing ED attendance and hospital admissions among high impact users, while improving their care. ED attendance went down by 33% and hospital admissions reduced by 67% for those high impact users enrolled in SHarED where data was available. One high impact user (HIU) at Gloucestershire Hospitals said, “Seeing the HIU team has helped with my health anxiety. The support provided and the implementation of my support plan has been reassuring. I feel like I am now in a better place.” The estimated saving on reduced ED attendance and hospital admissions was £333,529, with a net saving of £193,585 when SHarED costs are deducted. Assuming the reduction in attendance and admissions was consistent across all EDs involved, the total cost saving would be £388,680 with a net cost saving of £248,736.

The SHarED approach promoted more integrated care for high impact users

Interviews showed that both ED staff and high impact users found SHarED beneficial. Staff believed care was more appropriate, consistent and person-centred. They also felt patients would experience less stigma, as staff were more empowered to help them. The SHarED approach promoted more integrated care for high impact users by improving communication between health and care providers.Teams are now working with their Trusts and the NHS England High Intensity User Programme on implementation and scale up.

NIHR Applied Research Collaborations

NIHR Applied Research Collaborations support applied health and care research that responds to, and meets, the needs of local populations and local health and care systems.