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)

Background The 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. Aim SHarED 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. Methods We 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. Results Staff 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). Conclusion SHarED 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 topic Frequent 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 adds The 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 policy SHarED 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by the West of England Academic Health Science Network (AHSN). The views expressed are those of the authors and not necessarily those of NHS England, NHS Improvement, the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the University of Bristol Faculty of Health Sciences Research Ethics Committee (approval code: 10275). Additionally, the qualitative study was approved by the NHS Health Research Authority (HRA) and Health and Care Research Wales (HCRW) (IRAS project ID: 300027) and local R&D from the five Trusts, and the analysis of the anonymised quantitative data collected as part of the SHarED programme for service evaluation was managed using a Data Protection Impact Assessment with the five Trusts. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes In order to preserve the anonymity of the interview participants, the interview data will not be made available. The rest of the data related to this study will be available upon reasonable request.