Author: Vanesther Hamer

Sally Buckland from the Bristol Royal Infirmary reflects on setting up their High Impact User Team and the launch of the SHarED project with the West of England AHSN.

Within every Emergency Department you will find a cohort of patients who have multiple attendances. Many of these patients have multiple needs and a high proportion are known to the community mental health services. The liaison psychiatry team at the Bristol Royal Infirmary had long recognised that many of the patients they saw in the Emergency Department following self-harm had existing care plans with the community services, and early interventions sought to ensure that care coordinators were able to advise on psychiatric support of their patients who were frequent attenders to the emergency department.

Other specialist teams, such as drug and alcohol services within the hospital, were also seeing similar patterns of attendance, often this group of patients were known to several teams, who began to look at ways of ensuring consistency of care.

In 2014 the High Impact User Team was set up within the Bristol Royal Infirmary Emergency Department to work alongside this cohort of patients and healthcare professionals with the aim of reducing unnecessary attendances and relieving pressure on the Emergency Department.

What quickly transpired though through this work was that there was a negative culture surrounding High Impact Users that also needed to be addressed. Staff were often reluctant to deal with High Impact Users and there was a common theme of negativity around their attendances.

A problem SHarED

Through time the work of the High Impact User Team has grown and the team expanded to meet the demand. In 2019 we began working with the West of England AHSN and launched SHarED (Supporting High impAct useRs to the Emergency Department) – a project to establish a network of High Impact User Teams within the Emergency Departments across the West of England.

Culture has been an important part of this work and, in an attempt to understand it further, staff at all SHarED sites have completed a survey relating to their experiences. Through this we have been able to gather important information about the culture surrounding some of our most vulnerable and complex patients. High Impact Users are, and continue to be, a group that staff struggle to engage with. But why is this?

Understanding the culture

High Impact Users are time intensive. Their presentations are rarely purely for medical reasons. They often have complex social and safeguarding issues that take significant time and resources to work out. Staff can end up feeling resentful if they find themselves spending less time with other patients as a result. Due to the complexity of their care there is often a concern about a risk of medical mismanagement.

A high proportion High Impact Users can be violent and aggressive in their behaviour. Staff often feel afraid and vulnerable in their presence. There is a significant level of risk management involved when dealing with these patients.

As Healthcare professionals it can become ingrained in us that we need to ‘fix’ our patients. The solutions often required in the case of the High Impact User are often longer term and can take time to implement. The perception that we are not fixing the issue is demoralising.

This can be emotive work. High Impact Users can have a significant emotional impact on those caring for them and often raise feelings within us that make us feel uncomfortable. Dealing with pain, trauma and non-engagement is draining. Sometimes there can seem to be no way forward in breaking the cycle of attendance.

Many of this cohort of patients present with self-harm, or drug and alcohol addictions, issues which can be perceived as self-inflicted, and thus somehow less deserving of staff time.

Patients with mental illness and addictions are also less likely to be able to engage easily with support services, or follow suggested treatment plans.

Finding solutions

This is a chaotic and difficult group of patients to work with and it became quite apparent early on in our work that a collaborative multiagency approach was the way forward. We aim to work with the High Impact User, GP and other agencies involved in their care to create Personal Support Plans to be used when the patient attends the Emergency Department. It is a model that has proved to be extremely successful. Personal Support Plans are designed and written to inform clinicians of key information, including risks and appropriate management suggestions in order to support them to be able to provide the most appropriate care response.

Whilst Support Plans are in place to help guide and support clinicians in their decision making there have been other benefits that we have discovered through the course of our work. Through a support plan we can communicate vital information that will enable the clinician to understand someone’s journey to becoming a frequent attender. It is important to remember that right at the centre of this process is a person with complex needs, and often a history of trauma.  They are ultimately patients and deserve the same level of care regardless of the frequency of their attendances. We aim for clinicians to hear the voice of the patient through their Personal Support Plan.

Historically High Impact Users have been seen as a drain on resources, however we are now seeing that with the right management this can be overcome. By equipping healthcare professionals with the relevant information they can treat High Impact Users effectively thus saving time, money and ultimately, saving lives.

Through our experience of working with High Impact Users in The Bristol Royal Infirmary and the implementation of Personal Support Plans we have seen a culture start to change to one of compassion. We are excited to see the positive changes that the SHarED project will continue to engender within the other sites and within our own trust.

2020 was one of the most challenging years ever faced by the NHS. COVID has caused us to adapt and evolve our ways of working. We are grateful to the SHarED team for the way that they have kept to project running through these challenging times.

What next?

2021 will see the completion of the SHarED project. We look forward to working together as a network of High Impact User Teams across the West of England to continue to support our patients and clinicians and change and improve the culture around High Impact Users.

Becky Munroe and Jeanette Gibson work at Bath Road, a Milestones Trust residential care home for people with learning disabilities in South Gloucestershire. They recently attended the West of England AHSN’s online RESTORE2 training and are now training the rest of their staff team.

In this blog, Becky and Jeanette share the story of Henry, one of the residents at Bath Road, and how the team’s knowledge of the RESTORE2 tool helped make sure he quickly got the right medical treatment he needed.

When Henry (name changed for confidentiality), a gentleman living at Bath Road who has suffered with aspiration pneumonia on numerous occasions showed signs of being unwell, the staff took action.

They recognised that Henry was possibly suffering with a severe chest infection, as he was coughing a lot and not presenting as his usual self.

Rachel (one of our team members) immediately recognised that he may be unwell and after explaining, isolated him in his bedroom and tested for COVID-19. She then explained that she was going to contact the GP. Rachel contacted the GP and had to await a call back.

Whilst waiting, Rachel who was trained in RESTORE2 carried out all the observations with Dave, another member of staff. Dave had not yet been trained but had access to our RESTORE2 resources. Rachel and Dave’s observations gave the resident a NEWS score of 4.

When the GP called back, he asked if we had completed any observations and Rachel and Dave were able to provide all the details. The GP was happy to prescribe antibiotics, which were urgently delivered to the service. The GP was also happy we had completed the observations and had all relevant facts to hand.

Our use of RESTORE2 resulted in a positive outcome for Henry. He did not need to be admitted to hospital, as had been the case previously when he had a similar health issue. Henry was able to continue to receive support in the comfort of his own home and his health improved much more quickly than when he’d gone into hospital before.

Both of us have recently attended the RESTORE2 training provided by the West of England AHSN and are currently rolling out RESTORE2 amongst the team at Bath Road.

Having the RESTORE2 tool has been a positive experience for the people who live at Bath Road and it’s enabling the team to spot and document signs of deterioration quickly and efficiently.

Consequently, staff are able to pass on critical information to the relevant medical professionals, and this in turn results in a quicker response and more positive outcome for the individuals we support.

Our use of RESTORE2 is also supporting us to reduce inappropriate hospital admissions, thereby enabling the team to reduce footfall into the service during the current COVID-19 pandemic.

Fessey House is a residential care home in Swindon for people with dementia, learning disabilities and other enhanced needs. Local GP, Chris Turner and Senior Community Nurse, Soghra Bi have been supporting Fessey House to introduce RESTORE2, in collaboration with the local Clinical Commissioning Group (CCG), to help staff more quickly identify when residents’ health is deteriorating.

Here Chris and Soghra share how staff at Fessey House have been supported by the West of England AHSN’s online RESTORE2 training, and how the residents are benefiting.

Soghra Bi, Swindon Intermediate Care Centre Liaison Nurse Assessor, Fessey House:

The carers in Fessey House were enthusiastic from the outset and worked hard to complete the RESTORE2 training. The majority had never taken physiological observations before but quickly became competent in the use of RESTORE2. They found the educational material very helpful.

Feedback from the carers who underwent the training was unanimously extremely favourable. They reported feeling empowered and confident in recognising deteriorating patients and felt better equipped to communicate their concerns to healthcare professionals to ensure that their residents got timely medical care.

The key takeaway message was to keep calm.

Fessey House reports that the RESTORE2 tool has already identified a resident with soft signs of deterioration and staff believe that the use of the tool allowed for earlier identification of deterioration and the need for medical intervention, and that treatment commenced sooner than would have occurred previously.

This resulted in the patient recovering sooner, with less of an impact on their functional ability and avoiding hospital re-admission.

Dr Chris Turner, GP, Swindon Community Health Services, Great Western Hospitals Foundation Trust:

On 7 September I was informed that the RESTORE2 toolkit which Soghra Bi, Senior Community Nurse, and I implemented in Fessey House had saved two GP visits that day.

The first patient was an elderly gentleman who looked unwell and carers identified that he was showing soft signs of deterioration. The carers used the RESTORE2 toolkit and calculated that his NEWS2 score was 7 and so called an ambulance as per the NEWS2 escalation. When the paramedics arrived they were very complementary and impressed with the use of the RESTORE2 tool and after conducting a further assessment of the gentleman, conveyed him to hospital.

The second patient was seen by a community nurse who was visiting to dress a wound on the gentleman’s leg. She took a set of observations and identified that his NEWS2 score was 3. She discussed this with the carers who explained about the RESTORE2 toolkit and that the escalation for such patients was to repeat the observations in 30 minutes. The carers repeated the observations half an hour later whilst the community nurse went on to see other patients. It had returned to zero and so the patient continued to be observed but required no further escalation.

The carers informed me that prior to RESTORE2 being in place they would have contacted the GP to come and see these patients. So this would have resulted in two GP visits from separate practices. Because of RESTORE2, two GP visits were avoided and, more importantly, ensured that one patient was promptly conveyed to hospital, avoiding the delay of waiting to see a GP first.

As a GP I can clearly see how RESTORE2 would benefit patients through the earlier identification of deterioration and treatment commencing earlier. When I am triaging home visits, having a NEWS2 score and soft signs of deterioration available allows me to ensure that a visit is prioritised within an appropriate timescale, and would avoid unnecessary visits where the most appropriate response is an emergency ambulance.

As more care and nursing homes start using the tool, I anticipate that there will be a reduction in unnecessary 999 calls, a reduction in hospital conveyance and a reduction in hospital length of stay for my patients, and a reduction in GP workload.