Research Article Common Presenting Problems for Young People...

Research ArticleCommon Presenting Problems for Young People Attendingthe Emergency Department

Dhurgshaarna Shanmugavadivel,1 Rebecca Sands,2 and Damian Wood1

1 Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus,Derby Road, Nottingham NG7 2UH, UK

2Department of Paediatrics, Sherwood Forest Hospitals NHS Foundation Trust, Kings Mill Hospital, Mansfield Road,Sutton-in-Ashfield, Nottingham NG17 4JL, UK

Correspondence should be addressed to Dhurgshaarna Shanmugavadivel; [email protected]

Received 9 January 2014; Revised 20 February 2014; Accepted 21 February 2014; Published 25 March 2014

Academic Editor: Bruno Megarbane

Copyright © 2014 Dhurgshaarna Shanmugavadivel et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Objective. To determine the common presenting problems for young people attending the emergency department. Design. Aretrospective review of electronic patient records of all young people between the ages of 13 and 17 who attended a UK UniversityHospital ED between 07/02/2007 and 06/02/2008 (𝑛 = 10455). Results. All emergency department attendances for young peopleover a one-year periodwere studied in order to determine the commonpresenting problems.Therewere a total of 10455 attendancesby 8303 young people.The presenting problem in 7505 (71.8%) was classified as injury. Of the remainder the commonest presentingproblems reported for young people were abdominal pain (480, 16.3%), self-harm (314, 10.6%), fits, faints and funny turns (308,10.4%), breathing difficulty (213, 7.2%), and intoxication (178, 6.0%). Ten presenting problems accounted for 72% of noninjuryrelated attendances.Conclusions. Clinical guidelines andpathways developed for youngpeople attending the emergency departmentshould target the commonest presenting problems. In our cohort ten presenting problems account for almost three-quarters of allnoninjury attendances for young people. The presenting problems are different to those described in younger children in previousstudies. These results will inform the development of clinical pathways in order to improve emergency care.

1. Introduction

Adolescence is commonly regarded as a healthy period oflife and consequently there is a paucity of data regardingthe health of young people and how they access healthcare[1]. Paradoxically young people are especially vulnerableto health problems related to injury, suicide, pregnancy,substance misuse, and long term conditions. Young peoplerepresent a significant proportion of the population and thisproportion is increasing, especially in the ethnic minoritygroups [2, 3]. The number of emergency admissions in olderadolescents has risen steadily since the mid-1990s whilstadmissions for younger children have fallen in recent years[3]. There is limited published English data on the reasonsfor young people being admitted to hospital, the reasonsthey attend hospital services, or healthcare utilisation ingeneral [1].

Armon et al. carried out the first study in the UK lookingat the common paediatric presentations to the emergencydepartment. They identified that high quality data regardingpaediatric attendances is required in order to plan services[4]. Their data informed the development of a number ofpresenting problem based guidelines, which were derivedfrom best evidence, and have been shown to improve thequality of clinical care [4–7].

A search of the literature using Medline revealed nostudies looking at the presenting complaints of young peopleto the emergency department. In this study we aim todescribe the patterns of presenting problems to the emer-gency department of young people aged 13–17 years old,with the objective that the results will assist in planning anddeveloping clinical pathways and health services for youngpeople.

Hindawi Publishing CorporationAdvances in Emergency MedicineVolume 2014, Article ID 536080, 5 pageshttp://dx.doi.org/10.1155/2014/536080

2 Advances in Emergency Medicine

2. Patients and Methods

The study was undertaken in the emergency department atthe Queen’s Medical Centre, Nottingham, which providesemergency care to the population of Nottingham City andsurrounding localities. The population of Nottinghamshireconsists of around 785,800 people of which approximately93,000 are children aged 10–19 years [2]. The emergencydepartment at Queen’s Medical Centre sees approximately120,000 cases per year. Young people are usually seen ina separate paediatric area along with children althoughsome older adolescents may be seen in the adult section ofthe emergency department. Almost all young people withan acute presentation, irrespective of referral source, areinitially triaged in the emergency department; however, asmall number of young people with long term conditionsrequiring highly specialist paediatric care (including thoseat high risk of infection because of immune deficiencyor suppression) may be admitted directly to a specialistward area. For the study, patients were identified using theelectronic patient record and clinical information system(EDIS), iSOFT. Information regarding demographics, time,and source of referral is inputted by reception staff along withpresenting complaint based on report by parent or patient.Information regarding diagnosis and disposal is inputtedby emergency department medical and nursing staff. Weobtained data on all patients aged between 13 years 0 daysand 17 years 364 days who had attended between 00.01hours on 07/02/2007 and 23.59 hours on 06/02/2008. Patientswere classified using demographics and presenting problem.Additional information regarding route of referral, date andtime of attendance, and eventual outcome was all reviewed.The presenting problem was determined from informationentered into EDIS by the emergency department staff at timeof presentation.Where presenting problem was unclear fromthe EDIS system, the diagnosis was reviewed. If it was stillunclear, then the full emergency department patient recordwas examined.

Descriptive statistics including measurements of propor-tion and rank were applied to the data collected.

3. Results

There were a total of 10455 attendances by 8303 young peopleaged 13–17 years to the emergency department during thestudy year. The male to female ratio was 1.4 to 1 (58% males,42% females). The age distribution of the attendees is showninTable 1.Thenumbers ofmale attendeeswere similar in eachage group but there was a rising trend of female attendancesas they got older. The age and sex distribution is shown inFigure 1.

Injury was the most common presenting problemaccounting for 7505 (71.8%) of attendances. Excluding injury,presenting problems could be categorised into fourteenpresenting complaints and one further category, described as“Other” (𝑛 = 552), which comprises a variety of presentingproblems each with a frequency of less than 45 cases peryear. After excluding the “Other” category 72% medicalattendances to the emergency department can be accounted

Table 1: Age distribution of medical attendees.

Age 𝑛 (%)13 years 2022 (19.3)14 years 2056 (19.7)15 years 2105 (20.1)16 years 2026 (19.4)17 years 2246 (21.5)

1400

1200

1000

800

600

400

200

0

13 14 15 16 17

AgeN

umbe

r

Age of young people attending ED

FM

Figure 1: Age and sex of young people attending the emergencydepartment.

for by ten most common presenting problems, with the topthree (abdominal pain (480, 16.3%), self-harm (314, 10.6%),and fits, faints, and funny turns (308, 10.4%)) comprising37.3% of the attendances. Table 2 shows the numbers and rankorder for each presenting problem.

3.1. Referral and Attendance Patterns. Of the young peopleseen in the emergency department, 5333 (51%)were “walk-in”self-referrals attending without a parent/guardian and 2378(23%) were brought in by a parent/guardian with 1085 (10%)attending by ambulance. Only 317 (3%) were referred by GP,434 (4.2%) by school, and 23 (0.2%) referred by NottinghamEmergency Services Out-of-Hours Service (NEMS). Anothersmall group had been referred by theNHSwalk-in centre (98,0.9%) or by NHS direct (182, 1.7%).The sources of referral forattendees are presented in Table 3. The proportions of self-referrals were similar in the injury and noninjury groups witharound half of the young people self-referring.

The vast majority (𝑛 = 8888, 85%) of young peopleattended between 12:00 and 00:00. There was no particularseasonal variation in number of attendances.Most (𝑛 = 6623,80%) of young people attended just once to the emergencydepartment in the study year. A small but important number(𝑛 = 390, 4.7%) attended on more than three occasionsin the twelve-month study period. The highest number ofattendances by a single individual was 21.

With regard to eventual outcome 7849 (75%) were dis-charged from the department, 12% were admitted, and 6%received a clinic appointment, the majority of which were for

Advances in Emergency Medicine 3

Table 2: Presenting problems of medical attendees aged 13–17 years.

Presenting problem 𝑛 (%) RankAbdominal pain 480 (16.3) 1Self-harm 314 (10.6) 2Fits, faints, and funny turns 308 (10.4) 3Breathing difficulty 213 (7.2) 4Intoxication 178 (6.0) 5ENT problem 145 (5) 6Pregnancy related problem 144 (5) 7Chest pain 129 (4) 8Headache 120 (4) 9Allergic reaction 106 (4) 10Diarrhoea +/− vomiting 94 (3) 11Rash 63 (2) 12Febrile illness 53 (2) 13Swollen/painful limb 51 (2) 14

Table 3: Source of referrals of all attendees.

Source 𝑛 (%)Self 5333 (51.0)Parent/guardian 2378 (22.7)Ambulance/999 1085 (10.4)School 434 (4.2)General practice 317 (3.0)NHS direct 182 (1.7)Advised by medical staff 158 (1.5)Walk-in centre 98 (0.9)Other hospitals 89 (0.9)NEMS 23 (0.2)Other/unknown 358 (3.4)

fracture clinic. A further 6% either did not wait or refusedtreatment.

4. Discussion

We have outlined the common presenting problems of youngpeople to a large emergency department located within auniversity teaching hospital in England. Whilst we cannotmake a direct comparison to the cohort studied by Armonet al. owing to an overlap in age groups, it is clear that ourdata describes a different range of presenting complaints foryoung people when compared to younger children. This newdata can be used to inform the development of acute andemergency care pathways specifically aimed at the needs ofyoung people and their families.

The results of this study provide a broad brushstroke viewof how and when young people present to the emergencydepartment and their primary presenting problem. Althoughit is a retrospective study, all the data was inputted prospec-tively at the time of presentation. One potential weakness ofthe study is heterogeneity in the accuracy of the data inputtedby the emergency department reception staff at the timeof presentation. Another potential weakness is that this is

a single centre study; nevertheless the emergency departmentstudied is a large trauma centre in a medium sized UK city.We believe that this data will be useful to other emergencydepartments in the country. Another limitation is the agegroup studied (13–17 years) as this does not cover the broaderpopulation of adolescents defined by WHO as 10–19 yearolds. This study followed on from a previous project in ourdepartment looking at “teenagers” which used the 13–17 yeargroup. Another potential weakness is the lack of standardisedage banding for data on children and young people. Therecent report from the Children and Young People’s OutcomeForum suggested that data presentation for children andyoung people be standardised into five-year age bandings[8]. If this recommendation is widely adopted it may affectthe comparability of our results with future studies; howeverour results still provide a useful snapshot view of emergencyhealthcare utilisation by young people of secondary schoolage. Our study lacked a direct comparison group and wehope to address this when we repeat this study ten years onusing standardised 5-year age bands to provide comparatorsbetween age groupings. We also acknowledge that there is atime lag as the data collected is from 2007 to 2008. Whilst itmay be argued that presentations may have changed in thelast 5 years, looking at our recent 10-year follow-up study oncommon medical presentations to the paediatric emergencydepartment, we found there were no differences in whatchildren presented with ten years on, only differences inproportions [9].

Our results challenge some myths regarding young peo-ple’s emergency department use, in particular the time of dayat which they present and the assumption that many adoles-cents patients are repeat attenders. It highlights interestingpatterns for further exploration especially the increasingnumber of female attendees as a proportion of the totalwith increasing age and the absence of seasonal variation inattendances seen in younger children.

We have also shown that the majority of young people(51%) refer themselves to the emergency department; only3% were referred by their GP. Looking at the patterns ofreferral source therewas no difference between the injury andnoninjury group. Whilst we would expect young people withinjuries to refer themselves to the emergency department, itis interesting to see that similar numbers of young peoplewithmedical presentations self-refer.There aremany possibleexplanations for this which our study was not designed toanswer. We know that the trend in health seeking behaviourover the past decade is moving towards emergency care[10, 11]. There are many potential barriers to young peopleaccessing primary care including the lack of 24-hour accessand concerns about breeches of confidentiality when their GPalso provides healthcare for the rest of their family. Attendingthe emergency department may help them overcome thesecommonly reported barriers to accessing healthcare. Ourdata along with Sir Ian Kennedy’s report highlights the needto focus on access to acute services for young people in linewith the “You’re Welcome” guidance [11, 12].

Injuries, intoxication, pregnancy related problems, andvulnerability to self-harm are well-characterised health issuesaffecting young people in the ED [9, 13]. We now know

4 Advances in Emergency Medicine

that abdominal pain, fits, and breathing difficulty are the topmedical problems with chest pains, headaches, ENT prob-lems, and reaction/allergies amongst the top ten presentingproblems.Guidelines, pathways, and training should focus onthese areas as they represent a distinct pattern of presentingproblems when compared to young children.

5. Conclusion

We describe the most common adolescent health problemspresenting to the emergency department and whilst injury isby far the most common reason for attendance, ten problemsaccount for three-quarters of noninjury attendances. Ourstudy also highlights that young people often self-refer foremergency and acute care.

6. Article Summary

6.1. Article Focus

(i) What do young people present with to the emergencydepartment?

(ii) Are their presentations different to those of youngchildren?

6.2. Key Messages

(i) This study demonstrates that young people presentwith different health problems than younger children.

(ii) 75% of attendances relate to just ten presenting prob-lems, the top medical presentations being abdominalpain, fits, and breathing difficulty.

(iii) This data will help to develop guidelines, clinicalpathways, and training programmes for healthcareprofessionals to ensure we are in line with recentguidance from the Department of Health, QualityCriteria for Young People Friendly Services.

6.3. Strengths and Limitations

(i) This study looked not only at medical presentationsbut also surgical presentations and injuries with adataset spanning one year.

(ii) It lacked a direct comparison group; however, stillprovides useful information on presentations whichare clearly different to those of younger children.

Ethical Approval

Ethical approval was not required.

Conflict of Interests

We have all completed the unified competing interest formand declare that there are no competing interests. There wasno support from any organisation for the submitted work,no financial relationships with any organisations that might

have an interest in the submitted work in the previous threeyears and there are no other relationships or activities thathave influenced the paper.

Authors’ Contribution

Damian Wood and Rebecca Sands contributed to the plan-ning of the project and project design. Dhurgshaarna Shan-mugavadivel, Damian Wood, and Rebecca Sands collectedthe data, analysed the data, and drafted this paper together.Dhurgshaarna Shanmugavadivel as corresponding author isresponsible for the content of the paper and overall guarantor.

Acknowledgment

The authors would like to thank all the staff in the emergencydepartment for all their work in inputting data on a daily basisonto EDIS.

References

[1] M. D. Resnick, R. F. Catalano, S. M. Sawyer, R. Viner, and G.C. Patton, “Seizing the opportunities of adolescent health,”TheLancet, vol. 379, no. 9826, pp. 1564–1567, 2012.

[2] “Office of National Statistics,” Census Data, 2011.[3] J. Coleman, F. Brooks, and P. Threadgold, Key Data on Adoles-

cence, 2011.[4] K. Armon, T. Stephenson, V. Gabriel et al., “Determining

the common medical presenting problems to an accident andemergency department,” Archives of Disease in Childhood, vol.84, no. 5, pp. 390–392, 2001.

[5] K. Armon, T. Stephenson, R. MacFaul, P. Eccleston, and U.Werneke, “An evidence and consensus based guideline for acutediarrhoea management,” Archives of Disease in Childhood, vol.85, no. 2, pp. 132–141, 2001.

[6] K. Armon, T. Stephenson, R. MacFaul, P. Hemingway, U.Werneke, and S. Smith, “An evidence and consensus basedguideline for the management of a child after a seizure,”Emergency Medicine Journal, vol. 20, no. 1, pp. 13–20, 2003.

[7] K. Armon, R. MacFaul, P. Hemingway, U. Werneke, and T.Stephenson, “The impact of presenting problem based guide-lines for children with medical problems in an accident andemergency department,” Archives of Disease in Childhood, vol.89, no. 2, pp. 159–164, 2004.

[8] K. Hawton, K. Rodham, E. Evans, and R. Weatherall, “Delib-erate self harm in adolescents: self report survey in schools inEngland,” British Medical Journal, vol. 325, no. 7374, pp. 1207–1211, 2002.

[9] R. Sands, D. Shanmugavadivel, T. Stephenson, and D. Wood,“Medical problems presenting to paediatric emergency depart-ments: 10 Years on,” Emergency Medicine Journal, vol. 29, no. 5,pp. 379–382, 2012.

[10] RCPCH, Not Just a Phase—A Guide to the Participation ofChildren and Young People in Health Services, 2010.

[11] I. Kennedy, “Getting it right for children and young peo-ple. Overcoming cultural Barriers in the NHS so as toMeet their Need. London, UK, Department of Health,” 2010,http://www.dh.gov.uk.

Advances in Emergency Medicine 5

[12] D. Wilkinson and A. J. Robinson, “You’re Welcome quality cri-teria: making health services young-people-friendly,” SexuallyTransmitted Infections, vol. 85, no. 3, pp. 233–234, 2009.

[13] “Department of Health,” Report of the Children and YoungPeople’s Outcomes Forum, 2012.

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