Common Presenting Problems for Young People Attending the Emergency Department

Objective. To determine the common presenting problems for young people attending the emergency department. Design. A retrospective review of electronic patient records of all young people between the ages of 13 and 17 who attended a UK University Hospital ED between 07/02/2007 and 06/02/2008 (n = 10455). Results. All emergency department attendances for young people over a one-year periodwere studied in order to determine the commonpresenting problems.Therewere a total of 10455 attendances by 8303 young people.The presenting problem in 7505 (71.8%) was classified as injury. Of the remainder the commonest presenting problems 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 noninjury related attendances.Conclusions. Clinical guidelines andpathways developed for youngpeople attending the emergency department should target the commonest presenting problems. In our cohort ten presenting problems account for almost three-quarters of all noninjury attendances for young people. The presenting problems are different to those described in younger children in previous studies. These results will inform the development of clinical pathways in order to improve emergency care.


Introduction
Adolescence is commonly regarded as a healthy period of life and consequently there is a paucity of data regarding the health of young people and how they access healthcare [1].Paradoxically young people are especially vulnerable to health problems related to injury, suicide, pregnancy, substance misuse, and long term conditions.Young people represent a significant proportion of the population and this proportion is increasing, especially in the ethnic minority groups [2,3].The number of emergency admissions in older adolescents has risen steadily since the mid-1990s whilst admissions for younger children have fallen in recent years [3].There is limited published English data on the reasons for young people being admitted to hospital, the reasons they attend hospital services, or healthcare utilisation in general [1].
Armon et al. carried out the first study in the UK looking at the common paediatric presentations to the emergency department.They identified that high quality data regarding paediatric attendances is required in order to plan services [4].Their data informed the development of a number of presenting problem based guidelines, which were derived from best evidence, and have been shown to improve the quality of clinical care [4][5][6][7].
A search of the literature using Medline revealed no studies looking at the presenting complaints of young people to the emergency department.In this study we aim to describe the patterns of presenting problems to the emergency department of young people aged 13-17 years old, with the objective that the results will assist in planning and developing clinical pathways and health services for young people.

Patients and Methods
The study was undertaken in the emergency department at the Queen's Medical Centre, Nottingham, which provides emergency care to the population of Nottingham City and surrounding localities.The population of Nottinghamshire consists of around 785,800 people of which approximately 93,000 are children aged 10-19 years [2].The emergency department at Queen's Medical Centre sees approximately 120,000 cases per year.Young people are usually seen in a separate paediatric area along with children although some older adolescents may be seen in the adult section of the emergency department.Almost all young people with an acute presentation, irrespective of referral source, are initially triaged in the emergency department; however, a small number of young people with long term conditions requiring highly specialist paediatric care (including those at high risk of infection because of immune deficiency or suppression) may be admitted directly to a specialist ward area.For the study, patients were identified using the electronic patient record and clinical information system (EDIS), iSOFT.Information regarding demographics, time, and source of referral is inputted by reception staff along with presenting complaint based on report by parent or patient.Information regarding diagnosis and disposal is inputted by emergency department medical and nursing staff.We obtained data on all patients aged between 13 years 0 days and 17 years 364 days who had attended between 00.01 hours on 07/02/2007 and 23.59 hours on 06/02/2008.Patients were classified using demographics and presenting problem.Additional information regarding route of referral, date and time of attendance, and eventual outcome was all reviewed.The presenting problem was determined from information entered into EDIS by the emergency department staff at time of presentation.Where presenting problem was unclear from the EDIS system, the diagnosis was reviewed.If it was still unclear, then the full emergency department patient record was examined.
Descriptive statistics including measurements of proportion and rank were applied to the data collected.

Results
There were a total of 10455 attendances by 8303 young people aged 13-17 years to the emergency department during the study year.The male to female ratio was 1.4 to 1 (58% males, 42% females).The age distribution of the attendees is shown in Table 1.The numbers of male attendees were similar in each age group but there was a rising trend of female attendances as they got older.The age and sex distribution is shown in Figure 1.
Injury was the most common presenting problem accounting for 7505 (71.8%) of attendances.Excluding injury, presenting problems could be categorised into fourteen presenting complaints and one further category, described as "Other" ( = 552), which comprises a variety of presenting problems each with a frequency of less than 45 cases per year.After excluding the "Other" category 72% medical attendances to the emergency department can be accounted for by ten most common presenting problems, with the top three (abdominal pain (480, 16.3%), self-harm (314, 10.6%), and fits, faints, and funny turns (308, 10.4%)) comprising 37.3% of the attendances.Table 2 shows the numbers and rank order for each presenting problem.

Referral and Attendance Patterns.
Of the young people seen 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 Nottingham Emergency Services Out-of-Hours Service (NEMS).Another small group had been referred by the NHS walk-in centre (98, 0.9%) or by NHS direct (182, 1.7%).The sources of referral for attendees are presented in Table 3.The proportions of selfreferrals were similar in the injury and noninjury groups with around half of the young people self-referring.
The vast majority ( = 8888, 85%) of young people attended between 12:00 and 00:00.There was no particular seasonal variation in number of attendances.Most ( = 6623, 80%) of young people attended just once to the emergency department in the study year.A small but important number ( = 390, 4.7%) attended on more than three occasions in the twelve-month study period.The highest number of attendances by a single individual was 21.
With regard to eventual outcome 7849 (75%) were discharged from the department, 12% were admitted, and 6% received a clinic appointment, the majority of which were for

Discussion
We have outlined the common presenting problems of young people to a large emergency department located within a university teaching hospital in England.Whilst we cannot make a direct comparison to the cohort studied by Armon et al. owing to an overlap in age groups, it is clear that our data describes a different range of presenting complaints for young people when compared to younger children.This new data can be used to inform the development of acute and emergency care pathways specifically aimed at the needs of young people and their families.
The results of this study provide a broad brushstroke view of how and when young people present to the emergency department and their primary presenting problem.Although it is a retrospective study, all the data was inputted prospectively at the time of presentation.One potential weakness of the study is heterogeneity in the accuracy of the data inputted by the emergency department reception staff at the time of presentation.Another potential weakness is that this is a single centre study; nevertheless the emergency department studied is a large trauma centre in a medium sized UK city.We believe that this data will be useful to other emergency departments in the country.Another limitation is the age group studied (13-17 years) as this does not cover the broader population of adolescents defined by WHO as 10-19 year olds.This study followed on from a previous project in our department looking at "teenagers" which used the 13-17 year group.Another potential weakness is the lack of standardised age banding for data on children and young people.The recent report from the Children and Young People's Outcome Forum suggested that data presentation for children and young people be standardised into five-year age bandings [8].If this recommendation is widely adopted it may affect the comparability of our results with future studies; however our results still provide a useful snapshot view of emergency healthcare utilisation by young people of secondary school age.Our study lacked a direct comparison group and we hope to address this when we repeat this study ten years on using standardised 5-year age bands to provide comparators between age groupings.We also acknowledge that there is a time lag as the data collected is from 2007 to 2008.Whilst it may be argued that presentations may have changed in the last 5 years, looking at our recent 10-year follow-up study on common medical presentations to the paediatric emergency department, we found there were no differences in what children presented with ten years on, only differences in proportions [9].
Our results challenge some myths regarding young people's emergency department use, in particular the time of day at which they present and the assumption that many adolescents patients are repeat attenders.It highlights interesting patterns for further exploration especially the increasing number of female attendees as a proportion of the total with increasing age and the absence of seasonal variation in attendances seen in younger children.
We have also shown that the majority of young people (51%) refer themselves to the emergency department; only 3% were referred by their GP.Looking at the patterns of referral source there was no difference between the injury and noninjury group.Whilst we would expect young people with injuries to refer themselves to the emergency department, it is interesting to see that similar numbers of young people with medical presentations self-refer.There are many possible explanations for this which our study was not designed to answer.We know that the trend in health seeking behaviour over the past decade is moving towards emergency care [10,11].There are many potential barriers to young people accessing primary care including the lack of 24-hour access and concerns about breeches of confidentiality when their GP also provides healthcare for the rest of their family.Attending the emergency department may help them overcome these commonly reported barriers to accessing healthcare.Our data along with Sir Ian Kennedy's report highlights the need to focus on access to acute services for young people in line with the "You're Welcome" guidance [11,12].
Injuries, intoxication, pregnancy related problems, and vulnerability to self-harm are well-characterised health issues affecting young people in the ED [9,13].We now know that abdominal pain, fits, and breathing difficulty are the top medical problems with chest pains, headaches, ENT problems, and reaction/allergies amongst the top ten presenting problems.Guidelines, pathways, and training should focus on these areas as they represent a distinct pattern of presenting problems when compared to young children.

Conclusion
We describe the most common adolescent health problems presenting to the emergency department and whilst injury is by far the most common reason for attendance, ten problems account for three-quarters of noninjury attendances.Our study also highlights that young people often self-refer for emergency and acute care.

Article Focus
(i) What do young people present with to the emergency department?(ii) Are their presentations different to those of young children?

Key Messages
(i) This study demonstrates that young people present with different health problems than younger children.(ii) 75% of attendances relate to just ten presenting problems, the top medical presentations being abdominal pain, fits, and breathing difficulty.(iii) This data will help to develop guidelines, clinical pathways, and training programmes for healthcare professionals to ensure we are in line with recent guidance from the Department of Health, Quality Criteria for Young People Friendly Services.

Strengths and Limitations
(i) This study looked not only at medical presentations but also surgical presentations and injuries with a dataset spanning one year.(ii) It lacked a direct comparison group; however, still provides useful information on presentations which are clearly different to those of younger children.

Table 1 :
Age distribution of medical attendees.

Table 3 :
Source of referrals of all attendees.