Mortality rates

The RCEM report shows that adolescent patients are the only age group whose mortality rate is increasing in the UK, and highlights long-term gains from providing optimal care for this group.

It says adolescents and young adults are likely to have many years ahead of them when they may consult health services, ‘so dealing with them in a positive way will optimise this now and for future dealings’.

Portsmouth Hospitals NHS Trust trainee advanced clinical practitioner (paediatric emergency medicine) Carly Snowdon says: ‘Nurses can improve the experience by remaining nonjudgemental, and advocating for the best interests of their adolescent patients.

‘Treating each as an individual also helps them to feel more seen and less alienated.’

While the present system persists, there are small adaptations that can be made in EDs to make the experience easier for adolescents and young adults.

Ms Snowdon says: ‘Be as least restrictive as possible, within the bounds of patient safety and best interests. For example, facilitating the ability to go outside to de-escalate frustration, when this is practical.’

Ms Golding says EDs should have ‘a quiet, designated room which is well-designed, safe, with muted colours and activities to distract or calm’ and suggests providing self-help information on sleep, diet, exercise, hobbies and relationships.

What is the best training for nurses caring for adolescent people?

Emergency department nurses should ideally be trained to Level 3 Child Safeguarding if their department sees children, says Royal College of Emergency Medicine Advanced Care Practitioner Forum chair Ashleigh Lowther (pictured).

She says: ‘Also know who your trust’s child safeguarding lead is, and how you can access locally arranged training.’

Trainee advanced clinical practitioner (paediatric emergency medicine) Carly Snowdon, who like Ms Lowther works at Portsmouth Hospitals NHS Trust, says: ‘Becoming a mental health awareness advocate is very useful training to put yourself in the shoes of the patients.

‘Child and adolescent mental health services also run spotlight sessions which can be accessed for free.’

Psychosocial assessment

Carrying out a psychosocial assessment is also an important tool in providing the most appropriate care for adolescents in EDs.

One internationally recognised tool is the HEEADSSS assessment, taking in home, education/employment, activities, drugs, sex and relationships, self-harm and depression, safety and abuse. The assessment starts with simple questions about a patient’s life to allow a rapport to develop, before delving into more personal and possibly sensitive areas.

Ms Snowdon says: ‘Psychosocial assessment is vital to delivering holistic care in a period of life when parents can be unaware of aspects of their child’s life.

‘They are also at increased risk of sexual abuse, radicalisation, involvement in county lines etc. Checking in with the adolescent to ensure they are safe and providing nonjudgemental health promotion and health education can be vital at this crucial time.’

Ms Lowther says: ‘Many EDs have specific organisations that can help with accessing community support. This could be life-changing for an older adolescent, who may be an adult in the eyes of the law.’

She says ED staff should feel comfortable in referring to children’s social services and CAMHS teams.

Liaison services

Ms Snowdon says: ‘CAMHS are making good inroads to bridging the gap between hospital and community care with in-hospital liaison services linking acute care to ongoing care. But it is important to remember that their services are as overwhelmed as ours.’

She says ED staff must also be vigilant for potential safeguarding issues. ‘Referrals should be made for any presentation where harm has been caused to the patient – either self-inflicted or perpetrated by an assailant – or if the mechanism of injury does not fit the history that they have given.’

For a host of reasons, some young patients may refuse treatment. The reasons might include panic about finding themselves in the ED, fear based on a lack of understanding around treatment or just adolescent rebelliousness around not wanting to conform to what adults suggest.

According to Ms Lowther, refusal of treatment can be a particularly tricky issue when caring for adolescents and young adults. ‘The issue of paediatric versus adult consent is a whole separate article on its own – for example, while the legal age of consent in England is 16, anyone under 18 is considered a child,’ Ms Lowther says.

‘It is good practice to assume competence in all of these patients – but if you need to fully assess the capacity then it should be done using the four-stage capacity assessment. My main advice is to get senior help early. These decisions are ones to be made by a senior team, and with as much help and guidance as is required.’

Ms Snowdon says: ‘Your next steps depend on what treatment they are refusing. Is it necessary? Can it be adapted to something they will agree to? Consider the severity of consequences if the treatment is not administered.

‘If refusal of treatment may lead to their death or a severe permanent injury, their decision can be overruled by the Court of Protection, which oversees the operation of the Mental Capacity Act.

Find out more

Royal College of Emergency Medicine (2023) Management of Adolescent/Young Adult (AYA) Patients in the Emergency Department.