What nurses need to know to care for young adult patients in EDs
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What nurses need to know to care for young adult patients in EDs

Norman Miller Health journalist

Adolescents or young adults who need emergency care fall through a services gap, and end up in paediatric or adult emergency departments

When an adolescent or young adult patient needs emergency care, they will be taken to either a paediatric or adult emergency department (ED) – neither of which is likely to be ideally equipped to meet their needs.

Emergency Nurse. 31, 5, 7-8. doi: 10.7748/en.31.5.7.s5

Published: 05 September 2023


Picture credit: iStock

The Royal College of Emergency Medicine (RCEM), which defines adolescents and young adults as being between 12 and 25 years, says many in the age group are ‘falling through the gap between the two services’.

An RCEM report states that patients can find the differences between paediatric and adult care to be ‘extreme’, and says that the situation is not acceptable.

Consultant nurse child and adolescent mental health specialist Kate Golding, who has worked in EDs as well as child and adolescent mental health services (CAMHS), says: ‘The hospital environment can be overwhelming for adolescents, exacerbated by their possible emotional dysregulation.’

It leaves healthcare professionals in a difficult situation. Ashleigh Lowther, advanced clinical practitioner (adult and paediatric emergency medicine) at Portsmouth Hospitals NHS Trust as well as RCEM Advanced Care Practitioner Forum chair, says: ‘There is sometimes no defined pathway for those aged 16 and 17, and you may find yourself referring to an adult service that you know is not fit for purpose for this age group.’

‘Policies are valuable, but more designated service provision and additional training to support this age group is vital’

Carly Snowdon, trainee advanced clinical practitioner (paediatric emergency medicine)

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.

Benefits of a bespoke policy for young adults aged 16-19

The authors of a Royal College of Emergency Medicine report say they would strongly advocate for a bespoke policy for young adults aged between 16 and 19, within the broader group between 12 and 25.

Trainee advanced clinical practitioner (paediatric emergency medicine) Carly Snowdon says: ‘Many departments already have bespoke policies that are of great benefit – but that shouldn’t take away from advocating for individuals.

‘They should ensure they cover the diverse needs this age group requires, with room for flexibility. Policies are valuable, but more designated service provision and additional training to support this age group is vital.’

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.

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