Adolescents and young adults on the acute medical unit: how might we do it better?

How do YAAs present to the AMU?

There is a lack of precision in the epidemiological data with regard to acute presentations in 15–30 year olds. However, a number of patterns of presentation are reasonably clear:

• new presentations of acute disease – particularly gastrointestinal, endocrine and respiratory illnesses²

• new presentations of chronic disease – 25% of cancer diagnoses now occur in the acute setting⁹

• as a result of risk-taking behaviour, including drug and substance abuse, self-harm and unsafe sex⁸

• less frequent presentations of patients with chronic, complex disease, experiencing either exacerbations of disease or other intercurrent illnesses, including patients with ‘paediatric’ conditions, such as cystic fibrosis, transitioning into adult care⁷

• patients with severe and complex disabilities.⁸

The differences in patterns between YAAs and other age groups are partially explained by their strong preference for using acute services rather than seeing a general practitioner.¹⁰

YAAs and the AMU: challenges

Caring for adolescents and young adults presents unique challenges in the AMU setting, due to their distinct biological and psychological profiles. YAAs are very different from both children aged <15 and adults aged >25. Between the ages of 15 and 20, the process of physiological maturation is still being completed, with continuing endocrine changes and fluctuating hormonal drives. Complex neuropsychological changes are ongoing with, for example, the maturation of the prefrontal cortex; this is involved in inhibitory control, planning and decision-making, and is not completed until late in the third decade, meaning that YAAs may react differently from older adults or children in any given situation.¹¹ YAAs can also be considered culturally distinct, with their own rules for social interaction, and different interpretations from adults, particularly for subconscious aspects of communication, such as dress, eye contact, body language, and tone and pitch of voice.¹² The physical, emotional and cultural aspects of maturation also do not necessarily proceed at the same rate, with levels of physical maturation often outstripping emotional and/or social maturation, particularly in males.

These complex developmental changes may impact directly on presentations of illness. Not only are YAAs more likely to present with illnesses and consequences of risk-seeking behaviour, but those with chronic illnesses are less likely to adhere to treatment regimens and disengage from medical care.¹³ This is reflected by the fact that the mortality for patients after renal transplantation is higher in 18–25 year olds than any other group,¹⁴ with similar findings for patients with diabetes mellitus aged 15–35.¹⁵

The AMU setting also poses distinct challenges. In the first instance, there is no universal agreement on what the division between ‘paediatric’ and ‘adult’ care is or should be. This results in a lack of uniformity not only between hospitals, but also between departments within hospitals. For example, a patient seen in a paediatric A&E catering for YAAs aged up to 18 may be admitted to an adult ward if the threshold for a paediatric admission is 16 years. Decisions about the most appropriate bed location should take into account a patient's physical and emotional maturation, as well his or her medical needs, but these may not be clear or well understood at the time of admission. Services, such as Childhood and Adolescent Mental Health Services (CAMHSs), may be available in A&E, but not on the ward. These issues around boundaries of care can lead to discontinuity, fragmentation and delays in care at a time of high medical risk and marked family stress.

The physical environment of the AMU can also be problematic. YAAs value privacy highly, and have a strong preference for personal bathrooms, which are usually in short supply. YAAs also frequently cite the lack of communal space and restricted access to mobile phones and the internet as key problems.¹⁶ They often have different sleep patterns from adults, which can make the routine of the ward challenging.¹⁷ AMUs also often have problems providing overnight accommodation for parents and carers for YAAs with chronic/complex needs, which can be a source of frustration.

Staff in the acute setting often feel that they lack the skills to deal properly with YAAs and this is reflected in the reporting of their symptoms, particularly pain, being much less well managed than in adults.^3,18 Medical staff report being less confident, not only in caring for unfamiliar conditions, but also in dealing with ‘adult’ conditions, such as inflammatory bowel disease, in younger patients.¹⁹ Nurses report feeling poorly prepared to deal with patients with complex needs²⁰ and to cope with patients who may have multiple social issues and exhibit challenging or disruptive behaviour on the ward.²¹

Both staff and YAA patients alike report problems with communication in the acute setting. Studies have found that a significant proportion of doctors feel uncomfortable talking to young people.¹² YAAs are more likely to report lower scores than other adults for being treated with respect and dignity, and rate the skills/attitudes of their doctors less highly. This is especially true of younger females.³ This may be attributed, in part, to YAAs reacting more emotionally and less rationally than adults in a similar situation, as well as a lack of staff training in appropriate communication skills.

These issues are all highlighted in patients with chronic conditions who are ‘transitioning’ from paediatric to adult care.²² Where previously their care will have been provided by a stable team with whom they had a long-term relationship, they may be confronted by staff who not only are unknown to them, but may have limited experience in managing their condition. Pathways for care that were previously clear may need renegotiation, with resulting confusion and frustration.

National policy on YAAs

The comparatively poor outcomes for YAAs have increasingly been recognised at the national level.^4,7 Not only has the need for better transition of YAAs with chronic or complex conditions from paediatric services been highlighted, but it is recognised that all YAAs should be receiving better and more appropriate care, regardless of the setting. This is reflected in commissioners incorporating ideal standards of care specifically for YAAs within specialist services, such as the Diabetes Best Practice Tariff. More generally, the Department of Health published the You’re Welcome quality criteria in 2011.²³ These have since been endorsed by the World Health Organization. The domains (Table 1) contain recommendations that may be challenging for AMUs, but are likely to be co-opted into standards for YAA care and used to support negotiations with commissioning bodies. The Royal College of Physicians also recently released a position statement on the care of YAAs (Box 1).

Box 1. RCP's position statement on the care of adolescent and young adult patients

Ideal solutions

Adolescent units have been suggested as the gold standard in caring for adolescents and younger adults (14–19 year olds). Although seemingly suitable for only larger institutions, calculations have found that any hospital with a minimum catchment of 50,000 people would have sufficient numbers of patients to support a 12-bedded adolescent unit.²⁴ Co-design projects with YAA contributors favour a combination of four-bed and single rooms, adequate bathroom facilities, and a room for socialising and leisure activities. Staff on adolescent units should receive specialised training and, crucially, have a CAMHS worker on-site each day. Models of consultant cover and responsibility vary, but these could include ‘shared care’ arrangements, with acute physicians providing input as appropriate. There is little doubt that such units improve patient experience – although only about 10% of YAAs receive care on such units, patients report receiving much better care than in either child or adult settings.²⁵

Where adolescent units are not feasible, some of this gap could potentially be filled by a young persons team. As a minimum, this could consist of a lead nurse and CAMHS or mental health liaison workers, but could also include or link with: nurse specialists in learning disabilities, and substance misuse or sexual health; physiotherapists; social workers; and nutritionists. As well as providing stable outpatient services, these teams are able to support acute admissions by ensuring that the environment is as suitable as possible, supporting staff with training, and providing some degree of continuity of care when the patient is transferred to another team or is discharged.

Practical tips for the AMU

Although redesigning services specifically to accommodate YAAs might seem onerous and expensive, there is still much that can be done quickly and easily to improve the care that adolescents and young adults receive on AMUs. Aspects of care that might be rapidly addressed include:

• having clear pathways for the acute care of those aged between 14 and 19 years. This will require discussion by A&E, the AMU and paediatric services to locally agree chronological and/or developmental criteria for the place of inpatient care

• being aware of the support services available for YAAs. This should include pathways of referral to CAHMS, if available

• appointing a lead clinician and lead nurse to act as champions, ensuring that the needs of YAAs are considered in all aspects of AMU design/operation/training

• ensuring that patient information leaflets are appropriate for younger patients, as well as providing leaflets on accessing age-appropriate health support services

• policies covering visits and/or accommodation of patients and carers should be reviewed and revised with younger patients with complex needs in mind

• ensuring that young patients have adequate pain relief.

Staff should receive basic training on communicating with younger patients. Tips for improving communication are outlined in Box 2.

Box 2. Tips for dealing with young adults and adolescents

Bridging the gap between paediatric and adult services

Establishing better relationships between the AMU and paediatric services could also make an immediate and concrete difference to patient care. Many paediatric teams now actively ‘transition’ patients from paediatric to adult services,²² but there is frequently a gap concerning what happens to patients who require emergency adult admission during the transition process. Being aware of how local transition programmes function can, in itself, be extremely useful, because many have identified team leads, records of care plans and agreed pathways for follow-up. AMUs can also look to take a more active role in transition programmes, particularly in bigger units where there may be scope to identify an AMU lead for YAAs. This might include helping to arrange visits for YAAs to the AMU, agreeing advance plans for acute care in discussion with patients and paediatric staff, or working on shared care pathways for transitioning patients.

Where there is no local paediatric service or no transitional programmes are offered, many of the key principles are still applicable. Patients aged 14–19 years who are frequent attenders or have complex care needs can be identified. Individual management plans can then be formulated, with input from the responsible paediatrician, and the family and specialist services, before being shared with any involved parties, such as the family, the GP, ambulance services and school/college. Copies can be kept on the AMU or marked on the electronic patient record where available. After each admission, feedback can be sought from the patient and his or her family and the care plan updated as needed. Experience suggests that such care planning can significantly impact on experience, improve care and help prevent complaints.

Conclusion

YAAs present to AMUs more frequently and are more prone to poor outcomes than previously recognised. By considering the distinct needs of YAAs using nationally agreed templates, such as the You’re Welcome criteria, responsive, patient-centred care can be delivered to this vulnerable group. AMUs need to liaise with colleagues in paediatric and emergency medicine, as well as other stakeholders, to streamline and improve care delivery. Although this may present a challenge to many AMUs, changes should benefit patients and staff alike.