Article Text
Abstract
Advocates of adolescent health have long argued for the development of dedicated inpatient units. In the UK, many recently built children's hospitals have included adolescent wards, with further wards actively planned for new builds. In Australia, adolescent wards have been established in all but one of the major children's hospitals and will be a feature of all three new children's hospitals currently being built (in Melbourne, Brisbane and Perth). Despite growing interest in the development of adolescent inpatient facilities, and evidence that they improve quality, there is little in the recent literature to guide those tasked with setting up or running such units. Those who currently operate such wards thus have the regular task of fielding enquiries from colleagues about developing and operating hospital-based services for young people. The aim of this article is therefore to describe our experiences of developing and working on adolescent wards in Australia and the UK, focusing on the ward design, case-mix, staffing requirements and ward philosophy and discussing the benefits and potential disadvantages of a dedicated adolescent ward.
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Introduction
There is increasing recognition of the burden of health problems affecting adolescents.1,–,4 The Royal College of Paediatrics and Child Health (RCPCH) and Royal Australasian College of Physicians have responded to this challenge in a number of ways.5,–,7 The RCPCH curriculum contains adolescent health competencies, an expansion of those within the European Academy of Paediatrics common trunk training.8 An e-learning package, part of a multiprofessional educational program funded by the Department of Health for England, covers all the RCPCH adolescent competencies and those of other UK medical colleges.9 A Young Persons' Health Special Interest Group has been formed to develop training,10 including a study module outlining competencies needed for a special interest in adolescent health.11 In addition, a multidisciplinary Association for Young People's Health has been established, supported by a range of medical and nursing Royal Colleges and government departments.12 These developments have occurred alongside a European training initiative in adolescent health (Euteach).13
In Australasia, the Royal Australasian College of Physicians Joint Adolescent Health Committee, which guides the development of adolescent health policy and training, has produced four position statements/policies (transition to adult care, routine adolescent health screening, confidentiality and health of incarcerated adolescents),14 and a training resource for basic trainees.7 An advanced training curriculum in adolescent and young adult medicine, open to trainees in paediatric and adult medicine, will commence in 2012.15 A strength of the Joint Adolescent Health Committee is the involvement of paediatricians and adult physicians, emphasising the need for input from both disciplines. In the UK, adult physicians from the Royal College of Physicians are beginning to play a greater role in this area.16
The history of adolescent wards in Australia and the UK
Advocates of adolescent health have long argued in favour of dedicated inpatient units.17,–,20 In Australia, the first adolescent ward was established in 1981 at Westmead Hospital, a general hospital. Wards have since been established in all but one of the major children's hospitals, with the ward at Princess Margaret Hospital (PMH) in Perth set up in 1993.20 In the UK, adolescent wards were developed in a number of hospitals during the 1980s and 1990s, particularly specialist units serving teenagers with cancer or cystic fibrosis.21The first comprehensive adolescent ward was established at the Middlesex Hospital in 1997. In 2001, an RCPCH survey reported that 12% of hospitals (not just children's hospitals) had some form of dedicated adolescent inpatient facilities.22 In a large UK young patient survey in 2004, 10% of 12- to 14-year-old and 18% of 15- to 17-year-old respondents reported being cared for in a unit with separate facilities for young people.23 These were a heterogeneous mix, mostly separate bays within a children's ward. Another survey reported that 56 of 225 hospitals in England and Wales had separate adolescent facilities – either a dedicated ward or bay within a children's ward.19 Recently built children's hospitals have included adolescent wards, with more planned for new builds in England, Scotland and the Irish Republic. In Australia, adolescent wards are planned in all three new children's hospitals currently being built.
The evidence base for supporting adolescent wards rests on the stated desires of young people, satisfaction surveys and evidence that adolescent wards increase quality of care. Young people wish to be treated within dedicated facilities that respect their rights, maintain confidentiality and privacy and provide age-appropriate educational and leisure activities.22 24,–,26 Core quality issues (confidentiality, communication, information giving, partnership, respect) are rated more highly by young people cared for in adolescent facilities compared with peers in children's or adult wards.23 Even the provision of limited facilities seems to improve quality of care. Findings are similar for specialist wards; satisfaction with the environmental aspects of care is higher when admitted to an adolescent specialist (eg, oncology) ward.27 28 These data relate to patient-reported aspects of care, which are central to modern understandings of healthcare quality.23 There is evidence that processes of care that are more patient centred lead to improved outcomes.29 Thus, using patient perceptions of care for systems improvement may lead to better health outcomes.30
Developing an adolescent inpatient ward
There is little to guide those tasked with setting up an adolescent ward.20 A systematic literature review in 1998 found mainly anecdote and expert opinion.25 Little has changed since. Those currently operating adolescent wards regularly receive enquiries from colleagues about developing such services. The remainder of this article describes the authors' experiences, derived from developing and working on a total of six different units across Australia and the UK over 20 years.
General and children's hospitals regularly admit enough adolescents to fill a ward.31,–,33 Most adolescent wards in Australia and the UK act as general medical/surgical wards, staffed by paediatric and some adult trained nurses, led by a clinical nurse manager.20 Permanent nursing staff are skilled in medical and surgical specialties to ensure that the standard of care is equivalent to that delivered on the specialty ‘home’ wards. This includes management of acute and chronic problems and palliative care (eg, caring for a young person with cystic fibrosis and end-stage lung disease). Senior nursing staff develop and deliver training in issues specific to nursing adolescents.
Wards typically contain a mixture of open bays and single or shared rooms. Bays are arranged on a single-sex basis. Occasionally, young men and women need to be cared for in the same bay (depending on the male/female mix within the ward), although this is not ideal. Young people requiring isolation have single rooms. Attempts are made to overcome the problems of isolation through availability of television, DVDs, supervised internet access and one-to-one teaching.34 Separate examination rooms, a treatment room, kitchen and private interview rooms are essential. Although the latter are required on all wards, the particular value attached to confidentiality and privacy by young people highlights the need for these. Adolescents' participation in the design and running of the ward is important, in line with RCPCH guidelines highlighting the need to involve young people in health service development.35 36
Case mix
Adolescence is a developmental stage rather than a specific age range. However, age ranges for admission are needed for pragmatic operational reasons. Typically, the lower limit for admission to an adolescent ward is 12 or 13 years, although 10- or 11-year-old children may rarely be admitted if they are considered, developmentally, to be an adolescent. The upper age limit is variable depending on hospital policy. Data from Perth and Melbourne children's hospitals demonstrate that it is not unusual to admit those aged 20 years.32 37 With increasing acceptance of the concept of adolescent and young adult medicine, dedicated young adult units are beginning to be established in some hospitals, with the specialty of oncology leading the way.21
Patients are admitted to the ward under the care of their specialist team. Physicians and senior nurses with adolescent health expertise are vital to provide leadership and advocacy, support colleagues and offer a consultative service. Some specialities (eg, endocrinology, rheumatology, oncology, gastroenterology) often include staff with a special interest in adolescent health. Because of the frequency of comorbid mental health problems among adolescent inpatients, support from psychological medicine is essential.4 38 Young people who deliberately self-harm are admitted under a medical team and transferred to a psychiatric ward, if indicated, once medically stable. A regular multidisciplinary ward meeting allows staff to discuss inpatient and ward issues, providing an excellent training opportunity.39
Tables 1 and 2 provide a breakdown of the case-mix of admissions to the ward at PMH from July 2000 to June 2009. These demonstrate a spread across the range of medical and surgical specialities. A significant proportion are acute admissions (eg, for acute abdominal pain, trauma, deliberate self-harm). A similar broad range of admissions and specialties is treated in the adolescent ward at University College Hospital, London.
Some specialties (eg, cardiology, burns, oncology, nephrology) prefer to admit adolescents to their ‘home’, rather than the adolescent, ward, reflecting a need to balance the requirements of the specialty with those of the young person. It is essential that the care of adolescents requiring highly specialised medical and nursing input is concentrated in areas with access to this expertise, both staffing and technical. However, it remains important to address these young people's developmental needs. Options include departments developing their own adolescent ward or a specific area within the main ward (eg, Teenage Cancer Trust wards/units, of which there are currently 16 in the UK, with more planned).21 For most conditions and specialities, the benefits of managing adolescents together outweigh their specialist nursing needs. Not uncommonly, senior medical staff claim that their patients are best managed on ‘their’ wards where staff can deliver more specialist care. However, our experience demonstrates that a general ward provides excellent specialist care through appropriate management of nursing skill-mix and use of clinical nurse specialists.
Philosophy
Adolescent wards embrace a broad view of health, providing opportunities to address issues that are not the primary reason for admission. In most units, staff are expected to perform opportunistic health screening, often based on the HEADSS framework (table 3).14 40 Access to private interview rooms facilitates this practice. A pilot study of the feasibility and results of opportunistic screening at PMH, targeted towards surgical inpatients, has recently been completed (manuscript in preparation).
Other advantages and disadvantages
Advantages
Supporting healthy adolescent development
Adolescent wards address developmental needs (table 4). This is particularly important for those with chronic illness.41,–,43 Staff encourage independence; discuss health-risk behaviour, treatment adherence and health promotion; and support parents in their role of parenting an adolescent, rather than a child. A schoolroom emphasises the importance of education and provides structure to the day, assistance with school reintegration and opportunities for social interaction. These are enhanced through peer support programs and dedicated non-clinical areas where young people can meet.44 45 An example is the adolescent activity area at PMH, Club Ado, a joint venture with the Starlight Foundation.45 Complementary to the ongoing outpatient process, the ward provides opportunities to assist young people in managing their transition to adult care.
Adolescents with complex medical and psychosocial problems
These include adolescents with eating disorders, chronic fatigue and pain syndromes and unexplained symptoms.46 47 For the latter group, the multidisciplinary environment of the ward seems to provide an important contribution to improved outcomes. Management involves recognition and validation that symptoms are genuine, acknowledgement that such presentations are common and explanation that successful treatment is possible using a rehabilitative approach.48
Advocacy and training opportunities
A ward is a visible sign of a hospital's commitment to adolescent health, sending a message that this is part of core hospital business.46 The concentration of adolescent inpatients in one area provides a critical mass around which training and service development can be built (see below).
Disadvantages
This concentration of adolescents in one area potentially risks staff on other wards missing out on training opportunities. At the University College Hospital, all adolescents younger than 18 years, except those in intensive care or under the infectious diseases team, are admitted to the 40-bed adolescent floor. In contrast, at PMH, the majority of adolescents are not admitted to the adolescent ward because of the limited number of beds.32 Thus, all hospital staff need adolescent health training. This is achieved through secondments to the adolescent ward and training sessions for those working in other wards and clinical areas (eg, outpatients).
Adolescents may observe and mimic behaviours, such as self-harm or dietary restriction, displayed by others. Ward staff must identify inappropriate behaviour or unhealthy relationships – for example, bullying, sexual activity, smoking and other drug use. Young people's participation in developing guidelines for appropriate behaviour on the ward may protect against these.35
There is a risk of making the ward too comfortable, especially for those with difficult home circumstances. A regular multidisciplinary ward meeting provides a forum in which to highlight problems and discuss management strategies.
Summary
Adolescent wards are a growing feature of many hospitals. The existing literature provides support for their continuing presence and development. A challenge for adolescent health advocates is to add to this evidence base to strengthen the argument in favour of providing a dedicated adolescent ward in every children's and general hospital.
References
Footnotes
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Competing interests None.
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Funding None.
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Provenance and peer review Not commissioned; externally peer reviewed