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Advances in Emergency Medicine

Volume 2014, Article ID 536080, 5 pages
http://dx.doi.org/10.1155/2014/536080

Research Article
Common Presenting Problems for Young People Attending
the Emergency Department
Dhurgshaarna Shanmugavadivel,1 Rebecca Sands,2 and Damian Wood1
1

Nottingham Childrens Hospital, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus,
Derby Road, Nottingham NG7 2UH, UK
2
Department of Paediatrics, Sherwood Forest Hospitals NHS Foundation Trust, Kings Mill Hospital, Mansfield Road,
Sutton-in-Ashfield, Nottingham NG17 4JL, UK
Correspondence should be addressed to Dhurgshaarna Shanmugavadivel; shaarnashan@doctors.org.uk
Received 9 January 2014; Revised 20 February 2014; Accepted 21 February 2014; Published 25 March 2014
Academic Editor: Bruno Megarbane
Copyright 2014 Dhurgshaarna Shanmugavadivel et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
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 ( = 10455). Results. All emergency department attendances for young people
over a one-year period were studied in order to determine the common presenting problems. There were 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 and pathways developed for young people 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.

1. 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 [47].
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 1317 years old,
with the objective that the results will assist in planning and
developing clinical pathways and health services for young
people.

Advances in Emergency Medicine

2. Patients and Methods

3. Results
There were a total of 10455 attendances by 8303 young people
aged 1317 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

2022
2056
2105
2026
2246

Age
13 years
14 years
15 years
16 years
17 years

(%)
(19.3)
(19.7)
(20.1)
(19.4)
(21.5)

Age of young people attending ED

1400

1200
1000
Number

The study was undertaken in the emergency department at

the Queens 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 1019 years [2]. The emergency
department at Queens 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.

Table 1: Age distribution of medical attendees.

800
600
400
200
0

13

14

15
Age

16

17

F
M

Figure 1: Age and sex of young people attending the emergency

department.

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.
3.1. 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

Advances in Emergency Medicine

Table 2: Presenting problems of medical attendees aged 1317 years.

Presenting problem
Abdominal pain
Self-harm
Fits, faints, and funny turns
Breathing difficulty
Intoxication
ENT problem
Pregnancy related problem
Chest pain
Headache
Allergic reaction
Diarrhoea +/ vomiting
Rash
Febrile illness
Swollen/painful limb

480
314
308
213
178
145
144
129
120
106
94
63
53
51

(%)
(16.3)
(10.6)
(10.4)
(7.2)
(6.0)
(5)
(5)
(4)
(4)
(4)
(3)
(2)
(2)
(2)

Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Table 3: Source of referrals of all attendees.

Source
Self
Parent/guardian
Ambulance/999
School
General practice
NHS direct
Advised by medical staff
Walk-in centre
Other hospitals
NEMS
Other/unknown

5333
2378
1085
434
317
182
158
98
89
23
358

(%)
(51.0)
(22.7)
(10.4)
(4.2)
(3.0)
(1.7)
(1.5)
(0.9)
(0.9)
(0.2)
(3.4)

fracture clinic. A further 6% either did not wait or refused

treatment.

4. 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 (1317 years) as this does not cover the broader
population of adolescents defined by WHO as 1019 year
olds. This study followed on from a previous project in our
department looking at teenagers which used the 1317 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 Peoples 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 peoples 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 Kennedys report highlights the need
to focus on access to acute services for young people in line
with the Youre 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

Advances in Emergency Medicine

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.

5. 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.

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

have an interest in the submitted work in the previous three

years and there are no other relationships or activities that
have influenced the paper.

Authors Contribution
Damian Wood and Rebecca Sands contributed to the planning of the project and project design. Dhurgshaarna Shanmugavadivel, Damian Wood, and Rebecca Sands collected
the data, analysed the data, and drafted this paper together.
Dhurgshaarna Shanmugavadivel as corresponding author is
responsible for the content of the paper and overall guarantor.

Acknowledgment
The authors would like to thank all the staff in the emergency
department for all their work in inputting data on a daily basis
onto EDIS.

References
[1] M. D. Resnick, R. F. Catalano, S. M. Sawyer, R. Viner, and G.
C. Patton, Seizing the opportunities of adolescent health, The
Lancet, vol. 379, no. 9826, pp. 15641567, 2012.
[2] Office of National Statistics, Census Data, 2011.

6.2. 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.
6.3. 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.

Ethical Approval
Ethical approval was not required.

[3] J. Coleman, F. Brooks, and P. Threadgold, Key Data on Adolescence, 2011.

[4] K. Armon, T. Stephenson, V. Gabriel et al., Determining
the common medical presenting problems to an accident and
emergency department, Archives of Disease in Childhood, vol.
84, no. 5, pp. 390392, 2001.
[5] K. Armon, T. Stephenson, R. MacFaul, P. Eccleston, and U.
Werneke, An evidence and consensus based guideline for acute
diarrhoea management, Archives of Disease in Childhood, vol.
85, no. 2, pp. 132141, 2001.
[6] K. Armon, T. Stephenson, R. MacFaul, P. Hemingway, U.
Werneke, and S. Smith, An evidence and consensus based
guideline for the management of a child after a seizure,
Emergency Medicine Journal, vol. 20, no. 1, pp. 1320, 2003.
[7] K. Armon, R. MacFaul, P. Hemingway, U. Werneke, and T.
Stephenson, The impact of presenting problem based guidelines for children with medical problems in an accident and
emergency department, Archives of Disease in Childhood, vol.
89, no. 2, pp. 159164, 2004.
[8] K. Hawton, K. Rodham, E. Evans, and R. Weatherall, Deliberate self harm in adolescents: self report survey in schools in
England, British Medical Journal, vol. 325, no. 7374, pp. 1207
1211, 2002.
[9] R. Sands, D. Shanmugavadivel, T. Stephenson, and D. Wood,
Medical problems presenting to paediatric emergency departments: 10 Years on, Emergency Medicine Journal, vol. 29, no. 5,
pp. 379382, 2012.

Conflict of Interests

[10] RCPCH, Not Just a PhaseA Guide to the Participation of

Children and Young People in Health Services, 2010.

We have all completed the unified competing interest form

and declare that there are no competing interests. There was
no support from any organisation for the submitted work,
no financial relationships with any organisations that might

[11] I. Kennedy, Getting it right for children and young people. Overcoming cultural Barriers in the NHS so as to
Meet their Need. London, UK, Department of Health, 2010,
http://www.dh.gov.uk.

Advances in Emergency Medicine

[12] D. Wilkinson and A. J. Robinson, Youre Welcome quality criteria: making health services young-people-friendly, Sexually
Transmitted Infections, vol. 85, no. 3, pp. 233234, 2009.
[13] Department of Health, Report of the Children and Young
Peoples Outcomes Forum, 2012.

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