HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS British Journal of Psychiatry Advances in Psychiatric Treatment All RCPsych Journals		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Subotsky, F. Articles by Santhouse, A. Search for Related Content PubMed Articles by Subotsky, F. Articles by Santhouse, A.

Risky presentations

An audit of accident and emergency presentation of older children

Belgrave Department of Child and Family Psychiatry, King's College Hospital, South London and Maudsley NHS Trust, Denmark Hill, London SE5 9RS

	Abstract

Top Abstract Introduction The study Statistics Findings Comment References

 
AIMS AND METHOD

The aim was to review the assessment and management of the psychosocial risk (including substance misuse) of older children presenting to the accident and emergency department, with a view to making recommendations to improve services. The method used was to inspect casualty records of attendances over two weeks of 11-16-year-olds.

RESULTS

In no cases was any note made of whether substance misuse might have occurred. Cases of apparent psychosocial risk were, however, dealt with appropriately in the main.

CLINICAL IMPLICATIONS

Brief advisory guidelines were written for accident and emergency staff to promote consideration of the misuse of substances in older children, and an information leaflet was developed for young people and their parents.

	Introduction

Top Abstract Introduction The study Statistics Findings Comment References

 
The presentation of deliberate self-harm (especially overdoses) to accident and emergency departments and subsequent management by child and adolescent mental health services is comparatively well documented (Brent, 1997; Royal College of Psychiatrists, 1998). However, it is now recognised that other ‘accident presentations’ are commonly associated with a range of psychosocial difficulties and "health-risky behaviour" (Milgram, 1993; Rivara, 1995). For instance, in the US substance misuse (alcohol or drugs) has been reported as commonly associated in teenagers with presentations in accident and emergency departments or trauma admissions (e.g. Loiselle, 1993; Mannenbach, 1997; Spain, 1997). Recommendations have been made to use screening more and subsequently refer those positive to appropriate services (Maio, 1994; Buchfurer & Radecki, 1996).

In the UK drug and alcohol use and misuse has increased among young teenagers (Health Advisory Service, 1996; Miller & Plant, 1996; Coleman, 1997). A British inner city casualty audit (Connor, 1997) revealed that about 200 under-17s were brought in under the influence of alcohol in one year. Anecdotally, the inner city casualty department of the hospital in which the child psychiatry department is located reported an increase of children attending in intoxicated states. However, very few had ever been referred to child psychiatry.

	The study

Top Abstract Introduction The study Statistics Findings Comment References

 
Casualty notes were collected on all 11- to 16-year-olds who had presented to the accident and emergency department during the course of two non-consecutive weeks. The entry made by the casualty officers was analysed and attenders were classified into three groups of risk:

1. A low-risk group, in which the history was internally consistent and compatible with the injury sustained, for example, a child brought in by a teacher with a cut finger, after attempting to ‘slam-dunk’ a basketball into the hoop.
   
2. A high-risk group, where either there was evidence of risk-taking behaviour, such as an overdose, or the history did not explain the injury.
   
3. An uncertain-risk group, where there was insufficient history to judge risk (this included four youngsters who did not wait to be seen).
   

A note was made of whether the possibility of drug or alcohol misuse had been enquired about.

The high- and low-risk groups were then compared against the following parameters, which were recorded on the casualty card:

1. who they were accompanied by (family member/nobody or person other than family);
   
2. gender;
   
3. age;
   
4. time of presentation (night/day);
   
5. diagnosis (medical/trauma);
   
6. outcome of attendance (discharged/admitted/‘other’).
   

	Statistics

Top Abstract Introduction The study Statistics Findings Comment References

 
The ² test was used to test associations of the binomial variables: risk, gender, who accompanied the patient, diagnosis, and outcome. The association of risk with night versus day was calculated using Fisher's exact test. The association of risk with age was calculated using the Mann—Whitney U-test and further logistic regression analysis.

	Findings

Top Abstract Introduction The study Statistics Findings Comment References

 
A total of 130 presentations of 11- to 16-year-olds to the accident and emergency department was recorded over the two weeks under study. In none of the 130 cases was a record made of an enquiry into the possibility of drug or alcohol use, regardless of the circumstances of the presentation. Of the 130, 71 (55%) were considered to be low-risk, 22 (17%) high-risk and 37 (28%) uncertain-risk (the last group was excluded from the statistical analysis).

Four parameters were not significantly associated with risk: age, gender, diagnosis and time of presentation. For outcome a high-risk individual was significantly less likely to be discharged, admitted for non-psychosocial reasons or followed up in the fracture clinic (P=0.006) (see Table 1). Of the 10 ‘other’ recorded for the high-risk group, four were sent back to the GP (one unwanted pregnancy, one self-harm, one medically unexplained shortness of breath and one child with recurrent fainting episodes). There were five referrals to child psychiatry, some of whom were admitted, all having harmed themselves in some way. One child was referred to casualty review, having punched through a window. It is of interest that four attenders said that they were pregnant or possibly pregnant.

Of the ‘other’ category in the low-risk group, five were referred back to the general practitioner (suture removal, chicken pox, conjunctivitis, asthma and laceration), two were referred to out-patients and one for casualty review, all with musculoskeletal injuries.

Of the ‘unascertained’ group four removed themselves before a full history or examination was taken. However, the presenting complaints were: one assault, one facial injury from a fight, one ‘inadvertently stabbed self’ and one rash — so that while the cases were not completely examined, risk looks high. Of these two were unaccompanied, two were with their mother.

When risk was compared with ‘accompanied by’, there was a significant result showing that risk was associated with not being accompanied by a family member on presentation to casualty (P=0.006), for example, a 15-year-old girl unaccompanied to casualty with a complaint of ‘Tippex in the eye’ raising the suspicion of solvent misuse (see Table 2).

	Comment

Top Abstract Introduction The study Statistics Findings Comment References

 
It is important to identify psychosocial risk contributors to the presentation of youngsters in accident and emergency departments and to recognise where drugs or alcohol are part of this. At least 17% of the 130 presentations to casualty of 11- to 16-year-olds were high risk in terms of evidence of behaviour or inconsistency of the injury with the history. We found that another indicator of difference between the groups was whether or not the child was accompanied by a member of the family, so that this is important to record. That the difference between the groups was recognised in some way by staff was reflected in the differences of outcome between high-risk and low-risk groups, with a higher proportion of the former being referred on to child psychiatry usually for deliberate self-harm or to the general practitioner. Only one case of self-harm out of six was not referred to child psychiatry. While there was no evidence in the casualty note system of referral on to social services there is a back-up notes review system provided by a liaison health visitor.

The specific problems of drugs and alcohol are still being overlooked despite evidence suggesting that there is increasing use of drugs and alcohol in the young, and that there is a strong likelihood of associated presentations in casualty. There may be a number of reasons for this. First of all, there may be pressures of time and that substance misuse is not even thought about. Second, if it is thought about and asked, what should the casualty doctor do with this information? If every child who experiments with drugs is referred, the child psychiatry services would be quickly swamped. Similarly, this creates a problem for the child psychiatry services, who do not necessarily have the expertise and experience in dealing with children with genuine addictions, or access to specialist services in the way adult psychiatrists do. Yet a casualty ‘crisis’ could be a good opportunity to pick up and intervene with those with substance misuse problems.

As the next stage of the audit we fed back the findings to a variety of groups — accident and emergency, the child psychiatry department, paediatricians. We developed brief advisory guidelines for casualty staff on how to assess and appropriately refer children who may have misused drugs or alcohol, and we have also produced a leaflet for young people and parents advising them about sources of help if there are concerns about the use of drugs or alcohol. Meanwhile, discussions with the addictions directorate and the local purchaser are ongoing and we hope to be able to provide better services for the target group of young people who misuse drugs and alcohol and have associated psycho-social problems.

	Acknowledgments

 
We are grateful for the goodwill and cooperation from the staff in accident and emergency at King's College Hospital, London, especially Dr Ruth Brown, consultant. We would also like to thank Dr Clive Holmes for statistical advice.

	References

Top Abstract Introduction The study Statistics Findings Comment References

 
BRENT, D. A. (1997) Practitioner review: the aftercare of adolescents with deliberate self-harm. Journal of Child Psychology and Psychiatry, 38, 277-286.[Medline]

BUCHFURER, L. A. & RADECKI, S. E. (1996) Alcohol and drug abuse in an urban trauma center: predictors of screening and detection. Journal of Addictive Diseases, 15, 65-74.[CrossRef][Medline]

COLEMAN, J. (1997) Key Data on Adolescence. Brighton: Trust for the Study of Adolescence.

CONNOR, J. (1997) Children and the ingestion of alcohol: a statistical analysis of children attending an A and E department. Accident and Emergency Nursing, 5, 185-188.[Medline]

HEALTH ADVISORY SERVICE (1996) Children and Young People: Substance Misuse Services — the Substance of Young Need. London: HMSO.

LOISELLE, J. M., BAKER, M. D., TEMPLETON, J. M., et al (1993) Substance abuse in adolescent trauma. Annals of Emergency Medicine, 22, 1530-1534.[CrossRef][Medline]

MAIO, R. F., PORTNOY, J., BLOW, F. C., et al (1994) Injury type, injury severity, and repeat occurrence of alcohol-related trauma in adolescents. Alcoholism, Clinical and Experimental Research, 18, 261-264.[Medline]

MANNENBACH, M. S., HARGARTEN, S. W., & PHELAN, M. B. (1997) Alcohol use among injured patients aged 12 to 18 years. Academic Emergency Medicine, 4, 40-44.[Medline]

MILGRAM, G. G. (1993) Adolescents, alcohol and aggression. Journal of Studies on Alcohol, 11 (suppl.), 53-61.

MILLER, P. & PLANT, M. (1996) Drinking, smoking and illicit drug use among fifteen and sixteen year olds in the United Kingdom. British Medical Journal, 313, 394-397.[Abstract/Free Full Text]

RIVARA, F. P. (1995) Crime, violence and injuries in children and adolescents: Common risk factors? Criminal Behaviour and Mental Health, 5, 367-385.

ROYAL COLLEGE OF PSYCHIATRISTS (1998) Managing Deliberate Self-Harm in Young People. Council Report CR 64. London: Royal College of Psychiatrists.

SPAIN, D. A., BOAZ, P. W., DAVIDSON, D. J., et al (1997) Risk-taking behaviors among adolescent trauma patients. Journal of Trauma, 43, 423-426.[Medline]

This Article Abstract Full Text (PDF) Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Subotsky, F. Articles by Santhouse, A. Search for Related Content PubMed Articles by Subotsky, F. Articles by Santhouse, A.