Saturday, 11 July 2015

Super-size me - Stratified safety netting

“The delivery of good medical care is to do as much nothing as possible” Law 13 of ‘The House of God’ by Samuel Shem (1)

As clinicians involved in the care of children, we have to do everything in our power to reduce unnecessary tests and treatments.  This can be perceived as inaction but those who know better recognise that there are two important interventions that are incorporated into every patient contact – observation and safety netting.  In paediatrics (including in General Practice and in Emergency Medicine) we rely on a watchful waiting approach to most childhood illness.  When that period of observation occurs in the child’s home, safety netting advice is not just an add-on, it is an intervention in its own right.

Why then do we treat is as a one-size-fits-all part of the consultation?  Why don’t we treat it with the importance that it deserves by quantifying it?  I suspect it is because we don’t know how to measure it.  So, to take this concept further we must first understand what makes up safety-netting.

I was first introduced to the concept of safety netting though the writings of Roger Neighbour.(2)  He wrote that safety netting was built around three questions:
  • If I’m right, what do I expect to happen?
  • How will I know if I’m wrong?
  • What would I do then?

I often ask my junior colleagues what they say to parents at the point of discharge and although they may not have heard of this model, they will tend to cover all of these three aspects leading me to the conclusion that to do so is fairly intuitive.  Where it goes wrong is that it often tends to be generic when it should be specific.

Taking the idea that safety netting is an intervention in its own right I would suggest that as well as making sure that the three dimensions are all present, we need to get the scale correct.  Think of it as you would the treatment of an acute asthma attack.  The British Thoracic Society (BTS) sets out definitions for moderate, severe and lifethreatening episodes* and gives clear guidance about the drugs, doses and routes indicated in each scenario.  I believe that we should consciously be doing the same for safety netting ill children.

* Note the comparison to fast food chain sizes – instead of small, medium and large, we have regular, large and super-sized.

I’ll give you an example.  When I see an ill child and discharge them with advice I could stratify my safety-netting as follows:

Level 1 (e.g. child with temperature, coryza and is running around and playing)

"Your child has a viral illness and at the moment they are reasonably well despite this.  Some children do become more unwell during a viral illness but most will be fine if their discomfort is managed with medicines such as paracetamol (acetaminophen) and they are given adequate fluids to drink.  If they seem to be significantly unwell despite this then further advice should be sought at that stage.  Your child certainly has nothing to suggest meningitis or anything similar at the moment but here is a leaflet showing the things that would suggest such an infection.  We like all parents to have one of these for information."

Level 2 (e.g. Child who is alert, had a high temperature earlier but now looks really well)

"Your child has a viral illness and although they have been unwell with it they have responded nicely to fluids and simple medicines.  As a result there is no reason at the moment to suspect any other infection. As long as they continue to do so they could be expected to be as they are for a few more days.  Occasionally a child will go on to get a second infection on top of the viral illness so if your child looks quite unwell despite the medicines, becomes floppy, lethargic or is unable to drink you should make sure that you get your child seen again fairly urgently.  Here is a leaflet…"

Level 3 (e.g. Child who has clear signs of viral upper respiratory tract infection but no red flags symptoms.  Despite this they are at the upper end of how unwell children are with a viral URTI.)

"Your child has a viral illness and although they are unwell with it I am sure that there are no signs of other infections such as pneumonia or meningitis at the moment.  When children are unwell with viral illnesses they are more prone to getting those more serious infections though so if they become any more unwell than they are now they should be reassessed urgently.  If a child has a straightforward viral illness their discomfort will usually respond to medicines such as paracetamol and they will usually drink enough to pass urine regularly.  If your child looks quite unwell despite doing these things, becomes floppy, lethargic or is unable to drink you should make sure that you get your child reassessed urgently.  Here is a leaflet…"

Hopefully, you can imagine all three children in your head.  There is a big element of this that doesn't translate well into written word.  With so much communication being non verbal, a script is only a taste of this concept.  When I give my super-sized safety net advice, I use every non-verbal cue at my disposal to communicate the importance of what I say.  I hope that this approach to safety netting will ensure that the children most at risk of secondary infections have had the level of illness taken into account and thus receive the appropriate level of the intervention.  This might address one of the common pitfalls of safety-netting which is that parents sometimes come away with the impression that the doctor thought that nothing was wrong and so were reluctant to seek further assessment when the situation changed. (3,4)

So, next time you are safety netting a child at the end of an encounter, think of it as an intervention and decide on whether it should be a small, a medium or a large one.

Edward Snelson
Available to crew any good sized Mediterranean yacht

  1. Samuel Shem. The House of God. 1979. ISBN 0-440-13368-8.
  2. Roger Neighbour. The Inner Consultation. 2nd edition 2004 ISBN 10: 1857756797

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