School Time Safety Netting

Safety netting is one of the most important interventions in acute paediatrics, whether you work in Primary or Secondary Care.  When we give safety netting advice, it is usually in the context of a medical problem that we expect to run a benign course and then resolve.  This is plan A.  Safety netting advice allows us to inform the patient (or responsible carer) when to activate plan B.

Plan B might be needed for a number of reasons:

The principles behind good safety netting are simple.

All of these factors are key to the success of the safety netting process.  Leaflets can be a very useful supplement to explanation and discussion.  The opportunity to ask questions is also essential.  Most importantly the parent should feel empowered to make an assessment and to return without feeling that they will be seen as over-anxious.

Recently, there was a lively discussion online (sparked by Damian Roland's writings about safety netting) about this subject, including some great tips about how to do it well and ways that it can go wrong.  One of the pitfalls that were mentioned was the possibility that discussion about the appropriateness of the attendance might get in the way of the touchy-feely aspect of the safety netting.  The gist was that if you discussed when not to come, this would be a barrier to appropriate attendance.  While I agree that this can happen, I don't believe that by discouraging attendance we are running this risk, as long as it is all done in a positive way.

The idea that discussing appropriate attendance is inherently negative is based on a false assumption: namely that the parent wants to come to the doctor.  Even where healthcare is free at the point of delivery there are many, many reasons why people do not want to see a doctor, with inconvenience being one of the most common.

Another issue is that the anxiety associated with the perceived need for a medical assessment is itself an unpleasant experience.  I think that doctors under-appreciate this because we are made to feel like the hero of the hour.  Someone was worried about a symptom and now we are the person to tell them that everything is almost certainly going to be fine.  Go us!

Probably the most common example that I can think of is the way that parents often think that a cough and fever equals a chest infection.  This is sometimes compounded by the belief that chest infection is often fatal - a rare outcome in a healthy child who is given appropriate treatment.

When I hear someone say that they have come to see me because they believe that their child has a chest infection and the child promptly runs off to play with the toys, I could be forgiven for having a 'why me?' moment.  I could use this opportunity to explain why this is an inappropriate attendance since the child is so very well.  That would be a tad self indulgent since I'm not the one with the worry.  Instead, I should make sure that my consultation finishes on a positive note, with good safety netting advice that encourages re-attendance, right?

Well, I think that the two things (good safety netting and discouraging unnecessary attendances) are far from mutually exclusive.

If anything, the two things work together in beautiful harmony and create the opportunity to take safety netting to a platinum standard.

What might this look like in practice?  For the child with the not-a-chest-infection, my school time safety netting might go like this:

It is absolutely important that parents do not feel criticised.  If fear of criticism leads to a child not being brought for assessment when needed, that is of course a bad thing.  So, we have to have the best of intentions when we talk about when and when not to seek medical advice.

I have no interest in doing myself out of a job by reducing attendances.  If anything, reducing avoidable attendances.   It takes me 2 minutes and zero stress to assess the child who has had a minor bump to the head.  If the parents who bring their child to see me when all that's happened is that they fell over and cried for a few seconds stop coming "because it's always best to get checked isn't it doctor?" then I'll just have to see more patients that take time and challenge my thought processes.  So why do I take the time to explain to every single parent the things that would constitute a reason to seek assessment for the next bumped head?

The answer is that it is in the best interests of the parent and child, so why wouldn't I?

Edward Snelson
Founder of MediLeaks
@sailordoctor

Disclaimer:  Exploring health beliefs can be hazardous.  Always wear a helmet.

I would love it if you would post the things that you educate parents about (in a positive way).  You could do that here, on Twitter or on Facebook.  If you post a comment here, don't worry if it doesn't appear straight away.  I have to check all comments before they are published.  (There are a lot of spammers out there!)

Think Sepsis - What does that mean?

You may have noticed that there are a lot more paediatric sepsis guidelines flying around these days.  When people write guidelines, they are trying to be helpful but it is always worth knowing why they decided to be helpful.  For example, guidelines for diagnosis of asthma in childhood are strongly motivated by the desire to reduce the overdiagnosis of asthma in childhood.  We know this because the guideline writers tell us.  They're quite good like that.

So what about sepsis?  Well there are two genuine problems that keep coming up around sepsis:

• Early diagnosis of sepsis
• Early and aggressive treatment of sepsis

There's probably more to it than that but that is the main thrust of what most sepsis guidelines are trying to achieve.

I think that the guidelines that have come out over the past few years have done a good job in guiding our management of sepsis.  Once you have decided a child has enough evidence of being septic to be treated, crack on and don't spare the horses.  There is no doubt that as a profession, we are getting our act together in this respect.

The first part is more tricky. diagnosing sepsis is difficult.  Sorry, let's be honest, it is really, really difficult.  Sepsis is missed all the time, and I am not talking about the overdiagnosis of missed sepsis which goes like this:

There is a two part truth which guideline writers and readers need to accept.  Sepsis is often missed because it is often easy to miss it.

So, back to the guideline writing - in order to help us diagnoses sepsis, guidelines have been written to help us to recognise sepsis.  As a colleague of mine recently pointed out, that only works if you know to look at the sepsis guideline.  If you are already looking at the sepsis guideline then the battle is already won, because if you are worried enough to look at the sepsis guideline, it's usually time to phone a friend.

So why is it easy to miss sepsis?  There are several reasons;

• The diagnosis of sepsis is subjective.  There is no mathematical equation (Fever + Tachycardia ≠ Sepsis), test or even definition that gives anyone the answer to the question does this child have sepsis. 2016 saw the third meeting of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine in an attempt to achieve a consensus definition of sepsis.  They will need to meet up again in 2018 if they are going to find true consensus about what sepsis is and what it looks like, since they couldn't quite decide the first three times.  Perhaps they just miss each other that much between conferences.
• Sepsis doesn't appear, it develops.  There is a reason that we don't have an issue with clinicians missing a diagnosis of croup.  Croup announces its arrival most helpfully.  If only sepsis did the same.  
• There is almost always another diagnosis to distract the clinician.  As mentioned above, before a child is diagnosable with sepsis, they usually have a prodromal illness.  A classic example of this is secondary sepsis in children with chickenpox.  It is completely understandable that when a child presents with fever and being miserable, having the typical chickenpox rash seems to make the diagnosis obvious.  However, some of these children have sepsis, and it is important to know when that is a strong possibility.
• All of the features of sepsis are non-specific and can belong to another diagnosis.  Features such as tachycardia are frequently difficult to interpret as a fast heart rate may be due to pain, fear or pyrexia - all of which occur in children who do not have sepsis.  In any case, there is no definition of tachycardia, so we rely on guideline figures.  
• You can't rely on any one feature to be present all of the time.  Even pyrexia may be absent.  Recognising severe sepsis is relatively easy, but we are being asked to recognise sepsis earlier, before it becomes severe.  That is much more of a challenge.

So, in summary, early sepsis is vague and it is easy to miss because it often hides behind a more obvious diagnosis.  The result is that guidelines are inherently too vague or too prescriptive when it comes to the recognition of sepsis.  Furthermore, if sepsis is not considered, the guideline is of no use whatsoever.

There is relatively simplistic way to deal with all of this.  Since the challenges are mainly about awareness and decision making, I think that a sepsis guideline could simply look like this:

Here are some footnotes on this:

• Recognising the unwell child starts with recognising the well child.  All sorts of factors are taken into consideration.  While many guidelines emphasise physiological values (heart rate etc.), the behaviour and activity of a child are very important.  The gut feel assessment of the parent and the clinician are also valid.
• The trajectory of the illness is not always treated with the importance that it deserves.  Children who are not septic often have periods of being subdued but then pick up and have a time where they look and behave as though they are much improved.  This is the "I can't believe how well my child looks now doctor!" effect.
• Recognising sepsis comes with experience but any clinician can think about the possibility of sepsis.  If you are unsure, get a further assessment.

So, thinking about sepsis is the crucial first step.  It's the deciding that takes the most skill.  Then, when it comes to acting, we should be getting on with with doing whatever we need to do without unnecessary delay.  Hopefully that has made it sound a lot more simple than it really is.

Edward Snelson
Simple is what I need
@sailordoctor

Disclaimer - Simplification is a huge cop out for medical writers, but it's also a lot of fun.  Try it sometime.

Fairy logic - how to avoid the understanding gap

I recently realised that my medical advice is not as good as it could be.  I tell parents and young people what will help their treatment have the maximum chance of success, but I do so without always thinking about how the advice might fall into an understanding gap.  From now on I am going to try to apply fairy logic whenever I give my explanation of what to do next.

Fairy logic?  Let me explain: In popular mythology, fairies are often need permission from people to do things.  As a result they look for opportunities to interpret what is said to them in inventive ways.  For example if a fairy wants to enter your abode, they need permission.  If they are told, "You can't come in my house" they may see the loophole and go into the garage instead.  In consultations, I think that this misunderstanding of convenience happens often, albeit unintentionally.

For example, with eczema treatment, I will advise that soap should be avoided.  I should probably include shampoo and shower gel in that to avoid misinterpretation.

Other examples include

• "Stopping milk" when cow's milk protein allergy is suspected (should be stopping milk and anything containing milk, milk products like cheese or having these as an ingredient)
• "Smoking in the house is associated with chest problems in children" (should be that having a smoker who lives in the house is associated with chest problems in children.  Avoiding smoking in the house and car is good, but quitting is better.)

I know that time is at a premium when there are lots of patients to be seen.  However to avoid that misinterpretation you have to be specific and be comprehensive.  If you have examples of circumstances which benefit from this, why not post them in the comments section?  I suspect that there will be plenty of times that I am not aware of when I need to apply fairy logic to avoid the gap.

Edward Snelson
@sailordoctor

Disclaimer: I am largely basing my knowledge of fairies and their way of thinking on the writings of Eoin Colfer, but I'm not even sure he's ever really met a fairy.

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

@sailordoctor

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. 2^nd edition 2004 ISBN 10: 1857756797
3. Safety netting in healthcare settings: what it means, andfor whom? Arch Dis Child Educ Pract Ed 2014;99:48-53doi:10.1136/archdischild-2012-303056
4. The safety netting behaviour of first contact clinicians: aqualitative study C. Jones et al, BMC Family Practice open access

In Praise of Doing Nothing (Easter Egg – good safety-netting and saving lives)

When I ask parents if they have seen their GP about an illness they often reply, “Yes but they didn't do anything.”  I am most encouraged whenever I hear this.  So, no-one has done any tests or prescribed any treatment?  “Excellent” say I, “and your child is the healthier for it.” 

Here's why:

So, if you are one of these clinicians who are doing a lot of nothing, you have my thanks and admiration, because I know how much work it takes.   All I would like to do is add my top tips for making sure that the child with… let’s say a viral URTI, is sent out into the world with the best possible advice and safety-netting.  Why?  Because safety-netting is what makes all the difference when a child with an uncomplicated viral illness develops a secondary infection (or other complication).

• Try not to say the words ‘just a virus’ or ‘only a virus.’  Parents will tend to feel that you have not recognised how unwell their child is.  Acknowledge that the child is unwell and explain that viruses can make children quite unwell.
• To balance this, (lest they ignore signs of serious illness) explain that the hallmark of viral illness is that the child will intermittently pick up and look reasonable, often quite suddenly.  Children with sepsis and meningitis do not go from playing to lethargic and back again every few hours.
• Explain that children with a viral illness do sometimes get another infection added on which is usually more serious.  For this reason they must seek reassessment if the child is not picking up or if new problems develop such as abnormal breathing etc.  This part is especially important as occasionally I will see children brought in who are severely septic and the parents have delayed seeking another assessment because they were given what sounded to them like an ‘everything is fine and will be fine’ appraisal by the clinician that they saw.
• Advise regular paracetamol, fluids and to avoid overdressing the child.
• Do not tell parents that if the illness continues they should go to their emergency department to be assessed.  If they are well enough to be sent home then persistence of symptoms does not really warrant an ED attendance.  Save the ED option for the child who is worsening despite paracetamol etc.

It is truly an art to get that balance between being reassuring enough and safety-netting well.  However the worst possible thing would be to add tests to uncertainty or treatments to cover improbabilities.  So thank you and please keep doing nothing.

Edward Snelson

@sailordoctor

Disclaimer:  Safety-netting was invented by Roger Neighbour or possibly Houdini.  Check Wikipedia if you want.