Article Text

Download PDFPDF

Fifteen-minute consultation: Safety netting effectively
  1. Sebastian Jason Gray1,
  2. Ian D Wacogne2,
  3. Damian Roland3,4
  1. 1 Department of Paediatrics, Salisbury NHS Foundation Trust, Salisbury, UK
  2. 2 Department of General Paediatrics, Birmingham Children’s Hospital, Birmingham, UK
  3. 3 Department of Health Sciences, University of Leicester, Leicester, UK
  4. 4 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
  1. Correspondence to Dr Sebastian Jason Gray, Paediatric Department, Salisbury District Hospital, Salisbury, SP2 8BJ, UK; Sebastian.Gray{at}Salisbury.nhs.uk

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

The incidence of life-threatening illness in children is at an all-time low while presentations and admissions to hospital increase.1 Healthcare professionals who have first contact with children and young people have a challenging job in judging who needs referral to secondary services and who can continue to be safely managed out of hospital. While the vast majority of children presenting for medical assessment have minor illnesses requiring little or no intervention, diseases evolve and early symptoms and signs may be very non-specific. Analysis of primary care records and retrospective questionnaires showed only half of meningococcal disease was detected at first presentation to primary care physicians.2 However, as evidence suggests that serious illness can superimpose on self-limiting infection3 not all returning patients could, or should, have been treated at first presentation. Given delayed or missed diagnoses can lead to catastrophic personal, societal and financial consequences; at the point of discharge, the advice given the families and carers is of critical importance.

Safety netting has likely always occurred but was only formally described in medicine in 1987.4 In the UK, it is a National Institute for Health and Care Excellence (NICE) quality standard defined as ’oral and/or written information on what symptoms to look out for, how to access further care, likely time course of expected illness and, if appropriate, the uncertainty of the diagnosis’.5

When children are seen in a hospital setting, they are often discharged with safety net advice. In theory, optimal education of parents during their index presentation should equip them with confidence and knowledge empowering them to manage their child at home unless ‘red flag’ symptoms or complications develop.

The outcomes of successful, and unsuccessful safety netting, are more difficult to define than might be first thought. Successful safety netting obviously includes parents returning with a child (when they would not necessarily have done so) who subsequently requires an intervention or admission. However, in order to capture all of these children a necessary consequence of safety netting is that some children will return who do not require any intervention and are subsequently discharged again. This is different from a parent feeling empowered to safely manage their child at home when they may have returned to a healthcare provider for further advice, which is still successful safety netting. The concept of ‘unnecessary representation’ is controversial and divides opinions. Parents need to feel empowered to represent if concerned and not feel like they are being perceived as ‘time wasters’.6 However representation rates are increasingly being used as a quality metric, to the point of affecting hospital payments in America. Due to the large variability in readmission rates between hospitals, a certain proportion are probably preventable. However, defining ‘preventable’ is varied and unclear. The necessity for a child representing may be perceived very differently by different parents but there will also be significant variation between medical professionals. On the other hand, having higher rates of representations has the potential to distract attention from sicker children requiring more urgent care and therefore pitching safety netting appropriately is therefore extremely challenging

If the safety net of when to represent fails, being able to represent for further explanations/assessment is an essential additional safety net in itself. We would argue therefore initial safety netting fails by one of three mechanisms:

  1. It was not given.

  2. It was poorly delivered, or understanding was not checked.

  3. It was insufficient.

Here, we explore the pros and cons of the various methods of safety netting as families have described a need for a range of approaches.7

Face-to-face/verbal

The majority of safety netting occurs verbally and integrating advice as part of a consultation has the benefits of catering for the individual patients, addressing specific concerns and checking understanding. Parental and health professional interpretation can vary significantly and being able to pick up on verbal and non-verbal cues is extremely useful. For example, if a parent were to exclaim, ‘Thank goodness, it is just a chest infection, the GP said it was pneumonia’, clarification would be possible. Likewise, a viral diagnosis can, in some family’s perception, appear to trivialise a child’s illness and leave parents frustrated. With effective communication skills (which include listening) ideas, concerns and expectations can be fully explored and addressed.

Parents can find information overwhelming for a variety of reasons (table 1), including:

  • Content (if too complex);

  • Amount of information (if too much);

  • Use of jargon;

  • Delivery speed (if too fast).

Table 1

Aspects of good and poor safety netting

Effectiveness of verbal safety netting is determined by rapport, bias (of both health professionals and parents), social gradients and level of experience of the assessing professional. Language barriers and health literacy will also determine understanding of information. What would be considered perfect safety netting for one family may be completely ineffective for another; one size does not fit all.8 Being adaptable, flexible and innovative in ensuring understanding is therefore essential to effectively safety net verbally.

The environment in which safety netting occurs face-to-face is also an important consideration. One British study found only a third of parents attending an emergency department knew what to look for when discharged.9 Hospitals can be noisy, scary places for those unfamiliar with them and at the point of presentation parents will likely be sleep-deprived and stressed. Methods therefore need to be employed to optimise the verbal safety netting process. Using teach-back methodology, whereby parents repeat back information given to them, may help improve understanding and reduce re-attendance but again relies on expert communication skills.

Written information and leaflets

The Department of Health in the UK states that high-quality information leaflets should be given in addition to verbal advice, although ‘high quality’ is not clearly defined.10 Having a point of reference for verbal explanations for families to refer to during times of uncertainty can be reassuring. Written patient information has been shown to be beneficial including improving confidence, reducing parental anxiety, reducing recovery time, improved hospital care satisfaction, reduced readmissions and improved adherence to discharge plans.8

The generation of written safety materials by individual units can improve the knowledge and education of staff which likely augments verbal explanations. Regional resources have the advantage of avoiding duplication and providing the same, consistent message, ideally transcending primary, secondary and tertiary care but may negate the upskilling of local units from having generated the material themselves.

Written information has to be accurate and easy to read and understand. The addition of illustrations or cartoons has been shown to improve understanding and satisfaction supporting a move away from the standardised trust documents historically portrayed as bland and uninteresting.11 Leaflets in different languages can provide safety netting when interpreters are not readily available and in some instances, while far from the ideal, may be the only safety netting method possible. However, it seems inevitable that if leaflets are produced in the 20 most commonly locally used languages, the next patient will only speak the 21st making it an almost Sisyphean task to keep leaflets in multiple languages up to date and relevant.

Audio-visual/videos

Although there is some evidence that certain populations (eg, the travelling community) may not interact well with this, videos have the potential to provide effective safety netting to those with low literacy who may not comprehend written information.7 Demonstration of concerning clinical signs with examples is superior to a verbal or written description and would work well in cases such as bronchiolitis when signs of respiratory distress could be displayed. However, for children presenting with atypical symptoms, there is a risk of patients slipping through the net. Content of videos would need to be carefully balanced to not terrify parents into coming back unnecessarily while ensuring that necessary representations still occur within a timely manner.

Videos would also have the advantage of being transferable and reusable with minimal environmental footprint, something that should be considered in every modernisation initiative in the National Health Service (NHS).

Internet, social media, websites and apps

There has been a significant rise in the use of the internet in health-seeking behaviours. However, the quality and accuracy of information has been found to be variable and recommended websites, such as those ending in ‘.edu’ or ‘.gov’ were deemed too complex by parents.12 13

Without clearly signposted resources, online information can heighten parental fears and anxiety through inaccurate or inconsistent advice, or an overwhelming amount of information.14 Despite dramatically increased use, some parents and carers still do not have reliable internet access. Effort needs to be made to minimise methods that may worsen health inequality for those at highest risk.

Vetting the quality of information available online is challenging but creation of communities of practice to provide sources of information could be further explored. For many medical mothers, the ‘Physician Mums’ Group UK’ on Facebook has become a primary source for advice and information. There is a wealth of balanced advice which has essentially been peer-reviewed, although in an unorthodox fashion. The potential benefit of translating this into a public resource would need to be balanced against risks that information about specific cases may not be generalisable and full physical assessment does not occur.

The use of apps for a source of parental information has been used in South-West England with the Handi app. Modern technological advances like this should be encouraged while ensuring that the most vulnerable families are not indirectly experiencing inferior care.

Prevention and general education

There is no doubt that public health and charity-led initiatives to highlight the features of conditions can be beneficial. Having a foundation of understanding and knowledge is likely to augment any subsequent safety netting that takes place.

With evolving viewing behaviours, future initiatives may rely on YouTube or streaming sites charitably agreeing to include public health information alongside the formal corporately sponsored advertisements.

Opportunistic education delivery to families could also be expanded. Using time spent waiting in emergency departments or GP practices with educational videos, posters, infographics are all potential ways to do this.

Education of the young people themselves is vitally important and health professionals should be involved in formulating a structured PSHE (Personal, Social, Health and Economic) curriculum working together with schools and teachers.

Conclusion

Safety netting can be considered an art. Although there are some general rules (table 1), there is no golden recipe to deliver the perfect verbal advice and like many aspects of paediatrics, necessitates a deepened skill setskill set to adapt to every individual circumstance.

Verbal advice alone is also insufficient but signposting to additional resources needs to be individualised—one size does not fit all. Paying lip service by adding ‘come back if you are worried’ to all discharge summaries may make the healthcare professional feel a bit better but is unlikely to significantly alter the family’s behaviour. There are many examples of poor safety netting (box 1).

Box 1

Examples of poor safety netting

Need for speed

During busy periods, the ever-growing number of patients to see and jobs to do undoubtedly impacts on our abilities to remain task-focussed. Rushing the verbal safety netting process may not adequately describe the expected natural course of the illness or miss covering salient features to watch for. This could result in ongoing parental anxiety, unnecessary health-seeking behaviour or even delay in necessary re-attendance.

Overwhelming parents with your impressive knowledge

As medical professionals who have studied for years, we have acquired a vast array of differential diagnoses for every presenting symptoms. Meticulously listing the signs and symptoms of each of these may increase rather than alleviate parental anxiety.

Assumption pitfalls

Assuming parental knowledge about medical illness is dangerous and it is much better to revise and repeat than to miss things completely.

Learning environment

When giving safety netting advice, you are effectively giving a mini tutorial. Think about the environment in which you best learn and try to recreate this for the family. Imparting safety net advice in a busy waiting room with screaming babies, noisy toys and the prying eyes of everyone around should be avoided.

Preconceived judgements

It is easy to see how preconceptions about paediatric presentations can arise. It is important to recognise that parents bring their children for medical assessment because they are worried something is wrong. Conflicting advice confounds the worry and confusion. The goalposts of evidence-based medicine are constantly moving and not all professionals will be up to date with every single paediatric condition. Dismissing or criticising previous advice risks harming the relationship and trust between the family and that practitioner and also with you. Be careful in how you address this. A child with normal observations whose parents are convinced is seriously unwell needs to be assumed to be seriously unwell until proven otherwise.

The general population sit somewhere on a normal variation bell-shaped curve for worrying. In order to capture those with a more relaxed tendency, safety netting will have to be pitched to inexorably have some unnecessary re-attendances. Most would agree we need safety netting to be more sensitive than specific. With the financial constraints with the NHS, unplanned re-attendances are likely to be increasingly scrutinised and used a quality indicator akin to some private healthcare systems. Safety netting functions to allow people to safely manage at home but re-attend in a timely manner should the need arise and extreme caution is required to find the correct balance. There is a balance that needs to be found taking into consideration the chance of underlying pathology and the concerns expressed by parents/carers. Figure 1 shows the model for safety netting. As with any model, we would quote George Box: ‘All models are wrong, some are useful’. In our model, we map the level of expressed concern of the parent or guardian against the increasing chance of reversible pathology or that which requires intervention. This gives us a theoretical diagonal line, where the actual level of illness of the child, and their presentation, matches the level of expressed concern of the parent or guardian. This then lets us examine different areas, for example, the child who is very unwell but the parents do not present, or the child who we struggle to perceive their illness, but their parents express high levels of concern. In this model, then, safety netting would attempt to do two things. It would bring together the parents and carers and clinician decision-makers judgement of level of illness which often may be divergent and it would make it clearer to all involved when escalation is needed.

Figure 1

Relationship between chance of pathology and level of expressed concerns by parent/guardian.

Ongoing resource development needs to ensure those at highest risk are considered and the reduced literacy, health literacy and technology access associated with deprivation do not further health inequality in the UK.

Case 1

You are an ST4 in general paediatrics and have been asked by your consultant to discharge and give safety net advice to the parents of a previously well infant aged 3 months with bronchiolitis who was feeding well with normal oxygen saturations and no significant respiratory distress on day 3 of the illness. Parents are from Eastern Europe and the nurse reports they are very anxious.

How would you approach this?

  • Ensure you are in a quiet, private area.

  • Establish language skills and arrange interpreter if necessary.

  • Establish what the family have already been told/understand.

  • Avoid using jargon.

  • Explain what bronchiolitis is, its natural course, what to look out for and contact details if worsening. This needs to be clear about what normal features of illness are and what are the features which would require parents to return.

  • Establish understanding of explanation.

  • Offer opportunity for questions and ensure you have addressed all ideas, concerns and expectations.

  • Supplement verbal information with written and/or other safety netting resources.

References

Footnotes

  • Contributors Article written by SJG with further editing from all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.