Safety netting is a cornerstone of paediatric practice.
Children are a vulnerable group. Their condition can deteriorate and improve rapidly. Uncertainty is inherent in paediatric emergency medicine. From the child with a fever to the infant with vomiting, we must safeguard children from harm.
Of course, we can’t admit every child to the hospital. Nor should we. The vast majority of patients in A&E return home with reassurance. Easy right? Reassure. Give advice. Send home. Simple?
You’re at the end of a busy shift and have a train to catch. You’ve put in blood, sweat, and tears and feel happy your last patient had a simple throat infection. You advise fluids and paracetamol for symptoms of headache and neck pain and to come back if worried. The mother is anxious; you give them a leaflet on fever and rush out the door.
Typically, our focus is on the front door of care, not the exit. Discharge care is often overlooked. Even in the best of circumstances, we are under pressure to maintain patient flow, especially as our emergency departments become busy again.
The next morning, coffee in hand, you walk in the department and hear the words that strike fear into the hearts of all who hear them…
“Do you remember that child you saw yesterday? They’re being admitted to intensive care, it looks like meningitis.”
What could you have done differently? More tests? Not necessarily needed, no? More time? They had been observed and appeared well for several hours. Senior review? You’d seen them with the Consultant and agreed on the diagnosis. Then what?
Safety netting
Why is it important?
Acute illness remains one of the UK’s most important causes of childhood mortality. Early infection is notoriously non-specific. Take meningitis. A diagnosis is made at the first presentation in only half of cases. So what do we do? We must educate parents about uncertainty. Discuss the potential for deterioration. Explain the importance of seeking further help if necessary. We must have a safety net.
What is it?
The term was first formally described in 1987. It means “advice about what to do and what to look out for to empower parents and carers to seek help if the child’s condition deteriorates further or if they need more support.”
What else should it cover?
In addition to the above, it is critical to cover how they should seek help, what they should expect ahead (the disease course) and when to become worried.
How should it be done?
Whilst verbal and written formats exemplify current practice, ranging from information leaflets to printed discharge letters, audiovisual and online resources are growing in abundance. Families report wanting this varied range of approaches.
Let’s consider the options.
Face to Face – individualized, personal but highly variable and time-dependent
TOP TIP – be adaptable (don’t just simply recite the same information each time)
Social, educational, and cultural differences may all necessitate adapting your usual spiel to truly achieve understanding. Remember, the parents are in an unfamiliar, often noisy, and stressful environment in addition to feeling worried about their child. Expect them to be a little distracted.
Leaflets – standardised, quality assured but not necessarily up to date and potentially bland and uninteresting.
TOP TIP – use leaflets to re-enforce verbal information
When taken home, written materials can often act as an aide memoir.
Audio-visual – engaging and memorable with the potential to overcome literacy and language barriers if well designed, though resource intensive and expensive upfront
Internet, social media, websites, and apps are many innovative ways to connect families with health information. Our responsibility is thus to navigate the clutter, signpost reliable resources, dispel myths and, therefore champion proper evidence-based materials.
TOP TIP – keep the message simple. It can be easy to overwhelm parents with information.
Remember, many parents may not wish to go on the internet. A few may even not have access to it.
Why tailor the information?
As ever, before talking, we must first listen. For example, one interview study found a mother worrying about “their child with cough dying at night through choking on phlegm.” How can we expect our advice to be heard if we do not listen to such fears?
Emotional distress (addressing this)
Physical symptoms (addressing these)
Information (providing this, particularly reassurance, diagnosis and explanation)
Care (basic care, including food, drink and friendliness)
Closure (finding out what’s wrong and, where possible, going home)
An awareness of these priorities can inform our conversations, helping us to better look after our patients from their perspective.
Okay, but what is the reality?
“You don’t actually know how much of that leaflet they’re gonna actually understand, take in, comprehend… going through things step by step, listening, understanding and explaining, I think is more beneficial” (Paediatric ED doctor).
“It’s very difficult to know ‘cause often they’ll nod their heads and say “yes I understand everything you say” and walk off and they might have no idea what we’ve just said” (ED staff nurse).
“If you’ve got a sick child at home and they’re moaning at you, you haven’t got the time to go on the internet… you’ve got a child hanging off your leg going, “Mummy I feel poorly, mummy I want this, mummy I want that”” (Mother).
“My doctor did give like an information leaflet… and I did read through it, because when you’ve got a sheet at least you can find time to do that” (Mother).
So how can we do it best?
After reviewing the literature and FOAMed (see further resources), here are my top tips for giving the best safety netting advice. Enjoy!
Sit down – it has been shown to increase the perception of empathy.
Verbalize back concerns – be explicit that important conditions have been excluded.
Explain things – share reasoning, show your process.
Highlight red flags – signs that necessitate reattendance.
Be specific – ‘If x happens, do y’
Reinforce – provide written leaflets.
Avoid criticism, foster understanding – put yourself in their shoes
Document advice – yes, write down what you said.
As with all good communication, ensure a quiet, private area and avoid using jargon.
Finally, directly ask if parents understand and are happy. Don’t assume they are.
Here is one good example to get you started…
“…your little guy is likely to continue to have vomiting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated. If, however, he becomes drowsy, develops a fever or fails to stay hydrated please call this number and come back to us.”
We must stop thinking of reattendance as a failure – patients do get worse, and some need to return.
Good quality safety netting means both you and your patients can get a better night’s sleep.
References
Almond S, Mant D, Thompson M: Diagnostic safety-netting. The British journal of general practice: the journal of the Royal College of General Practitioners 2009, 59(568):872–874
Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317–20.
Body R, Kaide E, Kendal S, et al. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners, Emergency Medicine Journal 2015;32:15-20.
CS Cornford, M Morgan, L Risdale, Why do Mothers Consult when their Children Cough?, Family Practice, Volume 10, Issue 2, July 1993, Pages 193–196
Gill P, Goldacre M, Mannt D, Heneghan C, Thomson A, Seagroatt V and Harnden A (2013) ‘Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis’, Archives of Disease in Childhood 98, 328–34.
Jones, C.H., Neill, S., Lakhanpaul, M. et al. The safety netting behaviour of first contact clinicians: a qualitative study. BMC Fam Pract 14, 140 (2013)
Jones CH, Neill S, Lakhanpaul M, et al. Information needs of parents for acute childhood illness: determining what, how, where and when of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 2014;4:e003874.
Knight K, van Leeuwen DM, Roland D, et al. YouTube: are parent-uploaded videos of their unwell children a useful source of medical information for other parents? Arch Dis Child 2017;102:910–4.
Mackert M, Kahlor L, Tyler D, et al. Designing e-health interventions for low-health-literate culturally diverse parents: addressing the obesity epidemic. Telemed J E Health 2009;15:672–7.
Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.
Neill SJ, Jones CH, Lakhanpaul M, et al. Parent’s information seeking in acute childhood illness: what helps and what hinders decision making? Health Expect 2015;18:3044–56.
NICE guideline [NG143], Fever in under 5s: assessment and initial management, November 2019. Available at https://www.nice.org.uk/Guidance/Ng143/evidence
Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95:580–2.
Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, Harnden A, Mant D, Levin M: Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006, 367(9508):397–403.3.
Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA, Janson S, Chambers T, McKee M: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. Bmj 2011, 342:d1277.2.
Further resources
RCPCH (2015) Facing the Future: Standards for acute general paediatric services. RCPCH.
RCPCH Safe System Framework, resources accessed 19th November 2019, https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration
Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM, #CommunicatED 1: Discharge & Safety Netting in ED, available at https://www.stemlynsblog.org/communicated-discharge-safety-netting/
Bruera, Eduardo & Palmer, J Lynn & Pace, Ellen & Zhang, Karen & Willey, Jie & Strasser, Florian & Bennett, Michael. (2007). A randomized, controlled trial of physician posture when breaking bad news to cancer patients. Palliative medicine. 21. 501-5.
Sarah Jarvis, Medico-legal adviser
BSc MBBS MRCGP, Playing it safe – safety netting advice, available at https://mdujournal.themdu.com/issue-archive/issue-4/playing-it-safe—safety-netting-advice
Damian Roland, BMedSci (Hons) MBBS MRCPCH, PhD, TIGHTEN UP YOUR SAFETY NET #WILTW, available at
https://rolobotrambles.com/tightenyoursafetynet/
Safety netting – a guide for professionals and parents of sick kids from GP Paedtips
Shame. How it affects patients and their relationships with health care professionals. https://abetternhs.wordpress.com/2012/11/16/shame/
The landscape of safety netting has certainly changed, I’m not aware of very recent reviews. The best organisation I believe is ASK SNIFF, Neill, S., Shang, C., Thompson, M. & Lakhanpaul, M. (2013) Developing Safety Netting Information for Parents: Reviewing the literature on effectiveness. RCN Annual International Nursing Research Conference, Belfast, 20th – 21st March 2013. If it were me I’d get in touch and collaborate with them. I’d love to read your dissertation, good luck!
Really like this article, thank you Carl. I’ve been doing a lot of paeds video consultations in primary care, as lots have with covid, good safety-netting is more important then ever (hence RCPCH poster launched this spring). I’d like to pursue the topic in more depth for my MSc dissertation. Do you know of any full literature reviews or is this still fairly unchartered territory? Dave Owen (ANP)