Safety Netting

Cite this article as:
Carl van Heyningen. Safety Netting, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28803

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, it is up to us to 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 you have a train to catch. You’ve put in blood, sweat, and tears and feel happy your last patient has a simple throat infection. You advise fluids, 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 begin to 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 that 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 most important causes of childhood mortality in the UK. Early illness is notoriously non-specific. Take meningitis. In only half of cases, diagnosis is made at the first presentation. 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 safety net. 

What is it?

The term was first formally described in 1987. Today, it has come to mean “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 in order 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 distracted a little. 

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 memoire.  

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, apps – there are many innovative methods of connecting families with health information. Our responsibility is thus to navigate the clutter, signpost reliable resources, dispel myths and thus champion true 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 based study found a mother worrying about “their child with cough dying at night through choking on phlegm.” If we do not listen to such fears how can we expect our own advice to be heard. 

Parental priorities

Parents priorities include… 

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.

Ok, 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 very best safety netting advice, enjoy! 

  • Sit down – it has been shown to increase the perception of empathy 
  • Verbalize back concerns – be explicit 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 

And 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 nights sleep. 

References

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.

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. 

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. 

Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.

NICE guideline [NG143], Fever in under 5s: assessment and initial management, November 2019

Available at https://www.nice.org.uk/Guidance/Ng143/evidence

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

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.

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. 

Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317–20.

Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95:580–2.

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.

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.

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

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.

(15) 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, C.H.D., Neill, S., Lakhanpaul, M., Roland, D., Singlehurst-Mooney, H. and Thompson, M., (2014) 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 4 (1). 

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/ 

Change the System, not the people: Neil Spenceley at DFTB19

Cite this article as:
Team DFTB. Change the System, not the people: Neil Spenceley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22275

Neil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety.

This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level.

If you just want to read one key paper to get you started then read this one from paediatric surgeon, Lucian Leape.

Leape LL. Error in medicine. Jama. 1994 Dec 21;272(23):1851-7.

If you want to read two papers (and we suggest you should) then download this one too.

Hollnagel E. Human error. InPosition paper for NATO conference on human error 1983 Aug.

 

 

 

Doodle medicine sketch by @char_durand 

 

©Ian Summers

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button

Selected References

 
Cook RI, Nemeth CP. “Those found responsible have been sacked”: some observations on the usefulness of error. Cognition, Technology & Work. 2010 Jun 1;12(2):87-93.
 
Katz D, Blasius K, Isaak R, Lipps J, Kushelev M, Goldberg A, Fastman J, Marsh B, DeMaria S. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ quality & safety. 2019 May 31:bmjqs-2019.
 
Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks RJ. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Qual Saf. 2017 May 1;26(5):381-7.
 
Hollnagel E, Amalberti R. The emperor’s new clothes: Or whatever happened to “human error”. InProceedings of the 4th international workshop on human error, safety and systems development 2001 Jun 11 (pp. 1-18). Linköping University.
 
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2017 May 1;26(5):417-22.
 
Wu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. BMJ Online 2000

Keeping little folk safe

Cite this article as:
Kristin Boyle. Keeping little folk safe, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.13844

If my house were a workplace, it would be an emergency department. We operate 24-7, there are frequent tears and sometimes blood, and always a little too much to do in the allocated time. We have also recently experienced a surge in workload, which has arrived in the form of a soft cheeked, downy haired, sweet smelling, all around delightful baby boy. We jokingly refer to him as The Royal Baby, for he is indeed a teeny dictator, but a benevolent one who bestows smiles generously upon his subjects, and is happy to converse with one and all, albeit with a limited vocabulary.

Trampoline injuries

Cite this article as:
Andrew Tagg. Trampoline injuries, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.7954

4-year-old Calvin received the best Christmas present ever – a trampoline of his very own! After spending the morning bouncing with his older brother, Iggy, he started to complain of pain in his left knee.  The trampoline was safety-netted so his parents were happy that he couldn’t have fallen out and so, mystified that he still refuses to walk, he is brought in to the emergency department.

 

Bottom line

  • Prevention is better than cure so employ these trampoline rules:
    • Only one child on the trampoline at a time
    • Always have adult supervision
    • Make sure the trampoline is in good working order
    • Keep it away from walls and other potential hazards

 

How common are trampoline injuries?

Trampoline related injuries are uncommon in adults. There were only 50 reported in Victoria between 2007 and 2013 with lower limb injuries being the most prevalent. 2200 children presenting to Victorian emergency departments within a similar time-frame. Victorian data demonstrated an 18% increase in multi-user injuries with an over-representation in children under 4 years old.  With Christmas approaching and trampolines being on many children’s’ wish lists the Victorian State Government has put out a press release to make parents more aware of the dangers.

 

Has legislation made any difference?

The Australian trampoline standard (AS 4989-2006) is a voluntary industry standard that recommends the protection of sharp edges, spring and frame padding. The Standards Australia Trampoline Committee is looking to make these standards mandatory.

Whilst injuries related to the makeup of the trampoline itself (i.e. spring and frame injuries), as well as fall injuries has decreased, there has been an increase in injuries related to one or more users. The use of safety-netting to stop kids falling off has not been shown to decrease the number of injuries. Parents may be falsely reassured that they do not need to supervise their kids once they are enclosed.

 

How are these kids injured?

Injuries occur to:

  • Multiple users
  • Falls from the trampoline
  • Impact with the frame or springs

Some of them fall into the structural framework of the apparatus but they are more likely to bump into each other or sustain a lower limb injury as a result of a double-bounce. If you really want to look into the physics of the double-bounce then read this riveting paper.

 

Are there any trampoline specific injury patterns?

Lower limb injuries are more common than upper and subtle proximal tibial physeal fractures may be difficult to detect on initial x-rays and require a bone-scan to make a delayed diagnosis. As the child bounces, often with another occupant, the knee hyperextends as is subjected to an axial load leading to a small torus or buckle fracture in the region of the physis. They may present with reluctance to walk after playing in the yard.

Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 20622

There are some less common injury patterns such as manubrio-sternal dislocations, vertebral artery dissection (due to cervical hyperextension and rotation) and atlanto-axial subluxation.

 

An X-ray revealed no obvious abnormality, even when the anterior tilt angle was taken into consideration. He was placed in an above-knee back-slab and referred on to orthopaedic outpatients for evaluation. A bone scan performed a few days after the injury, made the diagnosis of small fracture more likely. There were no adverse sequelae of this delay in diagnosis.

 

References

3AW talk to Warwick Teague (@doctorwozza) – Director of Trauma at the RCH, Melbourne

Arora V, Kimmel LA, Yu K, Gabbe BJ, Liew SM, Kamali Moaveni A. Trampoline related injuries in adults. Injury. 2015 Sep 11. pii: S0020-1383(15)00539-2.

Ashby K, Eager D, D’Elia A, Day L. Influence of voluntary standards and design modifications on trampoline injury in Victoria, Australia. Inj Prev. 2015 Oct;21(5):314-9.

Ashby K, Pointer S, Eager D, Day L. Australian trampoline injury patterns and  trends. Aust N Z J Public Health. 2015 Oct;39(5):491-4.

Briskin, Susannah, et al. “Trampoline safety in childhood and adolescence.”Pediatrics 130.4 (2012): 774-779.

Stranzinger, Enno, et al. “The anterior tilt angle of the proximal tibia epiphyseal plate: A significant radiological finding in young children with trampoline fractures.” European journal of radiology 83.8 (2014): 1433-1436.