What I learnt this week: Let’s consider ‘appropriateness’ inappropriate #WILTW

This is the 93rd #WILTW

I saw two children this week who were, by any measure of illness severity, both well. They were not in discomfort,  were both interested in their surroundings and had no derangement of their physiology (i.e normal heart and breathing rates). While some would have you believe their presence in an Emergency Department was inappropriate this was not the case. In fact one of the children attended on my specific instructions.

Currently most Emergency Departments are under considerable pressure. In-flow (the number of patients arriving in a given time frame) is high and out-flow (the transfer of patients to the wards) is slow.

(click here if the video doesn’t play)

Exit block and high inflow stretches the capacity of departments with the potential to result in patient harm. The situation is much worse in  adult practice than in paediatrics but considerable effort has gone into both streams to  reduce some of the pressures departments are under. This attention has resulted in an unfortunate phrase, “the inappropriate attender”. There isn’t a clear definition but most people would understand it to mean the patient who doesn’t need to be there. To use old parlance – It is neither an accident or an emergency.

So why were the patients I’d seen not inappropriate? Well here is the thing. Medicine is not black and white; even between experienced professionals there are differences of opinion on magnitude of illness. Why should we then expect parents to always make good judgement calls with no medical knowledge; especially when they have such an emotional bond invested in the situation? Furthermore there is an information balancing act that we are exposing families to which isn’t always equal. As explored in a previous #WILTW we simultaneously highlight the risks of sepsis, but tell people not to attend Emergency Departments and then denigrate  NHS 111.

Anxious mother and baby

One of the children had returned from a visit the previous day as she had developed symptoms I’d described to the father as things to look out for. Safety net advice should be given to all families or carers of children who are discharged home, especially those who are at risk of serious bacterial illness. While the patient had returned to the department very well she hadn’t passed urine in a considerable period of time. I had mentioned this in a safety net list prior to their discharge the previous day.

Safety Net

Had I been too concrete in my explanation? Had the father over-reacted and could they have gone to another health care service? While these are all concerns a commissioner of services may have expressed, the fact that I am (allegedly) experienced in safety netting and that the child had spent considerable time in the Emergency Department the previous day being observed, I think it would be churlish to criticise in this situation.

The second child had been brought to the department as their sibling had died of pneumonia the previous year. Having been unwell for a week with a cough and potential breathing difficulty the mother had become anxious he was becoming more unwell. It was late at night and she was very concerned about her son. The relief in her face on being told that he didn’t have a serious illness was obvious. Certainly perhaps an out-of-hours General Practitioner (Family Doctor) could have provided similar reassurance but I don’t think her attendance in an emergency department was unreasonable either.

I will be honest, I have seen children where I am surprised any form of health care has been sought let alone the Emergency Department. However in the context of increasing health care demand and changing public expectations I tend to find explanations behind many of our presentations which may be labelled ‘inappropriate’. I think it is time we removed this term and considered system wide interventions to best serve the patients who believe, and often do, need our help.

What have you learnt this week #WILTW

Details have been amended to ensure patient anonymity 

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6 thoughts on “What I learnt this week: Let’s consider ‘appropriateness’ inappropriate #WILTW”

  1. Great thoughts Damian
    I like to ask”why are you here” rather than focus on the patholphysiology.
    Most parents would really love to avoid the crazy ED waiting room. They usually have a good reason to brave it!
    Asking up front the “why” in genuine words saves a lot of second guessing
    Well directed reassurance is golden – where standardised DC instructions are often not reassuring at all
    Empathy…. it’s key
    Casey

    1. Directed safety net advice – very much agree. The other thing that goes wrong is the failure to recognise the natural history of illness. Don’t tell the parents of a child with diarrhoea or vomiting to return if the child vomits – that is what is going to happen! (i’ve seen families return to the department having only just made it to their cars…)
      Safety net advice needs to be focused on identify changes in behaviour or symptoms which demonstrate a change in the pattern of the illness not that the illness itself is ongoing…

      [except fever which needs at second thought at five days…]

  2. You make some excellent points. As an aside, I don’t think 111 as a service works well for most truly paediatric concerns (in my experience). Also I think whilst OOH GP/nurse practitioners are a great idea, often all parents want is that reassurance and many practitioners in OOH are not confident enough to give good safety-netting advice. I see parental frustration when they finally make it to PAU and I give them the simple reassurance and send them on their way. The solution is more general paediatric training but sadly we all know there is less investment in training as time goes on.

  3. Absolutely agree with Casey. Most parents don’t want to be waiting hours or visiting the ED. There is usually a reason.

    My safety net always includes the proviso, “its not uncommon for us to see the same child a number of times through a course of an illness like this, please do not hesitate to come back if you have any concerns or things change”.

    With a well crafted safety net, education about the disease, what normal progress would expected to look like, concerning signs and symptoms, the vast majority of parents wont return and the child will do well. The parents who return repeatedly often have an underling concern or issue that needs addressing…. Very very rarely do we see kids who are inappropriately brought to ED (less than 5%). Even a kid with otitis media is appropriate to be seen in ED if other avenues have been explored, parental anxiety etc.

  4. Having been told that I was an ‘over anxious medical mum’ when I took my daughter to an OOH GP many years ago, and subsequently being reticent about returning the following day (when she was promptly admitted to PICU with septic shock and then spent 4 weeks in hospital with mastoiditis and an extra dural abscess) I will never tell parents their attendance is inappropriate. It is impossible to be rational about your own child.

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