Tighten up your safety net #WILTW

This is the 176th #WILTW

Assume = to make an ‘ass’ out of ‘u’ and ‘me’.

Assumption is my enemy.

I can’t assume in a hectic resuscitation that an instruction has been heard unless it is confirmed back to me. I can’t assume relevant clinical signs have been identified when a patient is discussed with me and I can’t assume I always make the right diagnosis.

A further challenge when you become an autonomous practitioner is that it’s much more difficult to determine how your colleagues practice. The assumption is you do things in a similar way but you never really know this. It’s part of the reason why I enjoy immersing myself in Social Media. It’s a great way of determining and sense-checking what other people do.

Safety-netting, the provision of information to help patients or carers identify the need to consult a healthcare professional if a health concern arises or changes, is an important intervention where there are probably many different ways of saying the same thing.

https://www.pinterest.co.uk/pin/427560558347927388/

The assumption is that there is a common approach but recent conversations lead me to believe this may not be the case. If only to start a debate, I’ve determined the 5 principles I use to structure my safety netting advice.

Avoid enacted criticism – Your advice is about the future trajectory of illness not implying what the parents or carers could have done to have avoided seeing you in the first place.

Establish the process of making a diagnosis is a partnership – This is what you have told me and this is how I have interpreted it, so this is the suggestion for what we are going to do. I often quote a comment a parent/carer has made about their child’s illness. This demonstrates I have been listening and am interested in addressing concerns. This phase is important as this sets the scene for the key component of safety net advice..

Explain the natural history of the disease process if your diagnosis is correct – one of the worst things to do is suggest that typical symptoms of the illness you have diagnosed could be worrying. A child with gastroenteritis will vomit and have diarrhoea.

If he vomits bring him back” is NOT safety net advice.

“…your little guy is likely to continue to have vomitting 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” is more useful.

Explain what the features of illness will be if your diagnosis is incorrect or the disease process worsens – I am very clear to parents  that 24 hours is a long time in a small child’s life, the decision to discharge is based on the features of illness now. These may change.

Openly ensure shared understanding. I directly ask if the parents or carers are happy with the decision that is being made. It is rare to be caught out at this stage, but I still find some clinicians seem unable to read parental body language, so I always suggest my juniors do this.

I don’t assume that this is a perfect approach, and certainly there will be individual nuances at a patient level. Would love to hear from others about their approaches.

What have you learn this week? #WILTW

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4 thoughts on “Tighten up your safety net #WILTW”

  1. Great post Damian.

    As a researcher looking into safety-netting (mainly in primary care) I really like your definition of safety-netting. Although I would argue this is safety-netting ‘advice’, as I know other groups are working on different forms of safety-netting. I would also add into the definition if the current symptoms ‘abnormally persist’, e.g. fever in child >5 days, adult with rectal bleeding thought to be haemorrhoids, although I suppose you could argue this could be classified under a ‘healthcare concern arising’ if the patient / carer was given sufficient information to be able to identify this concern.

    I would also suggest that “If he vomits bring him back” is NOT SUFFICIENT / HELPFUL safety net advice, although again you could argue it does not fit the definition as there may be no ‘need’ to consult a healthcare profession should this situation arise!

    Interested to hear what you think about the national push for education around the symptoms of sepsis – mainly down to the hard work of the UK Sepsis Trust.

    I guess one of the unturned stones in my head, is any potential harms from safety-netting advice e.g. undue anxiety, unnecessary reconsultation (although I’m aware of the RCPCH study which REDUCED reconsultation rates!). There appears to be little research evidence in this area but I know which side I would rather be on both as a clinician and as a patient (the appropriately safety-netted side!).

    Looking forward to seeing more great work from the ASK-SNIFF team.

  2. Thanks Peter – all great comments/observations.

    One of the issues is the lack of clarity around what “safety netting” actually is. The definition I used was one we developed for ASKSNIFF but we concede if you consider safety netting in cancer, for example, it might not work was well.

    One of the things I didn’t cover in this blog was the difference between PRE- and POST- safety netting (i.e before or after clinical review) – the former typically delivered by information campaigns and the latter by direct contact. Bit as we’ve found in our research ( http://onlinelibrary.wiley.com/doi/10.1111/hex.12289/full) it’s important that a wide variety of methods are used in either circumstance.

    Without appearing coming across as too blunt my comment about the vomiting was made as too often I hear or am told this is the advice given. Personally I think it shows a lack of education in providing safety net advice which is fault of clinical educators (i.e people like myself) I think more than the individuals themselves.

    The awareness campaign led by the sepsis trust has probably been instrumental in saving lives. It is important we don’t confuse awareness, education and screening. I personally don’t believe current nationally “prescribed” screening processes are effective or valid and too much emphasis is placed on retrospective admonishment of not meeting screening targets. Much more work must be done on creating clinical valid and sustainable standards that can be used to drive improved performance in this area.

    I don’t believe good safety net advice causes unnecessary anxiety or an increased return rate (http://emj.bmj.com/content/28/Suppl_1/A13.3). I have no evidence to back this up but I am convinced badly delivered safety net advice does. In fact badly delivered safety net advice may be worse than not at all!

  3. The other component here is HANDOVER. Too often in Primary Care we receive ‘discharge sunmaries’ several weeks after the episode AND/OR peppered with phrases ‘GP to chase…’ on important tests.

    Re-frame the discharge summary from an administrative chore delegated to juniors, into a clinical handover between senior clinicians. As such needs to be concise, have a therapeutic trajectory and be agreed

    1. Thanks Tim – a great observation. A discharge summary is a form of “safety netting” and should probably follow the same principles!

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