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• Re:Holes in the net: safety netting in Emergency Departments needs to improve
  Evelien de Vos-Kerkhof
  Published on: 23 May 2016
• Holes in the net: safety netting in Emergency Departments needs to improve
  Hannah C Jacob
  Published on: 20 April 2016

• Published on: 23 May 2016

  Re:Holes in the net: safety netting in Emergency Departments needs to improve

  • Evelien de Vos-Kerkhof, resident in pediatrics & PhD student
  • Other Contributors:
    • Rianne Oostenbrink

  Dear editor,

  In their letter, colleagues Jacob et al. raised further evidence of the lack of standardised safety netting. We thank them for their comments emphasizing the disparity between paediatric trainees' perception of their safety netting practice and their documentation in the medical notes.

  To overcome the lack of information on the difference of given safety netting advice and its documentation...

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  Dear editor,

  In their letter, colleagues Jacob et al. raised further evidence of the lack of standardised safety netting. We thank them for their comments emphasizing the disparity between paediatric trainees' perception of their safety netting practice and their documentation in the medical notes.

  To overcome the lack of information on the difference of given safety netting advice and its documentation in the medical notes, the authors propose the introduction of a checklist. However, at this moment the effective components or the best way to perform this safety netting management still remains unknown.

  A systematic review of Neill et al. states that incomplete information on the illness of their child leaves parents still in need for help.(1) Moreover, irrelevant information reduces parents' trust in the intervention.(1) We know that parental knowledge and satisfaction improved more after video discharge instructions than after written discharge instructions alone.(2) So to proceed we think the next step is to focus on the parental role in the decision making process. One could think of parental monitoring of alarming signs and symptoms of their febrile child. A study on self-referred children with fever emphasized that many parents properly judged and acted on their febrile child's severity of illness.(3) In England every parent is trained to recognise petechial rash,(4) we might enlarge this knowledge to other alarming or reassuring signs and symptoms. This could be initiated for example for respiratory rate, a useful marker of pneumonia, one of the most frequent serious illness at the ED.(5) We are aware of current projects on this topic. A next step is evaluating the impact of such strategies providing improved information on patient (re)consultation.

  In addition to the recognition of deterioration, an important gap in safety netting literature is its time frame strategy. The development of optimal safety netting management should include clinical signs and symptoms, but also a disease specific time frame to inform parents when they should seek help again. This combination of safety netting determinants may establish new starting points for improvement of care.

  References: 1. Neill S, Roland D, Jones CH, Thompson M, Lakhanpaul M, group ASs. Information resources to aid parental decision-making on when to seek medical care for their acutely sick child: a narrative systematic review. BMJ Open. 2015;5:e008280 doi: 10.1136/bmjopen-2015-008280 [published Online. 2. Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to standard written instructions improved caregivers' understanding of their child's emergency department visit, plan, and follow-up: a randomized controlled trial. Pediatr Emerg Care. 2013;29:699-704 doi: 10.1097/PEC.0b013e3182955480 [published Online. 3. van Ierland Y, Seiger N, van Veen M, et al. Self-referral and serious illness in children with fever. Pediatrics. 2012;129:e643-51 doi: 10.1542/peds.2011-1952 [published Online. 4. Acutely sick kid safety netting interventions for families. http://asksniff.org.uk/ 5. Taylor JA, Del Beccaro M, Done S, Winters W. Establishing clinically relevant standards for tachypnea in febrile children younger than 2 years. Arch Pediatr Adolesc Med. 1995;149:283-7 Online.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 20 April 2016

  Holes in the net: safety netting in Emergency Departments needs to improve

  • Hannah C Jacob, Paediatric Trainee
  • Other Contributors:
    • Kate Cohen, Joseph Raine

  Safety netting in the Emergency Department (ED) is key to the practice of safe medicine. Following the article by de Vos-Kerkhof (1), we present further evidence to suggest that there is a lack of standardised safety netting. In addition, we found a disparity between paediatric trainees' perception of their safety netting practice and what they actually documented in the medical notes.

  In a retrospective case...

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  Safety netting in the Emergency Department (ED) is key to the practice of safe medicine. Following the article by de Vos-Kerkhof (1), we present further evidence to suggest that there is a lack of standardised safety netting. In addition, we found a disparity between paediatric trainees' perception of their safety netting practice and what they actually documented in the medical notes.

  In a retrospective case notes review of 100 consecutive ED attendances to our hospital seen by the paediatric team and discharged from ED, only 16% had documentation that the families had been told about the existence of uncertainty around the diagnosis and the course of the illness. This compares unfavourably with the fact that 73% of surveyed paediatric trainees reported that they routinely mentioned this to families. Furthermore, the signs and symptoms to look for had only been documented in 27% of cases, though 88% of trainees reported discussing this with the family. 39% of the notes reviewed had no specific safety netting documentation of any kind.

  It is clear that for non-consultant paediatricians, who are the clinicians seeing most referred children in ED, a gap exists between the safety netting that they report undertaking and what is documented. This may be in part because they provided verbal safety netting advice without documenting it but it also suggests that safety netting procedures are poor, despite the clinical and medico-legal imperative for adequate safety netting and documentation advocated by the National Institute for Health and Care Excellence(2).

  Clearly training for junior doctors on safety netting and its documentation needs to improve. A safety netting checklist and more high quality patient information leaflets may help clinicians to offer adequate advice and information to families at the time of discharge. (297 words)

  1. de Vos-Kerkhof E, Geurts DH, Wiggers M, Moll HA and Oostenbrink R. Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care. Archives of Disease in Childhood. 2016; 101: 131 -9.

  2. Fields E, Chard J, Murphy MS and Richardson M. Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance. BMJ (Clinical Research Ed). 2013; 346: f2866.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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