Abstract
In primary care, consultations often conclude with the patient being advised to seek medical care if their symptoms become worse or do not resolve; which is known as safety-netting advice (SNA). Although it is widely accepted that patients should be given SNA, studies have shown that there is a wide variation in the quantity and quality of SNA given to patients, with patients reporting that the information they receive is often vague and unhelpful. This article explains why providing patients with SNA is essential for safe practice and describes how safety-netting can be improved by coming to the consultation with pre-prepared SNA and a system for delivering that advice to the patient.
Case scenario
Emma is 5 years old, and has woken-up with a fever and a headache, which has developed overnight. Emma is normally fit and well. Your assessment reveals that Emma has no symptoms, signs or clinical findings to indicate the presence of a serious illness at the time of your assessment. Your impression is that Emma is in the early stages of an infective illness, the exact nature of which has yet to become apparent. How would you decide whether to refer, review or safety-net Emma and what safety-netting advice (SNA) would you give Emma and her mother?
SNA: Principles
Studies have shown that diagnostic uncertainty and incorrect diagnoses are relatively common in primary care and that they have the potential to cause serious harm to patients (Silverston, 2020a; Singh et al., 2017; Slawomirski et al., 2018).There is the potential for a serious complication from a minor illness to develop after the consultation. It is important to understand why these risks exist and why they occur more frequently during consultations in primary care. In Fig. 1, which is a model of the mechanics of diagnosis, it can be seen that diagnosis involves comparing the clinical assessment findings to what is known about the causes of a symptom and the diagnostic criteria for each cause, through the application of diagnostic reasoning. Each of the components of diagnosis is subject to its own limitations and imperfections. There is a limit to how much knowledge can be acquired, retained over time and recalled during a consultation. Clinical assessment is not a perfect information-gathering tool and the information that is gathered may be unreliable, inaccurate or misinterpreted. Diagnostic reasoning is affected by faulty heuristics, cognitive bias and both reasoning system and human errors. Any of these factors can result in a diagnosis being uncertain or incorrect.
The mechanics of diagnosis.
In primary and urgent care, the risks of diagnostic uncertainty and incorrect diagnoses are increased because of the wide range of patients and symptoms encountered, the large number of different causes for these symptoms and the infrequency with which some of these illnesses occur (Colliers et al., 2022). The nature of GP consultations and the high workload provide little opportunity for the GP to think about, reflect on and review diagnoses. However, one of the most common causes of diagnostic uncertainty and incorrect diagnoses in primary care stems from the relationship between illness, findings and diagnosis. Figure 1 shows the fundamental role that clinical assessment findings have in establishing the diagnosis. This creates the potential for a change in the findings to result in a change in the diagnosis. Figure 2 is a visual model of illness depicting the relationship between illness, findings and time. This shows that the findings are different at points A, B and C in the illness. The effect this has on diagnosis can be seen from the introduction of two illnesses to this model, one a serious (red line) illness and the other a minor (blue line) illness. At point A, it is impossible to distinguish the serious illness from the minor illness because the diagnostic findings that permit this have yet to develop. Similarly, a serious complication has yet to begin. This creates diagnostic uncertainty and the potential for a diagnosis made at point A in an illness to be incorrect. It also explains why the inability to establish the correct diagnosis at this point in the illness is not a reflection on the competence of the GP, but rather is due to the relationship that exists between illness, findings, time and diagnosis. In primary care, patients often present at point A in their illness, thus increasing the risk that a diagnosis may be uncertain or incorrect. The purpose of SNA is to help patients to manage these risks safely by providing them with the information that they need to be able to recognise that their illness is no longer following a blue line trajectory and what the response should be if this happens (Edwards et al., 2022).
The model of illness.
SNA: Practices
Before providing SNA, it is important to determine whether it would be more medically-appropriate and safer for the patient to be referred, or reviewed. This decision should be based on a holistic risk assessment and risk/benefit analysis, during which a wide range of medical, social and other factors need to be considered. A referral to hospital at point A in an illness is appropriate if investigations can deliver diagnostic certainty but it should be appreciated that investigations performed at this point in a serious illness have the potential to be either negative, or equivocal. Thus, the medical value of referral at point A may be limited and it may be more appropriate to review, or safety-net, the patient. Referral to hospital may be appropriate if the patient is at risk of developing a rapid-onset serious illness, or if the patient is medically or socially vulnerable, when close monitoring may be required until the period of highest risk to the patient has passed.
Deciding whether to review or safety-net a patient involves balancing the needs of the patient against the needs of the health care system. Some patients will require a medical review and re-assessment of their findings, but this needs to be balanced against the impact that this has on the number of appointments available for other patients. A medical review is indicated if it would require someone with medical knowledge, skills and equipment to re-assess the patient and interpret these within the context of the patient and their illness. A review is also required if there are concerns that the patient may be unable to understand, follow, or recall SNA, or if there are concerns that the patient may be unable or unwilling to make a follow-up appointment themselves. It is important that patients who are being reviewed are also given SNA, as their condition may deteriorate prior to the follow-up appointment. This is particularly important when the diagnosis is uncertain and a serious illness is included amongst the differential diagnoses, or if the patient is at increased risk of developing a rapid-onset, serious complication.
Once it has been determined that a referral or review is not indicated, the next step is to identify those patients in whom providing SNA is considered particularly important due to the increased risk of serious harm. This includes patients where a serious illness, such as cancer, features amongst the differential diagnoses, or when there is an increased risk of a serious complication developing later because the patient is medically or socially vulnerable (Almond et al., 2009; Heyhoe et al., 2022). It should also be provided to patients when time is used as a diagnostic tool to establish the correct diagnosis, or to postpone referral, investigation, or treatment. However, it should be appreciated that although these patients are at increased risk, other patients will have some level of risk and no-one is at no-risk of an adverse event. Diagnosis is not a perfect tool and illness is a dynamic process, which means that no matter how certain a diagnosis may be at one point in time, there is always the potential for that diagnosis to change and for the initial diagnosis to be incorrect. Medicine can be a humbling profession. Furthermore, although the risk of a serious complication, such as sepsis, may be small for the individual patient, it can be life-threatening or life-changing, should it occur.
A three-step approach should be adopted when providing SNA to patients. The first step is to create the medical content of the SNA, which is a function of the specific serious illnesses and complications that the patient is at risk of developing. This is why the medical content of the SNA given to a patient with a minor head injury differs from that for a patient with acute back pain, or for a child with a fever. A fundamental principle in setting the medical content of SNA is that treatment outcomes are generally related to the point in the illness at which treatment is initiated. In other words, it is better for the patient if treatment is initiated at point B in a serious illness or complication than at point C. Thus, the aim should be to inform patients of the earliest possible findings that would indicate that their illness is no longer following a blue line trajectory, but is beginning to take a red line trajectory, instead. This makes it necessary to explain to patients what the findings are for a normal pattern of a minor illness, so that they can recognise that any changes from this could indicate that a serious illness is developing. These are often the earliest indicators (early amber flags) of a developing serious illness. It also emphasises the importance of informing patients of the early findings (amber flag findings) for the specific serious illnesses and complications that the patient is at risk of developing, as well as the later findings (red flag findings).
This calls into question the clinical value of telling a patient to ‘come back if it gets worse’ without specifying the findings that should trigger a response. Although a patient is likely to recognise that they are at point C in a serious illness because of the severity or prolonged duration of the illness, they may not recognise or recognise the significance of the amber flag findings at point B. The result may be delayed treatment and a worse treatment outcome. If we want patients to respond at that right time, at the right speed, to the right place and in the right way, then we need to provide them with the specific information that is required to enable them to do this. For example, in the scenario above, telling Emma’s mother to ‘come back if it gets worse’ or ‘if she is worried’ is insufficient for her mother to make an informed decision about when and how she should respond. Studies have shown that patients often report that the SNA that they have received is vague and unhelpful for making informed decisions (Edwards, 2016; Jones et al., 2013; Cabral et al., 2014; Jones et al., 2019). An insight into how much information is required for informed decision-making can be gained from reading the SNA sheets for conditions such as minor head injuries, meningitis and sepsis (Meningitis Now, 2022; Reed, 2007; Sepsis Trust, 2020). In each case, the content was created by experienced clinicians working with feedback from patient groups to determine how much information was required by the patient/parent to make an informed decision. In the absence of detailed information, there is a risk that Emma may return either too late, when treatment is less effective or ineffective, or too early, when treatment is not required.
The next step is to convert the medical content into the patient content. This involves converting the medical information into a language and form that is patient-centred and patient-friendly. The aim should be to provide the patient with sufficient information to allow informed decision-making, but not to overload the patient with so much information that key messages are missed, or not remembered later. This is particularly important when SNA is only being delivered verbally, as studies have shown that 40–80% of information imparted during the consultation is forgotten immediately, and that there is further memory decay over the course of the illness (Kessels, 2003; Watson and McKinstry, 2009). This is why it is important to support verbally-delivered SNA with written information, whenever possible. If written information is not available, then the focus should be on providing the patient with the key amber and red flag findings, in a way that takes account of the patient’s age, language and culture and to deliver the information in a way and at a speed that the patient can understand and recall later.
However, best practice is to provide the patient with written information. Not only does this reduce the risk that key pieces of information may be forgotten over time by the patient, but it also changes the function of verbal SNA and the time required to deliver verbal SNA during the consultation. When written information is available, the purpose of verbal SNA is to introduce and reinforce information, rather than provide a detailed explanation. It should also be borne in mind that patients may be monitored by someone other than the person who was present during the consultation. Whereas the full content of written SNA can be shared with others caring for the patient, verbally-delivered SNA may not be passed on at all, or only in part.
One of the problems for both GPs and patients is that there is considerable variability in the quantity, quality and presentation of information between the various SNA sheets and other resources that are available. The option is to either distribute the best examples of what is available or to incorporate the information from these examples into a SNA template. A SNA template can include an explanation of safety-netting and include visual models to support the explanation and provide a uniform approach to the presentation of information, such as with a traffic light system of action plans. This makes it easier for patients to understand and access information across the symptoms and conditions covered by the different SNA sheets. Once the template has been created, the task of populating each SNA sheet with specific information from trusted sources can be shared amongst all the members of the practice team. Written information can be handed to the patient during face-to-face consultations, sent to the patient electronically when consulting remotely, or made available on the practice’s website, where it can help patients to decide whether or not they require an appointment and advise them on what they can do manage their symptoms themselves.
Safety-netting tools
Checklists, mnemonics and visual models are used in medicine to organise information and to facilitate its recall (Ely et al., 2011). The following safety-netting tools combine mnemonic checklists and visual models that can be used to help make the decision to refer, review, or safety-net a patient more systematic and to improve the content and delivery of SNA.
The 6-C’s risk assessment tool
The 6-C’s risk assessment tool (Box 1) is used to help make the decision on whether to refer, review, or safety-net a patient more systematic and holistic (Silverston, 2021). The first 3-C’s relate to the medical factors that need to be considered. Many guidelines contain symptom or disease-specific risk assessment and decision-making tools, such as the CRB-65 or DS CRB-65 score in patients with pneumonia (British Thoracic Society, 2009; Dwyer et al., 2014). Incorporating these criteria into the decision-making process can help make decisions more objective and consistent. It is important to consider whether a lay person is capable of identifying the specific amber or red flag findings, or whether a medical review is required to identify these. It is also important to evaluate whether a patient is capable of caring for themselves and calling for help if their condition deteriorates. This requires a careful and holistic evaluation, as there are many potential risks to consider. For example, a patient or carer with dementia may not be able to recall verbal SNA and a patient with alcohol or substance misuse problems may experience periods when they are incapable of caring for themselves or someone under their care. The 6-C’s.
The other 3-C’s involve checking for reasons why the patient may not be able to comprehend or follow SNA. There may be physical, mental, emotional, or practical reasons why a patient may be unable to follow SNA, or a language or culture barrier. Or, it may simply be that the child’s temperature needs to be monitored and a thermometer is not available to the patient. It is also important to confirm with the patient that they have understood the SNA that has been given and to ask whether any aspects of it require further explanation. If there are any doubts that the patient or carer may not have understood the information or may not be able to follow it, then a referral or medical review may be the safer option for all concerned.
SAFER medical content tool
The mnemonic SAFER (Box 2) can be used to help create a list of the specific amber and red flag findings of which the patient needs to be informed (Silverston, 2020b). The first is to identify the specific serious illnesses and complications that the patient is at risk of developing. A patient safety focus can be added to this by considering the causes that are most frequently missed, misdiagnosed or diagnosed late. In primary care, 70% of incorrect diagnoses involve three disease processes, namely cancers, acute vascular events and serious infections, known as ‘The Big-3’ (Newman-Toker et al., 2019). Early and atypical presentations of serious illnesses and complications are often incorrectly diagnosed, so it is important to consider these. A list of the amber and red flag findings for each of these can then be created. To this list, the findings that do fit with a normal pattern of a minor illness (green flag findings) and those that would not fit with this diagnosis (early amber flag findings) can be added. This information can then be used to populate a traffic light system of action plans for the patient to follow. SAFER.
SBART SNA tool
The mnemonic SBAR was developed to facilitate the transfer of information between clinicians during patient hand-overs and it can also be used for delivering verbal SNA to patients, as SBART (Box 3) (Park, 2020). This should begin with an explanation of what has and has not been found during the assessment, and the significance of these findings. Linking findings to diagnosis is helpful for patients, because it helps them to understand why certain diagnoses are being made, considered, or excluded and it introduces them to concepts such as diagnostic uncertainty and incorrect diagnoses in early illness. An explanation of what is expected to happen over the course of the illness can then be provided, so that the patient is aware about the normal pattern of that illness. Figure 3 can be used to help patients understand why a diagnosis can change over the course of an illness and why a diagnosis may be uncertain or incorrect at point A. It can also be used to help explain why SNA is required and its purpose. Patients who are at increased risk of serious complications because of their medical or social vulnerability can be given advice on measures that need to be taken to help protect themselves from harm, such as following Sick Day Rules, responding more rapidly to the development of an amber flag finding, or being supervised constantly at home until the danger period has passed (Health Improvement Scotland i-hub, 2021). SBART.
Explain what you have/have not found and the significance of these findings Explain what is expected to happen if the diagnosis is correct (symptoms, signs, duration)
Use Fig. 3 to help explain what might happen and why Discuss any specific risks that the patient has (i.e. comorbidities, medication, living alone)
Describe the assessment that is required: What to check for (amber & red flags) How to check for these findings How often to check for these findings (day/night)
Describe the response required: How rapidly to respond Where to respond to How to respond
Use Fig. 4 to introduce the traffic light system and action plans Provide the patient with a set of symptom or condition-specific action plans
Model of safety-netting.
The second part of the mnemonic involves explaining to the patient what is required from them in the way of the assessment that they need to perform and the response to the development of amber or red flag findings. When written information is being supplied to the patient, verbal SNA should aim to highlight the key points and clarify any points about which the patient is unsure. When written information is not available, it is important to focus the SNA on providing essential information, in the knowledge that the patient will only be able to recall a relatively small amount of information delivered during a consultation, or home visit. An ABCDEF (Box 4) approach can be used to focus attention on key findings about which patients and parents need to be aware, and for which they need to check. Patients need to know for what to check, how to check for these findings and how often. They also need to know how rapidly to respond to a finding, where they should respond to and how to access this response. A good way of bringing this information together for both GPs and patients is to create a traffic light system of action plans for the patient to follow. Figure 4 can be used to introduce this concept to the patient, as it helps patients to understand that symptoms and signs can change over the course of an illness and introduces terms such as green, amber and red flag findings and the action plans that are related to these findings. The assessment and response relating to each action plan can then be explained to the patient. ABCDEF.
Traffic light action plans.
Case scenario review
Unless there are any concerns raised during the 6-C’s assessment, it would be appropriate for Emma to remain at home, with SNA. However, what should that SNA be? Telling Emma’s mother to bring her back ‘if it gets worse’, or ‘if you are worried’ leaves her mother with more questions than answers. How much worse? How much more worried? For what should she check, and how often? Should she check Emma overnight, or leave her to sleep? If she thinks that Emma is getting worse, should she take her to hospital, contact NHS-111, or wait until surgery re-opens? Providing Emma’s mother with SNA that answers these questions can help her to make the right choice, at the right time. Emma has a headache and fever, which raises the possibility that she could be in the early stages of meningitis, or that she could develop sepsis later. Although these illnesses are both uncommon, they can be devastating for all concerned should they occur. In children, providing parents with SNA has been shown to have the potential to reduce both morbidity and mortality from serious illnesses such as sepsis and meningitis and to reduce the re-consultation rate in children with minor illnesses (Neill et al., 2018). Emma’s mother could be provided with written information, or directed to one of a number of websites that provide this information (Meningitis Now, 2019). When delivering verbal SNA to parents of children with a fever, the mnemonic ABCDEF (see box 4) can focus attention on the key findings for which to check, which is based on the National Institute for Health and Care Excellence (NICE) guideline for the assessment and management of children under the age of 5 who present with a fever (NICE, 2019).
Discussion
Limitations and imperfections in the diagnostic process create the potential for a diagnosis to be uncertain or incorrect, and the dynamic and often unpredictable nature of illness presents the possibility that a serious complication may develop after the consultation. This can result in serious harm for patients and heartache and complaints for GPs. Diagnostic risk requires diagnostic risk management strategies and interventions. When a patient presents at point A in their illness, as they often do in primary care, it is essential for safe practice that these risks are managed in the most effective and safest way possible. Time is an effective diagnostic tool for establishing a diagnosis, but it brings with it the risk that time may unmask the diagnosis of a serious illness, or that the patient may develop an uncommon, but serious, complication later. Providing patients with SNA is a way of protecting both the patient and the GP from these risks, which is why it is considered that providing patients with SNA is considered to be best practice. However, there is no consensus on either what the content of SNA should be, or how it should be delivered during the consultation (Edwards et al., 2022). A clue to what patients and specialists feel is required for informed decision-making can be seen in the SNA resources produced by organisations such as Meningitis Now and The UK Sepsis Trust.
The rationale for providing patients with SNA is that the diagnostic process is not perfect, and when adverse diagnostic events do occur it is better for the patient if treatment is initiated at point B in a serious illness than at point C. Similarly, even if the diagnosis is correct, there is always the potential for a serious complication to develop and the sooner that this is treated, the better the outcome is likely to be for the patient. Therefore, the purpose of SNA is to ensure that patients have all the information they require to be able to recognise and respond to the development of a serious illness or complication at the earliest possible point in time. The role of the GP is to present this information in a way that the patient can understand, recall and refer to later. This is the essence of good safety-netting skills in primary care (O’Riordan et al., 2011). Safety-netting tools and visual aids can be incorporated into GP consultations and embedded into electronic devices to serve as checklists and reminders to support written information. They can also be used to document that a safety-netting risk assessment has been performed and that the patient has been provided with symptom or condition-specific SNA. This has the potential to not only protect patients but also the GPs who care for them.
Key points
Limitations and imperfections in the diagnostic process lead to diagnostic uncertainty and incorrect diagnoses in primary care consultations and have the potential to cause serious harm to patients and complaints against doctors
Providing patients with safety-netting advice protects is a way of protecting both patients and doctors from harm and is essential for safe practice in primary care
Patients base decisions on when, how rapidly, where and how to seek medical advice on the quantity and quality of safety-netting advice that they receive
A 6-C’s risk assessment can help make the decision to refer, review, or safety-net a patient more holistic, objective, consistent and safe
SAFER can bring a patient safety focus to the medical content of safety-netting advice
SBART can help improve the patient content and delivery of SNA to patients
