Former GP Professor Paul Silverston discusses the purpose of safety-netting and offers advice on a structured approach to implementing it in practice
1: Know what is intended by safety-netting advice
Diagnosis involves comparing what you know to what you find through the application of diagnostic reasoning. Diagnoses are provisional and subject to change, and you should ensure patients know this. Limitations in knowledge, assessment or reasoning means a diagnosis may be uncertain or incorrect. Serious complications may develop later. The function of safety-netting advice is to ensure that the patient has the specific information that they require to know when, how rapidly, where and how to seek medical care if a serious illness or complication develops later. If the patient does develop a serious illness or complication, the treatment outcome is better if they seek medical care earlier rather than later, which is why it is important to tell patients about both the early (amber) and later (red) flag symptoms and signs to watch for.
2: Safety-netting advice protects you and your patient
Safety-netting is essential for safe practice in primary care because it protects you and your patients from the risk of serious harm arising from uncertain and incorrect diagnoses and from the potential for serious complications to develop later in the illness. Safety-netting also protects you from potential complaints or litigation, especially if it is supported by careful record-keeping of the advice that has been given to the patient.
3: Refer, review or safety-net?
Before giving a patient safety-netting advice, consider whether it would be safer or more medically appropriate to refer the patient to hospital, or arrange for them to be reviewed. Use a risk assessment tool, such as the 6Cs (see box 1) to ensure that you consider all the relevant factors when making this decision.
Box 1: The 6Cs
Criteria: Are there any criteria within the guidelines for that condition that recommend that the patient should be referred or reviewed?
Capable: Is a patient capable of identifying the amber and red flag findings, or is a medical review required?
Care: Is the patient able to monitor and care for themselves, or be monitored and cared for by others, at home?
Comply: Is the patient able to comply with your advice, practically and logistically?
Comprehend: Is the patient able to comprehend and retain your advice?
Confirm: Have you confirmed that the patient has understood and can follow your advice?
4: Explain why safety-netting advice is required
Explain to the patient that diagnoses are provisional, based on the symptoms the doctor knows about at the point of diagnosis. This introduces the concept that a change in symptoms over the course of an illness could lead to a change in the diagnosis, that a diagnosis made during the early stages of an illness could be incorrect, or that serious complications could develop later.
5: Explain what the purpose of safety-netting advice is
Then explain to the patient that the purpose of giving them safety-netting advice is to ensure that they seek medical care at the earliest sign of a serious illness or complication developing, when treatment is at its most effective. This helps patients to understand why it is important to follow the advice that they are given and share this advice with carers.
6: Be as specific as possible with your safety-netting instructions
Patients depend on the information in the safety-netting advice that they are given to decide when, how rapidly, where and how to seek medical care. Without specific information, a patient may return too soon, when care is not required, or too late, when care may not affect the outcome. Patients need specific information about the symptom or condition that they are presenting with. This should include how long to wait before seeking help if existing symptoms worsen or do not resolve, and which new symptoms should prompt further action.
7: Be SAFER
The mnemonic SAFER (see box 2) can prompt you to think about the serious illnesses and complications the patient is at risk of developing. It reminds you to consider the early and atypical presentations of serious illnesses that can present in this way, as well as the serious illnesses and complications that are most commonly missed, misdiagnosed or diagnosed late. Some 70% of ‘missed’ diagnoses in primary care involve cancer, acute vascular events and serious infections. Applying SAFER to the specific symptom the patient is presenting with can help you consider the potential causes of the serious illnesses and complications that the patient needs to be safety-netted for and the amber and red flag findings for these.
Box 2: SAFER
S: Which serious illnesses and complications is the patient at risk of developing?
A: Which alternative incorrect diagnoses is the patient at risk of with this symptom?
F: Which findings do not fit with a minor illness, or do fit with a serious illness?
E: Which early and atypical presentations of serious illness need to be considered?
R: What are the red and amber flag findings for these serious illnesses and complications, and green flag findings for the minor illnesses?
8: Use words and concepts patients can understand
The medical content of safety-net advice needs to be transformed into advice that the patient can readily understand and remember. Many terms commonly used by doctors are not understood by patients. A visual aid can help patients understand why a diagnosis might be uncertain or incorrect, and what amber and red flag findings represent.
9: Take a structured approach to safety-netting advice.
You can improve the verbal delivery of safety-netting advice by using the SBART system (see box 3). Explain the situation and background risks, so the patient understands why safety-netting advice is needed and important to follow. Explain the assessment and response required, so patients understand what they need to check for, how to check for it and how often, as well as how to respond should it happen. A traffic light system of action plans will help to bring it all together into a plan that patients can follow.
Box 3: SBART
- Explain why safety-netting advice is required, in terms of findings changing over time and the effect that this has on diagnosis.
- Explain that safety-netting advice helps the patient to recognise when, how rapidly, where and how to seek medical care, should a serious illness or complication develop
- Highlight the need to follow the advice and to share it with others who are monitoring and caring for the patient
- Discuss any specific risks that the patient has (ie medical conditions, medication, living alone, Sick Day Rules, falls)
- Discuss Dos and Don’ts in the patient’s care (Maintaining hydration, rest/mobilisation, medication to take/avoid).
- Describe the monitoring and interval checks that should be done during their illness:
– What to check for (amber and red flags)
– How to check for these findings
– How often to check for these findings (day/night)
- Explain the response required to the development of amber/red flag findings and patient/relative/carer concerns:
– Why to respond
– When to respond
– How rapidly to respond
– Where to respond to
– How to respond
Traffic light action plans
- Provide the patient with action plans:
– Green action plan: Normal pattern of minor illness and self-care plan
– Amber action plan: Symptoms and signs indicate that a serious illness or complication may be developing. Provide information on how rapidly, where and how to access medical care.
– Red action plan: Symptoms and signs indicate need to seek medical care immediately. Provide information on how rapidly, where and how to access medical care.
10: Provide information in written form.
Only a small amount of the information given verbally to the patient during a consultation is remembered immediately afterwards. Information may also need to be shared with those caring for the patient. Written information can be provided in hard copy, or emailed to patients after remote consultations, or made available online on the practice’s website. You can create a standardised safety-netting advice template, which can be populated with symptom- or medical condition-specific advice using the SBART approach. Best practice is to combine verbal and written safety-netting advice, using the consultation to highlight the important points that are detailed in the written safety-netting advice sheet.
Professor Paul Silverstone is a former GP and is a visiting professor at Anglia Ruskin University