Bradford VTS Online Resources:
path: SAFETY NETTING
path: SAFETY NETTING
- Excellent advice on safety-netting from CRUK
- Playing it safe – safety netting advice from the MDU
- Safety netting by MDDUS
- Follow Up & Safety netting by GP magazine
- Safety netting: evidence from a literature review 2019 (excellent)
- Safety Netting by Bristol Academic Centre of Primary Care
- SAFER – A mnemonic to improve safety netting advice
- Teaching Safety Netting in Primary Care
- EMIS – electronic safety netting guide
- EMIS – electronic safety netting toolkit
What is safety netting?
Safety-netting is information given to a patient or their carer during a primary care consultation, about actions to take if their condition fails to improve, changes or if they have further concerns about their health in the future. In other words it is about ‘contingency planning’ – sharing information with the patient or their carer about what action they should take if their condition fails to improve, changes or if they have further concerns about their health in the future.
GP Trainees should be taught the skill of safety netting. It is an important element of the consultation. Yes, it is a consultation micro-skill and yes, it can be taught. Continue reading this page to understand how.
Safety netting was formally introduced nearly 30 years ago by Roger Neighbour, who defined it as a process whereby the GP answers three questions:
- If I’m right, what do I expect to happen?
- How will I know if I am wrong?
- And what would I do then?
Safety netting is included in Neighbour’s own model of the consultation as well as the Calgary–Cambridge model, which includes safety netting in the section ‘closing the session’.
Why is it so important?
Management of uncertainty is frequently mentioned as a constant worry for GP trainees. We can never be 100% certain that a set of symptoms are NOT a feature of something serious. Inevitably, some will be and safety netting is a way to reduce the chance of missing that. It does this by educating the patient so that they can look out for things that would ordinarily worry us as doctors. Thus, safety netting may act as a contingency plan by providing patients with information on prognosis and ways of organising follow-up. Safety netting is defined as a consultation technique to help manage the risks with uncertainty.
- For patients – with safety netting there is less chance a serious illness will go missed. This means a patient might live longer and better lives than otherwise.
- For doctors – by practising safety netting there is less chance of missing something – makes the doctor feel better but also less risk of being sued. Inadequate safety netting has been associated with delays in cancer diagnosis
- For the health system – safety netting will mean that patients with serious and chronic things can be better managed if picked up early. Less costly than picking them up too late.
High risk clinical situations that always require safety netting
- The diagnosis is uncertain and the differential diagnosis includes serious illness, particularly illness that can progress very rapidly.
- The diagnosis is certain but carries a known risk of serious complications.
- The patient (for reasons of age or comorbidity) has an increased risk of serious illness or complications.
Ram's 3 part method for Safety Netting (EDF)
Safety netting is considered to be particularly important when consulting with children, the acutely unwell, patients with multimorbidity, and those with mental health problems. But we would urge you to do it with everyone. Safety netting is more than solely the communication of uncertainty within a consultation. It should include plans for follow-up as well as important administrative aspects, such as the communication of test results and management of hospital letters.
RAM’S 3 PART METHOD TO SAFETY NETTING (EDF)
Research says that patients aren’t particularly satisfied with how GPs do safety netting. Why? The have reported that safety-netting advice is often too vague to be useful (Cabral et al, “They just say everything’s a virus”; Patient Educ Couns 2014). So, the whole point of this 3-part method is to make your safety netting advice as specific as possible with only the most useful and relevant information.
In other words, what you expect to happen; the usual natural trajectory of the working diagnosis (i.e. its likely time course or natural history).
- What else might you expect to develop?
- When you expect it to get better and resolve?
- What indicates things are not going to plan?
In other words, worrying symptoms, red flags or amber symptoms indicating some other illness, a serious disease, or simply the disease not getting better.
- If possible, try and limit the symptoms/signs to a maximum of 3 things plus “even if you simply feel more unwell” (as patients usually can’t remember anymore).
- For example “I think it’s a water infection and it should settle with these tablets and by drinking plenty of water. It should settle within a few days. However, if that you have blood in your urine, your flanks are sore, you have any shivering episodes or even if you simply feel more unwell, then please call to see a doctor straight away: either calling us or 111 if after hours”
- If it is necessary to mention 4 or more things, write them down for the patient to remember.
Plan future appointments (follow-up) to ensure timely re-assessment of a patient’s condition if new symptoms, worrying red flags or the trajectory of the illness is not following what was expected.
- a) Give specific advice on HOW to contact the medical service (e.g. ring, make an appointment)
- “Please make an appointment for next Friday to see me again.”
- “Call 111 if you…”
- “You must call 999 and ask for an ambulance if..”
- “If you have not heard from the fast-track cancer team within two weeks, please telephone reception urgently and let them know so they can chase it up”. (Safety netting is not just about symptoms, but follow up of investigations and hospital referrals too
- b) Give specific advice on WHO to call or see.
- “Please make an appointment with me for2 weeks’ time and I will double check on how your headaches are getting on.”
- “However, if you notice that you’re getting any double vision or vomiting, then please come and see the emergency doctor immediately“
- “And if we are closed, then call 111 and speak to the emergency doctor there”.
- “However, if you start getting any fits, faints or funny turns, please call 999 and ask for an ambulance.“
- example, say “if no better in 2 weeks.” Do not be ambiguous by saying “in 2-3 weeks’ time”. If you want the time period to stick in the patient’s head easier, you might say “Okay, today is Tuesday. So, if things are not better by next Friday, please come back in” (is better than saying in 10 days’ time).
- b) Give specific advice on the TIME-FRAME
- Do not say “If it is getting worse come back”. Why is this bad? How long should the patient give to see if the symptoms settle down – you have not said! As a doctor – you are the best person that knows! You cannot leave this with the patient to decide.
- Do not be ambiguous by saying “in 2-3 weeks’ time”. Choose – is it 2 weeks or 3 weeks? You cannot let a patient make this clinical decision.
- Example: “I do expect the diarrhoea to settle within the next 10 days. So, if things are no better in 2 weeks’ time, make an appointment to see me.”
- PS If you want the time period to stick in the patient’s head easier, you might say “Okay, today is Tuesday. So, if things are not better by the Tuesday after next week, then come and see me.”
- a) Give specific advice on HOW to contact the medical service (e.g. ring, make an appointment)
I expect your tummy pains and diarrhoea to settle within 10; hopefully, each day gets better. However, I need you to keep an eye out for the following things – if your diarrhoea continues beyond 10 days, or you develop new things like vomiting or bleeding from your back passage. If you get any of these, then make sure you ring and get to see the GP within a week. If the bleeding is bad, then clearly ring us and see our emergency GP on the same day or if it’s really bad, just get someone to take you down to A&E or call and ambulance. However, I really don’t expect that to happen and do think you will make a good recovery.
Paul Silverston describes a mnemonic to help facilitate the development of symptom-based, patient safety-focused, safety-netting advice.
- S = What SERIOUS causes and complications do I need to make the patient aware of?
- A = What ALTERNATIVE diagnoses do I need to make the patient aware of?
- F = What specific FINDINGS do I need to make the patient aware of that would mandate the need for a medical re-assessment?
- E = What EARLY/atypical presentations of serious illnesses do I need to make the patient aware of?
- R = What RED FLAG symptoms and signs do I need to make the patient aware of?
Paul Silverston describes an approach to see if it is appropriate for you to handover the safety-netting monitoring role over to the patient (or whether it is safer for you to bring them back for a formal review).
- Is the patient CAPABLE of checking for the criteria that determine the need for a medical re-assessment, or is medical review required?
- Is the patient mentally, physically and medico-legally COMPETENT to assess and monitor themselves, or someone else?
- Can the patient COMPLY with the advice and instructions that you are providing, practically & logistically?
- Can the patient COMPREHEND the advice and instructions that you are providing?
- Have you CONFIRMED that the patient has fully understood and appreciated the significance of your advice?
Top Tips on safety netting
From “Safety netting for primary care: evidence from a literature review” by Jones et al, BJGP 2019
- Remember, your diagnostic uncertainty may occur due to patients presenting very early in the illness process, making medically unexplained symptoms more likely.
- If the diagnosis is uncertain, that uncertainty should be communicated to the patient (or parent/carer) so that they are empowered to re-consult if necessary.
- If you are not sure of the aetiology, explain this to the patient. This reduces the risk of false reassurance and most patients appreciate the honesty.
- If there is a recognised risk of deterioration or complications developing then the safety-net advice should include the specific clinical features (including red flags) that the patient (or parent/carer) should look out for. This could include a description of symptoms of serious illness such as meningitis in an unwell child, or signs that may by suggestive of cancer in a patient presenting with non-specific symptoms, for example, a patient may be warned about rectal bleeding or diarrhoea if they present with unexplained vague abdominal pain.
- A key element of safety netting is to ensure that patients know how, and where, to seek help if things do not go as planned or expected.
- Always legitimise repeat visits so that patients feel able to return if symptoms persist or worsen. This will stop those at risk from “falling through the net”.
- When you’re telling patients to come back if xxx develops – tell them exactly where to come back. Should it be with the GP? Out of Hours? 111? A&E?
- Sometimes, it is both easier and safety just to simply book the patient back for a review yourself rather than relying on patients to do it. Don’t be afraid of doing this planned follow-up, even if your practice is concerned about the availability of appointments. Patient safety is paramount and trumps all else.
- Don’t forget to safety net around investigations and referrals too. So, for investigations you might say “they should call you for an MRI within the next 2 weeks. If you haven’t heart, will you ring the practice for the admin staff to chase?”. For referrals it might be “So, you should have heard from the orthopaedic team within the next 6 weeks. If you haven’t, please ring our admin staff at reception to chase”. And it’s especially important in 2ww referrals for suspected cancer. “You will hear from them within the next 2 weeks. So, remember, today is Wednesday so you should have heard something at the very latest on Wednesday in 2 weeks. If you haven’t please call the surgery and ask them to let me know ASAP and get them to chase at the same time.” Remember, patients often think “no news is good news” – when in fact it is not! So, we need to safety net because ultimately health care professionals retain responsibility for reviewing and acting on the results of investigations they have ordered!
- Sometimes, safety netting needs to be conveyed to others like carers, where you think a patient may not be up to the task of monitoring themselves.
- Ensure patients understand safety netting advice , with written instructions if needed.
- Safety netting should be documented in the notes to clearly show what you have said to the patient otherwise it may leave you susceptible to medico-legal criticism. So, instead of writing “safety netting advice given” how about just adding a little more “meat to the bone” with something like “Safety netted – discussed alarm features like haemoptysis, weight loss, voice change etc)”
Common pitfalls when safety netting
An example of a safety-netting statement would be “please make another appointment if your symptoms do not improve or anything new develops”. This is not specific enough. When should they make an appointment? With who – with you? And which symptoms don’t improve – are some symptoms more important than a cough. And after what specific period of time should a patient get in touch? For example, after a viral URTI, can the cough linger on after the 7 days? Would you worry if the symptoms were lots better but the patient still had a very slowly resolving cough at week 2? (Ans = no) Would you worry if the cough lingered on for more than 4 weeks? (ans = yes).
So, the common pitfalls are usually about being specific:
- Referring to “symptoms getting worse” rather than specifying which symptoms don’t better.
- Referring to “if any new symptoms develop” rather than specifying red flag symptoms.
- Referring to “if it doesn’t get better” rather than specifying a time period.
Electronic Safety Netting
A weakness of current safety-netting practices is the reliance on patients to re-appraise their symptoms and to make follow-up appointments.Worry about wasting the doctor’s time and not wanting to bother the doctor are well-documented barriers to help seeking in the UK. For patients who are given safety-netting advice when they consult, a potential pitfall is that 40–80% of medical information provided by healthcare practitioners is forgotten immediately, and almost half of the information that is remembered is recalled incorrectly (1). Evidence also suggests that misunderstanding and miscommunication are commonplace in primary care consultations (2). Could technology-based interventions (like text messaging) help? See the diagram on the right where they suggest where something like a text message might help in someone presenting with potential cancer symptoms (see place where the the phone icon is).
- Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219–222. [Europe PMC free article] [Abstract] [Google Scholar]
- Morgan S. Miscommunication between patients and general practitioners: implications for clinical practice. J Prim Health Care. 2013;5(2):123–128. [Abstract] [Google Scholar]
Sending SMS text
Many of us have SMS text built into our clinical systems. Otherwise, there are add ons like MJOG and AccuRx which make the whole process of sending texts painless. So how about thinking how you can create an automated texting system to help with safety netting. For example, you could create a set of generic texts. And then when you see a patient, after verbally safety netting, you could use one of the electronic plugins to generated one of the texts below to be sent at a certain time (e.g. 2 weeks from today). Automation is the key here to making this work of safety netting electronically as easy as possible. Here are some suggested texts…
- “Hello there, this is your doctor’s surgery. Just checking to see if your symptoms are any better. If not, please book another appointment to see a doctor this week”.
- “Hello there, this is your doctor’s surgery. I see that you have not attended a 2 week wait appointment that was arranged for you by the surgery. Can you please contact the surgery and let us know what happened. We can always arrange another.”
- “Hello there. Thanks for coming to see me recently. The consultation we had today left me with a bit of concern, so I would like to see you again. Please can you come back and see me within the next 2 weeks”.
- Can you think of others? Post a suggestion below.
Difficulties with SMS: Timing could be a problem. Remember, they’re going to get the text in say 2 weeks, but actually they’ve got to book an appointment, so it might be another 2 weeks before they actually come in. There is also the potential for technology and e-health to widen inequalities, increase workload, and raise medicolegal issues.
However, text message reminders have been shown to improve cancer screening uptake. Also, there is encouraging evidence that text messages can be used in primary care to monitor acute and chronic conditions, and that this reduces the cost of care, improves patient adherence, and promotes continuity of care. Primary care physicians in a survey study in Switzerland reported that the use of text messages improved patient follow-up. Also, patients have reported that safety-netting advice is often too vague to be useful, and txt-netting could potentially provide concrete advice for patients to refer back to.