CLINICAL RISK REDUCTION


Management by the GP It is important to identify any life- threatening features such as compromise of the airway, breathing or circulatory problems and decreased levels of consciousness (ABCD). Supportive action and admission to hospital as soon as possible is essential. The presence of high-risk signs or a characteristic meningococcal non- blanching rash requires immediate attention with appropriate treatment such as benzylpenicillin and referral to hospital. Do not be falsely reassured by a rash that blanches on pressure, if there are intermediate or high-risk signs present. Children with high-risk signs not considered to be immediately life threatening should nevertheless be referred urgently for assessment by the local paediatric specialist.


Greater care is required in managing the child with intermediate risk and the outcome will often depend on assessment of the child, parents and their ability to cope or identify any subsequent worsening in the child. The vast majority of children with some intermediate features will nevertheless settle but care should be taken to consider if they require admission to hospital. NICE guidelines state it is important to also consider: • the social and family circumstances • other illnesses the child or family members have


• parents’ or carers’ anxiety and instinct • contact with people with serious infectious diseases


• parents’ or carers’ concern, causing them to seek help repeatedly • recent travel abroad to


tropical/subtropical areas, or any high- risk areas for endemic infectious diseases


• previous family experience of serious illness or death due to feverish illness which has increased their anxiety levels


• whether the child’s fever has no obvious cause but is lasting longer than you would expect for a self- limiting illness.


Children with only low-risk features can be managed safely at home with appropriate advice for the parents.


AUTUMN 2011


ASSESSMENT High risk


• Weak high-pitched or continuous cry


awake


• Skin or mucous membranes


• Reduced skin turgor • Bile-stained vomiting


pale/mottled/blue or ashen


• Moderate or severe chest in-drawing


• Grunting • Bulging fontanelle


• Respiratory rate > 60 breaths per minute


• Appearing to be ill when assessed by the doctor


Medico-legal issues


Te possibility of making a clinical mistake is a daily hazard for GPs but legal risk is relatively low provided that you listen patiently, take a careful history, examine appropriately and seek to explain the condition to the parents while maintaining rapport. Clear and comprehensive notes are invaluable, both to the examining doctor and to anyone who subsequently sees the child. In the unlikely event of disaster, they also aid legal defence. Part of the assessment of the child should also include an assessment of the parents, including their level of awareness, tiredness, prior knowledge of their general coping abilities and family support, and also their understanding and agreement with the GP’s proposed action. When rapport seems very poor or the parent seems unduly anxious or unable to cope, it may be prudent to request a further opinion from a paediatric specialist or temporary admission to hospital. Doctors working in out-of-hours situations will almost certainly have no prior knowledge of the parents and should consider a lower threshold for onward referral (see Case study on page 20 of this issue). In the majority of cases the GP will decide to manage the child out of hospital and here it is particularly important to safety net – give specific advice about what


• Unable to rouse or if roused does not stay


Intermediate risk


• Awakes only with prolonged stimulation


Low risk


• Decreased activity • Poor feeding in infants


• Strong cry or not crying • Content/smiles • Stays awake


• Not responding normally to social cues


• New lump larger than 2 cm


• Pallor reported by a parent or carer


• Nasal flaring


• Capillary refill time of greater than three seconds


• Normal colour of skin lips and tongue


• Not smiling • Dry mucous membranes • Reduced urine output


• Normal skin and eyes


• Moist mucous membranes


• Normal response to social cues


to look out for and what to do if the child’s condition should worsen. Here it is crucial to understand the ability of a parent or carer to cope and tailor advice accordingly. Particularly stoical parents may delay seeking further help if overly reassured and may need to be encouraged to return. Having a set phrase for advice may be useful but should not prevent the doctor engaging the brain before safety netting. NICE suggests: • Provide the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed.


• Arrange a follow-up appointment at a certain time and place.


• Liaise with other healthcare professionals, including out-of-hours providers, to ensure the parent/carer has direct access to a further assessment for their child.


While there is no generally accepted rule, it is prudent to recognise that if a child is presenting for the second or third time in a very short period then either they are unwell or their parents may be struggling to cope. Onward referral should be considered in such a situation.


n Dr David Willox is a GP and medico- legal expert in primary care


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