Safety Netting Advice and Red Flags by Condition
General Principles of Safety Netting
All patients or parents should receive clear verbal safety netting advice supplemented with written materials, specifying what symptoms to watch for, when to seek help, and where to go if the condition worsens. 1
Core Components to Include:
- Expected disease course and typical duration of illness 2
- Specific alarm symptoms ("red flags") that require immediate medical attention 2
- When and where to seek help (e.g., return to clinic, emergency department, call 911) 1
- Confirmation of understanding by asking parents to repeat back key points 2, 3
Condition-Specific Safety Netting
1. Acute Respiratory Infections (Adults >16 years)
Red Flags - Seek Emergency Care Immediately:
- New or worsening breathlessness 1
- New or increased confusion 1
- Respiratory rate ≥30 breaths/min 1
- Systolic blood pressure <90 mmHg or diastolic ≤60 mmHg 1
- Symptoms worsen rapidly or significantly 1
- Becoming systemically very unwell 1
When to Return for Reassessment:
- Symptoms not improving after specified timeframe (typically 3-5 days for viral infections) 1
- Development of new symptoms 1
- Inability to manage symptoms at home 1
2. Meningococcal Disease (Children and Young People)
Red Flags - Administer Parenteral Antibiotics and Urgent Referral:
- Fever with petechial or purpuric rash 1
- Fever with vomiting, headache, neck stiffness, or photophobia 1
- Fever with non-specific symptoms in an unwell child where carer is concerned 1
Safety Netting for Unlikely but Possible Cases:
- Advise on specific symptoms of deterioration: worsening headache, increasing drowsiness, inability to tolerate light, new rash (especially non-blanching), vomiting, neck stiffness 1
- How to get emergency help: call 911 or go directly to emergency department 1
- Arrange interval assessment within 24 hours if diagnosis not supported but cannot be excluded 1
- Consider carer's ability to monitor and respond - if in doubt, lower threshold for referral 1
3. Motor Delays (Pediatric)
Red Flags - Prompt Referral Required:
- Regression of motor skills (loss of previously acquired abilities) 1
- Loss of strength 1
- Concerns with respiration or swallowing 1
- Profound hypotonia in infancy 1
- Asymmetric motor findings 1
Safety Netting for Mild Abnormalities:
- Explain that clinical changes require urgent reevaluation 1
- Provide time-definite follow-up plan (specific date for next assessment) 1
- Advise parents to return immediately if child develops any red flag symptoms above 1
4. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (Children and Young People)
Red Flags - Emergency Referral (<24 hours):
- Redness (bilateral or unilateral) PLUS any of the following (RAPID acronym): 1
- Acuity loss (vision changes)
- Pain (moderate to severe ocular pain, not just irritation)
- Intolerance to light (photophobia)
- Damage to cornea (visible ulceration, haze, opacity, purulent discharge)
Post-Discharge Safety Netting:
- Potential long-term problems to monitor: 1
- Skin pigmentation changes and scarring
- Nail abnormalities
- Eye problems (requires ongoing ophthalmology follow-up)
- Oral and dental complications
- Respiratory issues (particularly bronchiolitis obliterans)
- Urogenital problems
- Risk of recurrence if infection was the trigger 1
- Provide written information and direct to patient support groups 1
5. Dupilumab-Related Ocular Surface Disorders (Atopic Dermatitis Patients)
Red Flags - Emergency Ophthalmology Referral (<24 hours):
- Unilateral redness (consider other causes like herpes simplex virus) 1
- Bilateral redness PLUS any red flag: 1
- Acuity loss
- Moderate to severe ocular pain (beyond irritation)
- Intolerance to light
- Visible corneal damage
Safety Netting for New Symptoms:
- New ocular symptoms should prompt initiation of assessment pathway 1
- For children <7 years: discuss with ophthalmology before initiating treatment (due to visual development plasticity) 1
- For children ≥7 years: simple treatment can start, but progression requires ophthalmology assessment 1
6. Sore Throat and Headache (Teenagers)
Red Flags - Immediate Intervention Required:
- Severe headache with fever and neck stiffness (consider meningitis) 4
- Sudden severe "thunderclap" headache 4
- Headache with altered consciousness or confusion 4
- Difficulty breathing or swallowing 4
- Signs of dehydration 4
When to Return:
- Symptoms worsen rapidly or significantly 4
- No improvement after 3-4 days despite symptomatic treatment 4
- Becoming systemically very unwell 4
- Development of new symptoms (rash, difficulty breathing, severe pain) 4
Expected Course:
- Viral sore throat typically improves in 3-5 days 4
- Antibiotics (if prescribed) provide only 1-2 days faster symptom resolution 4
7. Quadriparesis/Acute Weakness
Red Flags - Emergency Evaluation Required:
- Acute onset of weakness (suggests vascular cause like spinal cord ischemia) 5
- Respiratory compromise (high cervical lesions) - requires immediate airway management 5
- Bladder or bowel dysfunction (suggests cauda equina syndrome or spinal cord compression) 5
- Fever with localized back pain (concern for epidural abscess) 5
- Sharp sensory level on examination 5
Documentation and Follow-Up
Critical Practice Points:
- Document safety netting advice in patient notes to facilitate continuity of care 3
- Tailor advice to the patient's specific situation, previous healthcare experiences, and personal circumstances 3
- Check understanding by asking patients/parents to explain back what they should watch for 2, 3
- Provide both verbal and written resources - written materials alone are insufficient 2, 3
- Lower threshold for referral in patients with comorbidities, multimorbidity, frailty, or when caregiver capacity is uncertain 1