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9 Escalation of care

Introduction
NHS Direct is a service that provides telephone-based advice. When a parent or carer calls this
service a remote assessment is undertaken. In this context, the term remote indicates that the
healthcare professional is geographically remote from the child. Remote assessment is often
necessary in other settings and often takes place out-of-hours. When patients request an urgent
consultation with their general practitioner, or if they call the ambulance service a remote
assessment of the child’s needs is necessary. 56
With remote assessment it is necessary to determine the degree of urgency, the level of care
required by the child, and the appropriate care environment. It must reliably identify those
children with clinical manifestations suggesting serious illness. However, it is also essential that
it successfully identifies those for whom home care is both safe and appropriate. 56
Healthcare professionals responsible for remote assessment may have varying levels of skill and
experience. They can be supported in their role through the use of written protocols or decision-
support computer software. Effective remote assessment is a challenge. It must rely completely
on the information provided by the caller. Parental anxiety and other factors make the remote
assessment of a young child especially challenging. Parents may report the symptom that causes
them concern but may fail to reveal other significant manifestations of illness. Close listening and
critical thinking are crucial to identifying important cues. 56
In some circumstances, the healthcare professional may see the child, but physical examination
may not be within the scope of practice for that individual. In that circumstance, it may also be
appropriate to follow remote assessment guidance. 56
In all cases, the key escalation of care considerations for the remote assessor are:
1. Is a face-to-face assessment required?
2. Can the child be effectively and safely managed at home?
3. If face-to-face assessment is necessary, should this be in a community or hospital setting?
If there is a face-to-face assessment in a primary care setting and the child can be examined it
may be necessary to consider whether referral to a secondary care setting is required.

Clinical question
What key symptoms and signs of gastroenteritis indicate the need for an escalation of level of
care?
Evidence overview
Literature searches were performed but no relevant research was identified for inclusion.
Therefore, the GDG was assisted in its considerations regarding escalation of care by a Delphi
panel consensus employed for the Feverish Illness guideline on this matter.
56
That Delphi process identified several factors that should be considered when deciding whether
to admit a child with fever to hospital. They were:
• social and family circumstances
• other illnesses that affect the child or other family members
• parental anxiety and instinct (based on their knowledge of their child)
• contacts with other people who have serious infectious diseases
• recent travel abroad to tropical/subtropical areas, or areas with a high risk of endemic
infectious disease
• when the parent or carer’s concern for their child’s current illness has caused them to seek
healthcare advice repeatedly

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