Page 160 - 15Diarrhoeaandvomiting

Escalation of care

• where the family has experienced a previous serious illness or death due to feverish illness
which has increased their anxiety levels
• when a feverish illness has no obvious cause, but the child remains ill longer than expected
for a self-limiting illness.
GDG translation from evidence to recommendations

The GDG agreed that there were four considerations that should influence the decision to
escalate care:

1. the presence of diagnostic uncertainty
2. the presence of risk factors for dehydration
3. clinical dehydration associated with red flag symptoms and signs (see Table 4.6)
4. other factors:
• adverse social and family circumstances – the healthcare professional may have concerns
regarding the carer’s ability to monitor or treat the child appropriately
• the presence of other illnesses in the child or family members
• if the carer’s concern has led to repeated requests for advice regarding the illness
• if the parental anxiety and instinct regarding the child’s illness (based on their knowledge
of their child) is high.
Children in the community might be cared for at home or at an out-of-hours centre with the
support of a community children’s nursing team, or they might require referral to an emergency
department.
In making its recommendations, the GDG considered each of these from the perspectives of
healthcare professionals conducting first a remote assessment and second a community-based
face-to-face assessment.
Remote assessment
The GDG agreed that children with symptoms or signs suggesting that the child might not have
gastroenteritis but an alternative serious condition should be referred for face-to-face assessment
in a primary or secondary care setting. The GDG considered that those with risk factors for
dehydration, symptoms suggestive of dehydration or adverse social or family circumstances
would require a face-to-face assessment. Those with dehydration associated with ‘red flags’ (see
Table 4.6) would usually require assessment in a secondary care setting.
Community face-to-face assessment
Those healthcare professionals responsible for face-to-face assessment in the community should
have the necessary knowledge and skills to determine whether referral to secondary care is
required. Children with symptoms or signs suggesting an alternative serious condition would
require referral to secondary care. Children with dehydration associated with red flag symptoms
or signs (see Table 4.6) would either require early and repeated face-to-face review or referral
to secondary care, based on professional judgement. Consideration should be given to referring
those at high risk of dehydration.

Safety netting
Safety netting is a recognised concept 202 taking a number of forms. In the context of gastroenteritis,
it might consist of the following: discussion with the parent or carer about the symptoms and
signs (especially red flags – see Table 4.6) in dehydration, and shock that they should look for.
Written information could also be provided. The parent or carer is then given advice on how
and in what circumstances they should seek further advice or request a face-to-face assessment.
Where appropriate, it should be agreed that a re-assessment will take place, and the timing and
arrangements for that assessment should be made clear.

Good safety netting arrangements ensure continuity of care. They take account of the possibility
that the child may deteriorate. The GDG did not consider that it should be prescriptive about
precise safety netting arrangements to be employed. These should be determined taking account
of local services and professional support.

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