Safety netting

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Safety netting is a diagnostic management strategy that aims to ensures patients are monitored throughout the diagnostic process until their symptoms or signs are explained and results have been acted upon or their symptoms are resolved.

Some cancer symptoms are easily recognised, where timely management and referral for suspected cancer may be straightforward, but this is not always the case. Patients presenting with non-specific symptoms can cause diagnostic uncertainty and be difficult to manage, which can result in longer primary care intervals and later stage diagnosis [1] For example, abdominal pain is a common symptom associated with multiple cancers as well as benign diagnoses [2,3].
Safety netting is an essential process to help manage uncertainty in the diagnosis and management of patients by providing information for patients and organising follow-up after contact with a health professional.   

Patients need to be informed of when, why and how to book a follow-up appointment should their symptoms persist, worsen or change.
Safety netting may be performed at the time of the contact between health professional and patient, or may happen after the contact through active monitoring and administrative systems to manage results and referrals” [1]  For example, abdominal pain is a common symptom associated with multiple cancers as well as benign diagnoses [2,3].
Patients who are referred for suspected cancer should be aware that their further investigation is due to possible cancer, to help the patient understand the risk of cancer associated with their symptoms and the importance of attending their future appointment. Careful and balanced communication is important to avoid unnecessary patient distress, for example, when known, it may be appropriate to inform patients of their individual risk of cancer and that a referral has been made to rule out a cancer diagnosis.

 

 

References

  1. Jones, D., et al., Safety netting for primary care: evidence from a literature review. British Journal of General Practice, 2019. 69(678): p. e70-e79.
  2. Koo, M.M., et al., The nature and frequency of abdominal symptoms in cancer patients and their associations with time to help-seeking: evidence from a national audit of cancer diagnosis. J Public Health (Oxf), 2018. 40(3): p. e388-e395.
  3. Renzi C, Lyratzopoulos G, Hamilton W, Rachet B. Opportunities for reducing emergency diagnoses of colon cancer in women and men: A data-linkage study on pre-diagnostic symptomatic presentations and benign diagnoses. European journal of cancer care. 2019;28(2):e13000.Safety netting of primary care tests

Retrospective clinical reviews showed that one in four cancers diagnosed in England (2014) had an avoidable delay to their diagnosis, with nearly half (49%) of delays happening in primary care [2]. The authors suggest that avoidable delays attributed to patient factors (for example presence of comorbidities), which occur after presentation, may benefit from improved safety netting or communication to patients.

Broadly, the evidence [1-3] suggests that the key components of safety netting fit within:

  • Patient symptom follow-up
  • Diagnostics, including the possibility of false negative results.
  • Referral for further investigation

One study found that patients who are being referred for further investigation may feel a lack of transparency in the referral process, be concerned about being ‘lost in the system’ and not knowing what to expect [1]. The research also suggested that GP’s providing information and reassurance regarding a referral is considered by a patient to be as important as the speed of their referral. Therefore, it is important to ask patient’s what they would like to know about their referral.

All three aspects of safety netting are addressed within the existing suspected cancer guidelines (see NICE, NG12 (2015) and the Scottish Cancer Referral Guidelines for Suspected Cancer(2019))*.  

*While the Northern Ireland Cancer Network (NICaN) provide primary care guidance for suspected cancer referrals for GP’s practicing in Northern Ireland, safety netting advice is not included. As safety netting is an important component of timely referral and management of suspected cancer, all information provided on this page and in wider resources is applicable UK-wide.

References:

  1. Jones, D., et al., Safety netting for primary care: evidence from a literature review. British Journal of General Practice, 2019. 69(678): p. e70-e79.
  2. Swann R, Lyratzopoulos G, Rubin G, Pickworth E, McPhail S. The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients. Cancer epidemiology. 2020;64:101617.
  3. Nicholson BD, Mant D, Bankhead C. Can safety-netting improve cancer detection in patients with vague symptoms?. BMJ. 2016;355:i5515. Published 2016 Nov 9. doi:10.1136/bmj.i5515

Patients need to be informed of when, why and how to book a follow-up appointment should their symptoms persist, worsen or change.

  • Consider the likely time course of current symptoms (e.g. cough, bowel symptoms, pain)
  • Tell patients when to come back if symptoms do not resolve in the expected time course, and the specific warning/ red flag symptoms or changes to look out for
  • Check the patient understands the safety netting advice (considering language and/or health literacy barriers). It may be useful to consider sending text message reminders to reaffirm your safety netting advice for patients [4].
  • Consider referral after repeated consultations for the same symptom where the diagnosis is uncertain (e.g. three strikes and you are in)
  • Code all symptoms, diagnostic tests, referrals and set up appropriate diary alerts
  • Detail safety netting advice in the medical notes (as understood by the patient)
  • Make use of clinical IT systems that alert you of repeat consultations for unexplained symptoms
 

Primary care tests

Cancer referral Guidelines recommend several investigations for patients presenting with suspected signs and symptoms of cancer, including Chest X-Ray (CXR) and FIT (for symptomatic patients). However, a negative test result does not always rule out cancer, especially among patients with unresolved symptoms

  • Communicate to the patient the reasons for the test and importance of coming back if symptoms continue, even after a negative test result
  • Code all diagnostic tests and retain (or explicitly pass on) responsibility over initiated investigations until results are reviewed and acted upon appropriately
  • Consider the accuracy of diagnostic tests and what the result adds to a patient’s clinical picture. For example,  there is evidence to suggests a CXR false negative rate of up to 23%¹·². A negative CXR result could potentially give false reassurance to the patient and their GP. It is important to monitor and safety net symptomatic patients who receive a negative CXR result, until symptoms are explained or resolve. For further information, see our FIT key differences infographics for England.
  • The threshold to determine a positive result is much lower for symptomatic patients than it is for patients in the bowel screening programme who are presumed to be asymptomatic. Therefore, health professionals and patients should not be reassured by a recent negative screening result if a patient presents with possible symptoms of bowel cancer.
  • Inform patients about how to obtain their results and have a system for contacting patients with positive test results and for those who fail to attend for follow up
  • Have a system to document that all results have been viewed, acted upon appropriately and followed up
  • Be aware of practice policies in place to ensure that tests/ investigations ordered by locums are followed up
  • Ensure practice staff involved in logging results are aware of reasons for urgent tests and referrals

Referrals

Patients who are urgently referred for suspected cancer should be aware that their investigation is due to possible cancer, to help the patient understand the risk of cancer associated with their symptoms and the importance of attending their future appointment. Careful and balanced communication is important to avoid unnecessary patient distress, for example, when known, it may be appropriate to inform patients of their individual risk of cancer and that a referral has been made to rule out a cancer diagnosis.

  • Ask your patient what they would like to know about their referral
  • Explain to patient’s that they are being referred on a suspected cancer pathway, and what to expect at their next appointment
  • Communicate the importance of attending appointments (where appropriate, signpost to CRUK’s Urgent Referral Explained leaflet)
  • Check the patient understands the safety netting advice (considering language and/or literacy barriers)
  • Code referrals and set up appropriate diary alerts
  • Detail safety netting advice in the medical notes (as understood by the patient)
  • Obtain up to date contact details for patients undergoing tests or referrals

References

  1. Stapley, S., D. Sharp, and W. Hamilton, Negative chest X-rays in primary care patients with lung cancer. Br J Gen Pract, 2006. 56(529): p. 570-3.
  2. Bradley, S.H., M.P.T. Kennedy, and R.D. Neal, Recognising Lung Cancer in Primary Care. Adv Ther, 2019. 36(1): p. 19-30.

In line with the PCN service specification on early cancer diagnosis 2021/22  requirements, practices of a PCN must use the relevant SNOMED code for Safety Netting. Only those codes included in the supporting Business Rules will be acceptable to allow CQRS calculations. A PCN’s Core Network Practices will therefore need to ensure that they use the relevant codes and if necessary, re-code patients.

Ensure you use the new SNOMED code for: Delivery of safety netting for patients on urgent referral pathway for suspected cancer. You can search for this by putting in ‘cancer safety netting’ into your code browser and will find the code 1239431000000107.

However, to make the best use of this, we would advise using safety netting templates which incorporate this SNOMED code and allow you to tick the relevant section on the templates, as well as set a date for any reminders.

Have a look at your PCN’s use of the official Snomed codes for Safety Netting compared to other PCNs, using the PCN dashboard.

Click on the links below for more recommendations on safety netting

To review the effectiveness of your safety netting processes in practice you could undertake the following actions:

  • Conduct Learning Events for patients diagnosed via an emergency presentation.
  • Conduct an annual audit of new cancer diagnoses (e.g. internal practice audit or if you have participated in the  National Cancer Diagnosis Audit) you can check your cases in your report.
  • Enquire about free tailored support for your PCN from your local CRUK Facilitator. Facilitators can provide free workshop for your PCNs and tailored assistance in safety netting involving PCN clinical and administrative teams

For a summary table of all of the tops tips and a flow chart that incorporates Safety netting into practice please click here see Safety netting table and flow chart

Current safety netting practices vary among GPs and between primary care practices [1-3]. Research is under way to further investigate barriers and opportunities for improving safety netting.

For example, NG12 doesn’t specify whose responsibility it is ultimately to ensure symptom follow-up– GP’s or patient’s.

Current clinical IT systems hold a great potential to streamline safety netting into everyday patient care. The impact of an EMIS integrated safety netting toolkit for symptoms of cancer is currently being evaluated through the Early Detection and Diagnosis Committee.

References

  1. https://www.cancerresearchuk.org/funding-for-researchers/applying-for-fu... for primary care: evidence from a literature review. British Journal of General Practice, 2019. 69(678): p. e70-e79.
  2. Swann R, Lyratzopoulos G, Rubin G, Pickworth E, McPhail S. The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients. Cancer epidemiology. 2020;64:101617.
  3. Nicholson BD, Mant D, Bankhead C. Can safety-netting improve cancer detection in patients with vague symptoms?. BMJ. 2016;355:i5515. Published 2016 Nov 9. doi:10.1136/bmj.i5515

1. What is the main advantage of safety netting today over how it used to be done in the past?

The combination of face-to-face safety netting and IT systems could be really powerful. A simple request to book a follow-up appointment could be supported by a system to identify patients who have not attended for their follow-up within a specified timeframe (Dr Brian Nicholson)

2. Not every practice has a safety netting protocol in place. What is your advice to GPs interested in motivating their practice to establish one?

GPs can make the case for safety netting using learning events (formerly called Significant Event Analysis) from their own practice. A practice-wide non-judgemental and open dialogue can aid learning and embedding improved practices into safety netting systems. Online resources and support from the CRUK Facilitator Programme can also be helpful (Dr Ishani Patel).
Practices can start by looking at the list  of questions on CRUK website to identify potential gaps in their practice. If you want to set up a system, EMIS Web has a template and video. For SystmOne some practices use scheduled tasks and templates are available, here is a short video by CRUK Strategic GP Rawan Pandev

3. How do you negotiate responsibility between patients and practice, in relation to the follow-ups? And in relation to attending the two week wait appointments for suspected cancer? 

This requires clinical judgement. Some patients respond to leaflets and clarity of purpose of the referral ie to exclude cancer. Others may need clear verbal information. Many of us use clinical system integrated text reminder systems. As GPs , we do have a role in following up non-attenders for 2 week wait appointments. In my practice all such referrals are safety netted by secretaries. (CRUK Strategic GP Rawan Pandev)

4. Are there other safety netting actions that tends to get overlooked but have a potential for speeding up cancer diagnosis?

Proactive safety netting should be extended to suspected cancer referral attendance (combined with e-referrals), direct access diagnostics and vague symptoms. Also tracking patient attendance and outcomes for blood tests/ imaging/ endoscopy/ suspected cancer outpatient appointments using the relevant electronic healthcare record functionality or API /plug-in software. (Dr Ishani Patel)

5. What are the three safety netting actions each GP can do, regardless of their IT or practice-level environment?

Each GP can consider “what if this patient does not attend for this test/appointment/follow up?” What could be the consequence? Results reported as normal, but persisting symptoms, merit continuing review by the GP. An example is normal first CXRs in patients in lung cancer (up to 25% of lung cancers in some series). Ask yourself if there is a robust system of following up investigations and patients in your practice. It can help to look at past Learning Events (previously called SEAs) to see if this has been an issue in the past. (CRUK Strategic GP Rawan Pandev)

6. In your view, what can be done to improve safety netting evidence and practice? 

We do safety netting in different ways and don’t talk about it, so it can be difficult to know exactly what is being done, and to identify and share good practice. We need to share best practice and generate evidence for which types of safety netting are most effective and for whom. Formal ways of collecting and analysing such data are being explored. (Dr Brian Nicholson)

7. Finally, what is the most recent safety netting measure introduced in your practice?

We introduced a safety net prompt to help track advice and guidance requested from secondary care – this was suggested by our secretaries and has become routine for us. (CRUK Strategic GP Rawan Pandev)

CRUK Safety Netting Workbook - A self-assessment checklist that can support to aid discussions around safety netting principles and best practice.

MacMillan’s Primary care top 10 tips: safety netting - Selected safety netting tips, with a rationale and what to consider within each tip.

Pan London suspected cancer safety netting guide - Tips on how to use clinical IT systems to pro-actively recall DNAs, how to track patients’ attendance of tests and investigations and how to set up reminders to follow-up low-risk patients.

Macmillan Safety netting and coding training module. An e learning course which is primarily aimed at GPs and GP trainees, however other primary care clinical staff may find it valuable too. The content of this course is designed to improve the clinician's quality of coding and safety netting in the context of cancer.

RCGP/MacMillan comprehensive guideline, tools and a template for conducting learning events at the practice level

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