Reassurance, expectation setting and safety-netting advice

What it is

Safety-netting is the part of a plan that covers what has not yet happened. Where a condition is likely to be self-limited, the visit ends with more than a diagnosis: reassurance about what the condition is, a clear idea of how long the symptoms will last, and instructions to return if there are new signs or symptoms. Where a condition is managed without an operation, those three parts carry even more weight, because the plan itself depends on the patient returning and on being able to monitor.

How it is treated

Three worked settings show the shape of the advice:

• Fever without localizing signs in a child: management depends on the age of the child and the findings on examination. For children 3-36 months of age with a fever of 39°C (102°F) or below, reassurance that this is likely a self-limited viral infection is appropriate, with instructions to return if there are new signs or symptoms. Above 39°C, in a child who has received appropriate vaccines on schedule, a urinalysis and culture should be performed for all children under 6 months and for uncircumcised boys under 2 years, and a more extensive workup is appropriate below 3 months of age.
• Acute bronchitis: supportive care is made easier by informing the patient that symptoms are likely to last 2-3 weeks. Symptoms may be managed with measures such as dextromethorphan, guaifenesin or honey, and antibiotics are not indicated, since even in smokers the agent is viral at least 90% of the time.
• Uncomplicated appendicitis in a stable adult who prefers to avoid surgery: the plan is antibiotics with safety-netting and a discussion of the risk that it comes back, not antibiotics with discharge and no follow-up. Shared decision-making should cover the risk of recurrence and of failure, follow-up must be reliable, and the patient must be aware of the signs of treatment failure. The failure risk is given as about 20 to 30%.