15: Jay

Jay is two and a half years old. She lives with her Mum and elder brother and attends a local nursery. When Mum collected her from nursery today the nursery reported that she had been reluctant to eat her lunch and had been less active than normal. She has a runny nose.

Jay is reluctant to eat her tea. She points to her throat and says it hurts. Mum takes her temperature and it is 37.7°C. Jay is pale. Mum gives her some paracetamol and puts her to bed early. She thinks that Jay has a cold and sore throat.

Jay’s symptoms have now lasted over 5 days. Mum hasn’t been too concerned as Jay remained playful. Today though she is worried as Jay is more lethargic, pale and subdued and Mum thinks that Jay’s cold is starting to go to her chest. She phones her GP and requests an appointment.

As Jay has been unwell for more than 5 days her GP is concerned that she is at risk of serious illness. Jay looks pale according to Mum, is subdued and less active than normal. Her respiratory rate is 42 breaths per minute, her heart rate is 140 beats per minute, her temperature is 37.7°C and she last had paracetamol 45 minutes ago. Jay has had fewer wet nappies in the last couple of days and is now reluctant to drink as well as eat.    

The GP assesses Jay using the Traffic light system for identifying risk of serious illness in children (NICE, 2013). Using the tool in the table below, what grade of risk do you think Jay has?

Traffic light system for identifying risk of serious illness (NICE, 2013)

 

 

Green – low risk

Amber – intermediate risk

Red – high risk

Colour

Normal colour

Pallor reported by parent/carer

Pale/mottled/ashen/

(of skin, lips or tongue)

blue

Activity

Responds normally to social cues

Not responding normally to social cues

No response

Content/smiles

No smile

Appears ill to a healthcare professional

Stays awake or awakens quickly

Wakes only with prolonged stimulation

Does not wake or if roused

does not stay awake

Strong normal cry/not crying

Decreased activity

Weak, high-pitched or continuous cry

Respiratory

  

Nasal flaring

Grunting

Tachypnoea:

Tachypnoea: RR >

60 breaths/minute

RR >50 breaths/ min,

  

age 6–12mth

Moderate or severe

chest indrawing

RR >40 breaths/

  

minute, age > 12mth

  

 

 

Oxygen saturation ≤95% in air

  

 

Crackles in the chest

  

Circulation and hydration

Normal skin

and eyes

Tachycardia:

Reduced skin turgor

Moist mucous

membranes

>160 beats/minute,

age <12 months
 

>150 beats/minute,

age 12–24 months

 

>140 beats/minute,

age 2–5 years

 

 

CRT ≥3 seconds

 

Dry mucous

membranes

 

Poor feeding in

infants

 

Reduced urine

output

Other

None of the

amber or red

symptoms or

signs

Age 3–6 months,

temperature ≥39°C

Age <3 months,

temperature ≥38°C

Fever for ≥5 days

Non-blanching

rash

Rigors

Bulging fontanelle

Swelling of a limb

or joint

 

Neck stiffness

Non-weight

bearing limb/not

using an extremity

Status epilepticus

 

Focal neurological

signs

 

Focal seizures

CRT– capillary refill time; RR – respiratory rate

› Suggested answers

The GP assesses Jay as being at intermediate risk of serious illness. Do you agree with their assessment? What actions would you take? (refer back to Table 14.3 in your textbook).

As Jay has amber features and has been unwell for more than 5 days the GP decides to assess Jay using the GP Sepsis tool developed by The UK Sepsis Trust. You can access this at:

http://sepsistrust.org/wp-content/uploads/2016/07/OOH-and-GP-telephone-triage-u5-NICE-Final-3.pdf

Jay has no Red Flag symptoms at present. However, she has several Amber Flags present.

Using the NICE Risk stratification tool for children under 5 years with suspected sepsis (NICE, 2016) the GP identifies that Jay meets several of the moderate to high risk criteria.

You can access the risk stratification tool at:

www.nice.org.uk/guidance/ng51/resources/table-3-risk-stratification-tool-for-children-aged-under-5-years-with-suspected-sepsis-2551487007

On the basis of these assessments and in line with NICE (2016) guidance the GP sends Jay to the local Emergency Department for further assessment and treatment. The GP faxes a brief, clear handover using the SBAR tool to the receiving Emergency Department.