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Feverish illness in children
1.4 Care pathway
A care pathway was used to identify patient flows and key decision points which informed the
development of clinical questions.
The GDG designed an outline care pathway early in the development process to explore how a child
with feverish illness might access, and be dealt with by, the health services. The resulting pathway is
shown in Figure 1.3. The pathway starts with a child at home with fever, and the pathway and
guideline come into effect when parents or carers decide to access the health services. The figure
also illustrates a number of other concepts that were crucial to the guideline development process.
More detailed clinical questions evolved from the pathway and the pathway was modified at the end
of the development process to incorporate the recommendations derived from the updated clinical
questions.
It was recognised that children with fever may currently be assessed by healthcare professionals who
either have or do not have recognised training and/or expertise in the management of children and
childhood diseases. In this guideline, professionals with specific training and/or expertise are
described as paediatric specialists and they are said to be working in specialist care. Those without
specific training and/or expertise are described as non-paediatric practitioners although it is
acknowledged that such practitioners may be managing children and their illnesses on a regular
basis. Non-paediatric practitioners are said to be working in non-specialist care.
For most children with feverish illness, the initial contact will be in non-specialist care. These contacts
will mostly be in primary care but some non-specialist contacts may also be made in secondary care,
for example in a general emergency department. A minority of these patients will then be referred on
to specialist care, for example in a paediatric assessment unit.
The GDG recognised that assessments of children with feverish illness can take place in three main
situations. These are represented by the shaded boxes on the care pathway in Figure 1.3. Broadly,
assessments can take place in two ways in non-specialist care. The first is a traditional face-to-face
encounter where the child undergoes a full clinical assessment, including history and physical
examination. This usually occurs in general practice but it could equally occur in a walk-in centre or a
hospital emergency department. Alternatively, the first point of contact could be with what has been
described as a remote assessment. This is where the child is assessed by a healthcare professional
who is unable to examine the child because the child is geographically remote from the assessor.
Remote assessments are becoming increasingly important in the health service and they are used
both in and out of normal working hours. Examples include NHS Direct and other telephone advice
services. In some circumstances, although the child is not geographically remote from the assessor, it
may not fall within the scope of practice for a particular healthcare professional to carry out a physical
examination of the child, for example a pharmacist. In these circumstances, the healthcare
professional may choose to follow the remote assessment guidance rather than the face-to-face
guidance that takes into account signs found on physical examination. In specialist care, the clinical
assessment will be undertaken by individuals trained in the care of sick children and the assessment
may take place in a paediatric assessment unit, on a children’s ward or in a dedicated paediatric
emergency department.
The care pathway demonstrates a number of possible outcomes from each type of encounter with the
health services. From a remote assessment, parents and carers will either be advised how to care for
their child at home with appropriate advice as to when to seek further attention, or they will be advised
to bring the child in for a formal clinical assessment. For the small number of children who have
symptoms suggestive of an immediately life-threatening illness, the parents or carers will be advised
to take the child for an immediate specialist assessment, for example by calling an ambulance. From
a clinical assessment in non-specialist care, a child may again be returned home with appropriate
advice. Alternatively, the child may be discharged with a ‘safety net’ that ensures that the child has
some kind of clinical review or planned further contact with the health services (see Chapter 7). If the
child is considered to be sick or potentially at risk of serious illness, the child will be referred to
specialist care. In many cases, a firm diagnosis will be made by the non-paediatric practitioner and
the child will be managed and treated accordingly. In these circumstances, the child progresses
beyond the scope of this guidance and it is expected that the child would be treated according to
relevant national or local guidelines.
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