Those of you who have been my GP trainees, will often hear me talk about red, amber and green patients.  Red patients are those that are worrying – like those that have features of meningitis.   Green patients are those that are not too worrying – like those who simply have a viral URTI.   And amber patients are those inbetween – i.e. those that you not quite sure of.  An  amber patient is not quite worrying as a red patient but also not as reassuring as a green patient.  

Those that are red patients are easy to manage – you usually admit them.   For example, a meningitis case, you would give benzylpenicillin (or equivalent if allergic) and admit them straight to hospital.   Can you see – whilst the condition is worrying, the decision-making involved is easy – you know what to do.   Those that are green patients are also easy to manage and again the decision-making is easy.   A simple viral URTI = watchful waiting with appropriate safety-netting.   But it is in the amber patients where decision-making becomes more difficult.   They are not as clear-cut as red and green patients.  These are require more complex decision making.   

Let’s explore this clinical decision-making in a bit more detail.

1. First of all think which light the patient is currently at – red, amber or green?
2. Then determine, according to their history so far, whether they have changed colours.

Scenarios:

• RELATIVELY STRAIGHT-FORWARD CLINICAL-DECISION MAKING
  • • • Patient initially started as green and remains green
        The decision-making, although it varies on the clinical presentation, is relatively easy.   For example, symptoms of a viral URTI which have become a bit worse but you still think viral URTI = watchful waiting + appropriate safety netting.  Or someone with back pain as a result of going on an activity trip – with no alarm features – you may suggest analgesia and exercises.  
      • Patient started green and is now red
        This is a lot more worrying.  You will most probably want to admit.  Using the example above – the patient who initially had what sounds like a viral URTI but now is very ill and on examination you think they may have a LRTI.   They look so unwell that you feel they need an admission,  for IV antibiotics.
      • Patient was amber but now red
        This is the patient who you were a bit worried about but upon review is actually worse.  So, take the possible LRTI who you gave antibiotics to, but then comes back a few days later and looks dreadful.  Clearly, they need admitting. 
      • Patient presents as red
        These always need admitting.  The patient who has had three fits today but no history of epilepsy or anything else.     Or the patient with meningitis features – you give benzylpen (or equivalent) and admit.   The patient who comes in a floppy drowsy worrying state.  You get the idea?
• MORE COMPLEX CLINICAL-DECISION MAKING
  • • • Patient started green and is now amber
        This is a bit more worrying.   You either want to start treatment and review.   For example, the patient who initially had what sounds like a viral URTI but now is more ill and on examination you think they may have a LRTI.   If they don’t look to bad for admission,  you might start antibiotics and review them in a few days (with appropriate safety-netting should things suddenly turn).

        
        Dr Edward Snelson (Paediatrician) writes: A 2 year old child presents with a cough, runny nose and a fever.  When you see them they are miserable but alert and interactive.  They have a temperature of 39.5, heart rate of 160 and are refusing to drink.  They last had any symptomatic treatment 6 hours ago.  The parent reports (you have to ask about this – it won’t usually be volunteered) that 2 hrs ago they looked much better and were drinking a bit.  Unlike actual traffic lights, unwell children swing from green to amber and back to green quite normally during uncomplicated self-limiting infections.  There is a reason that we mostly see unwell children between the age of 6 months and six years.  It’s not because they are high risk for dangerous infections.  In fact quite the opposite – it is a stage of life characterised by extreme response to simple infections.  The normal physiological response can look bad but usually resolves to reveal a reassuring baseline.  In many ways, a febrile unwell 2 week old is easier from a decision making point of view – that is a very high risk presentation.  A febrile unwell 2 year old is low risk but that presents a different problem – how to recognise the small number that do have a serious illness. What can be terribly inconvenient is the above situation.  The snapshot we are given is not green but also not red.  Red is also easier from a decision making point of view.  Amber presentations make us have to decide what to do next.  Here are your options:

        • • • Unwell children will often present with an amber feature which is felt to be related to a lack of symptomatic treatment rather than a sign of serious illness.  If that is the case you have the following options…
              • • • Send the child home with symptomatic treatment advice and safety netting advice
                  • Send the child home with symptomatic treatment advice and arrange remote or face-to-face review later
            • Refer the child to paediatrics
      • Patient was amber and remains amber
        This is a very difficult one.   You will want to either keep a close eye on the patient (through doing a few more tests, different treatment and a review in a few days time) or admit them.  For example, the LRTI that doesn’t seem to be settling despite 3 lots of antibiotics.   You might consider an urgent CT or even 2ww if there are other worrying features.
      • Patient was amber but now green
        Generally, you can relax a bit more – the patient seems to have gone through a bad patch and is now settling.  For example, those patients who sound like they were quite unwell (and should have seen), but have put off coming to the doctor and actually come in only when their symptoms seem prolonged although a lot better now.  So, take the patient who did not present to the doctor earlier, but sounded quite poorly with their chestiness (wasn’t eating or drinking much, found it slightly difficult to breathe, had rigors and chills) but presents to you in the second week because the cough hasn’t gone although they are feeling lots better and their breathing back to normal.   So, while you can relax a bit because they seem to be improving, always safety-net because the patient can turn again from their current green status to amber or red at short notice!   And this applies especially to infants and children – their colour situation can change suddenly even if they present to you as green.

        
        Dr Edward Snelson (Paediatrician) writes: Consider this scenario: A 2-year-old child presents with a cough, runny nose, and a fever.  The parent reports that a couple of hours ago they looked pale and lethargic.  They were shivering, and felt hot centrally but had cold hands and feet.  Now they have none of those things happening.  They are walking, talking and cheerfully interactive.  This is a very common scenario.  Parents and carers will often express a certain paradoxical frustration with the apparent wellness of the child.  The child appeared seriously unwell a couple of hours ago and the parent is now feeling that you will think that they have overreacted.

        
        What you can do:

        1. It is a good thing to acknowledge how unwell the child was and use that as an opportunity to..
        2. Explain why you as a clinician are happy with the child despite how concerning the child’s appearance was.  
        3. Safety-net in case the child turns again.   (Consider giving or signposting to something written)
        4. What you can say: “What you told me about how unwell (child’s name) was earlier sounds quite frightening. It is still very reassuring that they look better now. At this age children respond to infections quite strongly and that can cause some things that can look really concerning.  The temperatures can go very high and that immune response causes all of the things that you saw. It’s actually really good timing that they were at their best when I saw them because it allowed me to be able to be confident that it wasn’t signs of something like sepsis or meningitis. Children with sepsis and meningitis don’t do the things your child is doing now. I’m happy for you to continue managing your child’s illness with medicine that make them feel better such as paracetamol and ibuprofen.”

From this, you should be able to see that in terms of CLINICAL DECISION-MAKING, 

• Green patients are easy
• Red patients are relatively easy
• Amber patients is where the decision-making complexity lies and requires more careful thought.