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Complex or undifferentiated medical problems

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Anaemia

  • Severe anaemia (Hb <80g/L) with risk of cardiovascular and/or syncopal collapse
  • Anaemia associated with definite clinical features of overt gastrointestinal bleeding
  • Severe cytopaenias if patient is unwell (ie infection, symptomatic anaemia, active bleeding)
    • Neutrophils < 0.5x109/L
    • Haemoglobin < 80g/L
    • Platelets < 20x109/L

Complex or undifferentiated medical problems

  • Any sudden decompensation in clinical condition that carries risk of serious adverse events or death
  • Pyrexia of unknown origin with temp ≥ 39ºC
  • Pyrexia with neutropaenia
  • Delirium
  • Suspected systemic vasculitis associated with symptoms, signs or investigation results suggestive of vital organ involvement
  • Suspected temporal arteritis (giant cell arteritis) with markedly elevated ESR (>100) and/or jaw claudication and/or visual disturbance

Complex paediatric patients transitioning to adult services

  • Any sudden decompensation in clinical condition that carries risk of serious adverse events or death

Falls

  • Any fall occasioning serious trauma (including fractures, major soft tissue injury, head strike or concussion) that cannot be managed in primary care
  • Frequent falls (more than one every few days)

Medication review / poly-pharmacy

  • Anaphylactic or other serious adverse drug event
  • Markedly prolonged heart rate adjusted QT interval which may herald pro-arrhythmic event
  • Marked drug induced electrolyte abnormality (Na <120, K <3.0 or >6.0, corrected Ca >3.0, Mg <0.4)

Osteoarthritis, gout and joint pain

  • Acute non-traumatic monoarthritis causing severe pain and/or incapacitating loss of function and/or marked constitutional symptoms
  • Suspected septic arthritis

States of altered neurological function

  • Witnessed tonic-clonic (grand mal) seizures
  • Suspected transient ischaemic attack or stroke on the basis of focal neurological deficits
  • Delirium or acute confusional state
  • Severe headache or altered level of consciousness of sudden onset

Syncope / pre-syncope

  • Syncope / pre-syncope with any of the following concerning features
    • exertional onset
    • chest pain
    • persistent symptomatic hypotension (systolic BP < 90mmHg)
    • severe persistent headache
    • focal neurological deficits
    • preceded by palpitations
    • associated significant physical injury (e.g. fractures, extreme soft tissue trauma, intracranial bleeds) or causing motor vehicle accident
    • family history of sudden cardiac death

Unintentional weight loss

  • Uncontrolled hyperthyroidism with risk of thyroid storm
  • Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction
  • Associated severe electrolyte abnormalities (K+ <3.0 mmol/L, corrected Ca+ <1.6 or >3.0 mmol/L, Mg+ <0.4 mmol/L, PO4- <0.4mmol/L)

Wounds of uncertain cause or non-healing ulcers

  • Severe cellulitis with ongoing or worsening systemic symptoms or fevers despite oral antibiotics for 48 hours
  • Foot ulcer in diabetic patient that is not responding to oral antibiotics and regular wound cleaning
  • Any infected ulcer associated with systemic inflammatory response symptoms (SIRS) or excessive pain or features suggestive of abscess formation, osteomyelitis or deep tissue infection (necrotising fasciitis)
  • Acute Charcot arthropathy
  • Ulcers or wounds in a limb with markedly compromised circulation

Other

  • Any condition defined by other CPCs as requiring referral to emergency
  • Laboratory tests should be limited and dependent on the history and examination.
  • Available depression tools include:
    • PHQ-2 – 2 question screening tool
    • K-10 – 10 question screening tool
  • Consider referral to dietitian if significant weight loss reported.

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Unstable co-morbidities which require early medical intervention to prevent further deterioration that may result in emergency hospitalisation
    • Recent discharge from hospital or emergency department (<4 weeks) and need for ongoing surveillance and optimisation of co-morbidities
    • Acute exacerbation of chronic medical condition which impacts on other co-morbidities and requires close monitoring
    • Rapidly progressive or recent onset of undifferentiated syndromes (eg pyrexia [T<39°C] of unknown origin, marked decline in cognitive function, generalised sub-acute myalgia/arthralgia or other undifferentiated rheumatic syndromes, generalised lymphadenopathy) for which definitive diagnosis and/or management plan is required
    • Fatigue lasting more than 3 months and any of the following:
      • significant weight loss (≥5% body weight in previous 6 months)
      • recent and/or progressive onset in previously well, older patient
      • dyspnoea or other features suggestive of cardiorespiratory compromise
      • unexplained lymphadenopathy
      • presence of fever
  • Category 2
    (appointment within 90 calendar days)
    • Stable co-morbidities that require risk assessment and medical optimisation
    • Stable or slowly progressive undifferentiated syndromes (eg fatigue, decline in cognitive function, generalised lymphadenopathy) for which definitive diagnosis and/or management plan is required
    • Chronic symptoms (eg dyspnoea, dizziness, imbalance) or condition requiring investigations and management to minimise long term impairment
    • Chronic symptoms causing significant social/economic/functional impairment
    • Diagnostic dilemmas requiring further investigation or confirmation
    • Connective tissue disease which is active but not life threatening
    • Polymyalgia rheumatica (PMR)
  • Category 3
    (appointment within 365 calendar days)
    • Multiple co-morbidities in need of regular review where referral to two or more specialty clinics imposes an unacceptable burden on patients
    • Soft tissue rheumatism
    • Non-progressive fatigue lasting longer than 3 months that remains unexplained despite detailed investigation

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • General referral information
  • Relevant medical history, co-morbidities (including depression and anxiety) and medications (including an assessment of adherence)
  • Details of all treatments offered and assessment of efficacy
  • A clear indication of clinical question that the specialist is required to address
  • Details of any functional decline or cognitive impairment
  • FBC, ELFT, ESR & TSH results

In cases of suspected malignancy, pyrexia of unknown origin or generalised lymphadenopathy, also include:

  • CT scan chest/abdomen/pelvis
  • ANA plus full antibody profile if ANA > 1/640
  • Serum protein electrophoresis

In cases of myalgia/arthralgia, also include:

  • CPK results
  • ANA plus full antibody profile if ANA > 1/640

In cases of poorly controlled diabetes, also include:

  • HbA1c

In cases of suspected rheumatological or systemic inflammatory conditions, also include:

  • CRP, Rh factor & ANA results

In cases of suspected or known cardiorespiratory disease, also include:

  • CXR

In cases of unexplained fatigue of recent onset, also include:

  • Impact on daily life and work (including falling asleep while driving)
  • CXR
  • Urinalysis results
  • Calcium, ESR/CRP, iron studies, CPK (if muscle weakness or pain), vitamin B12 & folate results

3. Additional referral information Useful for processing the referral

  • Existing psychosocial issues and supports
  • Copies of discharge summaries and outpatient letters relating to encounters with other specialists
  • ECG
  • BNP (if available)
  • Magnesium and phosphate results (if appropriate)
  • Documentation relating to past hospitalisations and clinic visits for anxiety/depression (if appropriate)
  • Background information on occupational history and past infectious diseases (if appropriate)

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.