Referral to emergency

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.

  • nil

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Category 1 — appointment clinically indicated within 30 days

  • positive faecal immunochemical test (immunological faecal occult blood testing (iFOBT)/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH)
  • 45 to 74 years of age with high risk family history, for colonoscopy screening including:
    • first degree relative of known familial adenomatous polyposis (FAP) antibody individual (APC gene mutation)
    • first degree relative of known individual with Lynch syndrome
    • first degree relative of known individual with Lynch-like syndrome
  • sibling of individual with MUTYH gene mutation
  • people with possible high-risk syndrome, including:
    • signs of possible Peutz Jaegers e.g. buccal markings
    • signs of FAP e.g. atypical congenital hypertrophy of the retinal pigment epithelium

Category 2 — appointment clinically indicated within 90 days

  • people age 50 to 74 years with moderately increased risk, for colonoscopy screening as per the National Health and Medical Research Council (NHMRC) guidelines

Category 3 — appointment clinically indicated within 365 days

  • nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. 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.

History

  • indication for screening procedure (family and personal history/positive faecal immunochemical test (immunological faecal occult blood testing (iFOBT)/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH))
  • patient and family history of bowel or gastrointestinal (GI) cancer, e.g. age at diagnosis, precise relationship to the patient/family tree
  • past relevant medical history, including significant cardiovascular, respiratory, renal or liver disease and surgery, particularly abdominal surgery.
  • current medication, especially nonsteroidal anti-inflammatory drug, opioids, anti-depressants, selective serotonin reuptake inhibitors (SSRIs), anticoagulants, antiplatelets, diabetes medication
  • frailty, cognitive function, ability to use a digital “self-service” pathway

Examination

  • examination findings, including body mass index (BMI), abdominal and digital rectal examination (DRE)

Investigations

  • complete blood examination (CBE)
  • urea, electrolytes, and creatinine (UEC)
  • liver function tests (LFT)
  • relevant previous imaging, endoscopic, histology reports

Additional information to assist triage categorisation

Inappropriately performed immunological faecal occult blood testing (iFOBT)/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH) e.g. in people with very limited life expectancy, those with good quality colonoscopy within last 2 years:

  • people > 75 years without clear justification.

Charlson co-morbidity index

Age May have one of the following (1 point) May not have any of the following
75 to 79 years of age (3 points for age alone) — mild liver disease
— diabetes without end-organ damage
— cerebrovascular disease
ulcer disease
— connective tissue disease
chronic pulmonary disease
dementia
— peripheral vascular disease
— congestive heart failure
— myocardial infarction
 — moderate/moderate/severe liver disease
— diabetes with end-organ damage
— hemiplegia
— moderate or severe renal disease
— acquired immune deficiency syndrome (AIDS)
— metastatic/non-metastatic solid organ or haematopoietic malignancy
≥ 80 years
(4 points for age alone)
 May not have any of above medical conditions — 

Clinical management advice

This CPC for Colorectal Cancer (CRC) screening has been developed for people identified as average risk, asymptomatic community members, asymptomatic people with a higher risk family history.

Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.

As CRC screening in otherwise healthy individuals is now a safe, effective and routine practice, several sites in South Australia are now moving to the use of digital patient pathways for the triage and progression of referrals more directly through to colonoscopy. This improves efficiency and shortens waiting times to colonoscopy procedures for the right people. It is vital that General Practitioners provide as accurate a history as possible to enable safe and accurate triage to support this gain in care delivery.

Patients outside the recommended age for CRC screening as per National Health and Medical Research Council (NHMRC) guidelines, e.g. over 75 years of age, need to have their fitness for colonoscopy assessed against the Charlson score (see referral information) prior to referral.

National standards recommend a colonoscopy or other total colonic examination is performed within 120 days of an appropriately performed immunological faecal occult blood testing (iFOBT)/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH).

National Bowel Cancer Screening Program (NBCSP) recommendations from NHMRC advise performing faecal immunochemical tests (iFOBT/FIT/FHH) every 2 years in otherwise well asymptomatic people (The Royal Australian College of General Practitioners (RACGP) summary):

  • 50 to 74 years for people at or slightly above average risk family history of CRC
  • 40 to 74 years for people with moderate risk family history (outside of NBCSP between age 40-49)
  • 35 to 74 years for people with high risk family history (outside of NBCSP between age 35-49).

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient 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

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.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • 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 pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.