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.

  • suspected bowel obstruction – vomiting, significant distention, inability to pass flatus, obstipation
  • acute surgical pathology e.g. evidence of peritonism, tender ileal mass, systemic toxicity
  • acute severe ulcerative colitis (ASUC) ≥ 6 bloody bowel stools per 24 hours (Truelove and Witts criteria) as well as any of the following:
    • temperature > 37.8°C
    • pulse rate > 90 bpm
    • haemoglobin (Hb) < 105 g/l
    • C-reactive protein (CRP) > 30mg/L at presentation or erythrocyte sedimentation rate (ESR) > 30 mm

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

Known or suspected inflammatory bowel disease (IBD) with any of the following red flags:

  • rectal bleeding
  • significant or new anaemia
  • symptoms/signs of systemic illness + raised inflammatory markers
  • suspected bowel obstruction via the emergency department (ED)
  • fever and/or abdominal / perineal mass
  • significant bloody stools / diarrhoea ≥ 6 per day if acute severe ulcerative colitis (ASUC) via the ED
  • weight loss ≥ 5% of body weight in previous 6 months


Category 2 — appointment clinically indicated within 90 days

  • symptomatic known or suspected IBD without red flags

Category 3 — appointment clinically indicated within 365 days

  • monitoring and/or surveillance activities including surveillance colonoscopy

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

  • time course, pattern and duration of symptoms
  • any extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) features including:
    • eye disease (iritis, episcleritis)
    • skin lesions (pyoderma, erythema nodosum)
    • mouth ulceration
    • joint pain
  • perianal disease, yes/no description if present
  • diet, nutrition
  • mental health, psychosocial situation, employment, sick leave
  • medication adherence if known IBD
  • current and previous IBD therapy with response/toxicities/dates

Examination

  • abdominal mass (yes/no) especially in right iliac fossa
  • perianal and digital rectal exam
  • check for EIMs of IBD
  • nutrition assessment – weight loss, sarcopenia
  • signs of systemic toxicity – fever, tachycardia, peritonism

Investigations

  • complete blood examination (CBE)
  • C-reactive protein (CRP)
  • urea, electrolytes, and creatinine (UEC)
  • liver function tests (LFT)
  • faecal calprotectin
  • iron studies if haemoglobin (Hb) or mean corpuscular volume (MCV) are low
  • vitamin B12, folate, vitamin D – if signs of weight loss, malnutrition
  • stool microscopy, culture and sensitivity (MCS) and polymerase chain reaction (PCR) including Clostridium difficile (acute episode)
  • relevant imaging reports (computed tomography, magnetic resonance enterography, ultrasound, previous endo/colonoscopy)

Clinical management advice

Inflammatory bowel disease (IBD) usually requires specialist gastrointestinal coordination utilising a shared care model with General Practitioners.

Patients with known IBD should be reviewed by a specialist annually, or more frequently if requiring immunosuppression or biological therapies.

Attention to screening and surveillance activities along with maintenance of remission generally results in normal quality of life.

General Practitioners are an important part of ongoing patient management to ensure vaccinations are up to date, smoking cessation is encouraged, and cancer prevention activities adhered to.

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.

If a patient has been fully investigated within last 2 years and symptoms remain unchanged, clinician discretion is needed to appropriately refer and triage. In general, there is little value in repeat specialist assessment and/or endoscopic procedures in this scenario.

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.