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.

  • acute liver failure, e.g. INR > 1.5 and encephalopathy or INR > 2, in the absence of pre-existing liver disease
  • acute paracetamol toxicity, referral is indicated to paediatrician if no liver synthetic dysfunction
  • chronic liver failure with fever or sepsis
  • jaundice with confusion
  • newborn with persistent (> 6 weeks), severe, recurrent unconjugated hyperbilirubinemia despite phototherapy. Phone on-call gastroenterologist for advice.
  • post-transplant jaundice with fever or sepsis
  • sudden onset, obstructive jaundice

Please contact the on-call registrar to discuss your concerns prior to referral.

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

Exclusions

  • hepatitis A with no coagulopathy that is able to have follow up in the community
  • sonographic fatty liver with normal liver function tests and normal liver and spleen size, in a child who has a weight and BMI > 85th percentile as per age and sex appropriate percentile chart. Note: Child would benefit from dietitian or weight management referral in the first instance.

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • newborn with persistent jaundice (> 2 weeks) with a conjugated fraction > 20%, with or without pale stools and/or dark urine
    Note: presence of pale stools warrants an immediate contact to on-call gastroenterologist for advice
  • acute hepatitis with worsening liver function tests – contact on-call gastroenterologist for clinical advice while awaiting triage
  • chronic hepatitis – triage category may vary depending on presenting symptoms and investigations and will be determined by triaging clinician based on clinical information provided in referral
  • unexplained cirrhosis

Category 2 (appointment clinically indicated within 90 days)

  • liver lesion on ultrasound with normal liver function tests
  • liver disease treatment required that is outside the referrer’s scope of practice, for example, viral hepatitis, autoimmune liver disease, primary sclerosing cholangitis, Wilson’s disease, metabolic diseases
  • suspected steatotic liver disease or metabolic associated fatty liver disease (MAFLD)

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.

  • details of presenting condition including:
    • onset and duration of symptoms
    • frequency and severity of symptoms
  • medical management to date / treatment trialled and response
  • clinical history including:
    • current weight and length or height, with percentiles
    • growth chart trends including at least two weight measurements, with percentiles
    • any weight loss, including amount and timeframe
    • medical history, medications, immunisations and allergies
  • use of nutritional supplementation and/or over the counter and herbal medicines
  • risk factors for viral hepatitis
  • investigations including:
    • liver function test (LFT) results, current and previous
    • full blood count (FBC)
    • coagulation profile
    • hepatitis A serology (HAV IgG)
    • hepatitis B serology (HBV sAg, sAb, cAb)
    • hepatitis C serology (HCV Ab)
    • iron studies
    • Epstein-Barr virus (EBV) and cytomegalovirus (CMV) serology
    • upper abdomen ultrasound

Additional information to assist triage categorisation

  • alcohol intake, including duration and quantity, if relevant
  • vaccination history
  • any relevant family history, including family history of hepatitis B carriage/treatment/hepatoma
  • haemoglobin A1C (HbA1c)
  • creatine kinase, in presence of elevated transaminases
  • any previous ultrasound, computed tomography (CT) scan or magnetic resonance imaging (MRI) reports – including location and date of imaging
  • additional pathology tests, e.g. autoimmune hepatitis, Wilson’s disease, genetic disorders

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.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.