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 neurological signs (motor or sensory loss) associated with back pain
  • lower limb joint pain and associated inability to weight bear
  • joint pain in a child from a population at high risk of acute rheumatic fever — Aboriginal and Torres Strait Islander children

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

  • hypermobile Ehlers Danlos Syndrome without joint pain
  • benign hypermobility syndrome without joint pain
  • growing pain variants including:
    • Osgood Schlatter’s
    • Sindig larsen
  • children under 18 years with chronic pain (pain persisting for >3 months) without evidence of arthritis should be referred to the chronic pain service

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • inflammatory back pain +/- peripheral joint inflammatory disease
  • evidence of synovitis, arthritis or joint erosion on imaging
  • joint pain with elevated inflammatory markers that are otherwise unexplained
  • joint pain accompanied by symptoms or history of other inflammatory disease:
    • inflammatory bowel disease, uveitis, new rashes
  • joint deformity / decreased range of movement

Category 2 (appointment clinically indicated within 90 days)

  • undiagnosed cause of joint or musculoskeletal pain that is not listed in category 1
  • musculoskeletal pain with significant functional impairment on the child and family

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 of presenting complaint

  • duration and frequency of symptoms
  • pattern of pain - for example overnight waking with pain, morning pain, pain with exercise, early morning stiffness
  • aggravating and relieving factors
  • treatments used/sought so far including response to nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy or any other treatments
  • symptoms - bony tenderness or swelling,

Examination findings

  • reduced range of motion
  • deformity
  • associated muscle wasting

Additional information to assist triage categorisation

  • relevant diagnostic/imaging reports including location of company and accession number if available
  • any blood test results if available

Clinical management advice

For the below suspected conditions, please refer to orthopaedics:

  • septic arthritis - via emergency department for acute orthopaedics assessment
  • hip dysplasia

Non-steroidal anti-inflammatory drugs (NSAIDs)

  • nonsteroidal anti-inflammatory drugs (NSAIDs) can be commenced prior to rheumatology assessment unless contraindicated.
  • NSAIDs produce a good response and will assist to manage pain
  • consider trial of piroxicam 0.4mg/kg (maximum 20mg) once daily for 4 weeks and assess response (may require proton pump inhibitor cover)

Physiotherapy

  • for any back pain referrals, a referral to community physiotherapy should be initiated where possible prior to rheumatology referral
  • physiotherapy is useful to facilitate stretching and range of motion exercises and has proven benefit in both inflammatory and non-inflammatory back pain
  • Whilst the rheumatology service accepts referrals for children with joint pain, to investigate any underlying inflammatory conditions such as arthritis, the rheumatology service does not accept referrals for the investigation, diagnosis, or management of joint hypermobility syndromes. Children with suspected Marfan's or classical Ehlers-Danlos should be referred to the genetics or cardiology services.
  • children with other hypermobility related issues may benefit from review and management from a physiotherapist

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.

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.