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.

  • new neurological features in a patient with inflammatory back pain or previously diagnosed ankylosing spondylitis, for example bowel or bladder dysfunction or limb weakness
  • suspected sepsis or unexplained fever
  • complications of disease or therapy requiring emergent review – systemically unwell
  • unexplained illness or fever in a patient being treated with biologic or immunosuppressant medications
  • joint pain in someone from a population at high risk of acute rheumatic fever - Aboriginal and Torres Strait Islander individuals aged 18 to 20 years

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

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Exclusions

  • suspected infective cause of back pain, for example discitis and osteomyelitis – contact spinal services and infectious diseases for advice and refer to emergency if systemically unwell.

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • known or suspected ankylosing spondylitis and the patient is pregnant or planning a pregnancy

Category 2 (appointment clinically indicated within 90 days)

  • suspected ankylosing spondylitis / axial spondyloarthritis with or without peripheral symptoms and/ or extra articular manifestations
  • known ankylosing spondylitis / axial spondyloarthritis established on treatment including biologic / targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs)

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.

  • if the patient is pregnant or planning a pregnancy
  • complete medical history
  • details of previous medical management including the course of treatment and outcome, specifically, response to nonsteroidal anti-inflammatory drugs
  • current and previous medication history including non-prescription medicines, herbs and supplements
  • employment status
  • history of presenting condition:
    • description of joints affected and onset, characteristics
    • duration of symptoms
    • symptoms - severity of back pain / stiffness and peripheral symptoms, features of inflammatory back pain, for example, morning stiffness greater or less than 30 minutes, nocturnal pain
    • history of uveitis or inflammatory bowel disease
    • history of recent infection
  • clinical examination:
    • range of movement in lumbar spine
    • other joint examination positive findings
  • blood results including location of company and accession number if available:
    • full blood count (FBC)
    • liver function tests (LFTs
    • electrolytes, urea, creatinine (EUC)
    • estimated glomerular filtration rate (eGFR)
    • C-reactive protein (CRP)
    • erythrocyte sedimentation rate (ESR)
    • human leukocyte antigen B27 (HLA-B27)

Additional information to assist triage categorisation

  • family history of spondylarthritis or spondyloarthropathy associated condition, for example psoriasis, inflammatory bowel disease, or uveitis.
  • interference with activities of daily living and working ability — or example, has the patient had to stop or change work practices, are they requiring assistance with self care.
  • X-ray or other imaging of spine or sacroiliac joints if available including location of company and accession number
  • previous assessments or opinions from a rheumatologist or other relevant specialist or allied health clinician

Clinical management advice

To preserve rheumatology outpatient capacity for high acuity presentations, an alternative service model has been adopted at the Royal Adelaide Hospital (RAH) and The Queen Elizabeth Hospital (TQEH). Patients with uncomplicated non-inflammatory musculoskeletal conditions and recent onset inflammatory arthritis requiring fast tracking may be triaged into a physiotherapist-led clinic at the RAH or TQEH for assessment and management, with rheumatology consultant access as required. Outcomes may include provision of non-pharmacological management options in primary care or further imaging/pathology and review with a rheumatologist for ongoing care where indicated.

Contact the rheumatology registrar / rheumatologist on call before starting steroids wherever possible.

For mild to moderate inflammatory joint pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are most commonly used because of their known efficacy in treating pain, stiffness and swelling associated with established inflammatory rheumatological disease

  • Use the minimum effective dose of NSAID for the shortest time possible
  • Glucocorticoids including prednisolone are generally not recommended

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.