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.

  • evidence of systemic or major organ involvement
  • suspected sepsis or unexplained fever
  • severe disease with inability to function in the community — phone the rheumatology registrar or on call consultant to discuss options for admission

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

Inclusions

  • inflammation in multiple joints, typically involving either small joints or a mix of small and large joints, usually symmetrical.
  • may have systemic features of inflammation, for example, weight loss, fever or elevated inflammatory markers

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • known or suspected polyarthritis and the patient is pregnant
  • new onset or severely disabling flares of polyarthritis

Category 2 (appointment clinically indicated within 90 days)

  • flare of existing disease
  • possible or unclear recent onset polyarthrtis
  • non disabling flares of polyarthritis

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
  • family history of rheumatoid arthritis or autoimmune disease
  • details of previous medical management including the course of treatment and outcome
  • current and previous medication history including non-prescription medicines, herbs and supplements
  • alcohol and smoking history
  • employment status
  • clinical examination:
    • rash & other features of autoimmune disease for example Raynaud’s phenomenon, dyspnoea, joint swelling, tenderness, and restriction
    • functional impairment
  • 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)
    • urate
    • rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies
    • antinuclear antibody (ANA) titre and pattern must be included, if ANA is positive, extractable nuclear antigen (ENA) and dsDNA
    • urinalysis

History of presenting condition

  • description of joints affected and characteristics
    • recent onset symmetrical polyarticular joint inflammation
    • pattern of joint involvement, for example small versus large joints
    • multiple painful joints with swelling, early morning stiffness, greater or less than 30 minutes
    • typically, involvement of small peripheral joints, for example metacarpophalangeal joints and/ or metatarsophalangeal joints
  • duration of symptoms for < 6 weeks, > 6 weeks, > 12 months, > 2 years
  • systemic symptoms
  • recent travel, exposure to mosquito

Additional information to assist triage categorisation

  • interference with activities of daily living and working ability. For example, has the patient had to stop or change work practices, are they requiring assistance with self care.
  • Ross River virus, Barmah Forest Virus, parvovirus B19 serology if clinical suspicion
  • relevant diagnostic/imaging reports 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

Contact the rheumatology registrar / rheumatologist on call before starting corticosteroids 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.

In cases with more severe impairment, oral prednisolone could be considered, doses > 10mg not often required, dose < 7.5mg daily preferred if to be used beyond 2 weeks.

Encourage gentle exercise and avoid prolonged bed rest.

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.