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 organ failure (acute renal failure, neurological signs including motor and sensory loss, severe intractable abdominal pain)
  • acutely unwell children with purpura unexplained illness or fever in a patient being treated with biologic or immunosuppressant medicines
  • suspected Kawasaki’s disease

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

For clinical advice, please telephone the relevant specialty service.

Northern Adelaide Local Health Network 

Southern Adelaide Local Health Network

  • Flinders Medical Centre (08) 8204 5511, after hours on-call service for patients of all ages until 11:00 pm

Women’s and Children’s Hospital Network


Inclusions

  • connective tissue disease with troubling mucocutaneous manifestations
  • vasculitis with skin manifestations

Exclusions

  • connective tissue disease without mucocutaneous manifestations e.g. myositis

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • established systemic lupus erythematosus (SLE), juvenile dermatomyositis (JDM), vasculitis or other autoimmune connective tissue disease with troubling mucocutaneous manifestations, requiring dermatology assistance as well as rheumatological care
  • all patients with suspected cutaneous vasculitis including Henoch Schönlein Purpura mucocutaneous manifestations
  • suspected Discoid Lupus

Category 2 (appointment clinically indicated within 90 days)

  • morphea

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 condition:
    • duration and frequency of symptoms
    • nature of skin presentation, duration and progress information
    • pattern of joint pain, for example overnight waking with pain, morning pain, pain with exercise, early morning stiffness
  • specific clinical features for concern:
    • rash, mouth ulcers, pain, chest pain, anaemia, leucopoenia, thrombocytopenia, active urine sediment or proteinuria if lupus suspected
    • Raynaud's phenomenon or skin thickening if scleroderma suspected.
    • muscle weakness, rash (heliotrope, Gottron’s) if dermatomyositis is suspected
    • palpable purpuric or livedoid rash with or without associated symptoms eg muscle pain, marked early morning stiffness, nasal stuffiness, dyspnoea, cough with haemoptysis if small vessel vasculitis is suspected
    • purpuric rash, nephritis, lung or Ear, Nose and Throat (ENT) involvement, fever, constitutional features such as weight loss
  • aggravating and relieving factors
  • treatments used/sought so far including response to nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy or any other treatments
  • examination:
    • rashes, specifically vasculitis rashes
    • joint swelling
    • evidence of muscle weakness, for example Gower’s test
    • evidence of lymphadenopathy, organomegaly
    • blood pressure
  • any previous history of specialist therapy, including investigations and treatments

Additional information to assist triage categorisation

  • relevant diagnostic/imaging reports, including location of company and accession number
  • skin biopsy histology and DIF, if a general practitioner elects to undertake a biopsy prior to referral, please send any skin rash for histology (in Formalin) and Direct Immunofluorescence (in Michel’s medium, or fresh in Saline if not available)
  • take blood pressure if vasculitis is suspected
  • blood tests, if available
  • full blood count (FBC)
  • electrolytes, urea, creatinine (EUC)
  • liver function tests (LFTs)
  • C-reactive protein (CRP)
  • erythrocyte sedimentation rate (ESR)
  • complement levels (C3, C4)
  • rheumatoid factor, anti-CCP antibody
  • antinuclear antibody (ANA) titre and pattern must be included, extractable nuclear antigen (ENA), dsDNA, antineutrophil cytoplasmic antibodies (ANCA),
  • urinalysis, and sent fresh to lab for spun urine to look for red cell casts if vasculitis is suspected
  • urine protein-creatinine ratio
  • creatinine kinase
  • thyroid function

Clinical management advice

All patients transferring from an interstate service will likely be triaged as a category 2

Presentation

  • systemic lupus erythematosus (SLE) - multisystem inflammatory presentation often with arthritis, rash, anaemia, serositis, nephritis, CNS involvement, positive ANA.
  • juvenile dermatomyositis (JDM) – inflammatory myopathy with proximal weakness, typical skin rash, arthritis.
  • vasculitis - purpuric rash, nephritis, lung or ENT involvement, fever, constitutional features
  • other connective tissue disease - features include Raynaud’s phenomenon, rash, arthritis, serositis, myositis, proteinuria, positive ANA.
  • localised scleroderma (morphea) – discrete areas of skin inflammation and fibrosis.
  • Behcet’s disease – recurrent oral and/or genital ulcers, rash, arthritis, uveitis

Management

Early consideration of connective tissue disease is essential to allow prompt diagnosis and management.

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.