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 anaphylaxis:
    • difficult/noisy breathing
    • swelling of tongue
    • swelling/tightness in throat
    • difficulty talking and/or hoarse voice, wheeze, or persistent cough
    • persistent dizziness or collapse
    • persistent abdominal pain, vomiting after insect sting
  • adrenaline has been administered

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 

  • Lyell McEwin Hospital (08) 8182 9000, during business hours. After 5:00 pm contact either of the CALHN services. 

Southern Adelaide Local Health Network

Inclusions

  • acute or chronic (greater than 6 weeks) urticaria not responding to standard management (see ‘clinical management advice’)
  • urticarial vasculitis (non-migratory and fixed urticarial eruptions) or urticaria associated with systemic inflammatory disease

Exclusions

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • nil

Category 2 (appointment clinically indicated within 90 days)

  • urticarial vasculitis, non-migratory and fixed urticarial eruptions, or urticaria associated with systemic inflammatory disease

Category 3 (appointment clinically indicated within 365 days)

  • acute or chronic (greater than 6 weeks) urticaria not responding to standard management, see ‘clinical management advice’

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.

  • reason for referral
  • occupation
  • duration of symptoms
  • relevant pathology and imaging reports
  • past medical history
  • current medications
    • please specify if patient is taking any over the counter preparations or nonsteroidal anti- inflammatory drugs (NSAIDs) PRN, and whether they could be stopped
    • please also include duration of medication/s, particularly Angiotensin-Converting Enzyme Inhibitors (ACE-I) and note if any recent antibiotic exposures
  • clinical history and examination
  • please indicate if referral is more pressing due to significant distress or if interfering with childcare/school/work.
  • for chronic urticaria screening blood tests are not required
  • response to antihistamines, any other treatments
  • coexistence of angioedema

Additional information to assist triage categorisation

  • skin prick testing results if performed by immunology
  • colour photograph/s of urticaria
  • for patients with chronic urticaria, in which an underlying cause is suspected, the following investigations may be considered:
    • full blood count (FBC) - looking for eosinophilia associated with helminth infection
    • thyroid function tests (TFTs) and thyroid antibodies - associated with chronic urticaria)
    • strongyloides serology in patients who’ve travelled to endemic areas
    • erythrocyte sedimentation rate (ESR) or c-reactive protein (CRP) - elevated in autoinflammatory disorders
    • serum protein electrophoresis - looking for monoclonal gammopathy
    • antinuclear antibody (ANA) - associated with conective tissues diseases
    • C3/C4 - urticarial vasculitis can mimic urticaria, looking for low C3
    • total IgE - can help predict response to certain treatments
    • investigations for H.pylori if suspected to be relevant on history
    • anti-skin antibodies in patients with urticarial lesions, mimicking urticaria area suspected, primarily for bullous pemphigoid
    • stool multiplex, fecal analysis for ova, cysts and parasites

Clinical management advice

  • control of inflammation with intermittent courses of potent topical corticosteroids
  • antihistamines are used for symptomatic control; current guidelines support the safe use of non-sedating antihistamines in a dose range that is higher than indicated on standard packaging (up to 40mg Zyrtec or Claratyne, 360mg Telfast +/- H2 antagonists daily)
  • known trigger factors should be avoided; these may include aspirin and nonsteroidal anti- inflammatory drugs
  • avoiding excessive heat and the use of a soothing lotion (e.g. 0.5% menthol in aqueous cream) may be of benefit

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.