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.

  • active and uncontrolled bleeding which is unrelated to trauma or other known causes
  • suspected large thrombosis or pulmonary embolism

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

Inclusions

  • any episode of unprovoked thrombosis
  • patients with bleeding and abnormal coagulation screening tests
  • bleeding and a family history of severe bleeding disorder
  • patient with recurrent bleeding and normal coagulation screening tests
  • patient with no bleeding and a family history of mild or severe bleeding disorder
  • patient with family history or incidental finding of thrombosis risk
  • patient with no bleeding and an uncertain family history of a bleeding disorder

Exclusions

  • bleeding with known cause, for example post-surgical
  • first episode of provoked thrombosis which are associated with recent (<4-6 weeks) surgery, immobility or trauma are usually not reviewed in the haematology clinic
  • most patients with superficial thrombophlebitis
  • advice regarding anticoagulation can be sought from the duty haematologist but does not require a clinic review

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • any episodes of unprovoked thrombosis
  • patient with bleeding and abnormal coagulation screening tests
  • patient with bleeding and a family history of severe bleeding disorder

Category 2 (appointment clinically indicated within 90 days)

  • patient with family history or incidental finding of thrombosis risk
  • patient with recurrent bleeding and normal coagulation screening tests
  • patient with no bleeding and a family history of mild or severe bleeding disorder

Category 3 (appointment clinically indicated within 365 days)

  • patient with no bleeding and an uncertain family history of a bleeding disorder

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.

  • important psychosocial history or other barriers to accessing care
  • relevant medical history including: 
    • history of bleeding diathesis - gum bleeding post brushing, menorrhagia, spontaneous haematomas, bleeding post-surgical intervention, hemarthrosis, gastrointestinal and intracranial bleeding
  • family history of thrombotic or bleeding disorders
  • blood tests:
    • complete blood examination (CBE)
    • liver function tests (LFTs)
    • lactate dehydrogenase (LDH)
    • coagulation studies
    • international normalised ratio (INR)
    • activated partial thromboplastin time (APTT)
    • fibrinogen
    • Von Willebrand Factor Studies (if mucosal bleeding present)
    • coagulation assays appropriate to family history, for example factor assays for haemophilia
  • any available imaging for previous thrombosis

Additional information to assist triage categorisation

  • platelet function test
  • any thrombophilia workup

Clinical management advice

Antifibrinolytics (Tranexamic acid) is often helpful for mucosal bleeding (the most common form of bleeding) – mouth, epistaxis, menorrhagia. This may be given alone or as an adjunct therapy to Desmopressin/factor concentrate. For dose recommendations, see the Royal Children's Hospital Melbourne - Von Willebrand Disease vWD Clinical Practice Guideline

Prompt treatment of joint and muscle bleeding helps to prevent long term damage. If a bleed is identified, first, follow recommendations for clotting factor replacement when a joint or muscle bleed is suspected. See the Royal Children's Hospital - Haemophilia Clinical Practice Guideline for guidance.

For muscle and joint bleeds, the PRICE treatment strategies will limit bleeding and reduce pain. This should be initiated immediately.

  • Protection – immobilise the affected area in a position of comfort for example a splint, slings, or crutches.
  • Rest - rest the affected limb.
  • Ice - ice can be used for 10 to 20 minutes, every 1 to 2 hours for the first 24 to 48 hours.
  • Compression - compression limits the amount of bleeding. Compression can be applied to the area by use of an elastic bandage (ACE wrap) to wrap the injured joint. Wrap the joint from the lowest point to the highest point with gentle tension.
  • Elevation - elevate (raise) the injured area to a position higher than the heart. Elevate the area often for the next 2 to 3 days

Analgesia

  • do not use products containing aspirin or NSAIDS (for example, ibuprofen, diclofenac) as they may worsen bleeding
  • paracetamol may be sufficient. Opiates can be used for severe pain
  • splinting and immobilisation is an effective adjunct for reducing pain

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.