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 respiratory distress/acute respiratory failure
    • suspected or known respiratory disease presenting with:
      • imminent cardiorespiratory arrest
      • anaphylaxis or angiooedema
      • acute onset or worsening of breathlessness
      • confusion, drowsiness, very fast or very slow breathing, not able speak in full sentences at rest due to breathing difficulty, significant increase in the use of accessory muscles of respiration (e.g. neck muscles), cyanosis
      • finger pulse oximetry (SpO2) < 90% if this is not normal for the patient or significant worsening of the patient’s baseline SpO2
      • new onset low blood oxygen or high blood carbon dioxide level, or significant worsening of blood oxygen or carbon dioxide level from the patient’s baseline, if arterial blood gas results are available
    • these signs/symptoms/parameters may be accompanied by a high heart rate or blood pressure changes, significantly higher or lower than the patient’s baseline

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

  • Flinders Medical Centre, request Respiratory Consults Registrar (08) 8204 5511

Inclusions

Suspected or confirmed clinical disorders

  • sleep disordered breathing
    • obstructive sleep apnoea (OSA)
    • central sleep apnoea (CSA) syndromes, e.g. from heart or cerebrovascular disease
  • chronic hypoventilation syndromes (type 2 respiratory failure), including
    • obesity hypoventilation syndrome (OHS)
    • obstructive lung disease, e.g. chronic obstructive pulmonary disease (COPD), with or without overlap with OSA
    • neuromuscular disorder
    • chest wall respiratory disorder, e.g. kyphoscoliosis, post-poliomyelitis
    • hypoventilation related to medication or substance, e.g. opioid
  • chronic ventilatory failure requiring ventilatory support via tracheostomy, e.g. post-high cervical cord injury, rare congenital disorders

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • suspected or confirmed sleep disordered breathing (of any category) with any of the following:
    • road crash or work-related accident or near miss accident due to excessive sleepiness within the last 12 months
    • dozing at the wheel > once per month
    • Epworth Sleepiness Scale (ESS) score > 16
      • rapid excess for sleepy patients holding safety critical occupation
    • patients requiring urgent work-up for solid-organ or haematological transplantation, or prevention of serious deterioration in end-organ function, e.g. unstable heart or cerebrovascular disease
    • patients requiring pre-operative work-up for urgent non-emergency surgery scheduled< 4 weeks in whom treatment or optimisation of sleep disordered breathing is required
    • pregnancy
    • diagnostic sleep study demonstrating mean sleep oxygen saturation < 90%
  • suspected or confirmed chronic hypoventilation syndromes with any of the following*:
    • rapidly progressive neuromuscular disorder
    • newly diagnosed daytime hypercapnia with PaCO2 > 45 mmHg (if arterial blood gas (ABG) sampling undertaken), particularly if accompanied by symptoms of hypercapnia, e.g. drowsiness, sleepiness, morning headaches
      • does not include patients with known chronic hypoventilation with stable symptoms and hypercapnia at a satisfactory level as assessed by specialist Respiratory/Sleep Physician
  • chronic ventilatory failure requiring ventilatory support via tracheostomy
  • SA Prison patients commenced on positive airway pressure (PAP) therapy during incarceration seeking uninterrupted PAP therapy post-incarceration

*not meeting indication for emergency presentation or criteria for acute respiratory failure

Category 2 (appointment clinically indicated within 90 days)

  • suspected or confirmed sleep disordered breathing (of any category) with any of the following:
    • road crash or work-related accident or near miss accident due to excessive sleepiness within the last 5 years but not within the last 12 months
    • dozing at the wheel within the last 12 months and no more than once a month
    • Epworth Sleepiness Scale (ESS) score 10 to 15
    • patients holding safety critical occupation
    • patients with significant co-morbid end-organ disease, including, but not limited to, solid or haematological transplantation, Cystic Fibrosis, COPD, pulmonary hypertension, cardiac disease (arrythmia, ischaemia, heart failure), cerebrovascular disease, neurological or neurodegenerative disease, acromegaly
    • severe OSA with apnoea-hypopnoea index (AHI) > 30 per hour
  • suspected or confirmed chronichypoventilationsyndromes requiring diagnostic work-up or treatment optimisation respectively and not meeting criteria for Category 1, or indication for emergency presentation or criteria for acute respiratory failure

Category 3 (appointment clinically indicated within 365 days)

  • suspected or confirmed sleep disordered breathing not meeting indication for emergency presentation or criteria for acute respiratory failure, category 1 and category 2, but still require specialist respiratory/sleep clinic review

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.

  • triaging information
    • specify urgency (category 1, 2 or 3) according to triaging criteria
    • STOP-BANG or OSA50 and Epworth Sleepiness Scale (ESS) score for suspected obstructive sleep apnoea (OSA)
    • occupation
    • concession card status, health care card or pensioner
    • history of road crash or work-related accident or near miss accident due to sleepiness, including date, if relevant
    • frequency of dozing at the wheel, if relevant
    • reports of previous sleep and respiratory investigations if available
      • lung function and arterial blood gas (ABG) reports if available, for hypoventilation syndromes
    • advanced respiratory support, e.g. bilevel positive airway pressure (BPAP), ventilation via tracheostomy
  • suspected/confirmed sleep disordered breathing
    • duration and severity of symptoms including snoring, nocturnal choking/gasping, witnessed apnoeic episodes, unrefreshing sleep, morning headaches, excessive daytime sleepiness including instances of falling asleep inappropriate during the daytime or working shifts
    • known craniofacial abnormalities, e.g. large tonsils, retrognathia
    • treatment to date, e.g. positive airway pressure (PAP), oral appliance, surgery and response/outcome
  • hypoventilation syndromes
    • relevant diagnosis, suspected or confirmed, and treatment to date if applicable
  • relevant other clinical information
    • body mass index (BMI)significant co-morbidities, including cardiac, neurological, mental health, respiratory and non-respiratory sleep disorders
    • current medications, including those causing sedation
    • blood panel report if available, e.g. full blood count (FBC), electrolytes and renal function, thyroid function test

Additional information to assist triage categorisation

  • relevant allied health/diagnostic/imaging reports, including location of company and accession number

Clinical management advice

Scope of investigations/treatment/management provided

  • diagnostic and/or treatment optimisation sleep study
  • implementation and supervision/monitoring of positive airway pressure (PAP) therapy:
    • continuous positive airway pressure (CPAP) for obstructive sleep apnoea (OSA) especially if deemed not able to be managed by general practitoner alone, e.g.
      • review of poor CPAP responders
      • access to multi-disciplinary Ear, Nose & Throat, dental or oro-maxillofacial surgical pathway for OSA treatment in patients who have failed CPAP therapy
    • bi-level PAP for chronic hypoventilation syndromes
    • appropriate PAP and/or other therapies for central sleep apnoea (CSA) depending on aetiology
  • specialist management of sleep disordered breathing, including those with:
    • a history of road or work-related accident or near miss accident due to excessive sleepiness regardless of type of occupation
    • safety critical occupation, e.g. commercial drivers, operators of heavy machinery
    • residual excessive daytime sleepiness or symptoms of non-respiratory sleep disorder(s) despite optimal treatment of their primary disorder
    • co-morbid cardiopulmonary disorder(s) (e.g. chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), pulmonary hypertension, heart failure) or hypoventilation due to medication or substance (e.g. opioid)
  • multi-disciplinary management of complex respiratory needs, including
    • patients requiring ventilation via tracheostomy
    • patients with sleep disordered breathing requiring transition from paediatric to adultcare

Referring doctor is responsible for

  • assessing the immediate fitness to drive based on AustRoads 2022 guidelines, this may include advising the patient to avoid driving, and reporting to TransportSA if necessary
  • counselling the patient, including safe driving tips and good sleep hygiene
  • implementing lifestyle changes as part of healthy living and better sleep health measure, including:

Referral tips

  • a change in the patient’s clinical status (e.g. rapid clinical deterioration or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible
  • patients with suspected or proven Motor Neuron Disease (MND)/Amyotrophic Lateral Sclerosis (ALS) should be preferentially referred to the statewide multidisciplinary MND service at Southern Adelaide Local Health Network (SALHN)
  • referring medical officers may be asked to provide required information (e.g. STOP-BANG or OSA50 and Epworth Sleepiness Scale (ESS) scores, or report of any available/prior sleep study) before an appointment is provided
  • criteria for public funding of PAP equipment may vary across different local health networks (LHN). In general, these are based on:
    • concession card status
    • severity of sleep disordered breathing or hypoventilation syndromes
    • subjective and/or objective improvement with therapy
    • adherence to therapy (reaching minimum hours of usage/day)
    • satisfactory care of government-funded equipment
  • acceptability of non-tertiary sleep study reports for access to publicly funded PAP equipment will be at the discretion of the triaging sleep physician at the LHN concerned. In general reports must be clearly legible (colour copy preferred) and the quality of the studies must be deemed to be acceptable.

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.