fact sheet-landscape-excellence - home page - central ... · web viewsuspected septic arthritis...

Clinical Prioritisation CriteriaGeneral medicine CPC v 0.07

SummaryThis document contains the draft Clinical Prioritisation Criteria (CPC) for general medicine It is a consultation document only. It is not the final format or layout of the CPC and should be read in conjunction with the consultation overview.

For more information about the CPC development process and purpose, please see the accompanying CPC Consultation Overview.

ContentsSummary.............................................................................................................1

Contents.................................................................................................................1In scope for general medicine outpatient services.................................................3In scope paediatric conditions................................................................................4Out of scope for general medicine outpatient services..........................................4Referral to emergency............................................................................................5

Referral and outpatient criteria............................................................................7Anaemia not associated with iron deficiency..........................................................7Complex paediatric patients transitioning to adult services....................................8Complex or undifferentiated medical problems......................................................9Falls 11Fatigue (including chronic fatigue syndrome).......................................................13Medication review / poly-pharmacy......................................................................14Non-healing ulcers or wounds of uncertain cause...............................................15Osteoarthritis, gout and joint pain.........................................................................17Pre-operative medical assessment......................................................................18

States of altered neurological function (funny turns)............................................20Syncope / pre-syncope (non-cardiac origin).........................................................21Unintentional weight loss......................................................................................23

Intervention criteria............................................................................................25Out of scope for general medicine interventions..................................................25Urgency category for intervention........................................................................25Version control......................................................................................................26References...........................................................................................................27

In scope for general medicine outpatient servicesThe following conditions are proposed under the General Medicine CPC

Anaemia not associated with iron deficiency

Complex paediatric patients transitioning to adult services

Complex or undifferentiated medical problems

Falls

Fatigue (including chronic fatigue syndrome)

Medication review / poly-pharmacy

Non-healing ulcers or wounds of uncertain cause

Osteoarthritis, gout and joint pain

Pre-operative medical assessment

States of altered neurological function (funny turns)

Syncope / pre-syncope of non-cardiac origin

Unintentional weight loss

The following conditions may be seen within a General Medicine outpatient clinic however CPC have already been developed by the appropriate spe-cialty. The below CPC have been reviewed by the General Medicine CAG and no amendments to categorisation have been suggested. Depending on local service delivery, patients referred for the following conditions may be seen by a general medicine physician.

Abnormal liver function tests / jaundice (within Hepatology CPC)

Anaphylaxis and allergy management (not yet developed)

Asthma (to be developed in Respiratory CPC – not yet commenced)

Diabetes mellitus (within Diabetes and Endocrinology CPC)

Chest pain (to be developed in Cardiology CPC – in progress)

Chronic cough (to be developed in Respiratory CPC – not yet com-menced)

Disorders of salt and water (within Diabetes and Endocrinology CPC)

Headache/migraine (within Neurology CPC)

Heart failure (to be developed in Cardiology CPC – in progress)

High risk foot (within Diabetes and Endocrinology CPC)

Hypertension (to be developed in Cardiology CPC – in progress)

Hyperthyroidism (within Diabetes and Endocrinology CPC)

Hypothyroidism (within Diabetes and Endocrinology CPC)

Liver disease / fatty liver / liver failure (various liver conditions in Hepatol-ogy CPC)

Peripheral neuropathy (within Neurology CPC)

Pyelonephritis (may be done in Nephrology CPC – not yet commenced)

Clinical Prioritisation Criteria - 3 -

https://cpc.health.qld.gov.au/Condition/90/peripheral-neuropathy

https://cpc.health.qld.gov.au/Specialty/16/hepatology

https://cpc.health.qld.gov.au/Specialty/16/hepatology

https://cpc.health.qld.gov.au/Condition/221/hypothyroidism

https://cpc.health.qld.gov.au/Condition/220/hyperthyroidism

https://cpc.health.qld.gov.au/Condition/219/high-risk-foot

https://cpc.health.qld.gov.au/Condition/86/headachemigraine

https://cpc.health.qld.gov.au/Condition/232/disorders-of-salt-and-water

https://cpc.health.qld.gov.au/Condition/217/diabetes-mellitus

https://cpc.health.qld.gov.au/Condition/240/abnormal-liver-function-tests-jaundice

Seizures/epilepsy (within Neurology CPC)

Syncope – cardiac (to be developed within Cardiology CPC – in progress)

Thyroid enlargement/nodules (within Diabetes and Endocrinology CPC)

In scope paediatric conditionsThe following paediatric conditions have been suggested by the CPC Paediatric Advisory Group (PAG) to be considered under the General Medicine CPC

Given that a General Paediatrics CPC has already been developed, there is not likely to be any paediatric conditions within the General Medicine CPC.

Out of scope for general medicine outpatient servicesNot all services are funded in the Queensland public health system. Exceptions can always be made where clinically indicated. It is proposed that the following are not routinely provided in a public general medicine service

Clearly evident mental health disorders requiring psychiatric consultation

Genetic testing / counselling

Requests for respite care, ACAT assessments or other forms of assessment or supportive care in the presence of established diagnoses and manage-ment plans, or where patients with established mental capacity to make decisions refuse such assessments or care

Reviews relating to workers’ compensation claims, NDIS eligibility, disability pensions, driving license renewals, or other legal and administrative proce-dures

Reviews relating to drug withdrawal or detoxification


https://cpc.health.qld.gov.au/Condition/222/thyroid-enlargement-thyroid-nodules

https://cpc.health.qld.gov.au/Condition/87/seizuresepilepsy

Referral to emergencyIt is proposed that the following conditions should be sent directly to emergency:

Anaemia not associated with iron deficiency

Severe anaemia (Hb <80gm/l) with risk of cardiovascular and/or syncopal collapse

Severe cytopaenias if patient is unwell (ie infection, symptomatic an-aemia, active bleeding)

o Neutrophils < 0.5x109/L

o Haemoglobin < 80g/L

o Platelets < 20x109/L

Complex paediatric patients transitioning to adult services

Any sudden decompensation in clinical condition that carries risk of death or serious adverse events

Complex or undifferentiated medical problems


Pyrexia of unknown origin with temp ≥ 39ºC

Pyrexia with neutropaenia

Delirium

Falls

Any fall occasioning serious trauma (including fractures, major soft tissue injury, head strike or concussion) that cannot be managed in primary care.

Frequent falls (more than one every few days)

Fatigue (including chronic fatigue syndrome)

Clinical features that herald imminent cardiovascular collapse

Medication review / poly-pharmacy

Anaphylactic or other serious adverse drug event

Markedly prolonged QT interval which may herald pro-arrhythmic event

Marked drug induced electrolyte abnormality (Na <120, K <3.0 or >6.0, Ca >3.0, Mg <0.4)

Non-healing ulcers or wounds of uncertain cause

Severe cellulitis (with features of systemic inflammatory reaction syn-drome [SIRS])

Cellulitis failing to respond to oral antibiotics within 48 hours

Infected foot ulcer with systemic features

Acute charcot arthropathy

Critical limb ischaemia

Excessive pain – consider necrotising fasciitis

Suspected osteomyelitis


Osteoarthritis, gout and joint pain

Aggressive connective tissue disease

Suspected systemic vasculitis

Suspected temporal arteritis (giant cell arteritis)

Acute non-traumatic monoarthritis

Suspected septic arthritis

States of altered neurological function (funny turns)

Prolonged state (>30 mins) of altered neurological function

Witnessed tonic-clonic (grand mal) seizures

Focal neurological deficits

Delirium or acute confusional state

State of altered neurological function with associated severe headache or vomiting

State of altered neurological function with associated cardiorespiratory ab-normalities (tachycardia, tachypnoea, hypotension or severe hyperten-sion, cyanosis)

State of altered neurological function with known cardiac or neurological disease

Syncope / pre-syncope (non-cardiac origin)

Syncope / pre-syncope with any of the following Red flags

- exertional onset

- chest pain

- persistent symptomatic hypotension (systolic BP < 90mmHg)

- severe persistent headache

- focal neurological deficits

- preceded by palpitations

- associated injury

- family history of sudden cardiac death

Unintentional weight loss

Marked cachexia or malnutrition (BMI <15)

Uncontrolled hyperthyroidism with risk of thyroid storm

Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction

Other

Any condition defined by other CPCs as requiring referral to emergency


Referral and outpatient criteria

Anaemia not associated with iron deficiencyReferral to emergency

Severe anaemia (Hb <80gm/l) with risk of cardiovascular and/or syncopal collapse

Severe cytopaenias if patient is unwell (ie infection, symptomatic anaemia, active bleeding)

- Neutrophils < 0.5x109/L

- Haemoglobin < 80g/L

- Platelets < 20x109/L

Minimum referral criteria

Cat 130 days

Symptomatic anaemia

Anaemia with no obvious cause

Anaemia with significant weight loss (≥ 5% of body weight in previous 6 months)

Suspected haematological malignan-cies, with a combination of anaemia, weight loss, fevers, bone pain and night sweats

Cat 290 days

Persistent unexplained mild to moder-ate anaemia (Hb 90-110mg/l)

Anaemia refractory to iron and B12/folate supplementation

Cat 3365 days

Essential referral information(referral will be rejected without this)

Additional referral information(information that could be useful but is not essential to processing the referral)

General referral information

Details of relevant signs and symptoms

Details of all treatments offered and efficacy

Relevant medical history, co-morbidities and medications

Duration of anaemia (if known)

Medication history (especially NSAIDS, aspirin, corticosteroids, immunosup-pressants)

FBC, ELFT, ESR, TSH, iron studies, vitamin B12, folate results

Serial FBC results (if available)

History of alcohol and drug use

History of menorrhagia

CRP, Coombs test or haptoglobin results


Other useful information for referring practitioners (not exhaustive)

If dietary cause suspected, modify diet and/or refer to a dietitian If appropriate, treat with supplements (eg iron, vitamin B12, folate)

Cease any aggravating medications if possible (eg NSAIDS)

Please note that an Iron deficiency CPC has been developed by Gast-roenterology.

Please note that 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 manage -ment 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 a condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

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.

Complex paediatric patients transitioning to adult servicesReferral to emergency



Cat 130 days

Potentially unstable congenital dis-orders or diseases acquired in child-hood or adolescence that previously required ongoing review and manage-ment by paediatric services but now re-quire ongoing management by adult specialist services

Cat 290 days

Stable congenital disorders or diseases acquired in childhood or adolescence that previously required ongoing review and management by paediatric services but now require ongoing management by adult specialist services

Cat 3365 days




Relevant medical history, comorbidities and medications, including previous discharge summaries or outpatient letters from treating paediatric service

Details of all treatments previously offered and efficacy

Existing psychosocial supports

Patient or carer support services – eg disability or carer pensions, services provided by Disability Services Queensland, National Disability Insurance Scheme, or other support agencies


https://cpc.health.qld.gov.au/Condition/77/iron-deficiency

A clear indication of clinical issues that the specialist is required to address

Details of any functional decline or cognitive impairment

ECG

FBC & ELFT results (laboratory tests should be limited and dependent on the history and examination)

CXR report


Patients with cystic fibrosis should be managed by statewide cystic fibrosis services where possible.

Ensure that patients with conditions for which patient support groups exist that those patients in need of simple advice or support are familiarised with these groups.




Complex or undifferentiated medical problemsReferral to emergency


Pyrexia of unknown origin with temp ≥ 39ºC

Pyrexia with neutropaenia

Delirium


Cat 130 days

Unstable co-morbidities which require early medical intervention to prevent further deterioration that may result in emergency hospitalisation

Recent discharge from hospital or

Cat 290 days

Stable comorbidities that require risk assessment and medical optimisation

Stable or slowly progressive undifferen-tiated syndromes (eg fatigue, decline in cognitive function, generalised lymph-

Cat 3365 days

Multiple comorbidities in need of regu-lar review where referral to two or more specialty clinics imposes an un-acceptable burden on patients


emergency department (<4 weeks) and need for ongoing surveillance and optimisation of co-morbidities

Acute exacerbation of chronic medical condition which impacts on other co-morbidities and requires close monitor-ing

Rapidly progressive or recent onset of undifferentiated syndromes (eg pyrexia [T<39°C] of unknown origin, fatigue, decline in cognitive function, general-ised myalgia/arthralgia or other undif-ferentiated rheumatic syndromes, gen-eralised lymphadenopathy) for which definitive diagnosis and/or manage-ment plan is required

Clinical features suggesting malig-nancy

adenopathy) for which definitive dia-gnosis and/or management plan is re-quired

Chronic symptoms (eg dyspnoea, dizzi-ness, imbalance) or condition requiring investigations and management to min-imise long term impairment

Chronic symptoms causing significant social/economic/functional impairment

Diagnostic dilemmas requiring further investigation or confirmation




Relevant medical history, comorbidities and medications

Details of all treatments offered and efficacy

A clear indication of clinical question that the specialist is required to ad-dress

Details of any functional decline or cognitive impairment

CXR report

FBC, CRP, ESR, ELFT, TSH results

CT scan chest/abdomen/pelvis (in cases of pyrexia of unknown origin, gen-eralised lymphadenopathy or suspected malignancy)

CPK (in cases of myalgia)

HbA1c (in cases of poorly controlled diabetes)

ANA (in cases of pyrexia of unknown origin, myalgia/arthralgia) plus full anti-

Existing psychosocial supports

Copies of discharge summaries and outpatient letters relating to encounters with other specialists

ECG


body profile if ANA > 1/640

Serum protein electrophoresis (in cases of pyrexia of unknown origin, sus-pected malignancy)


Laboratory tests should be limited and dependent on the history and examination




FallsReferral to emergency

Any fall occasioning serious trauma (including fractures, major soft tissue injury, head strike or concussion) that cannot be managed in primary care

Frequent falls (more than one every few days)


Cat 130 days

Two or more falls in the previous month

Cat 290 days

Two or more falls in previous 12 months

Falls as part of an overall decline in physical, social or psychological func-tion

Cat 3365 days





Number of falls in the previous 12 months

Existing psychosocial supports (family, carers, home services, etc)

Copies of discharge summaries and outpatient letters relating to hospitali-


Assessment of cognitive function (MMSE or MOCA) in patients ≥ 65 years of age

Chronological profile of the impact of symptoms on ability to function

sations for falls, or visits to fall clinics, or home assessments for falls risk

Bone mineral densitometry report (if performed)

Home medications review report if available


A history of falls in the past year is the single most important risk factor for falls and is a predictor for further falls

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits. They should be considered for interventions that improve strength and balance.

The following links to cognitive assessment tools may be useful:

- General screening information: https://health.dementia.org.au/information/for-health-professionals/clinical-resources/cognitive-screening-and-assessment

- Montreal Cognitive Assessment (MOCA): http://dementiakt.com.au/doms/domains/cognition/moca

- GP assessment of cognition (GPCOG) tool: http://gpcog.com.au/

- Standardised mini-mental state examination (MMSE): https://www.ihpa.gov.au/sites/g/files/net636/f/publications/smmse-tool-v2.pdf

Consider referral to clinical pharmacist for Home Medical Review if evidence of polypharmacy.

Evidence for fall prevention strategies:

- exercise

- high dose vitamin D

- psychoactive medication withdrawal (particularly antidepressants, antipsychotics and benzodiazepines)

- occupational therapy home visit

- restricted multifocal spectacle use

- expedited cataract surgery (where required)

- podiatry intervention

- multifactorial assessment with targeted interventions (including referral to physiotherapist and/or dietitian as appropriate)





https://www.ihpa.gov.au/sites/g/files/net636/f/publications/smmse-tool-v2.pdf

http://gpcog.com.au/

http://dementiakt.com.au/doms/domains/cognition/moca

Fatigue (including chronic fatigue syndrome)Referral to emergency

Clinical features that herald imminent cardiovascular collapse


Cat 130 days

Fatigue lasting more than 3 months with any of the following Red flags:Red flags- significant weight loss (≥5% body

weight in previous 6 months)

- recent and/or progressive onset in previously well, older patient

- dyspnoea or other features sug-gestive of cardiorespiratory com-promise

- unexplained lymphadenopathy

- presence of fever

Cat 290 days

Unexplained and non-progressive fa-tigue lasting more than 3 months

Cat 3365 days




Relevant medical history, comorbidities (especially depression or anxiety) and medications

Impact on daily life and work (including falling asleep while driving)

CXR report

Urinalysis results for protein, blood and glucose

FBC, ELFT, calcium, ESR/CRP, TSH, iron studies, CPK (if muscle weak-ness or pain), vitamin B12 & folate results

Psychosocial supports

BNP (if available)

Magnesium and phosphate results (if appropriate)

Documentation relating to past hospitalisations and clinic visits for anxiety/depression

Background information on life stressors, work history, past infectious dis-eases



Available depression tools include

- PHQ-2 – 2 question screening tool

- K-10 – 10 question screening tool

Consider referral to dietitian if significant weight loss reported




Medication review / poly-pharmacyReferral to emergency

Anaphylactic or other serious adverse drug event

Markedly prolonged QT interval which may herald pro-arrhythmic event

Marked drug induced electrolyte abnormality (Na <120, K <3.0 or >6.0, Ca >3.0, Mg <0.4)


Cat 130 days

Suspected drug-induced syndromes (falls, confusion, bowel or bladder dys-function, fatigue)

Suspected drug-drug or drug-disease interaction of clinical significance

Recent medication-related hospitalisa-tion

Hyperpolypharmacy (≥10 regularly pre-scribed drugs)

Cat 290 days

Chemical or drug toxicity of a chronic nature

Medications where potential for harm potentially outweigh potential benefits in older patients

Polypharmacy (≥5 regularly prescribed drugs)

Suspected or known drug non-adher-ence

Cat 3365 days



General referral information, highlighting any specific drugs causing concern

Relevant medical history and comorbidities

List of all other doctors (specialists, GPs) who prescribe drugs for the pa-tient, and their contact details


https://www.beyondblue.org.au/the-facts/anxiety-and-depression-checklist-k10

http://www.phqscreeners.com/

Full list of medications including over the counter medications and comple-mentary medicines, and indications for each one

Past history of drug allergies or adverse reactions or medication-related hos-pitalisations

History of attempts to wean or cease specific medications

Details of any home medications review undertaken by pharmacists

Contact details for patient’s regular community pharmacist


Refer to Drug de-prescribing guidelines

Refer to the STOPP criteria




Non-healing ulcers or wounds of uncertain causeReferral to emergency

Severe cellulitis failing to respond to oral antibiotics within 48 hours

High risk foot ulcer in diabetic patient

Infected foot ulcer associated with systemic inflammatory response symptoms (SIRS)

Acute charcot arthropathy

Ulcers or wounds in a limb with markedly compromised circulation

Excessive pain – consider necrotising fasciitis

Suspected osteomyelitis or abscess formation



https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afu145

http://www.smgg.es/images/articulos/polypharmacy.pdf

Cat 130 days

Wound or ulcer of uncertain aetiology that is progressing in size despite dressings and leg elevation

Suspected malignant ulcer

Acute onset varicose ulcer

Acute onset ulcer in patients receiving high dose steroids or immunosup-pressive agents

Cat 290 days

Subacute or chronic ulcer of uncertain aetiology that is not responding to ap-propriate treatment (dressings, leg elev-ation)

Cat 3365 days




Relevant medical history, comorbidities (particularly diabetes, neuropathy, peripheral arterial disease, cognitive impairment, drug abuse, mental health problems) and medications

Wound history- duration- description and size- wound initiating event- presence of peripheral pulses if limb wound

Investigations (if performed)- any biopsies of the wound- leg ulcers

- arterial studies / Ankle Brachial Pressure Index- venous incompetence studies (note not venous ultrasound for acute

DVT) Treatment history - including

- wound care provided to date (including antibiotics, topical ointments, etc)- service provider (i.e. GP, practice nurse or domiciliary nursing service)

Residential status (lives alone, support networks, etc)

Access to wound care services, domiciliary nursing

Smoking status

Weight, height & BMI


The Wounds Australia Standards for Wound Prevention and Management may be provide additional management guidance

Consider using the Tissue, Infection/Inflammation, Moisture, Epithelial/Edge (T.I.M.E.) model

Consider using the Bates-Jenson Wound Assessment Tool

Consider referral to a dietitian to optimise nutritional status for wound healing

Please note that 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 manage -


http://www.smith-nephew.com/australia/wound-bed-preparation1/

http://www.woundsaustralia.com.au/2016/standards-for-wound-prevention-and-management-2016.pdf

ment by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.



Osteoarthritis, gout and joint painReferral to emergency

Aggressive connective tissue disease

Suspected systemic vasculitis

Suspected temporal arteritis (giant cell arteritis)

Acute non-traumatic monoarthritis

Suspected septic arthritis


Cat 130 days

Acute inflammatory arthritis

Polyarticular goutCat 290 days

Early inflammatory arthritis

Poly arthritis with functional impairment

Connective tissue disease which is act-ive but not life-threatening

Polymyalgia rheumatica (PMR)

Recurrent gout despite treatment with maximum tolerated allopurinol dose / progressive joint damage despite ther-apy / allopurinol intolerance

Chronic tophaceous gout

Cat 3365 days

Stable inflammatory arthritis

Complex osteoarthritis

Soft tissue rheumatism

Functional impairment and/or pain per-sists despite optimal management, such as physiotherapy, weight loss and analgesics





Description of joints affected (swelling, pain, morning stiffness)

Imaging of joints (XR/CT/MRI results)

Urinalysis results


Details of treatments offered and efficacy

Interference with activities of daily living and working ability

FBC, ELFT, ESR/CRP, uric acid, rheumatoid factor, anti CCP, anti-nuclear antibodies results


If appropriate, encourage weight loss and regular exercise

For management of gout:

- consider NSAIDs or colchicine for acute symptoms

- consider prophylaxis with allopurinol or probenecid (caution in CKD)

- dietary modification (particularly alcohol intake)

- modify medications that may contribute to gout where possible

- increase fluid intake

- consider referral to a physiotherapist

Please note that CPCs have been developed Knee pain (acute) and Knee pain (chronic) by orthopaedics.




Pre-operative medical assessmentReferral to emergency


Cat 130 days

High risk surgery (eg vascular surgery, major intra-cavity surgery, neurosur-gery)

High risk clinical factors (eg known car-

Cat 290 days

Moderate risk surgery (eg amputation, orthopaedic surgery, head and neck surgery, major breast and plastic sur-gery)

Cat 3365 days


https://cpc.health.qld.gov.au/Condition/94/chronic-knee-pain

https://cpc.health.qld.gov.au/Condition/93/acute-knee-pain

diac or respiratory disease, diabetes, chronic kidney disease, cirrhosis, neur-ological diseases, malnutrition)

Semi-urgent surgery

Older age (>70 years) and/or frailty

Past anaesthetic or peri-operative complications

Receiving anticoagulants or anti-plate-let agents

Moderate risk patient (eg hypertension, obesity, obstructive sleep apnoea)




Relevant medical history (including past surgical history), comorbidities and medications

Details about planned procedure, surgeon, and informed consent procedure

Usual exercise tolerance and level of physical activity

ECG (for patients with past cardiac history or multiple cardiac risk factors)

Spirometry (for current smokers and patients with known COPD)

Results of any past echocardiograph (in patients with known heart failure or valvular heart disease)

INR levels (for patients receiving warfarin)

FBC, ELFT (for high risk patients or patients undergoing moderate to high risk surgery, or known renal or liver disease)

Copies of correspondence received from surgeons, anaesthetists

Scheduled date of surgery (if known)

Nutritional status / report from dietitian review (where appropriate)

Pre-operative functional status and any other psychosocial factors that identify the patient as potentially requiring increased care needs at home at the time of discharge following the operation


Refer to guidelines regarding pre-operative cardiac assessment

Consider referral to a dietitian if the patient’s nutritional status impacts on surgery




https://www.mja.com.au/system/files/issues/199_10_181113/sco11066_fm.pdf


States of altered neurological function (funny turns)Referral to emergency

Prolonged state (>30 mins) of altered neurological function

Witnessed tonic-clonic (grand mal) seizures

Focal neurological deficits

Delirium or acute confusional state

State of altered neurological function with associated severe headache or vomiting

State of altered neurological function with associated cardiorespiratory abnormalities (tachycardia, tachypnoea, hypotension or severe hypertension, cyanosis)

State of altered neurological function with known cardiac or neurological disease


Cat 130 days

Frequent episodes (more than once a week) of dizziness (not vertigo), imbal-ance, memory loss, tinnitus, dissociat-ive state

Cat 290 days

Recurrent episodes (between 2 to 4 per month) of dizziness (not vertigo), imbal-ance, memory loss, dissociative state

Cat 3365 days

Intermittent episodes of altered neuro-logical function averaging no more than once a month




Relevant medical and psychiatric history, comorbidities and medications

Details of treatments offered and efficacy

FBC & ELFT results

ECG

Psychosocial supports

Work or life stressors, sleep deprivation

Results of previous EEG, CT or MRI-head, carotid arterial duplex scan (if performed)

Results of audiometry (if associated hearing loss)


Patients with known epilepsy that present with single seizures do not necessarily require a specialist referral if there are no injuries, focal neurological symp-toms or signs or any other new concerns.





Syncope / pre-syncope (non-cardiac origin)Referral to emergency

Syncope / pre-syncope with any of the following Red flags

Red flags

- exertional onset

- chest pain

- persistent symptomatic hypotension (systolic BP < 90mmHg)

- severe persistent headache

- focal neurological deficits

- preceded by palpitations

- associated significant injury

- family history of sudden cardiac death


Cat 130 days

Syncope with unclear aetiology (if sus-pected cardiac aetiology see Cardi-ology CPC)

Vasovagal syncope occurring on a weekly basis

Syncopal episodes that have resulted in physical injury

Symptomatic orthostatic hypotension (of more than 20mmHg decrease in

Cat 290 days

Vasovagal syncope occurring on less than weekly basis but at least once a month

Asymptomatic orthostatic hypotension

Cat 3365 days

Vasovagal syncope occurring infre-quently (less than once a month)


systolic blood pressure)





Details of clinical presentation

- include timeline since onset of symptoms

- precipitating factors

- any warning pre-syncopal symptoms

- loss of consciousness (complete vs partial; duration; nature of recovery)

- witnessed signs (including seizures, pallor, incontinence, cyanosis, irreg-ular or absent pulse during attack, associated injury)

Lying and standing BP

Drug and alcohol history

FBC, ELFT, TSH results

ECG

Any investigations relevant to comorbidities (eg HbA1c if diabetic, spirometry if COPD)

EEG results (if available)

Holter monitor or event monitor results (if available)

Echocardiogram results (if available)






Unintentional weight lossReferral to emergency

Uncontrolled hyperthyroidism with risk of thyroid storm

Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction


Cat 130 days

Significant weight loss (≥10% of body weight in previous 6 months) without anaemia *

Clinical features or test results sug-gestive of disseminated malignancy

Marked cachexia or malnutrition (BMI <15) *

Suspected malabsorption syndromes

Post-prandial angina

Uncontrolled anxiety or depression or pain syndromes causing marked loss of appetite

* Suspected or confirmed eating disorders should be managed in accordance with the Queensland Eating Disorder Service A guide to admission and inpatient treatment for people with eating disorders in Queensland

Cat 290 days

Unexplained weight loss (5-10% of body weight in previous 6 months) *

* Suspected or confirmed eating disorders should be managed in accordance with the Queensland Eating Disorder Service A guide to admission and inpatient treatment for people with eating disorders in Queens-land

Cat 3365 days




Relevant medical history and comorbidities

Full list of current medications including non-prescription medications

HbA1c results (if diabetic)

CXR report (if indicated)


http://hi.bns.health.qld.gov.au/mental_health/eating_disorder/documents/edos-inpat-qld.pdf






Weight, height and BMI

Exact weight loss and time period of loss

Any associated symptoms (e.g. cough, abdominal pain, change in bowel habits)

Alcohol and drug history (including smoking)

Assessment of mood and social situation (depression is a common cause of weight loss)

Appetite, recent dietary changes, food intolerances or avoidances, and ab-normal eating behaviours

Gastrointestinal or oral symptoms especially dysphagia, diarrhoea, gum dis-ease, poor dentition, loss of taste

FBC, ELFT, ESR/CRP, TSH, iron studies, vitamin B12 & folate results

Antitransglutaminase antibodies, IgA for coeliac disease in younger patients (aged < 40 years old) with associated iron deficiency


Unintentional weight loss <5% can be managed in primary care

If patient has anaemia please refer to Anaemia not associated with iron deficiency condition in the General Medicine CPC or the Iron deficiency anaemia con-dition within the Gastroenterology CPC

Available depression tools include

- PHQ-2 – 2 question screening tool

- K-10 – 10 question screening tool

If an eating disorder is suspected or confirmed consider referring to the Queensland Eating Disorder Service document: A guide to admission and inpatient treatment for people with eating disorders in Queensland

Consider referring to the MNHHS Refeeding Syndrome Identification and Management in Adults guideline





http://qheps.health.qld.gov.au/metronorth/policy/procedures/gui003.pdf



https://www.beyondblue.org.au/the-facts/anxiety-and-depression-checklist-k10

http://www.phqscreeners.com/

Intervention criteria

Out of scope for general medicine interventionsNot all services are funded in the Queensland public health system. Exceptions can always be made where clinically indicated. It is proposed that the following are not routinely provided in a public general medicine service:

Any invasive procedure with exception of paracentesis, thoracocentesis, lumbar puncture, proctoscopy/sigmoidoscopy

Specialised investigative interventions reserved for subspecialists (eg EEG, nerve conduction studies, EMG)

Some investigative interventions may be provided by general medicine services if local expertise is available (eg bone marrow aspiration and tre-phine, echocardiography)

Urgency category for interventionIntervention Minimum criteria Urgency

Nil


Version controlVersion Date Author Nature of amendment

0.01 17/7/17 CPC team (Katie Wykes) Initial version

0.02 26/7/17 CPC team (Katie Wykes) in consultation with Ian Scott

Revisions following consultation with clinical lead, A/Prof Ian Scott


Further revisions following consultation with clinical lead, A/Prof Ian Scott


Further revisions following consultation with clinical lead, A/Prof Ian Scott


Revisions incorporating CAG round 1 feedback


Further minor revisions following feedback from Statewide General Medicine Clinical Network and ongoing discussions about eating disorder management

0.07 25/10/17 CPC team (Katie Wykes) Amendments to some website links following CAG endorsement round


ReferencesAlfredHealth. (2013). Rheumatology referral guidelines.

AlfredHealth. (2015a). General medicine outpatient referral guidelines.

AlfredHealth. (2015b). Orthopaedic surgery outpatient referral guidelines.

Australian Society of Clinical Immunology and Allergy. (2017). Anaphylaxis.

Brisbane North HealthPathways. (2015). Anaemia in Adults.

Brisbane North HealthPathways. (n.d.). Osteoarthritis.

Cairns HealthPathways. (2015a). Anaemia in Adults.

Cairns HealthPathways. (2015b). Community Acquired Pneumonia (CAP) in Adults.

Cairns HealthPathways. (2015c). Deep Vein Thrombosis.

Cairns HealthPathways. (2015d). First Seizure in Adults.

Cairns HealthPathways. (2015e). Funny Turns.

Cairns HealthPathways. (2015f). Unintentional Weight Loss in Adults.

Cairns HealthPathways. (2016a). Cellulitis in adults.

Cairns HealthPathways. (2016b). Chronic fatigue syndrome.

Cairns HealthPathways. (2016c). Delirium.

Cairns HealthPathways. (2016d). Gout.

Cairns HealthPathways. (2016e). Knee osteoarthritis.

Cairns HealthPathways. (2016f). Osteoarthritis.

Cairns HealthPathways. (2016g). Pulmonary Embolism.

Cairns HealthPathways. (2017). Anaphylaxis.

Cairns HealthPathways. (n.d.). Hip osteoarthritis.

Cairns HHS. (2015). Skin Infections - Bacterial, Abscesses, Cellulitis.

Cairns Referral Criteria. (2015a). Geriatrics.

Cairns Referral Criteria. (2015b). Internal / General Medicine.

Cairns Referral Criteria. (2015c). Memory clinic.


Cairns Referral Criteria. (2016a). Immunology / Allergy.

Cairns Referral Criteria. (2016b). Rheumatology.

Calgary. (2016a). Path to care directory Specialty Specific Referral Guidelines - Medical Services.

Calgary. (2016b). Path to care directory Specialty Specific Referral Guidelines - Rheumatology.

Central Queensland HHS. (2015a). Internal medicine services.

Central Queensland HHS. (2015b). Referral criteria and triage category.

Central Queensland HHS. (2017). Haematology.

Darling Downs HHS. (2015). General Medicine referral guidelines.

Darling Downs HHS. (2016). General practice information folder.

Gold Coast HHS. (2012). Referral and triage guidelines - Rheumatology.

Hunter and New England HealthPathways. (2015). Hip osteoarthritis.

Hunter and New England HealthPathways. (2016a). Gout.

Hunter and New England HealthPathways. (2016b). Knee osteoarthritis.

Kirkbright, S., & Brown, S. (2012). Anaphylaxis Recognition and management. Australian Family Physician, 41, 366-370.

Mackay HealthPathways. (2015a). Anaemia in Adults.

Mackay HealthPathways. (2015b). Hip osteoarthritis.

Mackay HealthPathways. (2015c). Osteoarthritis.

Mackay HealthPathways. (2016a). Anaphylaxixs.

Mackay HealthPathways. (2016b). Cellulitis in adults.

Mackay HealthPathways. (2016c). Chronic fatigue syndrome.

Mackay HealthPathways. (2016d). Community Acquired Pneumonia (CAP).

Mackay HealthPathways. (2016e). Funny turns.

Mackay HealthPathways. (2016f). Gout.

Mackay HealthPathways. (2016g). Pulmonary Embolism.

Mackay HealthPathways. (2017). Deep Vein Thrombosis.

Mater. (2015). General medical - public patients.

Mater. (2016). Rheumatology.


Metro North HHS. (2015a). Anaemia.

Metro North HHS. (2015b). Dementia & memory problems.

Metro North HHS. (2015c). Dyspnoea.

Metro North HHS. (2015d). Fatigue.

Metro North HHS. (2015e). Fits, fains, falls and funny turns.

Metro North HHS. (2015f). Headache.

Metro North HHS. (2015g). Joint pain.

Metro North HHS. (2016). Weight loss.

Metro South HHS. (2015). Minimum referral criteria.

MonashHealth. (2015). Falls and Balance Clinic.

NICE. (2006). Dementia: supporting people with dementia and their carers in health and social care.

NICE. (2007a). Chronic fatigue syndrome - do not recommendation.

NICE. (2007b). Chronic fatigue syndrome - do not recommendation: daytime rest.

NICE. (2007c). Chronic fatigue syndrome /myalgic encephalomyelitis.

NICE. (2009). Rheumatoid arthritis in adults: management.

NICE. (2010a). Delirium prevention diagnosis and management.

NICE. (2010b). Transient loss of consciousness ('blackouts') in over 16s.

NICE. (2011). Food allergy in under 19s: assessment and diagnosis.

NICE. (2013a). Falls in older people: assessing risk and prevention.

NICE. (2013b). Rheumatoid arthritis in over 16s.

NICE. (2014a). Delirium in adults.

NICE. (2014b). Osteoarthritis: care and management.

NICE. (2015a). Falls in older people.

NICE. (2015b). Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.

NICE. (2016a). Anaphylaxis assessment and referral after emergency treatment.

NICE. (2016b). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes.

NICE. (2016c). Multimobidity clinical assessment and management.


Queensland Health CPC. (2016a). Dizziness/vertigo.

Queensland Health CPC. (2016b). Vascular - venous disease.

SA Health. (2014). Outpatient GP referral guidelines allergy / clinical immunology service.

SA Health. (2015a). General Medicine - NALHN Outpatient Referral Guidelines.

SA Health. (2015b). Rheumatology.

Statewide Dementia Clinical Network. (Unknown-a). Dementia enablement guide.

Statewide Dementia Clinical Network. (Unknown-b). Younder onset demntia - diagnosis guide.

Sunshine Coast HealthPathways. (2015a). Anaemia in Adults.

Sunshine Coast HealthPathways. (2015b). Christchurch Hospital Department of General Medicine - criteria.

Sunshine Coast HealthPathways. (2015c). Community Acquired Pneumonia.

Sunshine Coast HealthPathways. (2015d). CQHHS Specialist Outpatients GP referral guide.

Sunshine Coast HealthPathways. (2015e). Funny turns.

Sunshine Coast HealthPathways. (2015f). Unintentional weight loss in adults.

Sunshine Coast HealthPathways. (2016a). Cellulitis in adults.

Sunshine Coast HealthPathways. (2016b). Delirium.

Sunshine Coast HealthPathways. (2016c). Gout.

Sunshine Coast HealthPathways. (2016d). Hip Osteoarthritis.

Sunshine Coast HealthPathways. (2016e). Knee Osteoarthritis.

Sunshine Coast HealthPathways. (2016f). Osteoarthritis.

Sunshine Coast HealthPathways. (2016g). Pulmonary Embolism.

Sunshine Coast HealthPathways. (2017a). Anaphylaxixs.

Sunshine Coast HealthPathways. (2017b). Deep Vein Thrombosis.

Sunshine Coast HealthPathways. (2017c). First Carpometacarpal Joint (CMCJ) Osteoarthritis.

Sunshine Coast HHS. (2014). General Medicine referrals.

Tasmanian Health Services. (Unknown-a). Anaemia.

Tasmanian Health Services. (Unknown-b). Comprehensive Osteoarthritis Pathway.

Tasmanian Health Services. (Unknown-c). Crystal Arthritis (e.g. gout).


Tasmanian Health Services. (Unknown-d). Dizziness imbalance.

Tasmanian Health Services. (Unknown-e). Presyncope / Syncope.

Tasmanian Health Services. (Unknown-f). Tiredness and lethargy.

Townsville HealthPathways. (2015). Funny turns.

Townsville HealthPathways. (2016a). Anaemia in Adults.

Townsville HealthPathways. (2016b). Anaphylaxixs.

Townsville HealthPathways. (2016c). Cellulitis in Adults.

Townsville HealthPathways. (2016d). Chronic Fatigue Syndrome.

Townsville HealthPathways. (2016e). Deep Vein Thrombosis.

Townsville HealthPathways. (2016f). Gout.

Townsville HealthPathways. (2016g). Hip osteoarthritis.

Townsville HealthPathways. (2016h). Knee osteoarthritis.

Townsville HealthPathways. (2016i). Osteoarthritis.

Townsville HealthPathways. (2016j). Pulmonary Embolism.

Waldron, N., Hill, A., & Barker, A. (2012). Falls prevention in older adults Assessment and management. Australian Family Physician, 41, 930-935.

Western Australia. (2012). Orthopaedic referral recommendations.

Western Australia. (2014a). CPAC General Medicine.

Western Australia. (2014b). Gastroenteraology referral recommendations.

Western Australia. (2014c). Geriatric medicine referral recommendations.

Western Australia. (2014d). Haematology referral recommendations.

Western Australia. (2014e). Rheumatology referral recommendations.

Wide Bay HHS. (2012). Orthopaedic.

Wide Bay HHS. (2014a). General Medicine - only available in Wide Bay.

Wide Bay HHS. (2014b). Rheumatology.


fact sheet-landscape-excellence - home page - central ... · web viewsuspected septic arthritis...

Documents