General Medicine

Anaemia

• Severe anaemia (Hb <70g/L) with risk of cardiovascular and/or syncopal collapse
• Anaemia associated with definite clinical features of overt gastrointestinal bleeding e.g. haematemesis or melena
• Severe cytopaenias if patient is unwell (i.e. infection, symptomatic anaemia, active bleeding)
  • Neutrophils < 0.5x10⁹/L
  • Haemoglobin < 70g/L
  • Platelets < 20x10⁹/L

Hypertension

• Severe hypertension (systolic BP >180) with no known ischaemic heart disease, cardiomyopathy, or chronic kidney disease AND any of the following concerning features:
  • confusion
  • blurred vision
  • retinal haemorrhage
  • reduced level of consciousness
  • seizures
  • proteinuria
  • papilloedema
  • signs of heart failure
  • chest pain
  • headache
• If suspected gestational hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible
• If hypertension service available refer to hypertension service.

Complex or undifferentiated medical problems

• Any sudden decompensation in clinical condition that carries risk of serious adverse events or death
• Pyrexia of unknown origin with temp ≥ 39ºC
• Pyrexia with neutropaenia
• Delirium
• Suspected systemic vasculitis associated with symptoms, signs or investigation results suggestive of vital organ involvement
• Suspected temporal arteritis (giant cell arteritis) with markedly elevated ESR (>100) and/or jaw claudication and/or visual disturbance

Complex paediatric patients transitioning to adult services

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

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)

Medication review / polypharmacy

• Anaphylactic or other serious adverse drug event
• Markedly prolonged heart rate adjusted QT interval which may herald pro-arrhythmic event
• Marked drug induced electrolyte abnormality (Na <120, K <3.0 or >6.0, corrected Ca >3.0, Mg <0.4)

Osteoarthritis, gout and joint pain

• Acute non-traumatic monoarthritis causing severe pain and/or incapacitating loss of function and/or marked constitutional symptoms
• Suspected septic arthritis

States of altered neurological function

• Witnessed tonic-clonic (grand mal) seizures
• Suspected transient ischaemic attack or stroke based on focal neurological deficits
• Delirium or acute confusional state
• Severe headache or altered level of consciousness of sudden onset

Syncope / pre-syncope

• Syncope / pre-syncope with any of the following concerning features
  • exertional onset
  • chest pain
  • persistent symptomatic hypotension (systolic BP < 90mmHg)
  • severe persistent headache
  • focal neurological deficits
  • preceded by palpitations
  • associated significant physical injury (e.g. fractures, extreme soft tissue trauma, intracranial bleeds) or causing motor vehicle accident
  • family history of sudden cardiac death

Unintentional weight loss

• Uncontrolled hyperthyroidism with risk of thyroid storm
• Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction
• Associated severe electrolyte abnormalities (K+ <3.0 mmol/L, corrected Ca+ <1.6 or >3.0 mmol/L, Mg+ <0.4 mmol/L, PO4- <0.4mmol/L)

Wounds of uncertain cause or non-healing ulcers

• Severe cellulitis with ongoing or worsening systemic symptoms or fevers despite oral antibiotics for 48 hours
• Foot ulcer in diabetic patient that is not responding to oral antibiotics and regular wound cleaning
• Any infected ulcer associated with systemic inflammatory response symptoms (SIRS) or excessive pain or features suggestive of abscess formation, osteomyelitis or deep tissue infection (necrotising fasciitis)
• Acute Charcot arthropathy
• Ulcers or wounds in a limb with markedly compromised circulation

Chronic Deep vein thrombosis (DVT)

• Patient severely symptomatic e.g., severe swelling or pain.
• Pregnant or given birth within the past 6 weeks
• Present, or suspected, acute iliofemoral or supra-inguinal deep vein thrombosis
• Present or suspected acute laxiliary or subclavian vein thrombosis

Other

• Any condition defined by other CPCs as requiring referral to emergency