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.

  • severe symptomatic anaemia with:
    • haemodynamic instability i.e. shock
    • acute overt gastrointestinal (GI) bleeding (hematemesis/melena/hematochezia)
    • syncopal symptoms with/without ongoing blood loss
    • chest pain, dyspnoea

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Category 1 — appointment clinically indicated within 30 days

Iron deficiency with or without anaemia with any of the following red flags:

  • new onset, not previously investigated
  • no obvious explanation having excluded: menorrhagia, grand multiparity or recent delivery, vegetarian or vegan diet, recent long bone fracture or multi-trauma, recurrent epistaxis, combination of the above
  • recurrent iron deficiency after repletion and correction of putative cause, provide details of repletion and evidence – this situation raises the concern that real reason was missed first time
  • weight loss ≥ 10 % in previous 3 - 6 months (imaging needed)
  • high risk family history for colorectal cancer (CRC) or other gastrointestinal (GI) malignancy, more relevant for young patients

Category 2 — appointment clinically indicated within 90 days

  • known cause for recurrent iron deficiency, e.g. angioectasia (vascular malformations), inflammatory bowel disease (IBD), radiation proctitis.
  • known cause for functional iron deficiency, e.g. inflammatory disorders, renal failure

Category 3 — appointment clinically indicated within 365 days

  • nil

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.

History

  • time course and past history of iron deficiency
  • presence of overt gastrointestinal (GI) bleeding or other GI symptoms
  • dietary history including frequency and serving size of meat
  • history of overt blood loss, epistaxis, trauma or major illness in past 12 months
  • menstrual and childbearing history
  • family history of GI cancer, coeliac disease, inflammatory bowel disease (IBD) or pernicious anaemia
  • history of iron therapy (if given) e.g. oral or intravenously (IV) including IV iron dose & date given
  • response to iron therapy
  • current and past medication history, specifically the use of antiplatelets and/or anticoagulants, novel oral anticoagulants, nonsteroidal anti-inflammatory drugs (e.g. aspirin), COX inhibitors, oral iron, proton pump inhibitors, selective serotonin reuptake inhibitors (SSRIs, immunosuppressants, chemotherapy)
  • previous GI surgery including bariatric surgery/procedures

Examination

  • abdominal and per rectum (PR) examination (findings)

Investigations

  • complete blood examination (CBE) and trend including lowest haemoglobin (Hb) (and ferritin)
  • iron studies please specify on or off oral iron therapy and trend
  • urea, electrolytes, and creatinine (UEC)
  • liver function tests (LFT)
  • coeliac serology (to exclude)
  • erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), if inflammatory disease present
  • previous investigations, e.g. endoscopy, colonoscopy/capsule endoscopy (CE), scans

Additional information to assist triage categorisation

  • functional status (if elderly) e.g. mobility and cognition
  • second opinions for conditions already seen by the same specialty

Clinical management advice

Iron deficiency can arise in three ways and these mechanisms can co-exist. If one keeps these in mind, the appropriate approach to investigating and treating iron deficiency can be reliably achieved. Consider the following:

  • inadequate nutritional intake
  • excessive blood loss e.g. menorrhagia, slow gastrointestinal (GI) blood loss, epistaxis
  • malabsorption (most likely - coeliac disease).

The finding of iron deficiency with or without anaemia should always prompt a 2-pronged approach to:

  • replace iron to ameliorate symptoms, and
  • investigate and manage the specific cause of the deficiency.

These 2 approaches should be pursued in parallel and replacement can start while investigations are awaited.

Iron deficiency should be suspected on the red cell indices when mean corpuscular haemoglobin or mean corpuscular volume (MCV) are outside the lower end of the normal range. The only other common cause of this being thalassemia.

Serum ferritin is the most readily available and useful index of iron deficiency. Ferritin <15 mcg/L is diagnostic of iron deficiency, ferritin between 15–30 mcg/L is highly suggestive. Absolute iron deficiency may be present with ferritin levels up to 60–100 mcg/L (or sometimes higher) in the elderly or those with chronic disease (kidney or liver disease or heart failure), malignancy, inflammation, or systemic illness; Marker such as C-reactive protein (CRP) may be useful to identify coexisting inflammation. Response to iron therapy may also assist with diagnosis.

If iron status or cause of anaemia is unclear especially in the presence of chronic disease or inflammation or, if there are other significant complete blood examination (CBE)/blood film abnormalities, seek haematology advice (log in required) to interpret laboratory tests.

Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.

Request endoscopic investigation if:

  • male
  • non-menstruating female
  • menstruating and clinically appropriate e.g., aged ≥ 50 years even if no bowel symptoms, GI symptoms, family history of colorectal cancer (CRC), iron deficiency anaemia is refractory, recurrent or unexplained
  • with upper or lower GI symptoms (persistent abdominal pain, anorexia, weight loss or change in bowel habit) regardless of age
  • positive coeliac serology.

If a patient has been fully investigated within last 2 years and symptoms remain unchanged, clinician discretion is needed to appropriately refer and triage. In general, there is little value in repeat specialist assessment and/or endoscopic procedures in this scenario.

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.