PATH TO CARE DIRECTORY SPECIALTY SPECIFIC

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PATH TO CARE
DIRECTORY
CALGARY ZONE
SPECIALTY
SPECIFIC
GUIDELINES
table of contents
Specialty Specific Guidelines
CONTENTS
CANCER CARE - TOM BAKER CANCER CENTRE (TBCC)
Alberta Blood and Marrow Transplant Program - Adult ������������������������������������������������������������7
Alberta Thoracic Oncology Program - South�������������������������������������������������������������������������� 11
TBCC Colposcopy Clinic��������������������������������������������������������������������������������������������������������13
TBCC Rehab-Lymphedema Management Program����������������������������������������������������������������15
TBCC Tumour Groups������������������������������������������������������������������������������������������������������������18
TBCC Breast Tumour Group��������������������������������������������������������������������������������������������������20
TBCC Cutaneous Tumour Group��������������������������������������������������������������������������������������������24
TBCC Gastrointestinal (GI) Tumour Group ����������������������������������������������������������������������������25
TBCC Genitourinary (GU) Tumor Group ��������������������������������������������������������������������������������27
TBCC Gynecology Tumour Clinic ������������������������������������������������������������������������������������������29
TBCC Head & Neck Tumour Group����������������������������������������������������������������������������������������31
TBCC Hematology Tumour Group������������������������������������������������������������������������������������������33
TBCC Lung Tumour Group ����������������������������������������������������������������������������������������������������36
TBCC NeuroOncology Tumour Group������������������������������������������������������������������������������������39
TBCC Pain & Palliative Tumour Group ����������������������������������������������������������������������������������41
TBCC Sarcoma (Musculoskeletal) Tumour Group������������������������������������������������������������������43
CARDIAC CARE
Adult Congenital Heart Clinic��������������������������������������������������������������������������������������������������45
Atrial Fibrillation Clinic������������������������������������������������������������������������������������������������������������46
Cardiac Arrythmia Clinic ��������������������������������������������������������������������������������������������������������47
Cardiac Device Clinic (Pacemaker and ICD)��������������������������������������������������������������������������48
Cardiac Function Clinics ��������������������������������������������������������������������������������������������������������49
Cardiac Navigation Clinic (CNC)��������������������������������������������������������������������������������������������51
Connective Tissue Clinic��������������������������������������������������������������������������������������������������������53
Hypertrophic Cardiomyopathy Clinic��������������������������������������������������������������������������������������55
DEPARTMENTOFMEDICINE.COM/MAS
November 2014
II
Specialty Specific Guidelines
CLINICAL NEUROSCIENCES
Amyotrophic Lateral Sclerosis (ALS) / Motor Neuron Disease Clinic��������������������������������������56
Brain Injury (Rehabilitation) Clinic������������������������������������������������������������������������������������������57
Cognitive Neurosciences Clinic (CNC) ����������������������������������������������������������������������������������58
General Neurology (GNC)������������������������������������������������������������������������������������������������������60
Movement Disorders Clinic (MDC) ����������������������������������������������������������������������������������������64
Multiple Sclerosis (MS) Clinic ������������������������������������������������������������������������������������������������66
Neuromuscular Clinic (NMC)��������������������������������������������������������������������������������������������������71
Neurovestibular Clinic (South Health Campus)����������������������������������������������������������������������74
Seizure Clinic��������������������������������������������������������������������������������������������������������������������������76
Stroke Prevention Clinic (SPC)����������������������������������������������������������������������������������������������78
Urgent Neurology Clinic (UNC)����������������������������������������������������������������������������������������������80
HOME AND COMMUNITY CARE
C3 Program:Comprehensive Community Care for the Frail Elderly����������������������������������������82
Home Care ����������������������������������������������������������������������������������������������������������������������������85
Long Term Care����������������������������������������������������������������������������������������������������������������������89
Supportive Living Level 3��������������������������������������������������������������������������������������������������������91
Supportive Living Level 4 / Level 4 Dementia ������������������������������������������������������������������������93
MEDICAL GENETICS SERVICES
Cancer Genetics Clinic ����������������������������������������������������������������������������������������������������������96
Cardiovascular Genetics Clinic ����������������������������������������������������������������������������������������������97
Connective Tissue Disorders Clinic����������������������������������������������������������������������������������������98
General Genetics and Dysmorphology Clinic ������������������������������������������������������������������������99
Inherited Metabolic Disorder Clinic (IMDC)��������������������������������������������������������������������������100
Neurogenetics Clinic������������������������������������������������������������������������������������������������������������101
Ophthamology Genetics Clinic����������������������������������������������������������������������������������������������102
Prenatal Genetics Clinic ������������������������������������������������������������������������������������������������������103
DEPARTMENTOFMEDICINE.COM/MAS
November 2014
III
Specialty Specific Guidelines
MEDICAL SERVICES
Access Mental Health: Addiction and Mental Health Services, Calgary Zone ����������������������104
Calgary Ambulatory Lymphedema Service (CALS)��������������������������������������������������������������106
Calgary Headache Assessment and Management Program������������������������������������������������107
Chronic Pain Centre ������������������������������������������������������������������������������������������������������������ 110
Complex Chronic Disease Management Clinic – PLC���������������������������������������������������������� 112
Diabetes, Hypertension and Cholesterol Centre (DHCC) ���������������������������������������������������� 114
Endocrinology & Metabolism - Adult ������������������������������������������������������������������������������������ 117
Gastroenterology������������������������������������������������������������������������������������������������������������������123
General Internal Medicine����������������������������������������������������������������������������������������������������136
Hematology - Adult ��������������������������������������������������������������������������������������������������������������138
Hepatology ��������������������������������������������������������������������������������������������������������������������������146
Living Well with a Chronic Condition Program����������������������������������������������������������������������149
Nephrology ��������������������������������������������������������������������������������������������������������������������������153
PADIS Medical Toxicology Clinic������������������������������������������������������������������������������������������156
Respiratory Medicine������������������������������������������������������������������������������������������������������������159
Rheumatology Triage������������������������������������������������������������������������������������������������������������160
Senior’s Health & Geriatric Medicine������������������������������������������������������������������������������������163
Sleep Centre������������������������������������������������������������������������������������������������������������������������167
Southern Alberta HIV Clinic (SAC)����������������������������������������������������������������������������������������168
Vascular Risk Reduction Program����������������������������������������������������������������������������������������169
PALLIATIVE / END OF LIFE CARE
Grief Support Program����������������������������������������������������������������������������������������������������������170
Residential Hospice��������������������������������������������������������������������������������������������������������������171
Palliative Care Consult Service��������������������������������������������������������������������������������������������173
Urban Palliative Home Care Team����������������������������������������������������������������������������������������175
DEPARTMENTOFMEDICINE.COM/MAS
November 2014
IV
Specialty Specific Guidelines
PEDIATRICS
Augmentative Communication and Educational Technology Service (ACETS)��������������������178
Brachial Plexus Program������������������������������������������������������������������������������������������������������180
Infant Cranial Remodeling Program/Head Shape Clinic ������������������������������������������������������182
Movement Assessment Centre ��������������������������������������������������������������������������������������������184
Neurology Program��������������������������������������������������������������������������������������������������������������185
Neuromotor Program������������������������������������������������������������������������������������������������������������187
Neuromuscular Program������������������������������������������������������������������������������������������������������189
Neurosciences Adolescent Transition Program (NATP)��������������������������������������������������������191
Neuro Rehabilitation Program����������������������������������������������������������������������������������������������193
Orthotics ������������������������������������������������������������������������������������������������������������������������������195
Pediatric Gastroenterology, Hepatology & Nutrition��������������������������������������������������������������197
Seating Service��������������������������������������������������������������������������������������������������������������������200
SURGICAL SERVICES
Hepatopancreaticobiliary (HPB)��������������������������������������������������������������������������������������������201
WOMEN’S HEALTH AMBULATORY CARE (WHAC)
Calgary Breast Health Clinic ������������������������������������������������������������������������������������������������203
Colposcopy Program������������������������������������������������������������������������������������������������������������204
Early Pregnancy Loss Clinic ������������������������������������������������������������������������������������������������206
Gynecology Clinic(s)������������������������������������������������������������������������������������������������������������207
High Risk Breast Cancer Clinic��������������������������������������������������������������������������������������������208
Obstetrical Clinic(s)��������������������������������������������������������������������������������������������������������������210
Pelvic Floor Clinic ���������������������������������������������������������������������������������������������������������������� 211
Pregnancy and Infant Loss Program������������������������������������������������������������������������������������212
DEPARTMENTOFMEDICINE.COM/MAS
November 2014
V
Specialty Specific Guidelines
TOC
Purpose
The purpose of the Specialty Specific Guidelines
section is to ensure that specialty clinics receive all of
the information, tests and investigations required to
triage patients appropriately. The Specialty Specific
Guidelines also provides referring physicians with an
approximate timeline in which a patient will be seen
depending on the urgency of referral.
What you will find in the Specialty Specific Guidelines
All clinics, centres, groups, services and programs, etc. that are open for patient referral
are organized by specialty. For each clinic, group, service or program etc. the following
information is provided:
• The triage categories (e.g. urgent, semi urgent, routine referral) ***
• A description/and or examples of urgent, semi urgent, or routine referrals
• Process for referral (e.g. specific fax or phone numbers)
• Information, tests, and investigations required to triage the patient***
• Additional subspecialty requirements
*** NOTE: This information is required when submitting a referral.
DEPARTMENTOFMEDICINE.COM/MAS
Updated 4 Nov 2014
VI
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TOC
Alberta Blood and Marrow Transplant Program - Adult
403-521-3528
TRIAGE
CATEGORY
INCLUDING, BUT NOT LIMITED TO:
PROCESS
APPROPRIATE TIME
TO TRANSPLANT
URGENT
Allogeneic Transplant
Fax referral to Intake
Team:
WITHIN 8
WEEKS
• High cytogenetics risk acute
leukemia
atients in Southern
P
Alberta:
403-270-0782
(ONCE A DONOR
IS IDENTIFIED, IF
APPLICABLE)
• Acute leukemia requiring >1
cycle chemotherapy to achieve
remission
atients in Northern
P
Alberta:
780-989-4343
• Relapsed acute leukemia in
remission
• CMML-2 or RAEB-2, CML AP or
CP2
• MDS with evidence of
transformation
• Myelofibrosis in transformation
• Severe aplastic anemia
Autologous Transplant
• Lymphoblastic or Burkitt
lymphoma
• Relapsed Hodgkins lymphoma
• Relapsed aggressive lymphoma
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
7
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TOC
Alberta Blood and Marrow Transplant Program - Adult
403-521-3528
TRIAGE
CATEGORY
SEMI
URGENT
INCLUDING, BUT NOT LIMITED TO:
PROCESS
APPROPRIATE TIME
TO TRANSPLANT
Allogeneic Transplant
Fax referral to Intake
Team:
WITHIN 8 – 16
WEEKS
atients in Southern
P
Alberta:
403-270-0782
(ONCE A DONOR
IS IDENTIFIED, IF
APPLICABLE)
• Acute leukemia in first complete
remission without high-risk
cytogenetics
• Transfusion-dependent MDS
• Acute leukemia not in remission
• Lymphoblastic or Burkitt
lymphoma
atients in Northern
P
Alberta:
780-989-4343
Autologous Transplant
• Multiple myeloma
• Relapsed indolent lymphoma
• Acute leukemia in remission
• Relapsed germ cell tumour
ROUTINE
Allogeneic Transplant
• CLL or indolent NHL
• Hodgkins lymphoma
• Multiple myeloma
• Chronic myeloid leukemia,
resistant or intolerant to TKI’s
Autologous Transplant
ax referral to Intake
F
Team:
> 16 WEEKS
atients in Southern
P
Alberta:
403-270-0782
atients in Northern
P
Alberta:
780-989-4343
• Severe autoimmune diseases:
Crohn’s, Scleroderma, Multiple
Sclerosis
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
8
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
Alberta Blood and Marrow Transplant Program - Adult
TOC
403-521-3528
THE ALBERTA BLOOD AND MARROW TRANSPLANT PROGRAM WILL RECEIVE
REFERRALS FROM WITHIN THE PROVINCE OF ALBERTA.
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
• Provide all considered relevant by the referring
source.
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Provide all considered relevant by the
referring source.
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE (EXCEPT FOR
FAMILY HLA TYPING)*:
• Summary of medical and treatment history
• Results for HLA typing (if done) Include all typing results: patient and siblings (match or not)
• Pathology reports
• Bone marrow reports
• Chemotherapy records (include induction, consolidation and intrathecal)
• Race: (If patient’s parents are from more than one of the following groups, check applicable groups) i.e.
Caucasian / White; Black ; East Indian ; Asian/Pacific Islander; Hispanic; Native North American ;
Unknown ; Other (indicate)
• Radiation therapy records
• Radiology reports (CT, PET, CXR, u/s, echo, etc.)
• Recent blood work (include hematology, coagulation, chemistry and virology)
• LDH at diagnosis and latest result
*1) Indicate all pending results; 2) Referrals within TBCC, please do not duplicate any information that can
be found in the chart; 3) Referrals within CCI, please do not duplicate any information that can be found on
Aria.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
9
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
Alberta Blood and Marrow Transplant Program - Adult
TOC
403-521-3528
ADDITIONAL SUBSPECIALTY REQUIREMENTS TO PROVIDE:
INDICATE TYPE OF REFERRAL: (CLEARLY INDICATE IN SUMMARY OF MEDICAL AND
TREATMENT HISTORY)
• Family HLA Typing only
• Allogeneic Transplant
• Autologous Transplant
• BM/PBSC Collection
• 2nd Opinion
FAMILY HLA TYPING
FOR A REFERRAL SPECIFIC TO FAMILY HLA TYPING ONLY, PROVIDE THE
FOLLOWING:
• Summary of medical and treatment history
When a referral is made for family HLA typing or allogeneic transplant, the recipient (patient) must complete
the “Family Human Leukocyte Antigen (HLA) Typing Referral Form-Sibling” for each sibling’s demographic
identifiers for registration purposes.
Laboratory: Under no circumstances should HLA typing requisitions be handed out to the recipient for distribution to family
members. This will be coordinated by an Intake Registered Nurse who will also obtain consent from the potential donor for
disclosing the results to the transplant physician and the recipient. This process is mandatory per legislation and cellular therapy
accreditation standards.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
10
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
Alberta Thoracic Oncology Program - South
T riage
C ategory
EMERGENT
I ncluding ,
but not limited to :
• hemoptysis (100 ml or more in
less than 24 hours)
• SVC syndrome
P rocess
TOC
(403) 944-1774
A pproximate
time to be seen
Call 9-1-1 or proceed
to nearest Emergency
Department
SAME DAY
Fax to ATOP -S
WITHIN 7-14
DAYS
• dyspnea at rest
• neurological symptoms
URGENT
• suspected symptomatic lung
cancer
• minor hemoptysis (100 ml or
less/24 hours)
403-944-8848
• mediastinal lymphadenopathy
with suspicion of lymphoma
• symptomatic pleural effusion
• chest wall mass
SEMI
URGENT
• solitary pulmonary nodule
(asymptomatic)
Fax to ATOP -S
NON
URGENT
• assessment of subcentimeter
lung nodules
Fax to ATOP -S
DEPARTMENTOFMEDICINE.COM/MAS
403-944-8848
WITHIN 14-28
DAYS
4-8 WEEKS
403-944-8848
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
11
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
Alberta Thoracic Oncology Program - South
TOC
(403) 944-1774
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
• complete medical/surgical history
• smoking history
• complete medication list including oxygen/anticoagulation
• allergies
• CT chest
RELEVANT SYMPTOMS
• Any considered relevant by referring physicians
such as:
ºº hemoptysis
ºº pain
ºº breathlessness
ºº weight loss
SPECIFIC TESTS / INVESTIGATIONS TO
PROVIDE IF AVAILABLE
• CT chest
• all relevant current testing within 3 months
• current blood work including CBC, PTT/INR,
electrolytes, calcium, liver function tests, and
creatinine
• previous spirometry or pulmonary function testing
reports
• all relevant historical radiological investigations
• REQUIRED: CD if from out of province / territory
• chest imaging reports & CD if not available on
Alberta Netcare
• echocardiograms and other prior cardiac
consultation or testing
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
12
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Colposcopy Clinic
TRIAGE
CATEGORY
URGENT
EXAMPLES
403-698-8031
PROCESS
TIME TO BE SEEN
• PAP Smear - Squamous Cell
Carcinoma,
Colposcopy clinic / Clerk
403-698-8031
1 WEEK
• PAP - Adenocarcinoma
Colposcopy Nurse
403-698-8025
• PAP - Other Malignant types
TOC
Colposcopy Fax
403-228-1076
SEMI
URGENT
• ASC-H - Atypical Squamous
Cells – cannot exclude HSIL
Colposcopy clinic / Clerk
403-698-8031
• HSIL – High Grade Squamous
Intraepithelial Lesion (CIN 2-3)
Colposcopy Nurse
403-698-8025
• Atypical Glandular Cells
Adenocarinoma in Situ
• Abnormal appearing cervix
– regardless of PAP smear
findings
ROUTINE
• LSIL – Low Grade Squamous
Intraepithelial Lesion – 2 paps
at least 6 months apart over 2
years
• ASC-US (any type) – Atypical
Squamous cells of undetermined
significance - 2 paps at least 6
months apart over 2 years
1 MONTH
Colposcopy Fax
403-228-1076
Colposcopy clinic / Clerk
403-698-8031
4 MONTHS
Colposcopy Nurse
403-698-8025
Colposcopy Fax
403-228-1076
• Genital warts
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
13
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Colposcopy Clinic
SPECIFIC COMORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
403-698-8031
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Previous genital warts
• Abnormal appearing cervix
• Infectious disease – sexual transmitted agents
• Abnormal vaginal bleeding
• Any other concurrent medical problem
• Provide any considered relevant by the
referring physician
• Concurrent pregnancy
TOC
• Therapeutic abortion, D&C or Ablation within past 4
weeks
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• Histopathological reports – for any surgical procedure, biopsy, or cytology – PAP Smear
• History & Physical
• All related DI – Reports
• All relevant Consultation reports
Note: Colposcopy Clinic is a diagnostic service
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
14
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TOC
TBCC Rehab-Lymphedema Management Program
403-476-2448
TRIAGE
CATEGORY
APPROXIMATE TIME
TO BE SEEN
URGENT
INCLUDING, BUT NOT LIMITED TO:
• Weeping lower legs at risk for
infection or palliative clients
PROCESS
Fax referral to:
403-476-2457
1 WEEK
For more information
phone:
403-476-2448
ROUTINE
• Secondary, cancer-associated
lymphedema of arms, legs,
trunk, and/or breast
• Rehabilitation issues related to
cancer or cancer treatments,
such as radiation fibrosis,
axillary webbing/cording, ROM/
strength/function restrictions,
pain, fatigue, deconditioning
NOT SEEN
• Non-cancer related lymphedema
referrals are now seen at
the Calgary Ambulatory
Lymphedema Clinic.
Fax referral to:
403-476-2457
DEPENDENT
ON VOLUME
For more information
phone:
403-476-2448
SHELDON M. CHUMIR
HEALTH CENTRE
N/A
Call 403-955-6054
Fax 403-955-6910
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
15
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Rehab-Lymphedema Management Program
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
• History of the swelling
• Surgical history, including # and status of lymph
nodes, post-op complications
• Neurological symptoms
• Cellulitis history and treatments
• Any kidney dysfunction
403-476-2448
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Cancer history, including type and staging,
recurrence, metastases, present status
• Treatment history, chemo and radiation
TOC
• Pain
• Allergies, esp. latex, any creams
• Axillary web syndrome
• Radiation or adhesive capsulitis
• Shortness of breath or orthopnea
• Diabetes
• Cognitive impairment
• CHF
• Obesity(provide BMI)
• Osteoporosis
• Peripheral neuropathy
• History of DVT
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE IF PERFORMED:
• ABPI/TBPI results for affected lower limb
• Any pathology reports
• Any relevant imaging reports
• WBC and differentiation, hemoglobin, and albumin levels
ADDITIONAL SUBSPECIALTY REQUIREMENTS TO PROVIDE IF AVAILABLE:
• Suspected DVT must be ruled out with Doppler ultrasound
• Active infection/cellulitis must be treated and resolving
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
16
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Rehab-Lymphedema Management Program
TOC
403-476-2448
SERVICES WILL INCLUDE:
• Specialized outpatient assessment/consultation for cancer-associated lymphedema management by
physiotherapist &/or occupational therapist.
• Provision and application of compression bandages.
• Manual Lymph Drainage, as appropriate.
• Teaching regarding management of lymphedema, skin care, and exercises.
• Assessment for appropriate compression garments / systems.
• AADL authorizations for appropriate compression sleeves/stockings and /or reduction systems and other
appropriate ADL equipment.
• Up to ten (10) treatment sessions incorporating the above techniques, or as otherwise deemed appropriate
by the treating therapist
• Lymphedema education class available monthly
• Cancer-related Fatigue Management class available monthly
• Occupational/Physiotherapy assessments and appropriate treatments for conditions related to the cancer
or cancer treatments. Examples are:
ºº radiation capsulitis
ºº axillary webbing/cording
ºº decreased ROM/function
ºº fatigue
ºº pain
ºº spinal accessory nerve dysfunction
ºº decreased mobility
ºº deconditioning/weakness
• Written communication following assessment will be sent to referring physicians.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
17
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Tumour Groups
TRIAGE
CATEGORY
TOC
403-521-3722
INCLUDING, BUT NOT LIMITED TO:
PROCESS
ESTIMATED TIME
TO ASSESSMENT
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
•
Superior Vena Cava Syndrome
•
Raised Intracranial Pressure
•Life
threatening respiratory
difficulty
Refer to Appendix X for presenting
features/ symptoms; Reason for
urgency; Associated tumour types;
Action; Management.
•
Spinal Cord Compression
•
Electrolyte abnormalities
•Hypercalcemia
•
Malignant Bowel Obstruction
Potential Upper Airway
Obstruction
Send patient to
Emergency Room
and then page
oncologist on call:
403-944-1110
SAME DAY
If patient known to
TBCC: page appropriate
oncologist on call
(medical, radiation,
surgical, gynecological):
SAME DAY
403-944-1110
•
•
Febrile Neutropenia.
Refer to Appendix for Oncologic
Emergency Guidelines including
presenting features /symptons;
Reason for urgency; Associated
tumour types; Action; Management.
If patient is not known to
TBCC,
send patient to
Emergency Room.
URGENT
SEMI
URGENT
FOR TRIAGE CATEGORY DETAILS
OF SPECIFIC TBCC TUMOUR GROUPS,
SEE RELEVANT TUMOUR GROUP GUIDELINES.
ROUTINE
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
18
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Tumour Groups
TOC
403-521-3722
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE:
Provide all relevant
•
Pathology reports
•
Diagnostic imaging
•
Lab work
ADDITIONAL SUBSPECIALTY REQUIREMENTS TO PROVIDE IF AVAILABLE:
For referral requirements of specific TBCC Tumour Groups, see relevant Tumour Group guidelines.
To expedite the service provided to the patient, please ensure that the pathology report requirements for individual Tumour
Groups are met prior to submitting the referral.
Please note that the patient must be notified of referral prior to submission of referral to TBCC.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
19
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Breast Tumour Group
TOC
PH 403-521-3722
REFERRAL PROCESS
EXCLUSIONS
For patients with the following symptoms:
• Spinal cord compression
• Malignant hypercalcemia
(symptomatic)
• Significant hemoptysis (> 100ml/24
hours)
• Symptomatic central airway
obstruction
Refer directly to the emergency department
OR
Contact the RAAPID Line - SOUTH
1-800-661-1700 or 403-944-4486
PROCESS
Alberta has provincial requirements for confirmed breast cancer referrals. Consult the requirements on the
next pages and send to the location listed below.
TOM BAKER CANCER CENTRE, CALGARY
PH 403-521-3722
FAX 403-521-3245
PATIENTS SHOULD ONLY BE REFERRED TO THE CANCER CENTRE WHEN THEY HAVE
A CONFIRMED DIAGNOSIS OF CANCER
TO OBTAIN TISSUE PATHOLOGY / CYTOLOGY
Please refer to the listed service. If
there are clinical reasons as to why
this is not possible please contact the
Cancer Centre and ask to speak to the
on call physician
Calgary Breast Health Program
Foothills Medical Centre, Women’s Health Centre, North Tower,
1403 29 Street NW, Calgary, Alberta
Tel 403–944–2240
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
20
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Breast Tumour Group
TOC
PH 403-521-3722
MANDATORY REQUIREMENTS FOR ALL REFERRALS
PATIENT DEMOGRAPHICS
REFERRING PROVIDER
• Patient last name, first name, given names
• Name
• PHN/ULI
• Address, including city, province, postal code
• Gender
• Phone & fax
• Street address, including city, postal code,
province
FAMILY PHYSICIAN
• Home phone, other phone, preferred
• Name
• Email address
• Indicate if same as referrer or if patient has no
primary care provider
• Emergency contact name and phone
• Guardian name, relationship to patient, and
phone
• Street address, including city, province, postal
code
• Phone & fax
OTHER INFORMATION REQUIRED:
• Relevant medical history
• Economic and/or psychological factors
• Indicate if an interpreter is required and if so,
what language?
• Provide additional comments/special
considerations
• Physical limitations
• Indicate whether patient has been informed of
cancer diagnosis
CO-MORBIDITY
• History of stroke
• Liver disease (e.g. hepatitis B or C)
• Cardiovascular disease (e.g. prior MI)
• Diabetes
• Respiratory disease
• Rheumatologic disease (e.g. SLE, scleroderma)
• Peripheral vascular disease (PVD)
• Active infections (e.g. MRSA, shingles, TB, VRE)
• GI disease
• HIV
• Renal disease
• Cognitive issues
• DVT
• Any other current medical problem
• VTE
REQUESTED ACTION
• New patient referral
• Specific cancer clinical trial
• Cancer pain and symptom management
• Other
• Discussion in rounds
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
21
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Breast Tumour Group
R eason
for
R eferral
TOC
PH 403-521-3722
R equired I nvestigations
*A ssociated
T ime frames
APPROXIMATE TIME TO BE SEEN FOR ALL REFERRALS: WITHIN SIX WEEKS
ATTACHED
Tissue Pathology / Cytology
LAB INVESTIGATIONS
ALL REFERRALS
CBC, Creatinine, AST / ALT,
AP, total bilirubin, albumin,
Calcium, & LDH
21 days
STAGE 4
SUPERIOR VENA CAVA OBSTRUCTION
BRAIN METASTASES
BONE METASTASES (SYMPTOMATIC)
ATTACHED OR ORDERED *
Chest X-ray or CT
28 days
LYMPHANGITIC CARCINOMATOSIS
(SYMPTOMATIC) BREAST CANCER
Abdominal Imaging US or CT
28 days
Bone Scan
28 days
VISCERAL METASTASES (SYMPTOMATIC +/LIFE-THREATENING) BREAST CANCER
ASYMPTOMATIC METASTASES BREAST
CANCER
ATTACHED OR ORDERED *
Bilateral Mammography
STAGE 3
LOCALLY ADVANCED BREAST CANCER
DEPARTMENTOFMEDICINE.COM/MAS
3-6 months
Chest X-ray or CT
28 days
Abdominal imaging US or CT
28 days
Bone Scan
28 days
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
22
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Breast Tumour Group
R eason
for
R eferral
PH 403-521-3722
R equired I nvestigations
ATTACHED OR ORDERED *
STAGE 2
Bilateral Mammography
NODE POSITIVE BREAST CANCER
TOC
Chest X-ray
*A ssociated
T ime frames
3-6 months
28 days
STAGE 1
NODE NEGATIVE BREAST CANCER
ATTACHED OR ORDERED *
Bilateral Mammography
STAGE 0
3-6 months
DUCTAL CARCINOMA IN SITU POST
SEGMENTAL RESECTION BREAST CANCER
* If performed or ordered please provide a copy or the date ordered:
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
23
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Cutaneous Tumour Group
T riage
C ategory
I ncluding ,
but not limited to :
TOC
403-521-3928
P rocess
A pproximate
time
to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
URGENT
• Brain Metastases with history of
cancer
o to nearest
G
Emergency
• Spinal Cord Compression
efer to Oncological
R
Emergency Guidelines
in Appendix
• Painful bone metastases
Mark referral “urgent”
• Symptomatic Metastases
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
SAME DAY
1 WEEK
all triage coordinator to
C
discuss: 403-521-3928
ROUTINE
• New or recurrent Melanoma
• Non-Melanoma skin cancer
referred by Specialist
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
1 - 2 WEEKS
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
•Any
•Provide
other concurrent medical problem.
SPECIFIC TESTS / INVESTIGATIONS
REQUIRED:
any considered relevant by the
referring physician.
SPECIFIC TESTS / INVESTIGATIONS TO
PROVIDE IF AVAILABLE:
• Histopathological reports – for any surgical
procedures, biopsy, fine needle aspirate, surgery
• Chest X-ray – report, films if abnormal
• Any OR reports for node dissection
• History and Physical (inpatients)
• CT Scans – report and films /disc if not on
PACS
• Discharge Summary (inpatients)
• All other related DI – reports and films
• All lab work done in previous month
• Consultation notes
DEPARTMENTOFMEDICINE.COM/MAS
• Ultrasound – report and films – abdomen
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
24
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TOC
TBCC Gastrointestinal (GI) Tumour Group
403-521-3245
T riage
C ategory
A pproximate
I ncluding ,
to :
but not limited
P rocess
time
to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
URGENT
• Uncontrolled Bleeding
from Bowel
If patient not known to TBCC –
Go to nearest Emergency
SAME DAY
(EMERGENCY)
• Colorectal Cancers:
ax referral to TBCC Central
F
Access & Triage:
1 - 2 WEEKS
ºº Rectal Cancer,
resectable pre-operative
therapy
403-521-3245
ºº Esophageal Cancer,
resectable
pre-operative therapy
ºº Anal Cancer
SEMI
URGENT
• Colorectal cancer
Metastases
ax referral to TBCC Central
F
Access & Triage:
• Pancreatic Cancer unresected
403-521-3245
2 - 4 WEEKS
• Esophageal Cancer unresected
• Gastric Cancer Metastases
• Symptomatic Palliative
radiation for metastases
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
25
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TOC
TBCC Gastrointestinal (GI) Tumour Group
403-521-3245
ROUTINE
4 – 6 WEEKS
• Post-operative Adjunctive
Colorectal Cancers
ax referral to TBCC Central
F
Access & Triage:
• Rectal Cancer, high risk
stage 2 & 3
403-521-3245
• Colon Cancer, stage 3 and
high risk 2
(T4, poor differentiation)
• Gastric Cancer, Stage
1B to IVA – postoperative
adjunct
• Pancreatic Cancer – postoperative therapy
• Pancreatic Cancer
Palliative
SPECIFIC CO-MORBIDITY
INFORMATION TO IDENTIFY IF
RELEVANT:
• Infectious diseases
SPECIFIC SYMPTOM INFORMATION TO
IDENTIFY IF RELEVANT:
• Provide any considered relevant by the referring
physician.
• Liver disease
• Any other concurrent medical problem
SPECIFIC TESTS / INVESTIGATIONS REQUIRED:
• Histological confirmation of GI Malignancy is
required
• Endorectal Ultrasound – report
• Histopathological reports – for any surgical
procedure, biopsy
• Discharge Summary (inpatients)
• Any relevant OR reports for surgery for primary
tumor (current or previous), biopsy and definitive
surgery
• Colonoscopy /endoscopy – of done earlier, 2-3
years, do not send report
• History & Physical (inpatients)
• Ultrasound – Report – rectal, liver, abdomen;
• CT Scans – chest, abdomen, pelvis, – report and
films/disc
• Bone Scan – report, films/disc
• All other related DI reports and films
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• Barium Enema – report and films /disc
• Upper GI – report and films /disc
• Barium Swallow – report and films /disc
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
26
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Genitourinary (GU) Tumor Group
T riage
C ategory
I ncluding ,
but not limited to :
TOC
403-521-3245
P rocess
A pproximate
time to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
• Spinal cord compression
efer to Oncological
R
Emergency Guidelines in
Appendix
SAME DAY
Go to Emergency
URGENT
• Lymph node positive or
metastatic testicular cancer
• Uncontrolled hematuria
secondary to renal cell carcinoma
or TCC of urogenital tract
SEMI
URGENT
• Localized Bladder Cancerpreoperatively for neoadjuvant
chemotherapy
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
1 WEEK
Notify GU Triage
coordinator to discuss
403-521-3148
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
1 – 2 WEEKS
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
2 - 4 WEEKS
• Localized high risk prostate
cancer
ROUTINE
• Renal cell Carcinoma-any stage
• Bladder Cancer post resection
• Metastatic Bladder Cancer
• Localized low risk and
intermediate risk prostate cancer
• Penile cancer-any stage
• Resected testicular seminoma
requiring RT/Surveillance
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
27
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Genitourinary (GU) Tumor Group
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
403-521-3245
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
• Renal Dysfunction/disease
• Renal Dysfunction/disease
• Any other concurrent medical problems
• Any other concurrent medical problems
SPECIFIC SYMPTOM INFORMATION TO
IDENTIFY IF RELEVANT:
• Provide any considered relevant by referring
physician.
ALL REFERRALS
TOC
SPECIFIC SYMPTOM INFORMATION TO
IDENTIFY IF RELEVANT:
• Provide any considered relevant by referring
physician.
GENITOURINARY – TESTICULAR
• Histopathological reports relating to any surgical/
biopsy procedures.
• AFP and BHCG Tumor Marker – pre and post
operative
• Any relevant OR reports (TURP, orchidectomy,
prostatectomy, lymphadenectomy), surgery for
primary tumor (current and previous), inpatient
discharge summaries, history, and physical.
• Chest X-ray report
• If transferring from another cancer clinic/facility,
copies of all patient documentation.
GENITOURINARY – PROSTATE
• PSA Tumor Markers – recent and old
• Ultrasound report and film
• CT scan report and film – abdomen, pelvis, chest
• Ultrasound report – scrotal
GENITOURINARY – BLADDER
• Operative report – cystoscopy
• CT Scans report and films
• Bone Scans report and films
RENAL
• Bone Scan report and film
• CT scan report and film if available
• CT Scans report and films
• Ultrasound report and films
• Bone Scan report and films
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
28
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Gynecology Tumour Clinic
T riage
C ategory
I ncluding ,
but not limited to :
TOC
403-521-3083
P rocess
A pproximate
time to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
• Gestational trophoblastic
neoplasms (GTN)
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
48 HOURS
all triage coordinator to
C
discuss: 403-521-3083
URGENT
• New ovarian, peritoneal,
fallopian cancer diagnosis
• High grade endometrial cancer
• New diagnosis cervical cancer
• Pelvic mass - NYD
SEMI
URGENT
• New diagnosis of recurrent
cancer
• Vulvar cancer
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
1 WEEK
all triage coordinator to
C
discuss: 403-521-3083
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
1 – 2 WEEKS
Before referral - Call
Gynecologic oncologist to
discuss: 403-521-3721
4 WEEKS
• Vaginal cancer
• New endometrial cancer – low
grade
• Follow-up post-op Gyne cancer
diagnosis elsewhere – eg.
Endometrial cancer after surgery
if further Rx required
• Second opinion re: cancer
management from another gyn
oncologist
ROUTINE
• Follow up transfer patients from
another cancer centre
• High surgical risk technical skills
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
29
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Gynecology Tumour Clinic
403-521-3083
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Infectious diseases
• Provide any considered relevant by referring
physician
• Cardiac disease
TOC
• Any other concurrent medical problem
SPECIFIC TESTS/INVESTIGATIONS REQUIRED
• Histological confirmation of gynecological malignancy is required, unless pelvic mass with features of
malignancy, include CA 125 and pelvic exam
• Histopathological reports – for any surgical procedure, biopsy, or cytology – PAP Smear
• Operative reports for primary tumour (current or previous), biopsy, definitive surgery – hysterectomy, D&C,
salpingo-oophorectomy, vulvectomy, laparoscopy
• History & Physical (inpatients)
• Discharge Summary (inpatients)
• All lab work done within 1 month of visit – CA-125, BHCG
• Imaging of any pelvic mass - report
• If known cardiac disease - ECG & ECHO results within 3 months
• All Consultation reports
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• CT Scans – abdomen, pelvis – reports
• Ultrasounds reports/films
• Chest X-ray report/films
• All related DI – Reports and films/disc if not on PACS
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
30
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Head & Neck Tumour Group
T riage
C ategory
E xamples
TOC
403-521-3722
P rocess
T ime
to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
•Airway obstruction due to cancer
• Spinal cord compression
• Uncontrolled bleeding or pain
efer to Oncological
R
Emergency Guidelines in
Appendix
SAME DAY EMERGENCY
irways obstruction, page
A
ENT surgeon on call
Cord compression,
bleeding, pain
--> page Rad Onc on call
URGENT
•All invasive head & neck cancer
is considered urgent and will be
seen within 2 weeks
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
2 WEEKS
ROUTINE
•Benign conditions such as
schwannoma, glomus tumours,
fibroma
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
4 WEEKS
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
31
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Head & Neck Tumour Group
TOC
403-521-3722
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Any other concurrent medical problem
•Provide any considered relevant by the
referring physician.
SPECIFIC TESTS / INVESTIGATIONS REQUIRED:
• Histological confirmation of malignancy is required.
• *Histological confirmation may be waived prior to TBCC consult under certain circumstances, i.e.
inaccessible tumour location, poor patient condition (please indicate reason on referral form).
• Histopathological reports – for any surgical procedure, biopsy, either fine needle aspirate or excisional
biopsy.
• Operative reports to include surgeries for primary tumour – current or previous.
• History and physical (inpatients).
• Discharge summary (inpatients).
• All lab work done in previous month & pre-operative.
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• Chest X-ray – report and films/disc if not on PACS
• CT Scans – chest and head - report and films/disc if not on PACS
• All other related DI – reports and films
• Please indicate date and location of imaging studies. If ordered but not done, indicate date/location of
imaging to be done. For scans that are not available on the Calgary Health Region PACS server, a CD
Rom containing the images should be sent to TBCC from the outside radiology department
• Consultation reports
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
32
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Hematology Tumour Group
T riage
C ategory
I ncluding ,
but not limited to :
TOC
403-521-3722
P rocess
A pproximate
time to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
• Hematological malignancy with:
ºº Superior vena cava syndrome
ºº Malignant bowel obstruction
ºº Spinal cord compression
ºº Hydronephrosis and renal
failure
ºº Hypercalcemia
ºº Severe cytopenias ANC <0.5,
platelets <20, Hb <70
atient to be sent to
P
emergency room at FMC
or PLC
24 HOURS
all hematologist on call
C
to discuss care at either:
FMC 403-944-1110 or
PLC 403-943-4555
• New diagnosis of
ºº acute leukemia (new blasts on
CBC or blood smear) or
ºº highly aggressive lymphoma
(burkitt, lymphoblastic)
• Any bulky aggressive-lymphoma
at risk for tumour lysis syndrome
URGENT
• Severe symptoms (eg.
drenching night sweats, >10%
weight loss, fevers, pruritis, pain,
dyspnea, other) in setting of:
ºº lymphoma
ºº myeloma
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
1 WEEK
Call Hematologic
Malignancy Clinic to
discuss: 403-521-3722
ºº chronic myelogenous leukemia
ºº chronic lymphocytic leukemia
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
33
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Hematology Tumour Group
T riage
C ategory
SEMI
URGENT
I ncluding ,
but not limited to :
• New or relapsed diagnosis,
without distressing severe
symptoms:
TOC
403-521-3722
P rocess
A pproximate
time to be seen
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
2 WEEKS
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
4 WEEKS
ºº lymphoma
ºº myeloma
• Bone marrow transplant consult
for active aggressive malignancy
ROUTINE
• New or relapsed diagnosis,
without distressing symptoms:
ºº chronic myelogenous leukemia
ºº chronic lymphocytic leukemia
• Bone marrow transplant consult
for indolent malignancy, or
aggressive malignancy currently
in remission
• Any hematological malignancy
currently in remission
• Second opinion consults or
transfers from other centers
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
34
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Hematology Tumour Group
TOC
403-521-3722
SPECIFIC CO-MORBIDITY INFORMATION TO IDENTIFY IF RELEVANT
• Infectious disease
• Liver disease
• Any other concurrent medical problem
SPECIFIC TESTS/INVESTIGATIONS REQUIRED
• History and physical (inpatients) – current symptoms, questionable emergent conditions, co-morbidities,
pulmonary emboli
• Lab – CBC, chemistry
• CT – chest, abdomen, pelvis – lymphoma patients – order at time of referral
• Histopathological report from excisional biopsy by surgeon
• Severe unexplained pancytopenia or severe cytopenias – current and comparison old CBC & differential
results
• Set up test/investigations as done for hematology
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
In addition to consultation notes and pathology reports, please include copy of other tests.
LEUKEMIA:
• AML/ ALL - peripheral blood smear and HLA typing if potential stem cell candidate, PT, PTT, fibrinogen
• CLL – include serum protein electrophoresis, quantitative immunoglobulins: IgG, IgA, IgM, B-2 –
microglobulin, flow cytometry of peripheral blood for B-cell immunophenotying (CD5, CD19, CD23, Smlg)
LYMPHOMA:
• CT scan neck, chest, abdomen, pelvis
• Acute lymphoma - serum protein electrophoresis, B-2 – microglobulin,
• Hodgkin’s – same as acute lymphoma plus ESR if stage I – II
MYELOMA AND PLASMA CELL NEOPLASMS:
• Skeletal survey
• Serum protein electrophoresis, quantitative immunoglobulins: IgG, IgA, IgM, B-2 – microglobulin, C-reactive
protein
• Routine urinalysis, 24 hour urine protein electrophoresis
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
35
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Lung Tumour Group
TOC
PH 403-521-3722
REFERRAL PROCESS
EXCLUSIONS
For patients with the following symptoms:
• Spinal cord compression
• Malignant hypercalcemia (symptomatic)
• Significant hemoptysis (> 100ml/24
hours)
• Symptomatic central airway obstruction
Refer directly to the emergency department
OR
Contact the RAAPID Line:
1-800-661-1700 or 403-944-4486
Alberta has provincial requirements for medical and radiation oncology referrals for lung cancer. Consult the
requirements on the next pages and send to the location listed below.
TOM BAKER CANCER CENTRE, CALGARY
PH 403-521-3722
FAX 403-521-3245
PATIENTS SHOULD ONLY BE REFERRED TO THE CANCER CENTRE
WHEN THEY HAVE A CONFIRMED DIAGNOSIS OF CANCER
TO OBTAIN TISSUE PATHOLOGY / CYTOLOGY
Contact ATOP:
If there are clinical reasons
as to why this is not possible
please contact the cancer
centre and ask to speak to the
on call physician.
Alberta Thoracic Oncology Program, Foothills Medical Centre,
Health Sciences Centre, Area 6B, 1403 29 Street NW, Calgary, Alberta
T2N 2T9, Tel 403-944-1774, Fax 403-944-8848
http://www.albertahealthservices.ca/services.
asp?pid=service&rid=1008363
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
36
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Lung Tumour Group
TOC
PH 403-521-3722
MANDATORY REQUIREMENTS FOR ALL REFERRALS
PATIENT DEMOGRAPHICS
REFERRING PROVIDER
• Patient last name, first name, given names
• Name
• PHN/ULI
• Address, including city, province, postal code
• Gender
• Phone & fax
• Street address, including city, postal code,
province
FAMILY PHYSICIAN
• Home phone, other phone
• Name
• Email
• Emergency contact name and phone
• Indicate if same as referrer or if patient has no
primary care provider
• Guardian name, relationship to patient, and
phone
• Phone & fax
• Address, including city, province, postal code
OTHER INFORMATION REQUIRED:
• Relevant medical history
• Economic factors and psychological factors
• Indicate if an interpreter is required and if so,
what language?
• Provide additional comments/special
considerations
• Physical limitations
• Indicate whether patient has been informed of
cancer diagnosis
• Stage of disease
CO-MORBIDITY
• History of stroke
• VTE
• Cardiovascular disease (e.g. prior MI)
• Rheumatologic disease (e.g. SLE, Scleroderma)
• Respiratory disease
• Active infections (e.g. MRSA, Shingles, TB, VRE)
• Peripheral vascular disease (PVD)
• HIV
• GI disease
• Cognitive issues
• Liver disease (e.g. hepatitis B or C)
• Any other current medical problem
• Diabetes
• Renal disease
• DVT
• None
REQUESTED ACTION
• New patient referral
• Specific cancer clinical trial
• Cancer pain and symptom management
• Other
• Discussion in rounds
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
37
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Lung Tumour Group
R eason
for
R eferral
TOC
PH 403-521-3722
R equired I nvestigations
A ssociated
T imeframes *
APPROXIMATE TIME TO BE SEEN FOR ALL REFERRALS: WITHIN FOUR WEEKS
ALL REFERRALS
ATTACHED
Tissue pathology / cytology
ATTACHED OR ORDERED *
n/a
Chest x-ray or CT
28 days
Abdominal imaging US or CT
28 days
Bone scan
28 days
METASTASES BRAIN
CBC with differential
21 days
METASTASES BONE
(SYMPTOMATIC)
Renal function: creatinine
21 days
Liver function: ALT/AST, AP,
total bilirubin,LDH, albumin
21 days
Electrolytes: Calcium
21 days
SUPERIOR VENA CAVA
OBSTRUCTION
ATTACHED OR ORDERED *
MESOTHELIOMA
CT chest and upper abdomen
NON SMALL CELL LUNG
CANCER
ATTACHED OR ORDERED *
CT chest and upper abdomen
ATTACHED OR ORDERED *
SMALL CELL LUNG CANCER
THYMOMA/THYMIC
CARCINOMA
2 - 3 months
2 months
CT chest and upper abdomen
6 weeks
CT head
6 weeks
Bone scan
6 weeks
ATTACHED OR N/A
CT chest and upper abdomen
n/a
* IF PERFORMED OR ORDERED PLEASE PROVIDE A COPY OR THE DATE ORDERED
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
38
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC NeuroOncology Tumour Group
T riage
C ategory
I ncluding ,
but not limited to :
TOC
403-521-3722
P rocess
A pproximate
time to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
• Raised intracranial pressure
• Life threatening neurological
changes as result of brain
tumour
URGENT
• Glioblastoma multiforme
• Grade 3 glioma
ctivate EMS and go to
A
closest emergency
SAME DAY
EMERGENCY
eferred by CHR
R
neurosurgical Nurse
Clinician
1 – 2 WEEKS
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
SEMI
URGENT
• Grade 2 glioma
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
2 – 3 WEEKS
ROUTINE
• Pilocytic tumour
ax referral to TBCC
F
Central Access & Triage:
403-521-3245
4 WEEKS
• Meningioma – requiring nonsurgical treatment
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
39
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC NeuroOncology Tumour Group
TOC
403-521-3722
SPECIFIC CO-MORBIDITY INFORMATION TO IDENTIFY IF RELEVANT:
• History – seizures, focal neurological deficits
• Infectious disease
• Any other concurrent medical problem
• Detail medication including decadron and anti-epileptic dose
SPECIFIC SYMPTOM INFORMATION TO IDENTIFY IF RELEVANT:
• Provide any considered relevant by the referring physician.
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE:
• Histological confirmation is required
• Histopathological reports – any surgical procedure
• Surgery report – primary tumor, including all neurosurgery
• History & physical – inpatient
• Discharge summary – inpatient
• All recent lab work – including drug levels
• All related DI – report, films
• All relevant medical and surgical consultations
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
40
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Pain & Palliative Tumour Group
T riage
C ategory
I ncluding ,
but not limited to :
TOC
403-521-3589
P rocess
A pproximate
time
to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
• Spinal cord compression
• Go to Emergency
• Uncontrolled severe symptoms –
rated 9-10/10
• Cord compression
refer to Oncological
Emergency Guidelines
in appendix
• Delirium – acute onset confusion
URGENT
• Poorly controlled pain – rated
7-8/10
• Poorly controlled symptoms
including nausea & constipation
• Mild, unexplained cognitive
impairment
SEMI
URGENT
• Moderate pain – rated 4-6/10
ROUTINE
• Chronic mild pain – rating 1-3/10
• Moderate symptoms such as
nausea, constipation, fatigue,
anorexia/cachexia, psychosocial,
breathlessness
• Mild symptoms
• End of life planning
DEPARTMENTOFMEDICINE.COM/MAS
• Fax referral to TBCC
Central Access & Triage:
403-521-3245
SAME DAY
1 WEEK
• Notify Pain & Palliative
Triage Coordinator of
incoming referral:
403-521-3589
• Fax referral to TBCC
Central Access & Triage:
403-521-3245
2 WEEKS
• Fax referral to TBCC
Central Access & Triage:
403-521-3245
4 WEEKS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
41
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Pain & Palliative Tumour Group
TOC
403-521-3589
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Any other concurrent medical problem.
• Pain & symptoms and treatments already tried
to manage these.
• Provide any considered relevant by the
referring physician.
SPECIFIC TESTS/INVESTIGATIONS REQUIRED:
• List of symptom control medications – past & present
• Histological confirmation of malignancy
• Histopathological reports – for any surgical procedures, biopsy, or cytology
• Any operative reports for primary tumour (current or previous), biopsy and definitive surgery
• History and physical (inpatients)
• Discharge summary (inpatients)
• All lab work done in previous month
• The pain & palliative tumour group does not treat chronic non-malignant pain
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• All relevant DI – reports and films
• Consultation notes
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
42
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TOC
TBCC Sarcoma (Musculoskeletal) Tumour Group
403-521-3722
T riage
C ategory
A pproximate
I ncluding ,
but not limited to :
P rocess
time to be seen
Please note that if the condition of your patient changes to inpatient status after a new referral to the Tom
Baker Cancer Centre, please contact the main referral number so that we may assist in determining the best
timing and location for their first appointment.
EMERGENT
• Spinal cord compression
• Refer to Oncological
Emergency Guidelines in
Appendix
24 HOURS
URGENT
• Biopsy proven high grade soft
tissue sarcomas
• Mark referral “urgent”
2 WEEKS
• Rapidly growing or large soft
tissue mass without tissue
diagnosis
• Ewings
• Osteosarcoma
• Rhabdomyosarcoma
• Symptomatic metastases
• Neo-Adjuvant pre-operative
• Fax referral to TBCC
Central Access
&Triage:403-521-3245
• Call triage coordinator to
discuss if necessary:
403-521-3176
or
Clinic at: 403-521-3169
• chemotherapy
SEMI
URGENT
• Unresectable or metastatic,
progressive, symptomatic GIST
ROUTINE
• Biopsy proven desmoid tumours
• Post operative soft tissue
sarcomas with positive margins
• Post operative soft tissue
sarcomas with negative margins
• Fax referral to TBCC
Central Access
&Triage:403-521-3245
2 - 4 WEEKS
• Fax referral to TBCC
Central Access
&Triage:403-521-3245
4 WEEKS
• Adjuvant chemotherapy
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
43
Specialty Specific Guidelines
Cancer Care - Tom Baker Cancer Centre (TBCC)
TBCC Sarcoma (Musculoskeletal) Tumour Group
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
• Any other concurrent medical problem.
SPECIFIC TESTS/INVESTIGATIONS
REQUIRED:
• Consultation letter with specific reason for referral.
• History and physical.
• Histopathological reports for any surgical procedures,
biopsies.
• Any operative reports for primary tumour (current
orprevious), biopsy and definitive surgery.
• Discharge summary if hospitalized.
• Ewings, osteosarcoma, rhabdomyosarcoma, &
biopsy proven high grade sarcomas require CT chest
and local imaging within 4 weeks of appointment.
TOC
403-521-3722
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Provide any considered relevant by the
referring physician
SPECIFIC TESTS / INVESTIGATIONS
TO PROVIDE IF AVAILABLE:
• Histopathological confirmation of sarcoma
malignancy.
• All consultation reports.
• Reports and disks for chest x-rays, CT scans,
MRI scans and other relevant diagnostic
imaging done within past 6 months.
• All current & past imaging must be on disk –
unless on PACS.
• All lab work done in previous month.
DEPARTMENTOFMEDICINE.COM/MAS
Cancer Care - Tom Baker Cancer Centre (TBCC)
Updated 4 Nov 2014
44
Specialty Specific Guidelines
Cardiac Care
TOC
Adult Congenital Heart Clinic
403-943-4504 (PCL)
T ype of
P atient
Adult Congenital Heart Clinic sees patients with structural defects of the heart and great
vessels.
T riage
C ategory
I ncluding ,
URGENT
• Symptoms of cardiac
decompensation
but not limited to :
Call clinic for all urgent
referrals:
• New onset of heart failure or
rhythm abnormalities
403-943-4504
• Worsening symptoms following
recent hospitalization
AND
• Pregnancy
ROUTINE
P rocess
• Diagnosed or suspected structural
heart disease
SPECIFIC TESTS/INVESTIGATIONS
REQUIRED TO ENABLE TRIAGE
time to be seen
1 WEEK
Fax all referral information
to 403-291-6814
• Fax referral information
to 403-291-6814
8 WEEKS
SPECIFIC TESTS/INVESTIGATIONS
TO PROVIDE IF AVAILABLE
• Copies of any specialist consults
• Patient demographics
• If followed previously at pediatric congenital heart
clinic:
ºº Last clinic note
ºº All cardiac operative and interventional reports
ºº Most recent echo
A pproximate
• Most recent echo, MRI, CT, cardiac
catheterization, ecg, stress test, holter monitor
• Most recent chest x-ray, pulmonary function
tests
• Most recent blood work results
ºº Cardiac catheterization
ºº MRI
ºº CT
ºº Stress test
ºº Holter monitor
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
45
Specialty Specific Guidelines
Cardiac Care
TOC
Atrial Fibrillation Clinic
T riage
C ategory
ROUTINE
I ncluding ,
403-944-3339
but not limited to :
Atrial Fibrillation Clinic is focused
on the management of patients with
documented atrial fibrillation and/or
atrial flutter
P rocess
Clinic accepts referrals
from all physicians. Every
patient requires a family
physician for ongoing care.
A pproximate
time to be seen
VARIABLE
• Phone: 403-944-3339
• Fax all referral
information to clinic:
403-944-3580
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE
• Must have documented Atrial Fibrillation via 12 lead ECG, ECG strip, Holter monitor, or event recorder.
• Fax completed referral with all supporting documentation such as ECG, Holter, Exercise Stress Test,
Rhythm strip.
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
46
Specialty Specific Guidelines
Cardiac Care
TOC
Cardiac Arrythmia Clinic
T ype
of
patient
T riage
C ategory
ROUTINE
403-944-4632
Cardiac Arrhythmia Clinic sees patients with symptomatic Heart Rhythm abnormalities,
other than Atrial Fibrillation or rhythms requiring a pacemaker.
This service also provides consultation and follow up care for patients with Implantable
Cardioverter Defibrillators (ICD)
I ncluding ,
but not limited to :
Cardiac Arrhythmia Clinic deals
with Symptomatic Heart Rhythm
abnormalities, other than Atrial
Fibrillation or rhythms requiring
a pacemaker. This service also
provides consultation and follow up
care for patients with Implantable
Cardioverter Defibrillators (ICD).
P rocess
A pproximate
time to be seen
Clinic accepts referrals
from all physicians
Phone: 403-944-4632
Fax all referral information
to clinic:
403-670-0365
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE
Must have documented heart rhythm abnormalities or syncope, except Atrial Fibrillation (refer to Atrial
Fibrillation Clinic) or Brady Arrhythmias (refer to pacemaker clinic.
Fax complete referral with:
• Documentation of rhythm abnormalities
• Physician documentation of syncope
• Cardiac diagnostics such as ECG, ECHO, Holter, Exercise Stress (if available).
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
47
Specialty Specific Guidelines
Cardiac Care
TOC
Cardiac Device Clinic (Pacemaker and ICD)
T ype
of
patient
T riage
C ategory
ROUTINE
403-944-1188
This service provides consultation and follow up care for pacemaker and ICD patients.
This service also provides consultation and follow up care for patients with Implantable
Cardioverter Defibrillators (ICD)
I ncluding ,
but not limited to :
The Cardiac Device Clinic provides
centralized access to facilitate
timely patient assessment and
follow up care for patients requiring
a cardiac device or those patients
having an existing pacemaker or
ICD.
P rocess
Fax referral to Cardiac
Device clinic:
A pproximate
time to be seen
VARIABLE
403-270-0718
Pacemaker referrals for implant are accepted from Cardiologists. A family physician/ internal medicine etc.
may refer for consideration for ICD therapy and this will be directed to an Electrophysiologist for assessment
and decision.
PLEASE SEND THE FOLLOWING INFORMATION WITH THE INITIAL REFERRAL:
• Referral letter containing reason for referral
• Patient history
• Current medication list
•ECG’s
• LV function assessment if relevant, and documented rhythm strips and any other pertinent information
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
48
Specialty Specific Guidelines
Cardiac Care
Cardiac Function Clinics
TOC
FMC: 403-944-5900
PLC: 403-943-5579
T riage
C ategory
I ncluding ,
URGENT
DIAGNOSED Heart Failure patients
with:
but not limited to :
P rocess
• Active and changing symptoms,
typically exhibiting signs and
symptoms of heart failure
decompensation
• Patients with NYHA IV symptoms
• New onset of heart failure with
progressively worsening symptoms
• NYHA III symptoms and low BP
(< 100 mmHg), or symptomatic
hypotension
• Worsening symptoms following
recent hospital discharge
• New or Worsening heart failure
symptoms following cardiac
surgery,
• Worsening symptoms despite
previously stable active anti-failure
therapy
Call clinic for all urgent
referrals
RGH: 403-943-8623
SHC: 403-956-2603
A pproximate
time to be seen
LESS THAN ONE
WEEK
403-944-5900 (FMC)
403-943-5579 (PLC)
403-943-8623 (RGH)
403-956-2660 (SHC)
AND
Fax all referral
information to
appropriate CFC:
FMC: 403-283-7061
PLC: 403-943-6566
RGH: 403-943-8619
SHC: 403-956-2695
ELECTIVE
Heart Failure NYHA II-IV
Fax referral to
appropriate CFC:
1-2 WEEKS
FMC: 403-283-7061
PLC: 403-943-6566
RGH: 403-943-8619
SHC: 403-956-2695
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
49
Specialty Specific Guidelines
Cardiac Care
Cardiac Function Clinics
TOC
FMC: 403-944-5900
PLC: 403-943-5579
RGH: 403-943-8623
SHC: 403-956-2603
The Cardiac Function Clinics (CFC) are RN/MD directed clinics dedicated to the management of established
heart failure patients.
Care offered includes ongoing physical assessment and management of heart failure symptoms,
management of medical and non-medical treatments, ongoing patient teaching regarding diet, and lifestyle
and medication management.
Referrals must be accompanied by the name of the cardiologist* who has agreed to follow the patient
in the CFC, reports of all cardiac testing, clinic letters, discharge summary, ECG and recent lab tests.
Patients are typically discharged from the clinic if they demonstrate: a) resolution of HF, b) stabilization of HF
with requirement for less than 6 monthly visits or c) inability of the patient to follow their CHF plan or follow up.
*NOTE: if the patient does not have a cardiologist, please refer to Cardiac Navigation
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
FOR INPATIENTS:
• Basic patient identification and contact
information, as well as (if not contained in
documents below), co morbidity list, allergy list
and medication list.
• Cardiology consult / internal medicine consult
• Hospital discharge summary
• Copy of most recent ECG
• Chest x ray report copy
• Report of any ECHO, MRI, MUGA, cardiac
catheterization performed while in hospital, if
available
• Most recent cardiac blood work, and BNP if
available
FOR OUTPATIENTS:
• Name of attending heart failure physician/primary
cardiologist who has been asked to oversee the
care of the patient.
• Basic patient identification and contact
information, as well as (if not contained in
documents below), co-morbidity list, allergy list
and medication list.
• Cardiology consult / internal medicine consult
• Copy of most recent ECG
• Chest x ray report copy
• Copy of latest ECHOCARDIOGRAM report (and
any others if relevant)
• Report of any MRI, MUGA, cardiac
catheterization, if available
• Most recent cardiac blood work and BNP if
available
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
50
Specialty Specific Guidelines
Cardiac Care
TOC
Cardiac Navigation Clinic (CNC)
T riage
C ategory
EMERGENT
I ncluding ,
403-944-3278
but not limited to :
• Patients that need to be seen
immediately, for example:
ºº Acute or suspected MI
ºº Unstable Angina with chest
pain
P rocess
Go to Emergency, or
age Cardiologist on call:
P
403-944-1110
A pproximate
time to be seen
SAME DAY
(EMERGENCY)
ºº SBE actual/suspected
ºº Hemodynamically significant
arrhythmias
ºº Suspected aortic dissection
ºº Suspected cardiac
tamponade
URGENT
• Patients with cardiac conditions
that are not emergent, but are
deemed likely to deteriorate if
not seen by a cardiologist within
two weeks.
ax referral to Cardiac
F
Navigation Clinic:
403-944-3200
UP TO 2 WEEKS
SEMI
URGENT
• Known or suspected cardiac
conditions
that require cardiology
assessment more
urgently than the routine
timeframe.
Fax referral to Cardiac
Navigation Clinic:
403-944-3200
2-4 WEEKS
ROUTINE
• All other cardiac conditions that
can be seen through the
existing elective system.
• Fax referral to
appropriate clinic or
physician office if known
> 4 WEEKS
• If uncertain of referral
path, fax to Cardiac
Navigation Clinic:
403-944-3200
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
51
Specialty Specific Guidelines
Cardiac Care
TOC
Cardiac Navigation Clinic (CNC)
403-944-3278
SPECIFIC COMORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION TO
IDENTIFY IF RELEVANT:
• Diabetes
• Please provide details of any symptoms
experienced relevant to the suspected cardiac
condition.
• Thyroid disease
• Renal disfunction
• Sleep Apnea/Snoring
• Pulmonary (describe)
• Liver/GI (describe)
• Malignancy (5 years)
• Renal disease
CARDIAC SPECIFIC HISTORY TO
IDENTIFY IF RELEVANT:
SPECIFIC TESTS/INVESTIGATIONS
REQUIRED TO ENABLE TRIAGE:
• Please identify and provide supporting
documentation for any previous Cardiac
diagnoses, or relevant cardiac history, for example:
ºº Prior MI
ºº Prior PCI
ºº Prior CABG
ºº Hypertension
ºº Hyperlipidemia
ºº Smoking or cocaine use
• 12 Lead ECG or rhythm strips of arrhythmia (if
relevant)
• Recent Blood Work
ºº INR if patient on Coumadin
ºº Lipid Profile
ºº CBC, Lytes, Creatinine
ºº TSH, Digoxin level
• Emergency Physician record if patient being
referred from ED.
• Any other cardiac tests completed.
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
52
Specialty Specific Guidelines
Cardiac Care
TOC
Connective Tissue Clinic
T ype
of patient
T riage
C ategory
URGENT
403-943-4959 (PLC)
Connective Tissue Clinic sees patients with diseases of the connective tissue (Marfan
syndrome, Ehlers Danlos syndrome, Loeys-Dietz syndrome)
I ncluding ,
but not limited to :
Suspected or confirmed
diagnosis of connective tissue
disease (Marfan syndrom,
Ehlers-Danlos syndrome, LoeysDietz syndrome) AND measure
measurement of aortic root
greater than 4.5 cm on imaging
(echo, CT or MRI)
• *Referral for urgent
assessment at ACH Genetics
Clinic will be initiated by
Connective Tissue Clinic
P rocess
Call clinic for urgent
referrals
403-943-4959
A pproximate
time to be seen
WITHIN 2
WEEKS
AND
Fax all referral information
to:
403-291-6814
• *May require urgent referral
to cardiovascular/vascular
surgeon after assessment by
CTC cardiologist
SEMI-URGENT
• Suspected or confirmed
diagnosis of connective tissue
disease (Marfan syndrom,
Ehlers-Danlos syndrome,
Loeys-Dietz syndrome) AND
one or more of the following:
Fax all referral information
to:
403-291-6814
2 MONTHS
• Aortic root measurement of
4.0-4.5 cm on imaging (echo,
CT or MRI)
• Moderate-severe mitral or
aortic valve regurgitation
• Significant LV dysfunction
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
53
Specialty Specific Guidelines
Cardiac Care
TOC
Connective Tissue Clinic
T riage
C ategory
ELECTIVE
I ncluding ,
403-943-4959 (PLC)
but not limited to :
Suspected or confirmed
diagnosis of connective tissue
disease (Marfan syndrom,
Ehlers-Danlos syndrome, LoeysDietz syndrome)
P rocess
Fax all referral information
to:
403-291-6814
A pproximate
time to be seen
4-6 MONTHS
*Measurement of aortic root
normal or less than 3.9 cm on
echo imaging
*PATIENTS WITH SUSPECTED OR CONFIRMED DIAGNOSIS OF MIXED CONNECTIVE
TISSUE DISEASE OR OTHER AUTOIMMUNE DISORDERS (LLUPUS, SCLERODERMA,
POLYMYOSITIS, RAYNAUD’S SYNDROME) MAY REQUIRE ASSESSMENT BY CARDIOLOGY,
BUT ARE NOT SEEN IN THE CONNECTIVE TISSUE (CTC) CLINIC WHICH DEALS PRIMARILY
WITH GENETIC DISORDERS OF THE CONNECTIVE TISSUES.
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE
• Basic patient demographic information and contact information
• Documentation of past medical history to include a list of all current medications
IF AVAILABLE:
• Copies of any specialist consults (Cardiology/Internal Medicine/Genetics/Opthalmology/Cardiovascular or
Vascular Surgery
• Copies of cardiovascular or vascular operative reports
• Copies of any Echo, MRI, CT or Cardiac Catheteriization reports
• Copy of most recent ECG and/or Holter Monitor
• Copy of Chest X-ray and/or Pulmonary Function tests
• Most recent blood work results
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
54
Specialty Specific Guidelines
Cardiac Care
TOC
Hypertrophic Cardiomyopathy Clinic
T ype
of
patient
403-943-4959 (PLC)
Hypertrophic Cardiomyopathy Clinic sees patients with a genetic disorder of the
myocardium of the heart causing hypertrophy.
T riage
C ategory
I ncluding ,
URGENT
Suspected or confirmed HCM with
but not limited to :
P rocess
• New onset of heart failure
Call clinic for urgent
referrals
403-943-4959
• New onset or worsening of chest
pain
AND
• Medication side effects
• New onset of rhythm abnormality
documented on ECG or Holter
monitor
A pproximate
time to be seen
2-4 WEEKS
Fax all relevent information
to
403-291-6814
• Worsening symptoms following
recent hospitalization
• Complications during pregnancy
ELECTIVE
• Suspected or confirmed diagnosis
of HCM
• Fax all referral
information to
403-291-6814
3-6 MONTHS
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE
• Basic patient demographic information and contact information
• Documentation of past medical history to include a list of all current medications
• Copies of all echocardiograms, cardiac MRI, CT, cardiac catheterization reports
IF AVAILABLE:
• Copies of any specialist consults including cardiology, genetics, internal medicine, respiratory or
cardiovascular surgery
• Copies of any cardiovascular operative reports
• Copy of most recent ECG, exercise stress test, exercise test, and/or holter monitor
• Copy of chest x-ray and/or pulmonary function tests
• Most recent blood work results
DEPARTMENTOFMEDICINE.COM/MAS
Cardiac Care
Updated 4 Nov 2014
55
Specialty Specific Guidelines
Clinical Neurosciences
Amyotrophic Lateral Sclerosis (ALS) /
Motor Neuron Disease Clinic
T riage
C ategory
SUSPECTED
ALS
I ncluding ,
but not limited to :
• The Calgary ALS/Motor Neuron
Disease Clinic is involved in the
care of patients who have motor
neuron diseases (ALS/PLS/
Kennedy’s disease etc).
PH 403-956-3468
P rocess
FAX REFERRAL TO:
403-956-3492
A pproximate
time to be seen
2 – 6 WEEKS
• The clinic includes neurology,
respirology, physical medicine,
palliative care and allied health.
All suspected referrals of motor
neuron disease are reviewed by
the neurologist and may be seen
initially in the Neuromuscular
Intake Clinic to confirm
diagnosis.
MANDATORY INFORMATION REQUIRED FOR TRIAGE
• Patient history
• Neurological examination results
• List of medications
• Results of ALL diagnolstic tests completed to date: imaging, electrophysiology, blood work, biopsies
• If done outside Calgary, MR images on disk should accompany the report
• Data/consult from previous neurological consultations
NOTES
Incomplete or illegible referrals will be returned with a request for more information, before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
Referrals may be declined if they do not meet clinic criteria; in this case you will be notified and advised
regarding alternate referral destinations, if appropriate, but it will be your responsibility to make an alternate
referral.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
November 2014
56
Specialty Specific Guidelines
Clinical Neurosciences
TOC
Brain Injury (Rehabilitation) Clinic
T riage
C ategory
I ncluding ,
ROUTINE
Sequelae of moderate to severe
acquired brain injury, including:
but not limited to :
PH 403-944-8571
P rocess
A pproximate
time to be seen
Fax referral to 403-944-8578
6 MONTHS
Contact neurology or
neurosurgery
N/A
Contact the Calgary Brain
Injury Program:
N/A
• trauma
• encephalitis
• subarachnoid hemorrhage
• other conditions.
Typical concerns include:
• memory and cognitive
changes,
• speech complaints,
• emotional changes, and
• physical sequelae.
EXCLUSIONS
• Acute injuries
• Neurologic status concerns
• Concussions
• Mild traumatic brain injury
Ph: 403-944-8571
Fax: 403-944-8578
RELEVANT CO-MORBIDITY
• Previous brain injury
SPECIFIC TESTS / INVESTIGATIONS TO
PROVIDE IF AVAILABLE
• History of substance or alcohol abuse
• CT / MRI / Imaging results
• Mental health diagnosis
• Discharge summary
• Seizures
• Neuropsychologic assessment
• Therapist or consultant assessments
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
57
Specialty Specific Guidelines
Clinical Neurosciences
TOC
Cognitive Neurosciences Clinic (CNC)
T riage
C ategory
EMERGENT
I ncluding ,
but not limited to :
• Acute delirium.
• Behavioral complications of dementia
that are acutely compromising patient
or caregiver safety (e.g. psychosis,
agitation, violent behavior).
PH 403-944-4406
P rocess
A pproximate
time to be seen
Go directly to
emergency
department
N/A
SEMIURGENT
• New onset rapidly progressive dementia
(that is, onset of dementia within last 3
months with progressive accumulating
loss of function in activities of daily living
within that time frame).
Fax referral to:
403-944-8228
1 MONTH
ROUTINE
• Suspicion of cognitive impairment
or dementia caused by neurological
disease.
Fax referral to:
403-944-8228
<6 MONTHS
• Opinion on etiology of cognitive
impairment or dementia.
• Early-onset cognitive impairment or
dementia (<65 years).
• Cognitive symptoms with objective
evidence of poor cognition (e.g. by
MMSE or MoCA).
• Assistance with pharmacologic
management of memory impairment
in dementia (note: consults solely
for management of behavioural
complications of dementia will not
be accepted; consider referral to a
geriatrician or geriatric psychiatrist
instead).
NOT
ACCEPTED
WHEN THERE IS
DOCUMENTATION
OF DEMENTIA OR
OBJECTIVE EVIDENCE
OF POOR COGNITION
<12 MONTHS
FOR REFERRALS
FOR MEMORY
SYMPTOMS WITH NO
DOCUMENTATION OF
DECLINE IN FUNCTION
OR OBJECTIVE
TESTING SHOWING
POOR COGNITIVE
PERFORMANCE
• Referrals solely for management of behavioural complications of dementia.
• Referrals for capacity assessment or for driving assessment.
• Assessments for the Worker’s Compensation Board.
• Referrals for assistance with management of community support or for transition from
the community to assisted living; consider a referral to Senior’s Health instead (F: 403955-1514).
• Referrals for static cognitive impairment solely due to concussion, traumatic brain
injury or psychiatric diseases.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
58
Specialty Specific Guidelines
Clinical Neurosciences
Cognitive Neurosciences Clinic (CNC)
TOC
403-944-4406
The Cognitive Neurosciences Clinic (CNC) provides consultative advice on the diagnosis and management
of neurological diseases that cause cognitive impairment or dementia. Common diagnoses seen in the clinic
include Alzheimer’s disease, vascular cognitive impairment, cerebral amyloid angiopathy, mild cognitive
impairment, frontotemporal dementia, Lewy body disease and others. The Clinic will provide an assessment
of the etiology of dementia, order further investigations as appropriate, and provide recommendations for
management (e.g. with acetylcholinesterase inhibitors). Advice on community resources and support will
be provided however the referring physician, not the Clinic, will be responsible for intiating referrals (e.g. for
home care evaluation) as deemed necessary.
We strongly encourage administration of the validated Montreal Cognitive Assessment Tool (MoCA,
www.mocatest.org) when there are cognitive symptoms in patients with no evident functional
limitations and no known neurological disease. Patients that score 26 or higher are very unlikely to have
abnormal cognition or a neurological disease even when more extensive testing is performed; in this case
referral to the CNC may not be necessary.
MANDATORY INFORMATION REQUIRED FOR TRIAGE
• Brief description of history and examination results, or recent office note describing cognitive complaints.
• Results of MMSE, MoCA or other cognitive tests, if done.
• List of medications.
• Results of ALL diagnostic tests completed to date, including imaging and blood work.
• MR or CT images on disk should accompany the referral, if they were done outside Calgary.
• Notes from previous neurological, psychiatric or neuropsychological consultations.
NOTES
Incomplete or illegible referrals will be returned with a request for more information, before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
Referrals may be declined if they do not meet clinic criteria; in this case you will be notified and advised
regarding alternate referral destinations if appropriate but it will be your responsibility to make an alternate
referral.
Patients will be seen at either the Foothills Medical Centre or South Health Campus, depending on patient
location and relative wait list times.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
59
Specialty Specific Guidelines
Clinical Neurosciences
TOC
General Neurology (GNC)
T riage
C ategory
EMERGENT
I ncluding ,
PH 403-956-3461
but not limited to :
• Patients needing to be seen
emergently should go directly to the
Emergency Room (ER)
• If you are unsure of the urgency you
may speak with the neurologist on call
URGENT
SEMI
URGENT
• Adult patients with a new, acute
neurological problem requiring a
neurology consultation within 72
hours should fax referral to the Urgent
Neurology Clinic.
Onset within the past 3 months of a first
ever episode of:
• New motor +/- sensory deficit with or
without pain
P rocess
Go directly to an
emergency department
Approximate
time to be seen
N/A
Referring physician
should call RAAPID
South at 1-800-6611700
or
403-944-4486
to speak to a
neurologist
Fax referral to Urgent
Neurology Clinic (UNC)
403-270-1848
3-7 DAYS
See referral criteria for
Urgent Neurology Clinic
in this directory
Fax referral to Central
Access and Triage
(CAT): 403-476-8771
1-3 MONTHS
• New episodic confusion or amnesia
• Progressive weakness
• Progressive apahasia
• Progressive cognitive decline
• Progressive or intermittent dysarthria
and/or dysphagia
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
60
Specialty Specific Guidelines
Clinical Neurosciences
TOC
General Neurology (GNC)
T riage
C ategory
ROUTINE
I ncluding ,
PH 403-956-3461
but not limited to :
• Chronic unremitting or frequent
headache
• Chronic intermittent or persistent
dizziness or vertigo
• Epilepsy
• Sensory symptoms
• Gait problems
• Tremor
• Other movement disorders
P rocess
Fax referral to Central
Access and Triage
(CAT): 403-476-8771
Approximate
time to be seen
>3 MONTHS
For interim care call
RAAPID South
1-800-661-1700
or
(403) 944-4486
to speak to a
neurologist
• Chronic progressive limb weakness
• Mild cognitive impairment
• Chronic progressive cognitive decline
• Multi-focal neurological symptoms
without neurological signs
• Multi-focal neurological symptoms with
a normal or non-specific brain MRI
• Abnormal brain MRI (other than a
space occupying lesion)
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
61
Specialty Specific Guidelines
Clinical Neurosciences
TOC
General Neurology (GNC)
T riage
C ategory
EXCLUSIONS
REFERRALS
IN THESE
SITUATIONS
WILL NOT
GENERALLY
BE
ACCEPTED
I ncluding ,
PH 403-956-3461
but not limited to :
• Follow-up appointments
• Patients requiring follow-up after
discharge from the general neurology
service
P rocess
Approximate
time to be seen
Refer directly to previous neurologist or
subspecialty clinic.
• Patients already registered in a
subspecialty clinic
• Patients who hope to be seen sooner
than the subspecialty clinic can offer
• Second opinions
• Medicolegal assessments
Contact a neurologist’s office directly by
phone
• Workers’ Compensation Board
assessments
• Patients who no longer have a family
doctor and wish primary care for
their neurological problem from a
neurologist who has seen them in the
past
Another family physician is needed
• Acute trauma to the nervous system
with or without a neurological deficit
Consider a neurosurgeon for acute issues
requiring surgery or, if chronic refer to a
PM&R physician, or the Chronic Pain Centre
• Acute or chronic radiculopathy with
known structural cause (such as
disc extrusions)
• Failed back problems
• Patients who have had a traumatic
brain injury and suffer from postconcussion symptoms
DEPARTMENTOFMEDICINE.COM/MAS
Refer to Brain Injury (Rehabilitation) Clinic
Clinical Neurosciences
Updated 4 Nov 2014
62
Specialty Specific Guidelines
Clinical Neurosciences
General Neurology (GNC)
TOC
403-956-3461
MANDATORY INFORMATION REQUIRED FOR TRIAGE
• Referring physician’s name, address, telephone and fax numbers
• Patient’s name, date of birth, address and telephone numbers
• Reason for the neurology consult and why the consult is urgent
• As much clinical information as possible (including: onset, symptoms, physical exam and pertinent test
results)
• Referrals must be legible
ADDITIONAL INFORMATION TO FURTHER ENABLE TRIAGE AND TO OPTIMIZE EVEN ROUTINE
CONSULTATIONS:
• Previous neurology consult letters (or discharge summaries).
• Co-morbidities and medications.
• If a second opinion is requested of a specific neurologist please include the reason that a second opinion
is required, and the original consult note. The request may be declined and usually there is a long wait for
appointments.
NOTES:
Incomplete or illegible referrals will be returned with a request for more information, before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
Referrals may be declined if they do not meet clinic criteria; in this case you will be notified and advised
regarding alternate referral destinations if appropriate but it will be your responsibility to make an alternate
referral.
Patients may be seen at any site.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
63
Specialty Specific Guidelines
Clinical Neurosciences
TOC
Movement Disorders Clinic (MDC)
T riage
C ategory
I ncluding ,
but not limited to :
PH 403-944-4364
P rocess
A pprox .
time
to be seen
EMERGENT
• N/A
Send patient to Emergency
Room for assessment by ER
physicians
SAME DAY
URGENT
• Re-referrals:
For DBS issues please
contact the surgical nurse
coordinator (daytime) at:
403-944-4392 or
403-944-8152
USUALLY
SAME DAY
• Deep brain stimulator (DBS)
patients
• Sudden worsening of
Parkinson’s disease or dystonia
due to failure of battery or
pacemakers in patients with
deep brain stimulators (DBS).
• Need for urgent MRI scans
in patients with deep brain
stimulators
In the evening contact
call RAAPID South
1-800-661-1700
or
(403) 944-4486
to speak to a neurologist
• Patients of the Movement
Disorder Clinic
Fax referral to:
403-944-4063
• Rapid deterioration of
Parkinson’s disease or other
movement disorder
• New referrals:
• Severe progressive
Parkinsonism in children or
severe tics
Dr. Pringsheim will see at
the Tourette and Pediatric
Movement Disorders Clinic
at the Alberta Children’s
Hospital (ACH).
1 WEEK
For emergent cases please
page her:
403-212-8223-08511
or
Tel: 403-955-5982
Fax: 403-955-5990
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
64
Specialty Specific Guidelines
Clinical Neurosciences
TOC
Movement Disorders Clinic (MDC)
T riage
C ategory
ROUTINE
<3 MONTHS
I ncluding ,
but not limited to :
• Patients with hemi facial spasm,
blepharospasm or cervical
dystonia
• For adults and children with tics
PH 403-944-4364
P rocess
A pprox .
time
to be seen
Fax referral to MDC Clinic:
403-944-4063
3 MONTHS
Tourette and Pediatric
Movement Disorders Clinic,
ACH
2 MONTHS
Tel: 403-955-5982
Fax: 403-955-5990
ROUTINE
<6 MONTHS
• All other patients who do not fit
the above examples
Fax referral to MDC Clinic:
12 MONTHS
403-944-4063
SPECIFIC SYMPTOM INFORMATION TO IDENTIFY IF RELEVANT:
• If the patient has pre-existing movement disorder; the reason for the referral to MDC Clinic
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
REQUIRED INFORMATION FOR NEW REFERRALS:
• Previous neurology consult letters (or discharge summaries) if seen outside the Movement Disorders
Clinic.
• Copies of any previous MRI reports (if any).
• Results of all prior investigations completed to investigate the neurological symptoms (if any).
• A list of co-morbidities and medications.
NOTES:
Incomplete or illegible referrals will be returned for completion before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical Neurosciences
TOC
Multiple Sclerosis (MS) Clinic
T riage
C ategory
EMERGENT
I ncluding ,
PH 403-944-4253
but not limited to :
• Disabling symptoms associated
with inability to safely manage
as an outpatient. Paraparesis,
hemiparesis, and severe
dysphagia are typical examples.
• Severe psychiatric co-morbidities
(depression and psychosis) may
require emergency assessment
and psychiatric management.
Suicide is common in MS.
URGENT /
SEMI-URGENT
• New referrals, suspected MS
• New, persistent, sub acute CNS
symptoms in adults, suspected
by the referring physician to be
due to MS are rarely appropriate
for the MS Clinic.
• New, persistent, CNS symptoms
in children and adolescents
(age 16 and under), suspected
by the referring physician to
be due to CNS demyelination,
including optic neuritis,
transverse myelitis, acute
disseminated encephalomyitis
(ADEM), or neuromyelitis optica,
or other acquired demyelinating
syndromes should be referred to
Dr Jean Mah
DEPARTMENTOFMEDICINE.COM/MAS
P rocess
Send patient to
Emergency Room for
assessment by ER
physicians
A pproximate
time to be seen
N/A
or
call RAAPID South
1-800-661-1700
or
(403) 944-4486
to speak to a
neurologist
Refer adults to
General Neurology
or Urgent Neurology
Clinic as per their
guidelines (contact
info found in this
directory)
N/A
Dr. Jean K. Mah,
Pediatric Neurology
Clinic, Alberta
Children’s Hospital
Ph: 403-955-7602
Fax: 403-955-7609
Clinical Neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical Neurosciences
TOC
Multiple Sclerosis (MS) Clinic
T riage
C ategory
URGENT /
SEMI-URGENT
(CONTINUED)
I ncluding ,
PH 403-944-4253
but not limited to :
NEW REFERRALS:
• Patients diagnosed with MS but
who are not MS Clinic patients
and are not followed by a
non-MS clinic neurologist who
experience:
• Disabling relapses not thought to
require hospitalization.
• Moderate or severe treatment
adverse events in a patient
recently moved to our referral
area but started on MS therapy
by a previous neurologist.
• Patients newly diagnosed
with acute optic neuritis by an
ophthalmologist.
• Patients newly diagnosed with
MS or suspected MS by a
neurologist and who will not be
followed by that neurologist.
P rocess
Call or fax referral to
the MS Clinic.
Fax: 403-270-7162
Consider asking for
an MS specialist to
contact you for a
telephone consult
(much faster).
A pproximate
time to be seen
1-5 DAYS
for a telephone
consult between the
nurse practitioner
(fastest) or an MS
neurologist and the
referring MD.
Ph: 403-944-4253
1 WEEK
or
for clinic assessment
by nurse practitioner
of a relapsing MS
patient.
call RAAPID South
1-800-661-1700
or
(403) 944-4486
to speak to a
neurologist
1 MONTH
for clinic assessment
by a neurologist.
RE-REFERRAL OF CURRENT MS
CLINIC PATIENTS:
• Disabling relapses not thought to
require hospitalization.
• Moderate or severe treatment
adverse events.
• Assessment for concurrent or
potentially triggering factors
(especially infections) should be
completed by the referring MD.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
67
Specialty Specific Guidelines
Clinical Neurosciences
TOC
Multiple Sclerosis (MS) Clinic
PH 403-944-4253
T riage
C ategory
I ncluding ,
ROUTINE
NEW REFERRALS:
Fax to the MS Clinic
< 3 MONTHS:
• Patients with both focal CNS
symptoms and a brain MRI that
is highly suggestive of MS (see
below).
Fax: 403-270-7162
> one recent
relapse, rapid
recent worsening,
need to review MS
therapies, or clear
need for symptom
management.
but not limited to :
P rocess
• Patients diagnosed with MS,
probable MS, transverse myelitis,
or another demyelinating disease
by a neurologist if the other
neurologist is not also following
the patient.
A pproximate
time to be seen
< 6 MONTHS:
• Patients referred by a neurologist
for assessment of suspected
demyelinating disease.
Stable or slowly
progressive disease.
• Patients diagnosed with optic
neuritis by an ophthalmologist
or neurologist (unless the other
neurologist is also following the
patient).
RE-REFERRALS:
Fax to the MS Clinic:
< 3 MONTHS:
• Any current MS Clinic patient
with MS or suspected MS who
requests an MS Clinic reassessment.
Fax: 403-270-7162
Multiple recent
relapses, rapid recent
worsening, or need to
review MS therapies.
• Previous MS clinic patients who
were discharged because they
were believed not to have MS
must usually have new evidence
suggestive of MS and an MRI
strongly suggestive of MS to
be re-reviewed in MS Clinic. A
general neurology referral may be
more appropriate.
Consider requesting
a telephone consult
for interim care.
Ph: 403-944-4253
• Current MS Clinic patients
who have not been seen by a
clinic physician for at least 18
months may self refer for routine
assessment.
< 6 MONTHS:
SLOWLY
PROGRESSIVE
DISEASE.
Telephone consults will
usually occur within
days if urgent; within 3
weeks if not urgent.
< 12 MONTHS
STABLE MS
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical Neurosciences
Multiple Sclerosis (MS) Clinic
TOC
PH 403-944-4253
EXCLUSIONS
• Referrals to see people who live outside our referral area (Southern Alberta and the SE tip of BC) except in
exceptional circumstances.
• Referrals for second opinions for people outside our referral area, or for those who believe they have MS
despite an alternate neurologic opinion. Some MS Clinic physicians do provide this service. Contact the
MS Clinic for a current list of these physicians in their general neurology clinic.
PROCESS
In the Calgary MS Clinic the focus is on multidisciplinary care of Southern Albertans with MS and suspected
MS. Non-specific symptoms like numbness and tingling and non-specific MRI changes which include
demyelinating disease as a possible cause may be indications for neurology assessment but do not require
MS Clinic assessment.
MRI in MS and suspected MS: Many people, especially those over age 50, have non-specific T2
hyperintensities on brain MRI; often they are described as ‘sub-cortical’ or ‘punctate’. These are infrequently
due to MS. Three of the following imaging features are almost always present in MS: flame-shaped/ovoid
periventricular T2 lesions, infratentorial lesions (in the brainstem, cerebellum, or spinal cord), juxtacortical
lesions, and gadolinium enhancing lesions.
MANDATORY INFORMATION REQUIRED FOR TRIAGE
NEW REFERRALS
All newly referred patients who are accepted at the clinic receive education while on the wait list.
1. Previous neurology or ophthalmology consult letters and discharge summaries.
2. Copies of all previous MRI reports (if any).
3. Results of all prior investigations completed to investigate the neurologic symptoms (if any).
4. A list of co-morbidities and medications.
5. If referral is to assess focal symptom(s) in a person with an MRI suspicious for MS, please also describe
the focal symptom(s) including date(s) of onset and symptom evolution.
6. Provide details regarding symptoms that you believe require expedited assessment (sooner than 6
months).
7. If a telephone consult is requested please indicate this. Note the urgency and indicate your availability. If
urgent, please provide contact choices.
RE-REFERRALS
Indicate if an urgent or expedited assessment is requested and explain why including a timeline of patient
symptoms. You may be contacted for further discussion if the need for urgency is unclear. Please request a
telephone consult for interim care if required.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
69
Specialty Specific Guidelines
Clinical Neurosciences
Multiple Sclerosis (MS) Clinic
TOC
PH 403-944-4253
NOTES
Incomplete or illegible referrals will be returned with a request for more information, before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
Referrals may be declined if they do not meet clinic criteria; in this case you will be notified and advised
regarding alternate referral destinations if appropriate but it will be your responsibility to make an alternate
referral.
Patients will be seen at either the Foothills Medicial Centre or South Health Campus, depending on patient
location and relative wait list times.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical Neurosciences
TOC
SHC
FMC
Neuromuscular Clinic (NMC)
T riage
C ategory
I ncluding ,
EMERGENT
NEW OR RE‑REFERRING
but not limited to :
• A patient with a known diagnosis of
myasthenia gravis with increasing
problems with respiration
• Acute onset (within the past 7 days) of
weakness, sensory symptoms in both
legs, with or without urinary symptoms or
shortness of breath
• Recent onset (last one week) of major
motor and/or sensory deficits in 2 or more
peripheral nerve territories
• New onset (last one week) of a problem
with difficulty swallowing or breathing
PH 403-956-3454
PH 403-944-4415
P rocess
Go directly to
Emergency
Department
Approx.time to
be seen
SAME DAY
or
call RAAPID
South
1-800-661-1700
or
(403) 944-4486
to speak to a
neurologist
• Acute onset of weakness to both
legs, possibly including bowel/bladder
dysfunction and sensory disturbance
over legs (suspected spinal cord, cauda
equine, conus medullaris syndrome)
URGENT
NEW OR RE‑REFERRING
• Known diagnosis of myasthenia gravis but
with increasing problems with chewing,
swallowing and speaking or generalized
weakness
• Onset in past 2-3 weeks of new,
progressive sensory and motor deficits
resulting in impaired function
Phone
neuromuscular
clinic to ask the
neuromuscular
neurologist to be
paged to discuss
the case.
1-7 DAYS
• Recent (2-3 weeks) onset of motor and/
or sensory deficits in 2 or more peripheral
nerve territories
• Patient is discussed by telephone with
neuromuscular neurologist and triaged to
urgent
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical Neurosciences
TOC
SHC
FMC
Neuromuscular Clinic (NMC)
T riage
C ategory
SEMI-URGENT
I ncluding ,
but not limited to :
• Onset of progressive limb weakness or
swallowing/speech difficulties over weeks
to months associated with loss of muscle
bulk and, twitching of muscles
PH 403-956-3454
PH 403-944-4415
P rocess
Fax referrals to
Approx.time to
be seen
2-4 WEEKS
403-476-9634
• Progressive, primarily proximal limb
weakness +/- swallowing difficulties (or
problem in two or more nerve territories) of
not more than 2 to 3 months duration
• Progressive motor, sensory or bulbar
disorder with more recent (past 2-3
weeks) significant decline and loss of
ability to carry out activities of daily living
• Patient is discussed by telephone with
neuromuscular neurologist and triaged to
semi-urgent
ROUTINE
<3 MONTHS
• Chronic (more than 3 months) progressive
weakness and or/sensory deficits with a
stocking and glove pattern of involvement
without a diagnosis, or with a diagnosis
requiring treatment
Fax referrals to
ROUTINE
<6 MONTHS
• Known diagnoses of muscular dystrophy,
hereditary neuropathies, stable
myasthenia gravis, stable peripheral
neuropathies
Fax re-referrals:
403-476-9634
• Muscle cramping or pain of unknown
cause, elevated CKs of unknown cause
3 MONTHS
403-476-9634
>3
MONTHS
Phone
403-956-3454
or
403-944-4415
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
72
Specialty Specific Guidelines
Clinical Neurosciences
TOC
SHC
FMC
Neuromuscular Clinic (NMC)
PH 403-956-3454
PH 403-944-4415
MANDATORY INFORMATION REQUIRED FOR TRIAGE
• History, neurological examination results
• List of medications
• Results of ALL diagnostic tests completed to date-imaging, electrophysiology, blood work, biopsies
• If done outside Calgary, MR images on disk should accompany the report
• Data/consult from previous neurological consultations
NOTES
Incomplete or illegible referrals will be returned for completion before or during triage.
Referrals more appropriate for another neurology program will be forwarded for program triage (you will be
notified).
Patients may be seen at any site.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical Neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical Neurosciences
TOC
Neurovestibular Clinic (South Health Campus)
T riage
C ategory
I ncluding ,
EMERGENT
but not limited to :
• Acute vestibular syndrome (with
or without other neurological
symptoms or neck pain)
P rocess
403-956-3462
A pproximate
time to be seen
Send directly to
Emergency Department
SAME DAY
Fax or mail referral to
Neurovestibular Clinic,
South Health Campus:
< 14 DAYS
»» vertigo
»» nausea
»» vomiting
»» imbalance developing over
seconds or minutes
URGENT
• Isolated vertigo/dizziness within
the last 8 weeks.
Room 510120
4448 Front Street SE
Calgary, AB T3M 1M4
Fax: 403-956-3494
Phone: 403-956-3462
ROUTINE
• Isolated vertigo/dizziness of
more than 8 weeks duration.
• Recurrent spontaneous or
positional vertigo/dizziness of
less than 2 years duration.
Fax or mail referral to
Neurovestibular Clinic,
South Health Campus:
< 6 MONTHS
Room 510120
4448 Front Street SE
Calgary, AB T3M 1M4
Fax: 403-956-3494
Phone: 403-956-3462
EXCLUSIONS
DEPARTMENTOFMEDICINE.COM/MAS
• Patients with symptoms > 2
years or lightheadedness/presyncope
see: Suggested
evaluation and
management
Clinical Neurosciences
N/A
Updated 4 Nov 2014
74
Specialty Specific Guidelines
Clinical neurosciences
Neurovestibular Clinic (South Health Campus)
TOC
403-956-3462
Referred patients should have vertigo or dizziness characterized by impaired spatial orientation. Patients with
additional neurological symptoms or migraine should be referred to a general neurologist (Neurology Central
Triage fax: 403-476-8771) or, if acute, the Emergency Department. Patients with longstanding imbalance and
falls should be referred to the fall prevention clinic (fax: 403-955-1514).
MANDATORY INFORMATION TO ENABLE TRIAGE
• Detailed history, including:
»» symptom description, date of onset, duration (seconds, minutes, hours days, weeks or constant).
»» triggers (e.g., position change, head motion, elevators, darkness, valsalva)
»» otologic symptoms (e.g., ear pain, fullness, hearing loss, tinnitus).
• Results of ALL tests, including blood work, CT, MRI brain/IACs, results of hearing and vestibular laboratory
testing.
• Letters from all relevant consultations
• If CT or MR scans done outside Calgary are not available on Netcare, scans on CD should accompany the
referral
NOTES:
Patient appointments are booked with the earliest available neuro-otologist (Drs. S. Subramaniam, W.
Fletcher or B. Lange).
Incomplete or illegible referrals will be returned for completion before triage.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical neurosciences
TOC
Seizure Clinic
T riage
C ategory
EMERGENT
PH 403-944-4242
I ncluding ,
but not limited to :
• Status epilepticus-convulsive or
suspected non-convulsive
P rocess
Approximate
time to be seen
Send to emergency
department
SAME DAY
Fax referral to Urgent
Neurology Clinic (UNC)
403-270-1848
1 WEEK
• Frequent or sequential seizures
• Severe toxicity or adverse
reactions to treatment
URGENT
• First unprovoked seizure
See referral criteria for
Urgent Neurology Clinic in
this directory
SEMIURGENT
• Increase in number or severity
of seizures
• Moderate adverse effects of
treatment
• Newly diagnosed epilepsy
• Recurrence of seizures after
prolonged seizure free period.
Recurrence interferes with
driving, work.
ROUTINE
<3 MONTHS
• Intractable epilepsy adequate
trial of at least two anti-epileptic
drugs (AEDs)
Fax referral to the Seizure
Clinic and request an
appointment or an epilepsy
physician telephone consult
1 MONTH
FOR CLINIC
Phone: 403-944-4242
Fax: 403-476-9630
Fax referral to Seizure Clinic
3 MONTHS
Fax: 403-476-9630
• Not previously seen by
epileptologist
ROUTINE
<6 MONTHS
• Intractable epilepsy tried
multiple AEDs
DEPARTMENTOFMEDICINE.COM/MAS
Fax referral to Seizure Clinic
6 MONTHS
Fax: 403-476-9630
Clinical neurosciences
Updated 4 Nov 2014
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Specialty Specific Guidelines
Clinical neurosciences
Seizure Clinic
TOC
PH 403-944-4242
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• All medications and dosages
• Results of EEG, CT and MRI if done
ADDITIONAL SUBSPECIALTY REQUIREMENTS TO PROVIDE IF AVAILABLE:
• Previous consultation letters
NOTES:
Incomplete or illegible referrals will be returned for completion before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
DEPARTMENTOFMEDICINE.COM/MAS
Clinical neurosciences
Updated 4 Nov 2014
77
Specialty Specific Guidelines
Clinical neurosciences
Stroke Prevention Clinic (SPC)
TRIAGE
CATEGORY
EMERGENT
PH 403-944-1447
CRITERIA
PROCESS
• Transient motor weakness or
speech deficit within last 48
hours
Send patient to ED for
urgent assessment, CT
head and CTA extracranial
and intracranial vessels.
APROXIMATE TIME
TO BE SEEN
SAME DAY
Whether the patient will
be seen in the ED by the
stroke team will depend on
the results of the CT/CTA.
• Any possible TIA symptoms
within last 48 hours if patient
is known to have atrial
fibrillation and is not currently
anticoagulated
Send patient to ED for
urgent assessment, CT
head and anticoagulation if
appropriate.
URGENT
• Transient motor weakness or
speech deficit or any possible
TIA symptoms within last 3-7
days
Fax referral to SPC:
403-944-1154
2 DAYS
SEMI
URGENT
• Transient motor weakness or
speech deficit within last 8-14
days
Fax referral to SPC: 403-944-1154
14 DAYS
Fax referral to SPC: 403-944-1154
>90 DAYS
Patients will then be
referred urgently to the
stroke prevention clinic for
further assessment.
• Any focal symptoms if
patient has AF and not currently
anticoagulated
• Sudden blindness in one eye
(amaurosis fugax) in last 14 days
ROUTINE
All other suspected TIAs or other
stroke/neurovascular problems or
concerns.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical neurosciences
November 2014
78
Specialty Specific Guidelines
Clinical neurosciences
Stroke Prevention Clinic (SPC)
PH 403-944-1447
MANDATORY INFORMATION REQUIRED FOR TRIAGE
• Date of suspected TIA (if > 1 event, give dates of first and last)
• Specific focal symptoms (motor, speech, etc.) and event duration
• Vascular risk factors, any history of stroke
• Any atrial fibrillation and if so, indicate anticoagulation
TEST INFORMATION
Indicate if any lab work or imaging (when and where) has been ordered or is completed.
PLEASE NOTE:
Episodes of pre-syncope, loss of consciousness & memory loss, and recurrent episodes of dizziness are
unlikely to be TIAs.Consider referring these patients to the Emergency Department, Urgent Neurology Clinic
(ph: 403-944-2372) or General Neurology Clinic as appropriate.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical neurosciences
November 2014
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Specialty Specific Guidelines
Clinical neurosciences
TOC
Urgent Neurology Clinic (UNC)
T riage
C ategory
I ncluding ,
EMERGENT
PH 403-944-2372
but not limited to :
• Patients needing to be seen
emergently should go directly to the
emergency room (ER)
• If you are unsure of the urgency you
may speak with the neurologist on
call
P rocess
Go directly to an
emergency department
Approximate
time to be seen
N/A
Referring physician
should call RAAPID
South
1-800-661-1700
or
(403) 944-4486
to speak to a neurologist
3-7 DAYS
URGENT
• Adult patients with a new, acute
neurological problem requiring a
neurology consultation within 72
hours.
EXCLUSIONS
• Patients already assessed by either a neurologist or a neurology resident in the ER
Fax referral to
403-270-1848
• Patients who already have a neurologist should be re-referred to that neurologist
• Patients requiring ongoing neurological follow-up
• Patients with a chronic neurological condition
• Patients with a neurosurgical or spine problem
• Trauma / post-concussion patients
• Uncomplicated headaches with normal imaging of the brain
• Typical Bell’s palsy
• WCB
• Second opinions
• Medico-legal or Independant Medical
• In-patients
DEPARTMENTOFMEDICINE.COM/MAS
Clinical neurosciences
Updated 4 Nov 2014
80
Specialty Specific Guidelines
Clinical neurosciences
Urgent Neurology Clinic (UNC)
TOC
PH 403-944-2372
MANDATORY INFORMATION REQUIRED FOR TRAIGE
• Referring physician’s name, address telephone and fax numbers
• Patient’s name, date of birth, address and telephone numbers
• Reason for the neurology consult and why the consult is urgent
• As much clinical information as possible (including: onset, symptoms, physical exam and pertinent test
results)
• Referrals must be legible
NOTES
Incomplete or illegible referrals will be returned with a request for more information, before or during triage.
Referrals more appropriate for another neurology program will be forwarded (you will be notified).
Referrals may be declined if they do not meet clinic criteria; in this case you will be notified and advised
regarding alternate referral destinations if appropriate but it will be your responsibility to make an alternate
referral.
Patients will be seen at either the Foothills Medicial Centre or South Health Campus, depending on patient
location and relative wait list times.
DEPARTMENTOFMEDICINE.COM/MAS
Clinical neurosciences
Updated 4 Nov 2014
81
Specialty Specific Guidelines
Home and Community Care
TOC
C3 Program:
Comprehensive Community Care for the Frail Elderly
T riage
C ategory
I ncluding ,
SEMIURGENT
Client is in hospital or recently
discharged from hospital and not
expected to do well in community
but not limited to :
AND
Agrees with routine reasons for
referral listed below
AND
Client is registered with Home Care
or is concurrently referred to Home
Care
Carewest Beddington
(403) 520-3350
P rocess
Home Care Case
Manager makes a
request through the
PARIS information
system to the AHS Case
Manager for the C3
Program.
Carewest Sarcee
(403) 686-8140
A pproximate
time to be seen
7 DAYS
For inquiries:
Senior’s Team (NORTH)
403-943-2090
Senior’s Team (SOUTH)
403-943-9301
All potential C3 Program clients need to be registered with Home Care prior to referral to C3 Program.
To Register with Home Care:
As a non-physician referral source: call Community Care Access: 403-943-1920
or
Fax Home Care Community Referral Form to: Community Care Access: 403-943-1602.
As a Physician: call Community Care Access:403-943-1930
or
Fax Integrated Home Care Physician Referral Form to: Community Care Access: 403-943-1602
DEPARTMENTOFMEDICINE.COM/MAS
Home and Community Care
Updated 4 Nov 2014
82
Specialty Specific Guidelines
Home and Community Care
TOC
C3 Program:
Comprehensive Community Care for the Frail Elderly
T riage
C ategory
ROUTINE
I ncluding ,
but not limited to :
• Client diagnosis and medical
condition is chronic and
complex and requires consistent
medical monitoring to maintain
stabilization.
• Client requires intense case
management and care
coordination by a team of health
professionals.
• Client requires in-home personal
care services and/or day support
services.
• Family requires respite support
to continue caring for their
relative.
Carewest Beddington
(403) 520-3350
P rocess
Home Care Case
Manager makes a
request through the
PARIS information
system to the AHS Case
Manager for the C3
Program.
Carewest Sarcee
(403) 686-8140
A pproximate
time to be seen
14 DAYS
For inquiries:
Senior’s Team (NORTH)
403-943-2090
Senior’s Team (SOUTH)
403-943-9301
• Client has been admitted
to hospital and/or utilized
emergency services more than
once in the last 12 months.
• Client lives within the geographic
boundaries of the C3 Program
Day Centre.
AND
Client is registered with Home Care
or is concurrently referred to Home
Care
All potential C3 Program clients need to be registered with Home Care prior to referral to C3 Program.
To Register with Home Care:
As a non-physician referral source: call Community Care Access: 403-943-1920
or
Fax Home Care Community Referral Form to: Community Care Access: 403-943-1602.
As a Physician: call Community Care Access:403-943-1930
or
Fax Integrated Home Care Physician Referral Form to: Community Care Access: 403-943-1602
DEPARTMENTOFMEDICINE.COM/MAS
Home and Community Care
Updated 4 Nov 2014
83
Specialty Specific Guidelines
Home and Community Care
C3 Program:
Comprehensive Community Care for the Frail Elderly
TOC
Carewest Beddington
(403) 520-3350
Carewest Sarcee
(403) 686-8140
INCLUSION CRITERIA
• Client must be 65 years of age and over. Exceptions will be made for younger individuals if medical needs
are appropriate for the Program.
• Client may present with signs and symptoms of cognitive impairment or be diagnosed with a cognitive
impairment but their behaviour should not interfere with their ability to interact with other clients.
• All potential C3 Program clients need to be registered with Home Care prior to referral to C3 Program.
EXCLUSION CRITERIA
• Client is a total lift (two people required) and does not have a caregiver available to assist in the home.
• Client lives outside the geographical area of the C3 Program Day Centre.
• Client is unable to participate in Day Program activities and/or is unable to ride the C3 Program bus to and
from the Day Centre without significant supervision
C3 PROGRAM COMPONENTS:
• Medical services
• Day program, including access to assistance with tub bathing
• Transportation service to Day Centre
• Designated short-term beds (respite and treatment)
• Pharmacy services
• In-home personal care services
• Emergency response and telephone support
• On-site laboratory support (e.g. phlebotomy, ECG)
RELEVANT CLINIC POLICIES
Potential C3 Program clients receive an initial interdisciplinary assessment to confirm eligibility. Once
confirmed as eligible, clients are provisionally admitted to the C3 Program and have the opportunity to trial the
C3 Program for 2 – 3 weeks to ensure a suitable fit with services
DEPARTMENTOFMEDICINE.COM/MAS
Home and Community Care
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Home and Community Care
TOC
403-943-1920
Home Care
T riage
C ategory
EMERGENT
1-888-943-1920
I ncluding ,
but not limited to :
• Client requires immediate,
unplanned attention and/or
medical services;
and
• Client considered at risk at home
URGENT
• Client requires ‘same day’
medical procedure for postsurgical care (TURP, wound),
HPTP, etc.
P rocess
Call 9-1-1 or proceed
to nearest Emergency
Department
A pproximate
time to be seen
AS SOON AS
POSSIBLE
(Home Care cannot
accommodate emergent
clients)
Physicians
Call: 403-943-1930
WITHIN 24
HOURS
Fax: Integrated Home Care
Physician Referral Form to
Community Care Access at
403-943-1602.
All other referrers
Call: 403-943-1920 (or toll
free at 1-888-943-1920)
Fax: Home Care Community
Referral Form to Community
Care Access at 403-9431602.
(Note, for urgent access
to Palliative Home Care
Team, call (403) 955-6288.
For other specifics, see
Palliative Home Care Team
under Palliative / End of
Life Care in this Referral
Directory.)
DEPARTMENTOFMEDICINE.COM/MAS
Home and Community Care
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Home and Community Care
TOC
403-943-1920
Home Care
T riage
C ategory
SEMIURGENT
1-888-943-1920
I ncluding ,
but not limited to :
• client requires professional Home
Care intervention
• client has been recently
discharged from hospital
• client has no available support in
the home
P rocess
Physicians
Call: 403-943-1930
A pproximate
time to be seen
WITHIN 3
DAYS*
Fax: Integrated Home Care
Physician Referral Form to
Community Care Access at
403-943-1602.
All other referrers
Call: 403-943-1920 (or toll
free at 1-888-943-1920)
Fax: Home Care Community
Referral Form to Community
Care Access at 403-9431602.
ROUTINE
• client is medically stable and has
available home supports
Physicians
Call: 403-943-1930
WITHIN 7
DAYS*
Fax: Integrated Home Care
Physician Referral Form to
Community Care Access at
403-943-1602.
All other referrers
Call: 403-943-1920 (or toll
free at 1-888-943-1920)
Fax: Home Care Community
Referral Form to Community
Care Access at 403-9431602.
* NOTE - THE SENIOR COMMUNITY CARE COORDINATOR WILL TAKE THE URGENCY REQUEST
UNDER ADVISEMENT AND TRIAGE THE CLIENT IN RELATION TO CLIENT NEED AND STAFF
CASELOADS.
DEPARTMENTOFMEDICINE.COM/MAS
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Home and Community Care
TOC
403-943-1920
Home Care
1-888-943-1920
SERVICE LOCATIONS
While Home Care services are most commonly delivered in the client’s home setting, flexibility exists to
deliver some services in a Home Care clinic. A number of clinic locations are available across the City of
Calgary and in surrounding rural areas. The Home Care case manager will provide this information to Home
Care clients.
RELEVANT POLICIES
Home Care case managers use standardized assessment tools and processes to identify the client’s needs
and to link the most appropriate, available home and community services to support the individual and their
family. In addition, Home Care case managers play a role in assisting clients to access necessary medical
supplies or assistive equipment and technology e.g. through Alberta Aids to Daily Living (AADL).
Home Care clients may require and receive Home and Community Support Services including services
directed toward meeting therapeutic recreation and socialization needs and support with activities required
to live independently in the community. Home Care clients may require and receive caregiver support and
respite services to help the people in the client’s personal support system stay well as they carry out their
informal caregiver tasks. These services may include information and help to access services, education,
skills training and respite care
Anyone living in Alberta with a valid provincial health care card (or registration in progress) can receive Home
Care services as long as their health care needs can be safely met in the home.
Normal Hours of Operation: Monday – Sunday, including statutory holidays, 8:00 am - 4:15 pm
Home Care in the Calgary Zone offers ‘After Hours’ services to support anticipated or urgent needs of existing
Home Care clients. Self-referral can be made as well as referral by a family physician or other healthcare
provider. Telephone 403-955-6666 (Seniors / Adults / HTPT) for general needs and (403) 955-6288 (Palliative
Care) for end-of-life care needs.
ADDITIONAL NOTES:
PROFESSIONAL SERVICES INCLUDING NURSING, OCCUPATIONAL THERAPY, PHYSICAL THERAPY, OR
SOCIAL WORK THAT PROVIDE THE FOLLOWING:
• prevention, screening and intake;
• palliative or end-of-life care
• assessment of health status and/or medical
conditions;
• teaching and supervising self-care;
• performing treatments and procedures;
• rehabilitation to maximize function;
• medication administration;
DEPARTMENTOFMEDICINE.COM/MAS
• teaching care and procedures to family members
and other caregivers; and
• teaching and supervising home support
service providers providing individual care and
performing assigned activities.
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403-943-1920
Home Care
1-888-943-1920
PERSONAL CARE SERVICES INCLUDING ASSISTANCE WITH:
• personal hygiene (bathing and grooming);
• mobilization and transferring;
• dressing;
• assistance with dining, oral care; and
• toileting and incontinence management;
• assisting with medications.
TARGETED SERVICES ALSO EXIST IN THE AREAS OF:
• Respite Care, including
ºº Adult Day Support
ºº In-home day, evening, or night care
ºº Short term facility accommodation
• Geriatric Consult Service (for issues related to
medical complexity or frailty and chronic disease,
cognitive impairment, or repeated falls)
• Medically Complex and Frail Elderly (C3
Program)
• Skin and Wound Care
• Dementia / Cognitive Impairment
• Palliative / End-of-Life Care
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure.
DEPARTMENTOFMEDICINE.COM/MAS
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Long Term Care
403-943-1920
T riage
C ategory
I ncluding ,
ROUTINE
Referral can be initiated by:
ALL REFERR ALS
ARE
CONSIDERED
ROUTINE
but not limited to :
• patient
• family
• friends
• health care providers
• community agencies
All referrals are considered routine
P rocess
Referral is through
Transition Services:
• Persons in a hospital or
on a rehabilitation unit
may contact the transition
services coordinator
assigned to that unit /
hospital
A pproximate
time to be seen
CASE BY
CASE *
• Calgary residents call:
403-943-1920
(seven days a week)
• Call Community Care
Access line toll-free at
1-888-943-1920
LOCATIONS - MULTIPLE SITES WITHIN CALGARY AND RURAL AREAS
* Consistent provincial criteria are used to prioritize clients waiting for continuing care health services
or settings, including transfers between sites. Transition Services will take the requested urgency under
advisement and triage the individual’s assessed unmet needs in relation to available Long Term Care beds.
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Long Term Care
TOC
403-943-1920
ACCESS CRITERIA
Clients will be assessed as not able to safely cope in their home or in a lower level living option with or without
formal support.
Medical Conditions
Functional Status
• Will have complex unpredictable needs but are
clinically stable and can be managed safely with
24-hour on-site registered nurse and regularly
scheduled and unscheduled on-site physician
support
• Will have complex physical needs with care
requirements that cannot be met at home or in a
supportive living environment
• Complex end of life care needs
• Complex nutritional intake requirements
• Complex medication management
• May require the following types of assistance with
Activities of Daily Living (ADL):
• Intensive and extensive rehabilitation
requirements
• Complex nursing interventions
• Unscheduled assessments are often required to
address changing resident care issues
• Complex elimination requirements
Social Support
Cognitive Status
• May have any stage of dementia
• May have unpredictable behaviours placing self
and others at risk
• Informal caregivers remain a welcome and
integral contributor to the person-centred plan of
care
• There may be complex family dynamics requiring
24-hours/7-days RN on-site interventions
EXCLUSION CRITERIA FOR LONG TERM CARE
• Clients with unstable acute medical or psychiatric conditions who require acute care hospitalization
RELEVANT POLICIES
Once a client has been assessed and approved as requiring admission to an AHS-funded bed, Transition
Services will collaborate and discuss options with clients and their families before any decisions as to
intended site and timing of placement are made. Efforts will be made to keep couples together whenever
possible
ADDITIONAL NOTES:
There are Alberta residency requirements for Long Term Care centres that are AHS-funded:
• The individual must either have lived in Alberta for one year immediately before applying for benefits and
lived in Canada for at least ten years, or
• The individual must have lived in Alberta for three consecutive years at any time before applying for
benefits
• Residents in Long Term Care pay a fee to cover the costs of providing accommodations and services like
meals, housekeeping, and building maintenance.
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403-943-1920
Supportive Living Level 3
1-888-943-1920
T riage
C ategory
I ncluding ,
ROUTINE
Referral can be initiated by:
ALL REFERR ALS
ARE
CONSIDERED
ROUTINE
but not limited to :
• patient
• family
• friends
• health care providers
• community agencies
All referrals are considered routine
P rocess
Referral is through
Transition Services:
• Persons in a hospital or
on a rehabilitation unit
may contact the transition
services coordinator
assigned to that unit /
hospital
A pproximate
time to be seen
CASE BY
CASE *
• Calgary residents call:
403-943-1920
(seven days a week)
• Call Community Care
Access line toll-free at
1-888-943-1920
LOCATIONS - MULTIPLE SITES WITHIN CALGARY
* Consistent provincial criteria are used to prioritize clients waiting for continuing care health services
or settings, including transfers between sites. Transition Services will take the requested urgency under
advisement and triage the individual’s assessed unmet needs in relation to available supportive living beds
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403-943-1920
Supportive Living Level 3
1-888-943-1920
ACCESS CRITERIA
Clients will be assessed as not able to safely cope in their home or lower level living option with or without
informal support. They also will be assessed as requiring 24-hour personal care and support in a supportive,
structured, and supervised environment.
Medical Conditions
Functional Status
• Medical condition is stable and appropriately
managed without a 24-hour on-site registered
nurse or licensed practical nurse
• End of life care needs
• Mobilizes independently or with one-person
transfer
• Requires unscheduled personal care
Social Support
Cognitive Status
• May have mild dementia but behaviourally stable
• No known risk of elopement but may wander; is
easily redirected
• Informal caregivers remain a welcome and
integral contributor to the person-centred plan of
care
• No known risk of self-harm or harm to others
EXCLUSION CRITERIA
• Complete meal assistance
• Mechanical lift transfer / two-person transfer
• Chronic, unmanaged incontinence not amenable to interventions
RELEVANT POLICIES
Once a client has been assessed and approved as requiring admission to an AHS-funded bed, Transition
Services will collaborate and discuss options with clients and their families before any decisions as to
intended site and timing of placement are made. Efforts will be made to keep couples together whenever
possible
ADDITIONAL NOTES:
• Residents in Supportive Living are required to have their own family physician and provide their own
furniture.
• Residents in Supportive Living pay a fee to cover the costs of providing accommodations and services
like meals, housekeeping, and building maintenance. There are also additional costs for medications and
medical surgical supplies.
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Supportive Living Level 4 / Level 4 Dementia
T riage
C ategory
I ncluding ,
ROUTINE
Referral can be initiated by:
ALL REFERR ALS
ARE
CONSIDERED
ROUTINE
but not limited to :
• patient
• family
• friends
• health care providers
• community agencies
403-943-1920
1-888-943-1920
P rocess
Referral is through
Transition Services:
• Persons in a hospital or
on a rehabilitation unit
may contact the transition
services coordinator
assigned to that unit /
hospital
A pproximate
time to be seen
CASE BY
CASE *
• Calgary residents call:
403-943-1920
(seven days a week)
• Call Community Care
Access line toll-free at
1-888-943-1920
LOCATIONS - MULTIPLE SITES WITHIN CALGARY AND SURROUNDING RURAL AREAS
* Consistent provincial criteria are used to prioritize clients waiting for continuing care health services
or settings, including transfers between sites. Transition Services will take the requested urgency under
advisement and triage the individual’s assessed unmet needs in relation to available supportive living beds.
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Supportive Living Level 4 / Level 4 Dementia
403-943-1920
1-888-943-1920
ACCESS CRITERIA
Clients will be assessed as not able to safely cope in their home or lower level living option with or without
informal support. They also will be assessed as requiring 24-hour personal care and support in a supportive,
structured, and supervised environment.
Medical Conditions
Functional Status
• May be complex but are stable and appropriately
managed safely through an interdisciplinary,
person-centred plan of care
• Will have complex physical care needs that
cannot be met at home or in a lower level of
supportive living. May require the following types
of assistance with Activities of Daily Living:
• . Unscheduled professional assessments may be
required to adjust the plan of care
ºº Complete meal assistance, including tube
feeding
• . End of life care needs
ºº Mechanical lift transfer /two-person transfer
ºº Total assistance to mobilize
Cognitive Status
ºº Medication assistance or administration
• May have varying levels of dementia but are
behaviourally stable
• Minimal risk for elopement but may wander; is
easily redirected
• Minimal risk of self-harm or harm to others
ºº Chronic unmanaged incontinence
Social Support
• Informal caregivers remain a welcome and
integral contributor to the person-centred plan of
care
EXCLUSION CRITERIA
• Unpredictable behaviour placing self and others at risk
• Require intensive and/or extensive rehabilitation services that cannot be easily accessed
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Supportive Living Level 4 / Level 4 Dementia
TOC
403-943-1920
1-888-943-1920
SUPPORTIVE LIVING LEVEL 4 DEMENTIA
Supportive Living Level 4 Dementia differs from Supportive Living Level 4 above only in that it provides a
purposeful home-like design with small groupings of private bedrooms and associated spaces in a secured
therapeutic environment for those with moderately to severely impaired cognition.
Expected Cognitive Status for Supportive Living Level 4 Dementia
• Will have moderate dementia that may progress to later stages or other forms of cognitive impairment
• Lacks awareness of personal space of others
• Will have unpredictable behaviours, including wandering which may include risk for elopement
• May have unpredictable behaviours placing self and others at risk, but manageable in this environment
RELEVANT POLICIES
Once a client has been assessed and approved as requiring admission to an AHS-funded bed, Transition
Services will collaborate and discuss options with clients and their families before any decisions as to
intended site and timing of placement are made. Efforts will be made to keep couples together whenever
possible.
ADDITIONAL NOTES:
• Residents in Supportive Living are required to have their own family physician and provide their own
furniture.
• Residents in Supportive Living pay a fee to cover the costs of providing accommodations and services
like meals, housekeeping, and building maintenance. There are also additional costs for medications and
medical surgical supplies.
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Home and Community Care
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Medical Genetics Services
TOC
Cancer Genetics Clinic
T riage
C ategory
URGENT
ROUTINE
403-955-7373
E xamples
P rocess
Patients with palliative diagnoses,
and/or patients known to be at risk
for a familial gene mutation, and/or
patients with an “urgent referral”, as
per referring doctor
Phone: 403-955-7373
Assessment & genetic counselling
services for children and adults
to determine the likelihood of an
inherited predisposition to cancer
in a family, based on patient and
family history.
Phone: 403-955-7373
Approximate time
to be seen
WITHIN 1-2
WEEKS
Fax: 403-955-2701
Fax: 403-955-2701
WAIT LIST UP
TO 6 MONTHS
AFTER
RECEIPT OF
COMPLETED
FAMILY
HISTORY
FORM,
DEPENDING
ON TRIAGE
STATUS.
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
Pertinent medical records (i.e. cancer pathology, consultation letters), number of family members affected with
cancer and types, approximate ages at diagnosis, and details of relationship (i.e. maternal aunt, versus aunt).
Urgent referrals aside, appointments are not booked until patient returns a completed family history form, sent
when referral is received.
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Medical Genetics Services
Cardiovascular Genetics Clinic
T riage
C ategory
URGENT
TOC
PH 403-955-7373
E xamples
P rocess
Genetic diagnosis required to
determine further medical/surgical/
diagnostic interventions.
Page Geneticist on call:
403-955-7211
A pproximate
time to be seen
WARD
CONSULT
or
Phone: 403-955-7373
Fax: 403-955-2701
ROUTINE
• Patients known to be at risk for
an inherited cardiomyopathy,
for which a familial gene
mutation has been identified
• Diagnosis & genetic
counselling services for family
history of a suspected inherited
cardiomyopathy or arrhythmias.
Phone: 403-955-7373
4-12 WEEKS
Fax: 403-955-2701
• Children and adults presenting
with symptoms of a confirmed
family history of an inherited
cardiomyopathy and
arrhythmias (e.g. hypertrophic
cardiomyopathy and long QT
syndrome).
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
Medical records/consultations and diagnostic testing reports related to referral.
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Connective Tissue Disorders Clinic
T riage
C ategory
URGENT
403-955-7373
E xamples
P rocess
Genetic diagnosis required to
determine further medical/surgical/
diagnostic interventions.
Page Geneticist on call:
403-955-7211
or
Approximate time
to be seen
WARD
CONSULT:
EMERGENCYSAME OR
WITHIN 1 DAY.
Phone: 403-955-7373
ROUTINE
Diagnosis & genetic counselling
services for children and adults
s presenting with symptoms or a
confirmed family history of a a
genetic connective tissue disorder
such as Marfan syndrome, Ehlers
Danlos syndrome
Phone: 403-955-7373
WITHIN 3
MONTHS
Fax: 403-955-2701
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
Medical records/consultations and diagnostic testing reports related to referral.
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General Genetics and Dysmorphology Clinic
T riage
C ategory
E xamples
P rocess
URGENT
Diagnostic and genetic counselling
services by ward consult for:
Page Geneticist on call:
403-955-7211
• Newborn (livebirth or stillbirth) with
or
suspected genetic condition (eg.
Trisomy 21, multiple birth defects,
Phone: 403-955-7373
dysmorphic features)
403-955-7373
A pproximate
time to be seen
WARD CONSULT:
EMERGENCYSAME OR
WITHIN 1 DAY.
• Genetic diagnosis required to
determine further medical/surgical/
diagnostic interventions.
ROUTINE
Diagnosis & genetic counselling
services for:
• Children and adults presenting
with symptoms of or a confirmed
family history of a neurological/
neuromuscular such as Huntington
disease, Charcot Marie Tooth,
Spinal muscular atrophy,
Parkinsons disease)
Phone: 403-955-7373
LOW RISK: 9
MONTHS
Fax: 403-955-2701
• Predictive testing for Huntington
disease, familial ALS, and other
neurocognitive disorders
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
• Medical records/consultations and diagnostic testing reports related to referral.
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Inherited Metabolic Disorder Clinic (IMDC)
403-955-7696
T riage
C ategory
E xamples
P rocess
EMERGENT
NICU babies with:
Ward consult:
• Elevated ammonia, lactate
• New onset seizures•
• Hypoglycemia
Page Metabolic Physician
on call:
• Hepatomegaly
403-955-7211
• None diagnosis in crises (eg.
urea cycle disorder)
URGENT
• Positive newborn metabolic
screen
Fax referral to: 403-9553091
A pproximate
time to be seen
WARD CONSULT:
SAME DAY
(EMERGENCY)
SAME DAY OR
WITHIN 2 DAYS
Page metabolic physician
on call:
403-955-7211
SEMI
URGENT
• PKU with inter-current illness
• Noncompliant PKU or other
patient receiving prescribed
metabolic formula.
Clinic: 403-955-7696
DEPENDENT
ON IDENTIFIED
NEED
Outside clinic hours page
metabolic physician on call:
403-955-7211
ROUTINE
• New and follow up referrals not
triaged into above categories.
Clinic: 403-955-7696
Fax referral to: 403-9553091
TRIAGED. WAIT
LIST FOR LOW
RISK PATIENTS.
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
Referring source to provide all past medical history, consultations and relevant screening/diagnostic tests
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Neurogenetics Clinic
403-955-7373
T riage
C ategory
E xamples
P rocess
URGENT
Diagnostic and genetic counselling
services by ward consult for:
Page Geneticist on call:
• Newborn suspected with
neurological/neuromuscular
condition
• Genetic diagnosis required
to determine further medical/
surgical/ diagnostic interventions.
ROUTINE
Diagnosis & genetic counselling
services for:
• Children and adults presenting
with symptoms of or a confirmed
family history of a neurological/
neuromuscular such as
Huntington disease, Charcot
Marie Tooth, Spinal muscular
atrophy, Parkinsons disease)
403-955-7211
or
A pproximate
time to be seen
WARD CONSULT:
EMERGENCYSAME OR
WITHIN 1 DAY.
Phone: 403-955-7373
Phone: 403-955-7373
LOW RISK: 9
MONTHS
Fax: 403-955-2701
• Predictive testing for Huntington
disease, familial ALS, and other
neurocognitive disorders
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
• Medical records/consultations and diagnostic testing reports related to referral.
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TOC
Ophthamology Genetics Clinic
T riage
C ategory
ROUTINE
403-955-7373
E xamples
P rocess
Diagnosis & genetic counselling
services for children and adults
presenting with symptoms or a
a confirmed family history of an
inherited eye condition
Phone: 403-955-7373
A pproximate
time to be seen
6 MONTHS
Fax: 403-955-2701
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
Medical records/consultations and diagnostic testing reports related to referral.
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Prenatal Genetics Clinic
T riage
C ategory
URGENT
403-955-8375
E xamples
P rocess
• Genetic counselling to review results &
discuss management options following
an abnormal prenatal diagnosis result
from amniocentesis/ CVS.
Phone: 403-943-8375
Fax: 403-943-8376
A pproximate
time to be seen
SAME OR
WITHIN 2 DAYS
• Genetic counselling and /or diagnostic
services for a suspected or confirmed
anomaly(ies) detected by ultrasound
SEMI
URGENT
Genetic Counselling services for:
• Positive first trimester screen
Phone counselling
and/or 1:1 counselling
available.
WITHIN 2-5
DAYS
• Detected soft marker (eg. increased
nuchal translucency
• Teratogen query (eg. alcohol,
antieleptic, SSRI, radiation exposure)
• Maternal chronic condition placing
pregnancy at increased risk (eg. Type
2 diabetes, Epilepsy, parent with a birth
defect/genetic condition)
Phone: 403-943-8375
Fax: 403-943-8376
• Family history of a genetic condition
• Woman interested in risk information
and possible prenatal diagnosis options
(eg. of Fragile X, Duchenne muscular
dystrophy, hemoglobinopathies)
ROUTINE
Preconception counselling for family
history, maternal health condition of
concern.
Phone: 403-943-8375
Fax: 403-943-8376
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
Prenatal record, ultrasound reports, ABO, other completed blood work, medical records & relevant
consults. If patient is concerned re: familial genetic condition, relevant documentation of the condition
in affected family member
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medical services
TOC
Access Mental Health:
Addiction and Mental Health Services, Calgary Zone
T riage
C ategory
EMERGENT
I ncluding ,
but not limited to :
Clinical situation where there is an
imminent risk of serious harm or
death to self or others.
P rocess
CONNECT PATIENT
WITH IMMEDIATE
RESOURCES
• serious suicidal states
• 911
• violent states or states of
seriously impaired judgment
• Emergency
department
• delirium
• Urgent Care Centre
403-943-1500
A pproximate
time to be seen
DIRECT TO
EMERGENCY
SERVICES
• dementia
• acute psychosis
• severe dissociative state
• querying admission to hospital
URGENT
Acute but not necessarily severe
disorders or issues that necessitate
the need for urgent attention to
prevent further decompensation
• displaying some signs of
psychosis
• suicidal ideation without intent
• postpartum depression.
Connect patient with
Urgent Services:
• Mobile Response
Team Professional
Line (403) 297-2940
IMMEDIATE/
SAME DAY
Public access thru
Distress Centre
(403) 266-4357
(HELP)
• Mental Health Urgent
Care (SCHC)
31 Sunpark Plaza SE
• Urgent Mental Health
(SMCHC)
1213 - 4th Street SW
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Medical Services
TOC
Access Mental Health:
Addiction and Mental Health Services, Calgary Zone
T riage
C ategory
SEMIURGENT/
ROUTINE
I ncluding ,
but not limited to :
Requesting addiction/mental health
support
• mild to moderate mood disorder
P rocess
Fax referral to Access
Mental Health:
403-943-9044
• anxiety disorder
Or
• non-acute psychosis disorder
Call Access Mental
Health: 403-943-1500
• medication consultation.
* Patient requires treatment for
ongoing life stressors and is not in
an acute state.
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
• Suicidal /self injury risk assessment
Monday-Friday
8:00am-5:00pm
403-943-1500
A pproximate
time to be seen
5-10 DAYS*
* For referral to
be processed by
Access Mental
Health and directed
to appropriate
resource.
* Appointments to be
booked by receiving
program who have
and maintain their
own waitlist (varying
times).
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
Provide all considered relevant by the referring
source
• Substance use or abuse
• Is the client involved with the legal system?
• Is the client their own legal guardian? If not who is?
• If child, is Child & Family Services involved?
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE IF PERFORMED:
Attach any psychiatric consultations, reports or hospital admission records within past year (lab work not
required).
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Medical Services
TOC
Calgary Ambulatory Lymphedema Service (CALS)
T riage
C ategory
I ncluding ,
but not limited to :
P rocess
403-955-6052
A pproximate
time to be seen
SEMIURGENT
• Patient with lymphorrhea escaping lymph fluids through a
cut on the skin
FAX COMPLETED
REFERRAL FORM TO
403-955-6910
WITHIN 2
WEEKS
ROUTINE
• Primary or non-cancer related
lymphedema
FAX COMPLETED
REFERRAL FORM TO
403-955-6910
WITHIN
WEEKS
BASED ON CURRENT
CASELOAD
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
ALL REFERRALS
• Lower Extremity Vascular Assessment to be requested by referring clinician and completed by Radiology/
Vascular, showing ABI >0.5
• Renal Function tests (creatinine, BUN) and liver function tests to be done before referral – must indicate
that renal and liver function is not contraindicatied for Complex Decongestive Therapy. If test is abnormal
then some clinical judgment would need to be made by the lymphedema physician to decide whether they
are contraindications to any compression treatment (to avoid fluid overload).
ADDITIONAL NOTES:
Please ensure that the patient has the following medical clearance before referring (refer to ‘specific tests
required’ for referral):
• Deep Vein Thrombosis medically managed or stable, and is not contraindicated
• Liver and Renal functions medical managed, stable, and is not contraindicated
• Congestive Heart Disease medically managed, stable, and is not contraindicated
RELEVANT CLINIC POLICIES:
• Cancellation notification required at least 24 hours prior to appointment. The referring physician can
cancel the referral by calling 403-955-6052. The patient can cancel their appointment by calling 403-9556052.
• Patient will be discharged from service if there are two (2) events of “No Shows” or Patient Cancellations.
The referring physician’s office will be informed of the discharge. (Compliance with attendance is key to
best outcomes and service efficiency for all patients who are will rely on this service.)
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Calgary Headache Assessment and Management Program
403-956-3414
T riage
C ategory
A pproximate
I ncluding ,
EMERGENT
but not limited to :
• Thunderclap headache (severe headache
with peak intensity within seconds to 5
minutes from onset)
P rocess
time to be seen
Send to
Emergency
immediately
SAME DAY
Refer to urgent
neurology clinic
or discuss with
neurologist on
call
2-6 DAYS
Fax referral to
CHAMP with
appropriate triage
information.
1 TO 8 WEEKS
• Headache with fever and meningismus
• Headache with papilledema, altered level of
consciousness and / or focal signs
• Signs of acute glaucoma
URGENT
New headache or recent change in headache
pattern in a patient with:
• Relevant systemic illness, cancer
• Possible temporal arteritis and visual
symptoms (over age 50)
• Papilledema in an alert patient without focal
signs
SEMIURGENT
/ WILL BE
EXPEDITED
• Suspected cluster headache or other
trigeminal autonomic cephalalgias
• Suspected temporal arteritis with headache
but no other neurological symptoms
• Orthostatic headache (worse on standing)
suggestive of intracranial hypotension (CSF
leak).
Fax:
403-956-3497
• Unexplained neurological examination
findings in an alert patient with headache
without systemic disease or papilledema
• Headache precipitated (not just aggravated)
by cough, exertion, or straining
• Headache worse with lying down
• Patients with severe facial pain syndromes
• Other patients may be expedited based upon
information from the referring physician
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Calgary Headache Assessment and Management Program
403-956-3414
T riage
C ategory
A pproximate
ROUTINE
I ncluding ,
but not limited to :
Patients with migraine, tension-type headache,
and other chronic headache syndromes with
significant headache related disability.
P rocess
Fax referral to
CHAMP at
time to be seen
2 MONTHS*
403-956-3497
* Patients will be invited to an education seminar within 2 months, and can access other program components
after that. Patients will be triaged as approapriate and physician consultation will occur later. For some
patients, physician consultation my occur in a group setting.
NOT SEEN
Patients with headache on more than 14 days
a month related to head or neck injury should
be referred to the Calgary Chronic Pain Center
Headache Program.
Fax referral to
the Chronic Pain
Center Headache
Program
N/A
403-209-2954
INFORMATION REQUIRED TO ENABLE TRIAGE
The information on the next page is required to triage patients to the appropriate parts of our multidisciplinary
program. For your convenience, this page may be completed and faxed with your patient demographic
information. Please note that CHAMP does NOT accept out of province referrals.
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CALGARY HEADACHE ASSESSMENT AND MANAGEMENT PROGRAM (CHAMP) FAX 403-956-3497
Patient Name (last, first)
Main reason for referral
Please send copies of previous neuroimaging reports, consultation letters, and information on medications tried in the past
and their effectiveness or not
PROVISIONAL HEADACHE DIAGNOSIS (check one):
□ Migraine
□ Tension-type
□ Cluster and related headaches (Individual attack duration 3 hours or less)
□ Hemicrania continua (continuous unilateral headache, always on the
headache
same side)
□ Both migraine and
□ Facial pain syndrome
□ Other diagnosis (specify if possible)______________________________
tension-type headache
DAYS WITH HEADACHE PER MONTH (circle one):
0-5
6 – 10
11 – 14
15 - 29 but not every day
Every day
Facial pain syndrome
ACUTE (SYMPTOMATIC) MEDICATION USE (check all that apply)
□ Yes
□ No
Patient uses combination analgesics, codeine-containing analgesics, triptans,
tramadol, or ergotamines on 10 days a month or more.
□ Yes
□ No
Patient uses plain acetaminophen or NSAIDs on 15 days a month or more.
□ Yes
□ No
Patient uses opioids other than codeine on 10 days a month or more.
OTHER (check all that apply)
□ Yes
□ No
Has the patient suffered a previous neck or head injury which appears related to
the current headache problem?
□ Yes
□ No
Orthostatic headache (worse on standing) suggestive of intracranial hypotension
with CSF leak
□ Yes
□ No
Unexplained neurological examination findings, if yes - list findings
□ Yes
□ Yes
□ No
□ No
Headache precipitated (not just aggravated) by cough, exertion, or straining
Headache worse with lying down
Patient’s age at onset of current type of headache __________
□ Yes
□ No
Able to communicate well in English? Language spoken __________________
Other relevant information for CHAMP patient triage _____________________________________________
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Chronic Pain Centre
T riage
C ategory
FAST TRACK
403-943-9900
Including, but not limited to:
P rocess
To be determined by the Pain
Centre triage process based on
information provided
Fax referral to Chronic
Pain Centre
403-209-2954 (marked
urgent)
To discuss call 403-9439930
ROUTINE
A pproximate Time
to be seen
WITHIN 2–3
MONTHS
after return
of triage
questionnaire.
Headaches > 15 days/month
Fax referral to Chronic
Pain Centre
403-209-2954
WITHIN 6–10
MONTHS
Pelvic Pain – Must have seen a
community gynecologist
Fax referral to Chronic
Pain Centre
403-209-2954
WITHIN 3–8
MONTHS
Vulvar Pain – Must have seen a
community gynecologist
Fax referral to Chronic
Pain Centre
403-209-2954
WITHIN 3–8
MONTHS
Non-malignant chronic pain
Fax referral to Chronic
Pain Centre
403-209-2954
3–6 MONTHS
• Musculoskeletal Pain
• Neuropathic Pain
• Complex Regional Pain
Syndrome
to enter the
program. Up to
14 months to see
a physician
• Post Herpetic Neuralgia
• Spinal Pain
• Limb Pain
• Abdominal & Chest Pain
• Myalgias
• Peripheral Neuropathies
• Consideration for Spinal Cord
Stimulator
• Facial Pain
• Radiculopathy
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Chronic Pain Centre
403-943-9900
ADMISSION CRITERIA
• not have an Active WCB Claim
•
have a family doctor who is prepared to work with the treatment team, provide follow-up and is willing to
prescribe opioids if these are indicated and prove sucessful
•
be cognitively capable of participating in assessment and treatment
•
be in stable medical condition
•
not have a mental health condition that would preclude participation in assessment and treatment
•
not have an active (ie unstable or untreated) substance addiction
•
have current/valid Alberta Health Care coverage
•
must be over 18 years of age
It is essential to attach all relevant Diagnostic Imaging and Consult Letters in order to appropriately
triage your referral.
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Complex Chronic Disease Management Clinic – PLC
T riage
C ategory
URGENT
E xamples :
P rocess
2 or more chronic disease
conditions (i.e. COPD, dyslipidemia,
CHF, HTN, Diabetes or others),
excluding chronic pain and dialysis
patients,
Call the Complex Chronic
Disease Management Clinic –
PLC:
AND at least 1 hospital admission
and/or ED visit in the last year.
SEMIURGENT
2 or more chronic disease
conditions (i.e. COPD, dyslipidemia,
CHF, HTN, Diabetes or others),
excluding chronic pain and dialysis
patients,
403-943-4131
A pprox .
time
to be seen
1-2 DAYS
403-943-4131
These referrals may be
redirected to the urgent MTU
teaching clinic
Fax referral to the Complex
Chronic Disease Management
Clinic – PLC:
2 WEEKS
403-943-4133
AND at least 1 hospital admission
and/or ED visit in the last year.
ROUTINE
2 or more chronic disease
conditions (i.e. COPD, dyslipidemia,
CHF, HTN, Diabetes or others),
excluding chronic pain and dialysis
patients,
Fax referral to the Complex
Chronic Disease Management
Clinic – PLC:
4 WEEKS
403-943-4133
AND at least 1 hospital admission
and/or ED visit in the last year.
NOTE: If you have a complex patient who does not meet the above criteria, they will be considered on an
individual basis. Please call 403-943- 4131 or fax information to 403-943-4133
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Complex Chronic Disease Management Clinic – PLC
403-943-4131
The purpose of the Complex Chronic Disease Management Clinic (CCDMC) at the Peter Lougheed Centre
(PLC) is to decrease exacerbations of chronic conditions and acute care admissions/ emergency department
presentations though intensive disease management.
At the outpatient visit, the patient will be seen by Physician, Nurse Clinician, and Pharmacist. The frequency
of visits will depend on the needs of the patient.
Communication between CCDMC and the patient’s family physician/specialists is essential to ongoing
management and will be a priority to the CCDMC.
MANDATORY REQUIREMENTS REQUIRED ON THE REFERRAL:
• Referring location: (Hospital and Unit/ Doctor’s office/Other)
• Referring Physician: (name/ contact number)
• Family Physician: (name/ contact number)
• Determined urgency of referral (i.e. 2 weeks / 1 month)
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• Complete list of co-morbidities and current medication list
• Disease specific investigations as guided by patients’ chronic diseases, ie: if cardiac involvement,
provide all cardiac investigations and consultations.
• Recent discharge summaries (inpatient)
• Up to date lab investigations as guided by patients’ chronic diseases, ie: if diabetic, recent A1C and urine
microalbumin
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Diabetes, Hypertension and Cholesterol Centre (DHCC)
TRIAGE
CATEGORY
URGENT
EXAMPLES:
• Newly diagnosed type 1
• Uncontrolled, symptomatic diabetes with
fasting/ac BG > 20 mmol/L and/or ketones
>1.5
403-955-8118
PROCESS
APPROX.TIME TO
BE SEEN
Fax referral to
403-955-8634
WITHIN 24
HOURS
• +++ metabolically compromised type 2
diabetes requiring insulin
• Triglycerides > 15 mmol/L
• If pregnant with diabetes, refer to Diabetes in
Pregnancy Clinic at the hospital in which the
client will deliver
• For Ambulatory Blood Pressuring Monitoring
only
ºº BP>160/>100
ºº Transplant recipient or donor
ºº Symptomatic eg. syncope
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Diabetes, Hypertension and Cholesterol Centre (DHCC)
REGULAR
• All clients with type 1, including those with
recent severe hypoglycemia or DKA
Fax referral to
403-955-8634
403-955-8118
1 WEEK
• All clients with type 2 diabetes, hypertension
or dyslipidemia who are not urgent but meet
any of the following criteria:
ºº Type 2 diabetes on 2 or more agents other
than insulin with suboptimal control
ºº Insulin start
ºº Recent treatment for severe hypoglycemia
or hyperglycemia
ºº Change to current diabetes medications or
insulins
ºº Any client the referring physician requests
help with (beyond Living Well classes
and education as provided by CDM/PCN
educators), who has diabetes, hypertension
and/or dyslipidemia.
• For Ambulatory Blood Pressuring Monitoring
only:
ºº BP < 160/100
• For clients planning pregnancy, refer to
Diabetes in Pregnancy Clinic
Referral to DHCC includes referral to a health educator only. Please indicate clearly if a referral to a physician
specialist is required in addition to referral to a health educator. For referral to a physician specialist only, see
Endocrine and Metabolism section.
When appropriate, patients will be referred for education and exercise at Living Well.
BP and lab results specified are mandatory
All patients seen at DHCC will receive assessment, education and assistance with management to achieve
targets as per clinical practice guidelines unless otherwise specified by the physician or determined by the
educator in consultation with the physician
ASSISTANCE WITH MANAGEMENT INCLUDES:
• Diabetes educator many adjust diabetes medications or make recommendations according to guidelines
and protocol (available upon request).
• Referring physician will be contacted if medication has been adjusted substantially and at least every 2
months during therapeutic adjustment time
• Periodic alb glucose values to validate patient glucose testing equipment
• HbA1c every 3 months if not done by referringMedical
physician
Services
DEPARTMENTOFMEDICINE.COM/MAS
• Lipids every 3 months if not done by referring physician
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Diabetes, Hypertension and Cholesterol Centre (DHCC)
403-955-8118
SPECIFIC TESTS REQUIRED TO ENABLE TRIAGE
• HbA1c
• Lipid profile
• Current BP
• Type of diabetes
PLEASE INDICATE IF YOU WISH
• 24-hr ambulatory BP monitoring
• A consult with a specialist physician in addition to referral to health educators
• Insulin start. Orders must be provided and must include:
ºº Type of insulin
ºº Dosage in units
ºº Time of injection Eg. N or NPH 5-10 units ac at hs
ºº Changes to diabetes medications other than insulin if required eg.
• Diabetes agents that should be discontinued once the insulin is initiated
• Diabetes agents that should be continued once the insulin is initiated Dosage changes to other
diabetes medications, once the insulin is initiated
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Endocrinology & Metabolism - Adult
T riage
C ategory
EMERGENT
I ncluding ,
but not limited to :
• Diabetic Ketoacidosis
403-955-8633
P rocess
A pproximate
time to be seen
Send to Emergency
WITHIN 1 DAY
Call the Triage
Endocrinologist:
403-955-8633
(Mon-Fri 0900-1700)
WITHIN 1 DAY
• Severe Hypercalcemia > 3.5
• Severe Adrenal Insufficiency
VERY
URGENT
• Severe Hyperthyroidism
• Newly Diagnosed Diabetes
Mellitus
Type 1: not in DKA i.e. HCO3
>18
• Adrenal Insufficency
• Hypopituitarism with acute
symptoms
URGENT
• Hyperthyroidism (newly
diagnosed)
• Diabetes in Pregnancy
• Adrenal Mass > 4 cm
• Pituitary Tumor with Visual
Defect
and/or Hypofunction
• Hypercalcemia > 3
all the Endocrinologist on
C
call:
403-944-1110
(Mon-Fri 1700-0900 and
weekends)
ax referral to Endocrinology
F
Central Access & Triage:
403-955-8634
WITHIN 1
WEEK
iabetes in Pregnancy fax
D
referral to Clinic at:
FMC: 403-283-0921,
PLC: 403-943-5426
or RGH: 403-212-1232
• Hypertriglyceridemia TG > 15
• Endocrine Disorders in
Pregnancy
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Endocrinology & Metabolism - Adult
T riage
C ategory
I ncluding ,
SEMI
URGENT
but not limited to :
• Thyroid nodule: > 3 cm
or Family History of Thyroid
Cancer
or Cervical Lymphadenopathy
or Microcalcification on Thyroid
U/S
403-955-8633
P rocess
A pproximate
time to be seen
ax referral to Endocrinology
F
Central Access & Triage:
403-955-8634
WITHIN 4
WEEKS
ax referral to Endocrinology
F
Central Access & Triage:
403-955-8634
WITHIN 12 - 26
WEEKS
• Diabetes with Severe
Unrecognized Hypoglycemia
• Hypercalcemia - 2.6-2.9
• Diabetes A1c > 12%
ROUTINE
• Goitre with normal thyroid
function
• Pituitary Tumor
• Hirsutism
• Infertility
• Diabetes Planning Pregnancy
• Hyperlipidemia
• Osteoporosis
• Obesity
• Galactorrhea
• Gynecomastia
• Adrenal Mass < 4 cm
• Hypertension (diagnosis of
suspected endocrine cause)
• Amenorrhea
• Diabetes – inadequate control
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Endocrinology & Metabolism - Adult
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
• Provide all considered relevant by the referring
source.
403-955-8633
SPECIFIC SYMPTOM /PATIENT
INFORMATION TO IDENTIFY IF
RELEVANT:
• Provide all considered relevant by the referring
source.
• The Division of Endocrinology encourages
referring physicians to discuss atypical problems
or uncertain diagnoses with the endocrinologist
responsible for triage 403-955-8633.
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Endocrinology & Metabolism - Adult
403-955-8633
SPECIFIC TESTS /INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
THYROID
DYSFUNCTION
GOITRE OR THYROID
NODULE
PITUITARY MASS
• Free T4
• TSH
• TSH
• Prolactin
• Free T4
• Thyroid ultrasound
• Cortisol (before 0900 serum)
• Free Androgen index (male)
• MRI or CT report
SUSPECTED CUSHINGS
• 24 hour urinary free cortisol
GALACTORRHOEA
• Prolactin
ACROMEGALY
• Serum IGF-1
• TSH
ADRENAL
INSUFFICIENCY
• Call endocrinologist on call
with history.
ADRENAL MASS
AMENORRHOEA
• BP history
• Pregnancy Test
• Serum electrolytes
• TSH
• 24-hour Urine metanephrines
• Prolactin
• 24-hour Urine free cortisol
• FSH
• Radiology report (CT or MRI)
• LH
• Free Androgen Index
• Perform a progesterone challenge
(medroxyprogesterone acetate 5
mg daily
for 10 days) if the above are
normal.
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Endocrinology & Metabolism - Adult
DIABETES
• A1C (recent and historical)
• Lipid profile
LIPID DISORDERS
• Lipid profiles (recent and
past)
403-955-8633
HYPERCALCAEMIA AND
HYPOCALCAEMIA
• Serum calcium levels
• ALT
• TSH
• Microalbumin (random urine
microalbumin to creatinine
ratio)
• Fasting glucose
• Phosphate, albumin, magnesium,
creatine
• Urinalysis
• Serum PTH
• Serum creatinine
(and calculated GFR)
• ALT, CK and Alk Phos
HYPERTENSION
(SUSPECT
PHEOCHROMOCYTOMA)
HYPERTENSION
(SUSPECT
HYPERALDOSTERONISM)
• 24 hour urine metanephrines
• Electrolyte panel, Creatinine,
Aldosterone/Renin ratio
FRAGILITY FRACTURES /
OSTEOPOROSIS
• Bone density studies
• Serum calcium
• Phosphate
• Albumin
• Alk Phos
OBESITY / WEIGHT GAIN
HYPOGLYCEMIA (NON-DIABETIC)
• Lipid profile
• ALT
• Fasting glucose
• GGT
• ALT, GGT
• Alk Phos
• TSH
• Creatinine
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Endocrinology & Metabolism - Adult
ANY SIGNIFICANT CARDIAC DISEASE
403-955-8633
LIST OF CURRENT MEDICATIONS E.G.
• MI within 1 year
• anticoagulants (warfarin)
• Angina with minimal activity or at rest
• antiplatelet agents (ASA, Plavix®)
• Any internal defibrillator
• diabetes medications (insulin and/or oral
medications)
• Severe congestive heart failure
• Prosthetic heart valve/ valvulopathy
• A stroke within the past year
SUFFERING FROM RESPIRATORY
INSUFFICIENCY
ANY HISTORY OF:
• MRSA
• Is the patient on home O2?
• V RE
• Is the patient on CPAP?
• C. Difficile
• Is the patient a brittle asthmatic?
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Gastroenterology
PH 403-944-6535
EMERGENCY REFERRAL INFORMATION
For all reasons for referral listed below, refer directly to the Emergency Department
or
Contact the RAAPID Line South: 1-800-661-1700 or 403-944-4486
• Acute obstruction
• Perforation
MANDATORY REQUIREMENTS FOR ALL REFERRALS
CO-MORBIDITIES - PLEASE IDENTIFY IN THE REFERRAL IF THE PATIENT HAS ANY OF THE FOLLOWING:
• History of stroke
• Diabetes
• Cardiovascular disease (e.g. prior MI)
• Rheumatologic disease
(e.g. SLE, scleroderma
etc) Active infections
(e.g. MRSA, shingles,
TB, VRE)
• Respiratory disease
• Peripheral vascular disease
• GI disease (e.g.Crohn)
• Renal disease
• Liver disease (hepatitis B or C)
• HIV
• Any other concurrent
medical problem
• Sleep apnea with CPAP
• Medication history including
antithrombotics (type and
reason) and insulin / oral
hypoglycemic agent
• Cognitive issues
DIAGNOSTIC IMAGING
• Copy of any relevant diagnostic imaging - copy of image and the report
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Gastroenterology
PH 403-944-6535
REFERRAL REQUIREMENTS
Requirements for each reason for referral are listed alphabetically on the following pages
123
127
130
ABDOMINAL PAIN
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
LIVER MASS
ACUTE GASTROINTESTINAL
ACUTE LIVER DISEASE / HEPATITIS
124
ALTERED BOWEL FUNCTION
BARRETT’S ESOPHAGUS
CAPSULE ENDOSCOPY
ENDOSCOPIC ULTRASOUND
(EXAMINATION OF PANCREAS
BILE DUCT COLON ESOPHAGUS)
FAMILY HISTORY OF CANCER OF
COLON
128
PANCREATITIS
PERSONAL HISTORY OF PRIMARY
MALIGNANT NEOPLASM OF
GASTROINTESTINAL TRACT
POLYP OF COLON FOUND ON
INVESTIGATION
131
CELIAC DISEASE
FECAL IMMUNOCHEMICAL TEST
(FIT) : POSITIVE FINDING.
125
GALLBLADDER CALCULUS
132
CHRONIC CONSTIPATION
GASTROESOPHAGEAL REFLUX
DISEASE/ INDIGESTION
SCREENING FOR MALIGNANT
NEOPLASM OF LARGE INTESTINE
(PROCEDURE)
HEREDITARY NONPOLYPOSIS
COLON CANCER
133
129
SUSPECTED LIVER MASS
UNEXPLAINED WEIGHT LOSS
DIARRHEA
IMAGING OF GASTROINTESTINAL
TRACT ABNORMAL FINDING
DYSPHAGIA
INFLAMMATORY BOWEL DISEASE
CHRONIC LIVER DISEASE /
CHRONIC LIVER ENZYME
126
CIRRHOTIC LIVER DISEASE
RECTAL HEMORRHAGE
IRON DEFICIENCY ANEMIA
IRRITABLE BOWEL SYNDROME
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Gastroenterology
REASON
FOR REFERRAL
PH 403-944-6535
MANDATORY
INFORMATION
• Frequency
•Acute abdominal pain
• Severity
•Chronic abdominal pain
• Duration
ACUTE GASTROINTESTINAL
• Duration
•Hematemesis
• Frequency
ONE MONTH
• CBC , electrolytes, BUN,
creatinine
• LFTs – ALT, ALK Phos,
GGT and AST (where
available)
ONE MONTH
• CBC/ hemoglobin level
•Melena (define)
• Creatinine
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
ABDOMINAL PAIN
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
•Low hemoglobin
•Hematochezia
ACUTE LIVER DISEASE /
HEPATITIS
•ALT &/ AST > 1000
•ALT &/ AST > 250
• Medication history
including herbs /
remedies/ all OTC
drug use
• Symptoms (e.g.
jaundice, abdominal
pain etc)
• DM
• Alcohol intake
• BMI
ONE MONTH
• Liver enzymes: ALT, AST,
Alk phos, GGT, LDH
• Liver function: INR, Total /
direct bilirubin, albumin
• Etiological: Hep A, B, C
serology, IgG, IgA, IgM,
ANA, Anti-smooth muscle
antibody, ceruloplasmin,
ferritin, transferrin
saturation, alpha 1
antitrypsin level, monospot
• CBC, electrolytes,
creatinine
• Toxin screen
(acetaminophen, cocaine)
if applicable
3 MONTHS
• Previous liver enzymes if
available
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Gastroenterology
REASON
FOR REFERRAL
FUNCTION
BARRETT’S ESOPHAGUS
MANDATORY
INFORMATION
• Define what the
problem is including
duration of symptoms
• Duration of
symptoms
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
1 YEAR
• CBC
• n/a
• Use of PPI
CAPSULE ENDOSCOPY
•Not usually a family
physician direct referral
(either directly referred
or recommended by a
gastroenterologist / internal
medicine or a surgeon that
has seen and scoped the
patient)
• Indication / question
to be answered
• Relevant medications
e.g. NSAIDs, iron
•Celiac disease
•Non celiac gluten sensitivity
• Creatinine
• Ferritin
• BUN (if patient actively
bleeding)
• CT scan if available
• Is patient following a
gluten-free diet?
• Copy of small biopsy
imaging and report
• In general it is
preferred that small
bowel biopsies are
done to prove that
the patient has celiac
disease before a
gluten-free diet is
started.
DEPARTMENTOFMEDICINE.COM/MAS
• CBC
• Iron studies
•Gastrointestinal
hemorrhage
CELIAC DISEASE
8 WEEKS
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
ALTERED BOWEL
PH 403-944-6535
6 MONTHS
• CBC, ferritin
• IGA, Anti TTG or celiac
serology
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Gastroenterology
REASON
FOR REFERRAL
MANDATORY
INFORMATION
• Recent change in
bowel habit
• Define the problem
including the
frequency of bowel
movements and
duration of symptoms
CHRONIC LIVER DISEASE /
CHRONIC LIVER ENZYME
• Medication history
including herbs /
remedies / all OTC
drug use
• Symptoms (e.g.
jaundice, abdominal
pain, confusion,
pruritus, pedal
edema, ascites, GI
bleeding)
• Comorbidities (e.g.
DM, cholesterol, CAD
etc) /
• Alcohol intake /
• BMI
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
1 YEAR
• Recent change in bowel
habit
• Define the problem
including the frequency
of bowel movements and
duration of symptoms
3 MONTHS
• Liver enzymes: ALT, AST,
Alk phos, GGT, LDH
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
CHRONIC CONSTIPATION
PH 403-944-6535
• Liver function: INR, total /
direct bilirubin, albumin
• CBC, electrolytes,
creatinine
• Etiological: Hep B, C
serology, IgG,IgA, IgM,
ANA, Anti-smooth muscle
antibody, ceruloplasmin,
ferritin, transferrin
saturation, alpha 1
antitrypsin level
6 MONTHS
• Old liver enzymes
• Abdominal ultrasound
(with hepatic / portal vein
doppler where available
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Gastroenterology
REASON
FOR REFERRAL
•Decompensated jaundice,
encephalopathy, ascites or
varices
•Compensated
MANDATORY
INFORMATION
• Etiology- when / if
established.
• How was diagnosis
established?
• Symptoms (of
decompensation)
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
3 MONTHS
• Liver enzymes: ALT, AST,
Alk phos, GGT
• Liver function: INR, total /
direct bilirubin, albumin
• CBC, electrolytes,
creatinine
6 MONTHS
• Abdominal ultrasound
(with hepatic / portal vein
doppler where available)
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
CIRRHOTIC LIVER DISEASE
PH 403-944-6535
• CT / MRI if available
1 YEAR
• Liver biopsy / endoscopy
results if available
DIARRHEA
6 MONTHS
• Frequency
• Duration
• If relevant acute, stool
cultures for: C&S, O&P,
and C. difficile
• Stool form
• BMI
• TSH
• CBC
• CRP
• Celiac serology
DYSPHAGIA
8 WEEKS
• Duration
• Severity
• CBC (only for ages 50+)
• Solids or liquids?
• Progressive
or intermittent,
unchanged?
• Weight loss
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Gastroenterology
REASON
FOR REFERRAL
PH 403-944-6535
MANDATORY
INFORMATION
• Medical history
RETROGRADE
• Current medication
• CBC, INR, PTT
• To include all relevant
imaging (copy of
report and findings
for all)
3 MONTHS
ENDOSCOPIC
• Medical history
3 MONTHS
ULTRASOUND
• Current medication
RAPHY
(EXAMINATION OF
• ALT, ALP, GGT, bilirubin,
lipase, creatinine
• ALT, ALP, GGT, bilirubin,
lipase
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
1 MONTH
ENDOSCOPIC
CHOLANGIOPANCREATOG-
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
PANCREAS BILE DUCT
COLON ESOPHAGUS)
FAMILY HISTORY OF
CANCER OF COLON
1-2 YEARS
• Family history:
»» One 1st degree
relative with CRC
or adenomatous
polyps diagnosed <
60 years
• CBC, electrolytes,
creatinine
»» Two or more 1st
degree relatives
with CRC or
adenomatous
polyps diagnosed
at any age
• Screening begins at
age 40 or 10 years
earlier than the
youngest diagnosis in
the family, whichever
comes first
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Gastroenterology
REASON
FOR REFERRAL
PH 403-944-6535
MANDATORY
INFORMATION
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
• Age 50-84
TEST (FIT) : POSITIVE
• Must be
asymptomatic
• FIT testing (FOBT is no
longer available)
• This is not a test to
investigate anemia or
GI bleeding
• CBC, electrolytes,
creatinine
FINDING
• Please send referral
to the Forzani
McPhail Colon
Cancer Screening
Centre
GALLBLADDER CALCULUS
ONE MONTH
• Symptoms and
duration
• To include all relevant
imaging (copy of
report and findings
for all)
GASTROESOPHAGEAL
REFLUX DISEASE/
INDIGESTION
•Non-cardiac chest pain
UNDER DEVELOPMENT
1 - 2 YEARS
FECAL IMMUNOCHEMICAL
APPROXIMATE
WAIT TIMES
• CBC, ALT, alkaline,
phosphate, yGt, bilirubin,
lipase
• Ultrasound
• CT result if undertaken
1 YEAR
• Duration of
symptoms
• CBC
• Frequency of
symptoms
• Severity of symptoms
• Whether patient
is responding to
medication
HEREDITARY
NONPOLYPOSIS COLON
CANCER
DEPARTMENTOFMEDICINE.COM/MAS
• Suspected hereditary
cancer syndromes
should be referred
for genetic testing.
Screening to start at
time of diagnosis or
age ≥ 18 years.
6 MONTHS
• Genetic testing
• Previous colonoscopy
or pathology report if
applicable
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Gastroenterology
REASON
FOR REFERRAL
GASTROINTESTINAL TRACT
ABNORMAL FINDING
INFLAMMATORY BOWEL
DISEASE
• Active / suspected IBD
• Inactive IBD
MANDATORY
INFORMATION
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
• Why did you request
the imaging – include
a description of the
symptoms
3 MONTHS
• Recent change in
bowel habit
3 MONTHS
• Frequency, duration
of symptoms
• Severity of symptoms
• Current medical
treatment if any, and
information on past
treatment
• Recent CBC
• stool for C. difficile toxin,
pathogens if diarrhea
present
6 MONTHS
• CBC, electrolytes,
creatinine, CRP, iron,
ferritin
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
IMAGING OF
PH 403-944-6535
• Dysphasia
surveillance in IBD
patients requires:
»» a diagnosis of
IBD with colonic
involvement;
»» the duration of
disease
IRON DEFICIENCY ANEMIA
IRRITABLE BOWEL
SYNDROME
DEPARTMENTOFMEDICINE.COM/MAS
• Any GI symptoms
6 MONTHS
• Family history of
GI malignancy
(colorectal cancer,
gastric cancer)
• Ferritin
• Frequency & duration
of symptoms
• Severity of symptoms
includes functional
disability and
impairment
• TTG
6 MONTHS
• CBC, celiac serology,
TSH, and if diarrhea: stool
for O & P
• CRP
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Gastroenterology
REASON
FOR REFERRAL
MANDATORY
INFORMATION
• Weight and BMI
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
1 MONTH
• CBC, electrolytes, BUN,
ferritin, creatinine, liver
enzymes
• Bilirubin, hep B & C
serology, albumin, PTT,
INR
3 MONTHS
• Alpha fetoprotein
• CT / MRI if available
PANCREATITIS
•Acute pancreatitis
•Disorder of pancreas
•Disorder of biliary tract
•Primary sclerosing
cholangitis
• Hospitalization
details – discharge
summary and
relevant information
• Alcohol and
gallstones are
common causes of
pancreatitis - history
of both to be included
in medical history
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
LIVER MASS
PH 403-944-6535
2 MONTHS
• ALT, AST , alkaline
phosphatase, yGt, bilirubin,
lipase, liver enzymes
• Creatinine
• BUN
• Electrolytes
• CBC
• To include all relevant
imaging (copy of
report and findings
for all)
PERSONAL HISTORY OF
PRIMARY MALIGNANT
NEOPLASM OF
• Append copy of
previous colonoscopy
and pathology reports
1-2 YEARS
• Copy of
sigmoidoscopy or
imaging results
should be appended
1 -2 YEARS
• CBC, electrolytes,
creatinine
GASTROINTESTINAL TRACT
POLYP OF COLON FOUND
ON INVESTIGATION
DEPARTMENTOFMEDICINE.COM/MAS
• CBC, electrolytes,
creatinine
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Gastroenterology
REASON
FOR REFERRAL
•Age<50b.
•Age>50
MANDATORY
INFORMATION
• Recent change in
bowel habit
• Duration
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
1 MONTH
• CBC/ hemoglobin level
• Frequency
• Previous
colonoscopy / flexible
sigmoidoscopy or
imaging
• Reports if available
• Family history
DEPARTMENTOFMEDICINE.COM/MAS
Medical Services
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
RECTAL HEMORRHAGE
PH 403-944-6535
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Gastroenterology
REASON
FOR REFERRAL
PH 403-944-6535
MANDATORY
INFORMATION
• Age ≤74 years
MALIGNANT NEOPLASM
• Must be
asymptomatic. No GI
signs and symptoms
requiring specialist
consult (i.e. rectal
bleeding, change
in bowel habits,
anemia)
(PROCEDURE)
• CBC, electrolytes,
creatinine
• Expected to
benefit from cancer
screening, i.e. no
major co-morbidity
that would reduce life
expectancy to below
five years
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
1-2 YEARS
SCREENING FOR
OF LARGE INTESTINE
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
• Medication history
(antithrombotics,
insulin or oral
hypoglycemics)
• Body mass index
(BMI) and whether
patient requires
CPAP
• Recent or pending
surgeries; referral
should be deferred
3-6 months post
surgery.
• Copy of previous
colonoscopy and
pathology report (if
applicable)
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Gastroenterology
REASON
FOR REFERRAL
MANDATORY
INFORMATION
• How was it found?
(i.e. physical exam,
imaging)
• Comorbidities
(particularly liver
related e.g. viral
hepatitis
ESSENTIAL INVESTIGATIONS &
SUGGESTED TIME FRAME
1 MONTH
• Liver enzymes: ALT, AST,
Alk phos, GGT
• Liver function: INR, Total /
direct bilirubin, albumin
• CBC, electrolytes,
creatinine
• Alpha fetoprotein
3 MONTHS
• Abdominal ultrasound
APPROXIMATE
WAIT TIMES
UNDER DEVELOPMENT
SUSPECTED LIVER MASS
PH 403-944-6535
• If available ( CT. MRI)
UNEXPLAINED WEIGHT
LOSS
• Amount & duration of
weight loss including
BMI
• Any associated
symptoms?
• Medications
• Associated medical
conditions which
might contribute
to weight loss,
Addison’s, cancer,
celiac, COPD etc.
DEPARTMENTOFMEDICINE.COM/MAS
6 MONTHS
• CBC, ferritin
• Electrolytes, creatinine
• Liver enzymes (ALT, AST,
alkaline phosphatase,
bilirubin)
• Thyroid function test
• Celiac serology
• Albumin
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General Internal Medicine
T riage
C ategory
I ncluding ,
EMERGENT
•Oxygen
403-955-8657
but not limited to :
•
IV Therapy
•
Antibiotic etc.
P rocess
A pproximate
time to be seen
age general internist on
P
call:
FMC: 403-944-1110
RGH: 403-943-3000
PLC: 403-943-4555
SAME DAY
(EMERGENCY)
ax referral to General
F
Internal Medicine Central
Access & Triage:
403-270-8453
WITHIN 2
WEEKS
ax referral to General
F
Internal Medicine Central
Access & Triage:
403-270-8453
3-6 MONTHS
•DVT/PE
URGENT
ROUTINE
•
Accelerated hypertension
•
Heart failure
•
Acute inflammatory process
•
Poorly controlled diabetes
•
Diagnostic dilemmas
•
Multiple system disease
•Hypertension
•
(*For participating Internists
– see below)
Chronic renal failure
•Vascular
risk reduction
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
• Provide all considered relevant by the referring
source.
DEPARTMENTOFMEDICINE.COM/MAS
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Provide all considered relevant by the
referring source.
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General Internal Medicine
403-955-8657
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE: •
Provide all considered relevant by the referring source.
Chronic Renal Failure
• Trends in creatinines, urinalysis, diagnostic imaging, completed workup
HYPERTENSION
• Trends in BP, medication changes, past secondary hypertension w/u evidence of target organ damage
ADDITIONAL SUBSPECIALTY REQUIREMENTS TO PROVIDE IF AVAILABLE:
•Please
specify if appropriate which area within General Internal Medicine you consider your patient will
likely need to be seen by an internist specializing in:
ºº Chronic Renal Failure
ºº Cardiovascular Risk Reduction
ºº Hypertension
All referrals deemed urgent (approximate time to be seen is within 2 weeks) by the referring source should
be faxed through GIM central intake. GIM physicians at all 3 adult hospital sites attend in the GIM Urgent
Assessment Clinic. However, all referrals are triaged when received and, depending upon the circumstances of
the ‘urgency’, these may be reassigned a differing urgency status by central intake.
As of December 2012, the participating general internists for referrals to central intake deemed nonurgent
are:
DR GHAZWAN ALTABBAA
DR DON COOK
DR ROBERT HERMAN
DR MARCY MINTZ
DR CHRISTINE BANAGE
DR. P DAVIES
DR FAISAL JHANDIR
DR JEFF SCHAEFER
DR BARRY BAYLIS
DR STEPHEN DUNCAN
DR. L LAMBERT
DR JAN SPORINA
DR ALEEM BHARWANI
DR FIONA DUNNE
DR PIN LI
DR CAREN WU
DR. A BOSCAN
DR R HAWKINS
DR. IRENE MA
DR K ZARNKE
Please note that any nonurgent referrals to other, nonparticipating, general internists should be sent directly to
these physicians’ private offices.
You will receive notification of receipt of referral within 2 working days of receipt. Please call if you haven’t
received notification.
DEPARTMENTOFMEDICINE.COM/MAS
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Hematology - Adult
T riage
C ategory
I ncluding , but
limited to :
EMERGENT
403-944-8050
not
• Peripheral Blasts/
acute leukemia
• Suspected TTP
• New
thrombocytopenia
<10 or <20 with
bleeding
P rocess
Call haematologist on call at either
FMC 403-944-1110
A pproximate
time to be seen
WITHIN 24
HOURS
PLC 403-943-4555
• New neutrophil count
<0.2
Symptomatic anemia,
needing immediate RBC
transfusion
Refer to urgent care/ER
Bleeding in patient
with known bleeding
disorder (hemophilia,
von willebrand disease,
platelet function
disorders)
Monday to Friday 8am-4pm call the
Southern Alberta Rare Blood and
Bleeding Disorders Comprehensive
Care Program at FMC:
403-944-4057
After hours call the hematologist on call
at FMC.
If emergent treatment is necessary have
patient report to the nearest ER
ymptoms of Acute PE/
S
DVT
DEPARTMENTOFMEDICINE.COM/MAS
Refer to urgent care / ER
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Hematology - Adult
T riage
C ategory
I ncluding , but
limited to :
URGENT
403-944-8050
not
• New malignancy
diagnosis of multiple
myeloma, lymphoma,
CLL, CML,
amyloidosis. (*With
the appropriate
pathology report
as confirmation of
diagnosis.)
P rocess
Fax referral directly to Tom Baker
Cancer Centre 403-521-3245
*Make sure the pt is aware that they are
being referred to TBCC
A pproximate
time to be seen
DEPENDENT
ON TBCC
GUIDELINES
• For suspected
malignancies, see
“semi-urgent” below.
Severe new unexplained
pancytopenia or severe
individual cytopenias
• Hgb<85
• Plts<50 without
bleeding
• Neutrophils <0.5 with
no current infection
DEPARTMENTOFMEDICINE.COM/MAS
Hematology Central Access and Triage
Fax: 403-944-3001
1-2 WEEKS
Hematologist offices for:
Dr. Blahey
Phone: 403-266-1246
Fax: 403-233-9278
Dr. Lategan
Phone: 403-943-5423
Fax: 403-943-5220
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Hematology - Adult
T riage
C ategory
I ncluding , but
limited to :
URGENT
403-944-8050
not
• Thrombosis or
bleeding disorder or
other hematologic
disorder in a
pregnant pt
• Thrombosis related
consultation in
pregnancy
P rocess
Hematology Central Access and Triage
Fax: 944-3001
A pproximate
time to be seen
1-2 WEEKS
OR
Hematologist office for Drs Blahey, or
Lategan
OR
Maternal Disorders of Pregnancy Clinic
Fax: 403-283-6151
Pt with a known
bleeding disorder having
ANY invasive procedure
or dental work done
Call Southern Alberta Rare Blood and
Bleeding Disorders Comprehensive
Care Program
Preoperative
assessment for
anticoagulant bridging
for surgery
Pre Admission Clinic (Internal medicine)
Pre-op consultations to IM in the PreAdmission Clinic are made from the
surgeon on the OR booking request
form
DEPARTMENTOFMEDICINE.COM/MAS
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Hematology - Adult
T riage
C ategory
SEMI
URGENT
I ncluding ,
403-944-8050
but not limited to :
• MGUS
• Splenomegaly
• Lymphadenopathy. *see
requested investigations
• Moderate cytopenias
P rocess
Hematology Central Access
and Triage. Fax 403-9443001
A pproximate
time to be seen
WITHIN 4-12
WEEKS
OR
Hematologist office for Dr.
Blahey, or Lategan
• Moderate pancytopenia
• Lymphocytosis >5
• Elevated WBC
• Moderately/severely elevated
HgB
• Moderately/severely elevated Plts
• Genetic Hemochromatosis
*see requested investigations
• Moderate/severe eosinphilia
• Moderate/severe monocytosis
• Sickle Cell anemia
• G6PD deficiency
• Post-Thrombotic Syndrome
• Suspected bleeding disorder with
pending surgical procedure
• Iron deficiency, needing iron
infusion at PLC only
• Iron deficiency, needing iron
infusion at FMC
• Pre-existing diagnosis of
Hemophilia/Von Wilebrand
Disease/Platelet function disorder
• Hypogammaglobulinemia
DEPARTMENTOFMEDICINE.COM/MAS
Call 403-955-9227 to
arrange for referral privilege,
and then iron infusion can
be arranged through day
med.
Pt’s can be referred to the Southern
Alberta Rare Blood and Bleeding
Disorders Comprehensive Care
program after first being seen by a
Calgary haematologist
Fax referral to Internal
Medicine Central Access
and Triage, to see Dr. Caren
Wu
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Hematology - Adult
T riage
C ategory
ROUTINE 1
I ncluding ,
403-944-8050
but not limited to :
• Mild chronic pancytopenia
• Moderate Bicytopenias
• Personal or family history of
venous thrombosis or inherited
thrombophilia
• Duration of anticoagulation for
venous thromboembolic disease
ROUTINE 2
• Mild splenomegaly
P rocess
Hematology Central Access
and Triage.
Fax 403-944-3001
time to be seen
WITHIN 16-24
WEEKS
or
Hematologist office for Dr.
Blahey, or Lategan
• Suspected bleeding disorder,
with no current bleeding
Hematology Central Access
and Triage.
Fax 403-944-3001
• Chronic moderate cytopenia
or
• Chronic mild elevations in Hgb,
PLt, and WBC
Hematologist office for Dr.
Blahey, or Lategan
• Mild macrocytosis
A pproximate
WITHIN 24-32
WEEKS
• Thalassemia Trait counsel
• Sickle Cell Trait Counsel
ROUTINE 3
• Chronic neutrophils > 1.0
• Chronic platelets >100
• Lymphocytosis <5
Hematology Central Access
and Triage.
Fax 403-944-3001
OVER 1 YEAR
OR
Hematologist office for Dr.
Blahey, or Lategan
OR
Call haematologist on call
for phone consult
DEPARTMENTOFMEDICINE.COM/MAS
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Hematology - Adult
T riage
C ategory
NOT
ACCEPTED
I ncluding ,
403-944-8050
but not limited to :
P rocess
• Referrals for patients who are
<18 years of age
Fax Referral to ACH
Hematology
Fax: 403 955-7393
Phone: 403 955-7155
• High Ferritin referrals with normal
transferrin saturation
If high ferritin is due to fatty
liver, refer to Hepatology
Triage.
Fax: 403-9446559
Phone: 403-944-6541
• Low ferritin in a man or
menopausal woman
Refer to GI Central Access
and Triage
DEPARTMENTOFMEDICINE.COM/MAS
Medical Services
A pproximate
time to be seen
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Hematology - Adult
403-944-8050
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
MICROCYTIC ANEMIA
NORMOCYTIC ANEMIA
MACROCYTIC ANEMIA
THROMBOCYTOPENIA
CBC, EP, CR. LFT’s, fe,
ferritin, TIBC
CBC, EP, CR. LFT’s,
retics, SPEP, CRP, ESR,
fe, ferritin, TIBC, Vit B12
CBC, EP, CR. LFT’s,
TSH, Vit B12, ferritin,
retics, folate, SPEP
CBC, EP, CR. LFT’s,
Vit B12, LDH
NEUTROPENIA
LEUKOCYTOSIS
ELEVATED HEMOGLOBIN
THROMOBCYTOSIS
CBC, EP, CR. LFT’s, Vit
B12,
CBC, EP, CR. LFT’s, ca,
alb, ESR, CRP, blood
smear
CBC, EP, CR. LFT’s,
ABG’s, fe, ferritin, TIBC,
Vit B-12
CBC, EP, CR. LFT’s,
ferritin, CRP, ESR
MACROCYTOIS
EOSINOPHILIA
LYMPHOCYTOSIS
MGUS
CBC, EP, CR. LFT’s,
TSH, Vit B12, ferritin,
retics, folate, SPEP
CBC, EP, CR. LFT’s,
CRP
CBC, EP, CR. LFT’s,
SPEP, LDH, Quantitative
Immunoglobulins,
flowcytometry for
neoplastic lymphocyte
population
CBC, EP, CR.
LFT’s, Ca, alb, ESR,
CRP, Quantitative
Immunoglobulins,
SPEP, UPEP, serum
free light chains,
skeletal survey (*not
bone scan), Beta 2
Microglobulin, LDH
SPLENOMEGALY
LYMPHADENOPATHY
AMYLOIDOSIS
Ultrasound of abd,
CBC, EP, CR. LFT’s,
haptoglobin, DAT, SPEP,
LDH, Quantitative
Immunoglobulins, retics,
blood smear
CT C/A/P and
Excisional/Incisional
Biopsy results. (Not
FNA please.)
CBC, EP, CR. LFT’s,
INR, PTT, TSH,
SPEP, Quantitative
immunoglobulins, UPEP,
serumfree light chains
HIGH FERRITIN AND
HIGH TRANSFERRIN
SATURATION (FASTING)
DEPARTMENTOFMEDICINE.COM/MAS
CBC, EP, CR. LFT’s.
SPEP, Quantitative
Immunoglobulins,
ESR, CRP, Beta 2
microglobulin, ca, alb,
LDH
Medical Services
Genetic
Hemochromatosis
BW (molecular req),
abd ultrasound, CRP,
ESR, CBC, EP, CR.
LFT’s, INR, alb, TSH,
AFP, Hgb A1c, fasting
glucose, ferritin, iron
studies
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Hematology - Adult
403-944-8050
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
THROMBOSIS
SICKLE CELL
THALASSEMIA
All relevant current and
historical diagnostic
reports, thrombophilia
results if available
CBC, CR, electrolyte
panel, LFT’s,
haptoglobin, retics,
LDH, blood smear, hgb
electropheresis
CBC, EP, CR, LFT’s
fe, ferritin, tibc, hgb
electrophersis
DEPARTMENTOFMEDICINE.COM/MAS
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Hepatology
T riage
C ategory
EMERGENT
403-944-6555
I ncluding ,
but not limited to :
• Hepatocellular carcinoma (HCC)
• If obvious cholangio-carcinoma
or pancreatic carcinoma, refer to
Hepatobiliary Surgery
P rocess
A pproximate
time to be seen
Page Hepatologist on call or
send patient to Emergency
• Severe acute hepatitis
• ALT > 10-15 x upper limit
of normal (ULN)) or acute
presentation of autoimmune
hepatitis or Wilson disease
• Acute cholangitis
URGENT
Decompensated cirrhosis
Fax referral to Hepatology
Central Access & Triage:
• Variceal bleed
2-3 MONTHS
403-944-6559
• Ascites
• Encephalopathy
• Jaundice
Pregnancy related liver disease,
including hepatitis B virus (HBV)
(typical wait time is < 2 months)
Alcoholic hepatitis after discharge
from hospital on steroids or
pentoxifylline
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Hepatology
TRIAGE
CATEGORY
SEMIURGENT
403-944-6555
INCLUDING, BUT NOT LIMITED TO:
PROCESS
Compensated cirrhosis
Fax referral to Hepatology
Central Access & Triage:
• On biopsy, imaging, FibroScan,
or thrombocytopenia
APPROXIMATE
TIME TO BE SEEN
> 6 MONTHS
403-944-6559
• Hepatitis B potentially in need of
treatment
• HBV DNA +, increased ALT
• Anti-HBc +/HBsAg- if planned
transplantation, chemotherapy or
immunosuppression
ROUTINE
Non-alcoholic fatty liver disease
(NAFLD)
> 12 MONTHS
Hemochromatosis and/or elevated
ferritin
Hepatitis C (unless cirrhotic)
Hepatitis B immune-tolerant
• Normal ALT
• HBV DNA >10,000 IU/mL
Hepatitis B chronic carrier
• Normal ALT
• HBV DNA <1,000 IU/mL
Benign liver mass
• e.g. classic hemangioma or focal
nodular hyperplasia (FNH)
OTHER SPECIAL CLINIC(S)
• •Hepatocellular Carcinoma (HCC) Clinic
• •Non-alcoholic fatty liver disease (NAFLD) Clinic
• •Primary Sclerosing Cholangitis (PSC) Clinic
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Hepatology
403-944-6555
OTHER LAB TESTS HEPATOLOGIST MAY REQUEST:
HEPATITIS B
DIAGNOSTIC IMAGING REPORTS:
• HBsAg
• Abdominal U/S
• anti-HBs
• CT abdomen
• HBeAg
• MRI abdomen
• anti-HBe
• Contrast-enhanced U/S (CEUS) of the liver
• anti-HBc (total)
• Other: __________________
• anti-HBc (IgM)
• HBV DNA PCR *
OTHER:
• AMA, ANA, smooth muscle antibodies
• HIV serology
• ALT, AST, GGT, alkaline phosphatase
• Alpha-fetoprotein(AFP)
• Bilirubin, albumin, INR
• Anti-HAV (total)
* If Hepatologist asks for lab work up:
HEPATITIS C
• Anti-HCV
• HCV RNA PCR *
Note: on ALL referrals we request the following
information:
• HCV genotype
• List of current medications and allergies
• AMA, ANA, smooth muscle antibodies
• Any history of MRSA, VRE, C. Difficile
• ALT, AST, GGT, alkaline phosphatase
• Any language barrier requiring interpreter. If
yes, what language.
• Bilirubin, albumin, INR
• Cyoglobulins
Please use HBV DNA PCR (quantitative), HCV
RNA PCR (quantitative) and HCV Genotyping
requisitions
(Provincial Laboratory for Public Health
(Microbiology))
THE FOLLOWING REFERRALS WE DO NOT ACCEPT:
• Anti-HCV positive, HCV RNA negative
• Anti-HBs or anti-HBc positive, HBsAg negative (unless awaiting transplant or planned chemotherapy/
immunosuppression)
• Clear diagnosis of cholangiocarcinoma or pancreatic cancer (should be sent to Hepatobiliary Surgery)
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Living Well with a Chronic Condition Program
T riage
C ategory
I ncluding ,
ROUTINE
Referral can be initiated by:
but not limited to :
P rocess
• Call 403-943-2584
(403-9-HEALTH)
• physicians
OR
• health-care providers
FOR ALL
SERVICES
PH 403-943-2584
• Fax to: 403-955-6868
• patients
Illegible and/or incomplete
referrals will be returned
to source.
• caregivers
All referrals are considered routine
A pproximate
time to be seen
PATIENT IS
CONTACTED
WITHIN 2
BUSINESS
DAYS OF
RECEIPT OF
REFERRAL
Patient should have
knowledge about the
program and agree to
program involvement.
LOCATIONS - MULTIPLE SITES WITHIN CALGARY AND RURAL AREAS
CRITERIA FOR ALL LIVING WELL SERVICES
• Must have at least one chronic condition (except for education classes)
• Must be 18 years of age or older
• Must be cognitively capable of participating in group setting, except for one-on-one dietitian counselling
• Must be able to handle group situations without disrupting the class or group process and behave
appropriately in a social setting
• Must have at least basic English except for programs offered in other languages
• Cantonese/Mandarin - Exercise, some education, Better Choices, Better Health™ and dietitian counselling
• Hindi/Punjabi - Some education topics, Better Choices, Better Health™ and dietitian counselling
EXCLUSION CRITERIA FOR ALL LIVING WELL SERVICES
• Patients will be assessed on an individual basis; however, the following patients do NOT meet our eligibility
criteria for the service:
ºº Patients with developmental disabilities
ºº Patients with dementia or other memory issues who are unable to remember appointment times, or
retain and utilize the tools and skills provided
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Living Well with a Chronic Condition Program
PH 403-943-2584
SERVICES PROVIDED
SUPERVISED EXERCISE PROGRAM
$80.00
Three types of exercise classes are offered:
Subsidies available to those
who qualify.
Easy Going - For individuals who can weight bear and ambulate
independently with or without a walking aid. If clients are ambulatory but
require assistance with transfers they will be assessed for appropriateness
and will require a support person to attend with them. Focus is primarily on
improving mobility and balance.
Classes are led by healthcare professionals and fitness
leaders
Get Going - For individuals with some limitations to exercise who require
a moderate level of monitoring. Focus is primarily on aerobic endurance,
muscular strength/endurance, flexibility and balance.
Keep Going - For individuals with some limitations to exercise that require
minimal supervision. Focus is primarily on improving aerobic endurance,
muscular strength/endurance, flexibility and balance.
MANDATORY CRITERIA FOR EXERCISE PROGRAM:
• All patients need to be ambulatory
• Exercise classes are only held on week days during the day
• If patient requires a caregiver, then caregivers are required to stay with patient during these sessions
• Program is 8 weeks; patients attending sessions will require ability to transition out of this service after this
time frame. Patients will be supported through this transition
• Patients with notable cognitive deficits should have a mini-mental state examination completed within
3 months of the referral to Living Well with a Chronic Condition Program. Patients with scores >24 are
eligible for participation.
• To expedite triage, send the following results with the exercise referral (if available and less than 2 years
old):
ºº Exercise stress test
ºº Myocardial perfusion imaging
ºº Pulmonary function test (for patients diagnosed with asthma or COPD)
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Living Well with a Chronic Condition Program
PH 403-943-2584
DISEASE-SPECIFIC AND GENERAL EDUCATION CLASSES
Free
Classes are offered in a
variety of formats for varying
lengths of time depending on
the topic.
Classes are interactive and
led by a variety of health
professionals.
TOPICS INCLUDE:
• Arthritis
• Lung Disease
• Blood Pressure
• Non-alcoholic Fatty Liver Disease
• Celiac Disease
• Nutrition
• Cholesterol
• Osteoporosis
• Chronic Pain
• Parkinson’s Disease
• Diabetes
• Pre-diabetes
• Emotional Eating
• Sleep Hygiene
• Energy Conservation
• Smoking Cessation
• Falls Prevention
• Stress Management
• Hoping and Coping
• Stroke
• Irritable Bowel Syndrome
• Weight Management
• Kidney Health
If referring patients for counselling and education related to diabetes, hypertension and cholesterol, review
criteria for Diabetes, Hypertension and Cholesterol Centre (DHCC)
SELF MANAGEMENT – BETTER CHOICES, BETTER HEALTH™
Free
Patients learn and practice the skills they need
to take control and live successfully with their
chronic conditions
2.5 h/wk for 6 weeks
Classes are led by trained leaders who also have
chronic conditions
This is not a support group program
TOPICS:
• Goal setting and problem solving
• Coping with pain and fatigue
Disease-specific workshops are also available for
patients with chronic pain and diabetes
• Managing difficult emotions such as
frustration and fear
• Relaxation techniques
• Positive thinking skills
• Communication and creating positive
relationships with the health care team
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Living Well with a Chronic Condition Program
PH 403-943-2584
DIETITIAN COUNSELLING
Free
Nutrition counselling for conditions including the following:
• Celiac Disease
• Kidney Health
• Diabetes
• Kidney Stones
• Dyslipidemia
• Liver Cirrhosis
• Fatty Liver
• Malnutrition
• Food Allergy/Intolerance
• Obesity
• GI Diseases (Colitis, Constipation, Crohn’s Disease,
Diarrhea, Diverticular Disease, Gastroesophageal
Reflux Disease, Irritable Bowel Syndrome, etc.)
• Pancreatitis
• Gout
• Hepatitis
• Hypertension
• Hypoglycemia
• Pre-diabetes (IFG/IGT)
• Prenatal weight related concerns*
• Renal (GFR > 30)
• Short Bowel
• Sleep Apnea
• Unexplained weight loss
*For prenatal healthy eating education, refer to Birth & Babies program for nutrition classes
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Nephrology
Calgary
Lethbridge
Medicine Hat
Red Deer
TOC
PH 403-955-6389
PH 403-320-0633
PH 403-528-2911
PH 403-314-1435
T riage
C ategory
I ncluding ,
EMERGENT
• new diagnosis of eGFR <
10 mL/min/1.73m2 or
but not limited to :
Edmonton, GNH
Edmonton, RAH
Edmonton, UAH
P rocess
Page local nephrologist on call.
• rapid decline in eGFR over
days to weeks
Referral location to be selected
by referring physician.
• eGFR declining over weeks
to months PLUS hematuria
and/or albuminuria
Calgary
Fax (403) 955-6776
• eGFR < 15 mL/min/1.73m2
Edmonton
Grey Nuns Hospital
Fax (780) 468-9353
• acute nephrotic syndrome
(ACR > 180 mg/mmol or
proteinuria > 3g/d)
• suspected vasculitis /
autoimmune disease in the
setting of hematuria and/or
albuminuria
A pproximate
time to be seen
SAME DAY
(EMERGENCY)
• life threatening uremic
symptoms (marked
hyperkalemia > 6.5 mmol/L;
pulmonary edema and
kidney failure; pericarditis
and kidney failure)
URGENT
PH 780-468-3377
PH 780-496-9350
PH 780-407-7779
2-3 WEEKS
Royal Alexandra Hospital
Fax (780) 425-8475
University of Alberta Hospital
Fax (780) 407-7771
Lethbridge
Fax (403) 320-0353
Medicine Hat
Fax (403) 526-5818
Red Deer
Fax (403) 314-1437
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Nephrology
T riage
C ategory
ROUTINE
Calgary
Lethbridge
Medicine Hat
Red Deer
I ncluding ,
TOC
PH 403-955-6389
PH 403-320-0633
PH 403-528-2911
PH 403-314-1435
but not limited to :
• eGFR < 30 mL/min/1.73m2,
irrespective of albuminuria
or hematuria
• persistent albuminuria (ACR
> 60 mg/mmol), irrespective
of hematuria
• hematuria sustained and
not readily explained by a
urinary tract source with:
Edmonton, GNH
Edmonton, RAH
Edmonton, UAH
P rocess
Referral location to be selected
by referring physician.
PH 780-468-3377
PH 780-496-9350
PH 780-407-7779
A pproximate
time to be seen
3 - 6 MONTHS
Calgary
Fax (403) 955-6776
Edmonton
Grey Nuns Hospital
Fax (780) 468-9353
Royal Alexandra Hospital
Fax (780) 425-8475
ºº Persistent albuminuria
(ACR 3 – 60 mg/mmol)
irrespective of eGFR
University of Alberta Hospital
Fax (780) 407-7771
OR
Lethbridge
Fax (403) 320-0353
ºº eGFR < 60 mL/
min/1.73m2
• An unexplained, progressive
decline in eGFR ≥ 5 mL/
min/1.73m2 that occurs
over 6 months, confirmed
on repeat testing within 2-4
weeks (ACEi or ARBs can
cause a reversible reduction
in eGFR when initiated).
Medicine Hat
Fax (403) 526-5818
Red Deer
Fax (403) 314-1437
REFERRAL COULD BE CONSIDERED FOR ANY ONE OF THE FOLLOWING:
• CKD and hypertension refractory to treatment with 4 or more antihypertensive agents
• Persistent abnormalities of serum potassium
• Recurrent or extensive nephrolithiasis
• Hereditary kidney disease (e.g. polycystic kidney disease)
IF YOU HAVE PATIENTS THAT YOU ARE CONCERNED ABOUT THAT DO NOT FALL
WITHIN THESE CATEGORIES PLEASE CONTACT THE NEPHROLOGY GROUP IN YOUR
AREA.
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Nephrology
Calgary
Lethbridge
Medicine Hat
Red Deer
TOC
PH 403-955-6389
PH 403-320-0633
PH 403-528-2911
PH 403-314-1435
Edmonton, GNH
Edmonton, RAH
Edmonton, UAH
PH 780-468-3377
PH 780-496-9350
PH 780-407-7779
SPECIFIC CO-MORBIDITY INFORMATION TO IDENTIFY IF RELEVANT:
• Type 1 or Type 2 Diabetes
• Cerebrovascular disease
• Hypertension: controlled or uncontrolled
• Cancer (non-skin)
• Coronary artery disease
• Peripheral vascular disease
• Congestive heart failure
• Autoimmune disease (describe)
SPECIFIC SYMPTOM INFORMATION TO IDENTIFY IF RELEVANT:
• Elevated serum creatinine (decreased GFR)
• Hematuria
• Proteinuria
• Urolithiasis
MANDATORY TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
• Recent serum creatinine /
eGFR (including multiple
measurements over previous
years)
• Recent routine urinalysis
• Recent random urine albumin/
creatinine ratio (ACR) for known
diabetic patients or those patients
with eGFR < 60 mL/min/1.73m2
OTHER TESTS THAT MAY ASSIST TRIAGING:
• Electrolytes
• Phosphate
• Random glucose
• Ca ++
• CBC
• HbA1C (if patient has
diabetes)
• Fasting lipid profile
(within the last year)
• Renal ultrasound
(only if done)
NOTE:
Referrals for acute nephrolithiasis and renal masses suspicious for malignancy and enlarged prostate should
be referred to urology.
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PADIS Medical Toxicology Clinic
T riage
C ategory
EMERGENT
I ncluding ,
403-944-6950
but not limited to :
• Acute poisoning from
pharmaceuticals or drugs
of abuse (intentional or
unintentional).
• Acute exposures to
occupational or environmental
toxins.
URGENT
• Symptomatic patients with
elevated blood or urinary
metal concentrations
(e.g. elevated blood lead
concentration with peripheral
neuropathy).
P rocess
A pproximate
time to be seen
Call PADIS at 1-800-3321414 (open 24 hours) to
speak to an Information
Specialist regarding
management. The clinic is
not able to see emergent
patients.
Fax referral to 403-9446987.
1 MONTH
Fax referral to 403-9446987.
1-2 MONTHS
• Hospitalized patients requiring
toxicologic follow up after
discharge for poisoning.
• Evaluation of adverse drug
events from pharmaceuticals
and complementary/
alternative medicine
therapies.
SEMI
URGENT
• Opinions regarding chelation
therapy.
ROUTINE
• Patients with non specific
symptoms where a toxicologic
etiology is suspected.
• Interpretation of toxicology
tests already performed.
DEPARTMENTOFMEDICINE.COM/MAS
Fax referral to 403-944-6987.
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PADIS Medical Toxicology Clinic
403-944-6950
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
LEAD EXPOSURE
MERCURY EXPOSURE
ARSENIC EXPOSURE
CBC
Erythrocyte mercury (if
exposure is from organic
mercury source, such as
seafood)
24 hour urine for arsenic
Whole blood lead
Blood cobalt
Blood chromium
24 hour urine for
mercury (if exposure
is from inorganic
mercury source such as
antiseptics, photography
and waterproofing
chemicals)
CARBON MONOXIDE
EXPOSURE
Venous
carboxyhemoglobin
(COHb)concentration
RATTLESNAKE
ENVENOMATION FOLLOW
UP
GENERAL FOLLOW UP
AFTER DISCHARGE FROM
HOSPITAL
CBC
Provide all considered
relevant as per referring
physician.
INR
METAL ON METAL
HIP REPLACEMENT
ASSESSMENT
PTT
Fibrinogen
RELEVANT CO-MORBIDITY
Provide all considered relevant by the referring physician.
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE
• Relevant laboratory tests and diagnostic imaging results
• Relevant consultation letters (e.g. neurology, pulmonary, internal medicine)
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PADIS Medical Toxicology Clinic
403-944-6950
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE
Provide all considered relevant by the referring physician.
ADDITIONAL NOTES
• You may wish to discuss a patient with an Information Specialist or Medical Toxicologist prior to or instead
of initiating a referral. Please contact PADIS at 1-800-332-1414 to speak with an Information Specialist. The
Medical Toxicologist on call can be paged for you as necessary.
• The clinic is unable to see acutely ill/emergent patients. For management of acute exposures, please call
PADIS at 1-800-332-1414.
• Referrals are accepted from physicians only. We do not accept self-referrals from patients. WCB cases are
acceptable.
• Please provide a list of current medications and allergies, any history of MRSA, VRE, C. Difficile, and any
language barrier requiring interpreter (and what language).
• For children ages 0-17 requiring evaluation and recommendations for environmentally-realted health
conditions and consultation for environment/health questions should be referred to the Children’s
Environmental Health Clinic, Misericordia Community Hospital, Edmonton at 780-735-2731, fax 780-7352794, email [email protected]
• Exclusions: referrals for these situations will not be accepted:
• Please visit http://www.padis.ca/ for more information
EXCLUSIONS: REFERRALS FOR THESE SITUATIONS WILL NOT BE ACCEPTED
• Management of substance abuse/dependence/addiction (refer to Alberta Health Services Addictions and
Mental Health service in your area)
• Multiple chemical sensitivity/environmental illness/environmental sensitivity (please refer to https://www.
osha.gov/SLTC/multiplechemicalsensitivities/ for more information)
• Mold exposures (refer to Alberta Health Services Environmental Public Health service in your area)
• Evaluation for drug allergy (refer to CPSA website for specialists in Clinical Immunology and Allergy)
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Respiratory Medicine
403-943-4718
T riage
C ategory
I ncluding ,
URGENT
• Suspicious for lung cancer
but not limited to :
• Recurrent ER visits for respiratory
symptoms
• Hemoptysis
SEMI
URGENT
Fax referral to
Respiratory Medicine
Central Access &
Triage: A pproximate
time to be seen
WITHIN 1-2 WEEKS
403-944-1250
• Asthma/COPD
• Interstitial lung disease, not yet
diagnosed
• Pulmonary hypertension
ROUTINE
P rocess
ax referral to
F
Respiratory Medicine
Central Access &
Triage: • Progressive neuromuscular
disease
403-944-1250
• Cough
ax referral to
F
Respiratory Medicine
Central Access &
Triage: • Pulmonary rehabilitation
WITHIN 6-8 WEEKS
WITHIN 10-12
WEEKS
403-944-1250
SPECIFIC CO-MORBIDITY INFORMATION TO
IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION
TO IDENTIFY IF RELEVANT:
• Provide all considered relevant by the referring source
• Provide all considered relevant by the
referring source.
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
• Spirometry/pulmonary function testing reports
• Chest imaging reports
• Echocardiograms and other cardiac testing
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Rheumatology Triage
403-955-8735
T riage
C ategory
I ncluding ,
to :
EMERGENT
Aggressive Connective
Tissue Disease
but not limited
Systemic Vasculitis
P rocess
Page Rheumatologist on call:
403-944-1110
A pproximate
time to be seen
WITHIN 24
HOURS
Temporal Arteritis (Giant Cell
Arteritis
(Patients with acute nontraumatic monoarthritis
should be sent to the
Emergency Department for
assessment)
URGENT
Early Inflammatory Arthritis
Fax referral to 403-955-8199
Polyarthritis with functional
impairment
If concerned about patient or
the patient’s condition changes
from initial referral, Page
Rheumatologist on call 403-9441110 to discuss
Connective Tissue Disease
which is active but not life
threatening
1-8 WEEKS
Polymyalgia Rheumatica
Gout - Poorly controlled
SEMI
URGENT
ROUTINE
Stable Inflammatory Arthritis
Fax referral to 403-955-8199
6-12 MONTHS
Fax referral to 403-955-8199
UP TO 12
MONTHS OR
LONGER
Complex Osteoarthritis
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Rheumatology Triage
403-955-8735
MANDATORY TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
*IF MANDATORY INFORMATION IS NOT ATTACHED TO REFERRAL, IT WILL BE RETURNED
INFLAMMATORY ARTHRITIS/
POLYARTHRITIS
AUTOIMMUNE/CONNECTIVE
TISSUE DISORDER
CBC, CRP, creatinine,
ALT/ALk Phos/albumin,
urinalysis, RF, Anti CCP
CBC, CRP, creatinine,
ALT/ALk Phos, albumin,
urinalysis, RF, ANA,
ENA profile, C3, C4
Attach all investigations
to referral
Attach all investigations
to referral
POLYMYALGIA RHEUMATICA
GOUT
CBC, CRP, creatinine,
ALT, ALk Phos, albumin,
urinalysis, RF,
CBC, CRP, creatinine,
ALT, ALk Phos,
albumin, urinalysis, RF,
urate
Attach all investigations
to referral
VASCULITIS
MYOSITIS
SPONDYLOARTHROPATHY
CBC, CRP, creatinine,
ALT/ALk Phos, albumin,
urinalysis, RF, ANA,
ENA profile, C3, C4,
CBC, CRP, creatinine,
ALT, ALk Phos, albumin,
urinalysis, RF,CK
CBC, CRP, creatinine,
ALT, Alk Phos, Albumin,
urinalysis, RF
Attach all investigations
to referral
SI joints
ANCA
Attach all investigations
to referral
Attach all
investigations to
referral
Attach all investigations
to referral
RELEVANT CO-MORBIDITY
Relevant past medical and family medical history
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE
Baseline lab work for all referrals - CBC, CRP, creatinine, ALT,ALK PHOS, Albumin,urinalysis
Plus the following if concerned re: Inflammatory arthritis - RF, Anti CCP
Autoimmune disorder - ANA,ENA profile, C3, C4
Please attach all information to the referral.
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Rheumatology Triage
403-955-8735
RELEVANT SYMPTOMS
What is the question you are asking the Rheumatologist/Reason for referral?
Include description of joints affected, swelling, pain, morning stiffness
Duration of Symptoms
ADDITIONAL NOTES
If patient previously seen by another rheumatologist or other specialist please include the name and
consultation notes.
Treatments tried and responses - (specifically if treated with Prednisone)
Current medication list
**If you feel the patient needs to be seen urgently - please page the Rheumatologist on call at 403-944-1110.
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Senior’s Health & Geriatric Medicine
T riage
C ategory
I ncluding ,
EMERGENT
but not limited to :
• Acute confusion (delirium)
403-955-1525
P rocess
A pprox
time to
be seen
Go to Emergency
SAME DAY
(EMERGENCY)
ax referral to
F
Senior’s Health OneLine Referral: 403-9551514
1-2 WEEKS
• Disruptive behaviour in the setting
of a dementia
• New onset immobility
URGENT
• Recent or sub-acute decline in
function
• Failure to cope at home
(especially if safety concerns/
caregiver burn-out)
• Multiple falls in a short period of
time
• Rapid decline in cognition
ROUTINE
• Comprehensive geriatric
assessment/ Advice on
management of medically
complex or frail clients
eferral may be
R
forwarded to a more
appropriate Alberta
Health Services Calgary Zone service
• Fax referral to
Senior’s Health OneLine Referral: 403955-1514
2-4 MONTHS
• Falls
• Cognitive concerns including
access to Neuropsychological
testing
• Functional decline
• Review of medication
• Second opinion/advice on
management of a dementia
• Falls Prevention Clinic- clients
must be cognitively able to
participate in the assessment
and adhere with interventions
commonly recommended for
mimimizing the risk of future falls
(e.g., behaviour and medication
modifications, physical activity/
exercise program).
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Senior’s Health & Geriatric Medicine
NOT
ACCEPTED
• Referrals for adults <65 yrs.
• Referrals for capacity assessment
or driving assessment
• Referrals for medical-legal
assessments
• Referrals for third party
assessments (Immigration
assessments, WCB assessments,
fitness to work,, placement
issues, co-signatures for PD &
EPOA)
• Referrals for Falls Prevention
Clinic: clients suffering from
a moderate-severe or severe
dementia and clients who are
terminally ill with a life expectancy
of 6 months or less.
403-955-1525
For cognitive
assessment of clients <
65, fax referral to:
Neurosciences
Cognitive Assessment
Clinic
403-944-8228
CGMHS
Phone: 403-955-6155
Fax: 403-955-6169
• Referrals for primary mental
health issues should be directed
to Community Geriatric Mental
Health Services (CGMHS).
• Referrals for moderate and
severe BPSD (Behavioral &
Psychological Symptoms of
Dementia) should be directed to
CGMHS.
Seniors Health Clinics / services / programs provide multidisciplinary, consultative advice on the diagnosis and management
of adults age 65 or older with issues relating to medical complexity, frailty and chronic disease, functional decline, cognitive
impairment, dementia or falls. Referrals will be accepted from family physicians/ specialists.
Referrals from Home Care are accepted provided that the family physician is aware and agrees with sending the referral..
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Senior’s Health & Geriatric Medicine
403-955-1525
SPECIFIC TESTS / INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
• Goals or clear reason for referral
• Consults from other specialists ( last 2 -3 years)
• Results of cognitive testing (last 2-3 yrs.)
• Current medication list
• Past relevant medical information
• Recent blood work
• Diagnostic imaging
PLEASE SPECIFY IF APPROPRIATE WHICH SUBSPECIALTY CLINIC WITHIN SENIORS
HEALTH YOU CONSIDER YOUR PATIENT WILL LIKELY NEED TO BE SEEN BY:
SENIORS HEALTH CLINICS (RGH AND BRIDGELAND)
CALGARY FALL PREVENTION CLINIC
An in-home assessment is completed by a healthcare professional trained in falls prevention. Fall risks are
identified and specific recommendations are provided to the client and family physician. Patients must have
fallen within the last 12 months and cognitively be able to benefit from the assessment (mini-mental status
exam of 20/30 or greater).
CAREWEST DEALING WITH DEMENTIA
A time-limited ambulatory service for seniors with specific needs related to dementia, along with their
caregivers. The intent is to increase caregivers’ knowledge, skill and coping to enable them to better provide
support and care for their family member and to maintain their own well-being.
ACTIVITIES/SERVICES INCLUDE:
• Assessment, diagnosis and treatment by interdisciplinary team including geriatric psychiatrist.
• Interactive education sessions for primary caregivers
• Participation by the client and caregiver in group activities; modeling and coaching by the team.
• Supportive counselling; and linking with community services.
• Anticipated progress and needs of both client and family addressed.
• Clients and their caregivers normally attend four to five hours once per week for thirteen weeks
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Senior’s Health & Geriatric Medicine
403-955-1525
CAREWEST DAY HOSPITAL (NORTH & SOUTH)
A time-limited ambulatory treatment and rehabilitation program for frail seniors who are living at home with
medical and functional concerns, at risk for hospitalization or care centre admission. The focus is to promote
their well-being, functional abilities, and quality of life, through comprehensive assessment and treatment by
an interdisciplinary team with expertise and experience in the care of frail elderly.
ACTIVITIES / SERVICES INCLUDE:
• Collaborative assessment completed by team (social worker, physical therapist, occupational therapist,
recreation therapist, physician, and nurse; further assessment, treatment, and /or consultation available
from a speech language therapist, psychologist, geriatrician, geriatric psychiatrist, and pharmacist).
• Client centred, functional goals and treatment plan developed in collaboration with client, and family and/or
other care providers.
• Integrated therapy and treatment, including both individual and group activities.
• Links to appropriate community programs and services
• Discharge plan communicated to family physician, referral source, and home care (if involved).
• Clients normally attend five hours twice per week for three to four months
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Sleep Centre
T riage
C ategory
URGENT
403-944-2404
I ncluding ,
but not limited to :
• Severe daytime somnolence
P rocess
A pproximate
time to be seen
Fax referral to: 403-270-2718
WITHIN 1-2
MONTHS
• Respiratory failure
• Pulmonary HTN,
cardiomyopathy, uncontrolled
HTN
SEMI
URGENT
• Moderately severe daytime
somnolence
Fax referral to: 403-270-2718
WITHIN 2-4
MONTHS
ROUTINE
• Normal daytime somnolence
Fax referral to: 403-270-2718
12-18 MONTHS
SPECIFIC CO-MORBIDITY
INFORMATION REQUIRED:
SPECIFIC SYMPTOM INFORMATION
REQUIRED:
• Congestive Heart Failure *
• Please indicate nature of Severe Daytime
Somnolence, including but not limited to:
• Ischemic Heart Disease *
ºº Patient falls asleep and is at risk at work
(please specify profession)
• Cardiac Arrhythmias *
• Respiratory Failure (PO2 < 50, PCO2 > 50) *
ºº Patient falls asleep while driving (please
specify how often, and whether any accidents
have occurred)
• Stroke (specify year/s)
• Other Respiratory Disease
ºº Patient is a professional driver
• Neuromuscular Disease
• Please indicate if your patient is going for
major surgery within the next 6 months and the
reason.
• Other Neurologic Disease
* Please see Subspecialty section below for
required documents.
SPECIFIC TESTS /INVESTIGATIONS REQUIRED:
• Congestive Heart Failure, Ischemic Heart Disease and Cardiac Arrhythmias:
• Reports of recent investigations (Echo, MUGA, Angio, PFT’s if available)
Respiratory Failure:
• Reports of recent investigations (PFT’s, ABG’s, Echo if available)
• Current treatment (oxygen, CPAP, BiPAP)
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Southern Alberta HIV Clinic (SAC)
403-955-6399
T riage
C ategory
E xamples
P rocess
T ime
ROUTINE
•All
Fax referral form to SAC
at 403-955-6355, or call the clinic
at 403-955-6399
WITHIN 1-2
WEEKS
referrals to the Southern
Alberta HIV Clinic (SAC)
are considered routine and
treated equally.
to be seen
•All
patients must have
a positive HIV result, as
SAC does not perform HIV
screening tests.
SPECIFIC CO-MORBIDITY INFORMATION TO IDENTIFY IF RELEVANT:
•Provide
•Active
all considered relevant by the referring source
infections (e.g., active TB)
SPECIFIC SYMPTOM INFORMATION TO IDENTIFY IF RELEVANT:
•Provide
all considered relevant by the referring source
SPECIFIC TESTS / INVESTIGATIONS TO PROVIDE IF AVAILABLE:
•Positive
HIV result
•Recent
hospital admission records (within past year),
including location and approximate dates
ADDITIONAL SUBSPECIALTY REQUIREMENTS TO PROVIDE IF AVAILABLE:
•Language
•Barriers
needs
to care (e.g., transportation issues)
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Vascular Risk Reduction Program
T riage
C ategory
URGENT
SEMIURGENT
403-955-8032
E xamples
P rocess
Known atherosclerotic disease:
MI/CABG or CVA/TIA within the
past 3 months and/or Hgb A1c
> 9.0
Known atherosclerotic disease:
event greater than 3 months, or
PAD or carotid disease.
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
T ime
Fax referral to 403-955-8634
to be seen
4 – 6 WEEKS
8 – 10 WEEKS
Fax referral to 403-955-8634
SPECIFIC TESTS/INVESTIGATIONS
REQUIRED TO ENABLE TRIAGE:
• Diabetes
• History and Physical – most recent
• Thyroid Disease
• Current Medications with dosage
• CAD
• Discharge summary (inpatients)
• PAD
• Hgb A1C for those with diabetes
• CVA/TIA
• Fasting glucose
• Renal Disease
• Lipid Profile
• Smoker
• Electrolytes
• Creatinine
• TSH
• ALT and CK
NOTE:
The following conditions are not monitored or managed in this program:
• CHF
• Pulmonary HTN
• If a patient is on coumadin - INR’s are not monitored in this program..
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Palliative / End of Life Care
Grief Support Program
T riage
C ategory
URGENT
ROUTINE
I ncluding ,
TOC
403-955-8011
but not limited to :
P rocess
Crisis or urgent services are not
available or urgent care or support
is required prior to a booked session
with the Grief Support Program
Call Health Link Alberta
403-943-5465
Individual and group counselling for
those who are grieving the loss of
someone who has died.
Self-referrals call:
A pproximate
time to be seen
N/A
or call the Calgary Distress
Centre at 403-266-4357
2-3 WEEKS*
(403) 955-8011
*Approximate time to be seen – The average wait to access an individual grief support session is generally
2 – 3 weeks, depending on demand that fluctuates throughout the year. Thirty-five (35) grief support groups
are established each year - anyone interested in attending a group session needs to first have an individual
session with a counsellor.
SERVICE LOCATIONS
The Bob Glasgow Grief Support Centre
Phone – (403) 955-8011, Fax – (403) 955-8022
Richmond Road Diagnostic and Treatment Centre,
1820 Richmond Road S.W., Calgary, Alberta T2T 5C7
RELEVANT POLICIES
There is no charge for grief support services; however, tax deductible donations to the Grief Support Program
Fund are appreciated.
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Residential Hospice
T riage
C ategory
ALL
REFERRALS
I ncluding ,
TOC
403-944-1614
but not limited to :
P rocess
• Patient has a demonstrated
rate of deterioration of weeks to
days with extensive evidence of
disease
All referrals must be made
by a palliative consultant
or palliative home care
coordinator by calling:
• Patient and/or designated
decision-maker is agreeable to
no further aggressive or invasive
treatment intended to cure
disease.
Hospice Central Access at
(403) 944-1614
A pproximate
time to be seen
CASE BY
CASE*
• Signed Goals of Care are “C”
or “M2” as per AHS document #
HSC-38.
• Patient has a life-limiting illness
with an estimated prognosis of 3
months or less
REMARKS
• Hospices cannot accept patients who are at risk for elopement.
• Rosedale Hospice can only accept patients with primary disease of cancer..
* Hospice Central Access will take the urgency under advisement and triage the patient in relation to available
hospice beds.
RELEVANT SYMPTOMS
Physical symptoms such as pain, nausea, vomiting, constipation, bowel obstruction, anorexia / cachexia,
fatigue, and breathlessness are assessed and managed according to individual patient need.
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Residential Hospice
TOC
403-944-1614
SERVICE LOCATIONS
There are six hospice locations in Calgary and one near Okotoks.
The patient / family is required to select a minimum of three hospice preferences and is required to accept the
first available bed in that grouping, except in exceptional circumstances below
• Extreme geographic needs where placement at a particular Hospice would present true hardship
• Intrathecal or epidural catheter goes to Sarcee Hospice only
• Patient has complex needs which have been negotiated / discussed with a designated hospice by the
Manager, Hospice Access
RELEVANT POLICIES
Patients with complex needs (medical, nursing, psychosocial, spiritual) need to be identified to the Manager,
Hospice Operations / Central Access in order to assess for and arrange appropriate pre-admission needs.
Any ensuing discussion will take place before the patient is approved for the Hospice waitlist.
ADDITIONAL NOTES
• Diagnostic tests and other assessments are appropriate only when results are needed for palliation of
symptoms.
• All Hospices can manage subcutaneous medication administration and/or hydration, tracheostomies,
gastrostomy tubes, oxygen, respiratory treatments, pleurex drainage, intermittent suctioning, and BIPAP.
• Associated costs (exempt if going to Santuari Hospice) –
ºº Medication – patient should be registered with Alberta Blue Cross Palliative Care Program
ºº Oxygen – provided through private vendor agency
ºº No daily accommodation fee
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Palliative Care Consult Service
T riage
C ategory
EMERGENT
I ncluding ,
but not limited to :
403-944-2304
P rocess
Acute Care Patients
• patient is palliative;
• crisis pain and symptom
management;
• family / patient support for
psychosocial distress related to
end of life
• SCM order palliative
referral
or
call (403) 944-8294
Monday – Friday
0800-1600.
A pproximate
time to be seen
SAME DAY
If an in-person
visit is not
possible, then a
phone consult
will be provided.
• After hours,
call 403-944-1110
and ask for palliative
physician on call
URGENT
Community (Home)
• patient is palliative;
• pain / symptom assessment
with recommendation for
management;
• family / patient psychosocial
support;
• at risk for presenting to an
emergency department.
ROUTINE
• patient is palliative with
deteriorating physical and/or
cognitive decline;
• end-of-life decision making,
routine pain/symptom
management;
• patient / family psychosocial
spiritual support;
call 403-944-2304
and
fax referral to
403-270-9652
WITHIN 24 –
48 HOURS
All Rural Sites
call 403-995-2714
and
fax referral to
403-995-2619
Care Centres
WITHIN 1
WEEK
call 403-943-0251
and
fax referral to
403-943-0231
• need for information;
• transition to hospice
NOT SEEN
• Pediatric patients.
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Palliative Care Consult Service
TOC
403-944-2304
RELEVANT SYMPTOMS
Related to the palliative process, symptoms may include pain, dyspnea, cachexia related to advancing
disease, delirium, nausea / vomiting, and risk of terminal bleeding (hemorrhage), physical and cognitive
decline, psychosocial and/or spiritual distress in the patient and / or family, anticipatory grief in the patient and
/ or family. Need for further education regarding disease trajectory, prognosis, goals of care and end of life
planning / decision-making may also be required.
RELEVANT CO-MORBIDITIES
May include cancer, end-stage renal disease, end-stage cardiac disease, end-stage lung disease (e.g.
COPD, pulmonary fibrosis), end-stage liver disease, end-stage dementia, neurodegenerative diseases (e.g.,
ALS, multiple sclerosis, Parkinson’s disease)
SERVICE LOCATIONS
The Palliative Care Consult Service is available at all sites of care within the urban and rural boundaries of the
Calgary Zone including Acute Care, Community sites (Home, Care Centres and selected Specialty Clinics). If
you call the Palliative Care Consult Service Central Office at 403-944-2304, your call may be redirected to the
most appropriate team.
RELEVANT POLICIES
• Palliative Care Consultants do not assume care. The consultants work with the patient’s current medical
providers in a specialized and consultative role to better support the patient / family and attending teams.
• Referrers may be contacted by the consultant to discuss the patient further with an option of a joint visit. If
you have not been contacted within 48 hours of putting the referral in please call the Central Office at 403944-2304 to inquire.
• The Palliative Consult Service is not an emergency service.
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Urban Palliative Home Care Team
TOC
403-955-6288
PROCESS FOR REFERRALS
HOSPITAL OR TBCC CLIENTS not already on Home Care: contact Transition Services at the site.
COMMUNITY CLIENTS not already on Home Care: contact Community Care Access at 403-943-1920.
(Physicians can also call Community Care Access at 403-943-1930.)
HOSPICE CLIENTS: contact Community Care Access at 403-943-1920 once the discharge conference with
Palliative Home Care has taken place (call 403-955-6288 to arrange)
TRANSFER OF CURRENT HOME CARE CLIENTS in hospital or TBCC to Palliative Home Care: contact
Palliative Care Consult Service at 403-944-2304.
TRANSFER OF CURRENT HOME CARE CLIENTS in community to Palliative Home Care: fax referral to
Palliative CNS at 403-270-9652
Note – The Palliative Home Care Case Manager will take the urgency under advisement and triage the client
in relation to their caseload.
T riage
C ategory
I ncluding ,
but not limited to :
A pproximate
time to be seen
Note – The Palliative Home Care Case Manager will take the urgency under advisement and triage the client
in relation to their caseload
EMERGENT
Client is likely within 24 hours of end-of-life
WITHIN 24
HOURS
URGENT
Client is likely within days of end-of-life, has unstable symptom
management, or requires a daily task that the family cannot be taught
e.G. Peritoneal drain
24 – 48
HOURS
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Urban Palliative Home Care Team
T riage
C ategory
I ncluding ,
ROUTINE
but not limited to :
• The client has a progressive, life limiting illness for which there are
no further curative treatment options.
TOC
403-955-6288
A pproximate
time to be seen
3 - 7 DAYS
• The client requires complex end of life case management such as
ºº Ongoing assessment in response to frequently changing
symptoms
ºº Ongoing medication adjustments for pain and symptom
management
ºº Complex end of life decision-making
ºº Complex end of life psychosocial and / or spiritual issues
• The client and family understand and accept the palliative
approach to care.
• It is strongly recommended that, prior to admission to Palliative
Home Care, a goals of care discussion has taken place with the
client / family and this has been documented on the Advance Care
Planning Tracking Record.
• It is strongly recommended that the client have a family physician
in place to manage ongoing medical care.
EXCLUSION
CRITERIA
• The client does not have a progressive, life threatening illness.
• The client’s primary needs are for increased Home Care services
rather than complex end of life case management.
• Admission to Home Care is deemed unsafe for AHS staff, and/or
vendor staff, and/or if an intervention is required or requested that
is not in accordance with AHS Community Care Policies.
LOCATIONS - WITHIN THE CITY LIMITS OF CALGARY
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Urban Palliative Home Care Team
RELEVANT CO-MORBIDITIES
TOC
403-955-6288
RELEVANT SYMPTOMS
• Maladaptive coping mechanisms in the client and
/ or family
• Complex pain related to palliative processes
• Complicated anticipatory grief in the client and /
or family
• Cachexia related to advancing disease
• Complex end of life planning and decision-making
• Complex addiction and / or mental health issues
in the client
• Complex dyspnea
• Delirium
• Complex nausea / vomiting
• Risk of terminal bleeding (hemorrhage)
• Fungating wounds
• Client is expected to deteriorate due to increased
symptom burden
RELEVANT CLINIC POLICIES
ADDITIONAL NOTES
• Clients on Palliative Home Care can be
reassessed at regular intervals to determine their
suitability to remain on the Palliative Home Care
Program. The following criteria are considered in
client reassessment:
ºº Stable disease or very slow progression
ºº Improved function over a sustained period of
6 – 12 months
• Clients are discharged from Palliative Home Care
when transferred to Hospice or another Home
Care team.
• Clients who leave the Calgary Zone for two or
more consecutive months are discharged from
the Palliative Home Care Program.
Specific guidelines are considered by Palliative
Home Care Team and the Palliative Care Consult
Service, in conjunction with the admission criteria for
Palliative Home Care, to help identify whether clients
with a life-limiting disease would benefit from the
services of Palliative Home Care. Such guidelines
exist for the following disease conditions:
• ALS
• Cancer
• Dementia
• Neurodegenerative Diseases (e.g., Multiple
Sclerosis, Parkinson’s Disease)
• End-Stage Renal Disease
• End-Stage Cardiac Disease
• End-Stage Lung Disease (e.g. COPD, pulmonary
fibrosis)
• End-Stage Liver Disease
• Transplant Clients Awaiting Organs
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Pediatrics
TOC
Augmentative Communication and
Educational Technology Service (ACETS)
T riage
C ategory
PRIORITY
E xamples
P rocess
• Degenerative conditions
(e.g. muscular dystrophies,
multiple sclerosis).
Fax referral to ACETS:
• Palliative conditions (e.g.
cancer).
or
• Acute condition with sudden
loss of speech (e.g. brain
injury).
ROUTINE
• Clients with a stable medical
status who have a severe
communication impairment
and are unable to meet their
daily communication needs
through verbal speech.
403-955-7501
403-955-7912
Approximate time
to be seen
WITHIN TWO
MONTHS OF
RECEIPT OF
REFERRAL
Email: [email protected]
albertahealthservices.ca
Fax referral to ACETS:
403-955-7501
or
Email: [email protected]
albertahealthservices.ca
WITHIN ONE
MONTH FOR
CONTACT
AND SERVICE
SUPPORT TO
COMMUNITY
TEAM.
WITHIN 9-12
MONTHS
FOR DIRECT
CONSULT
SUPPORT.
ACETS PROVIDES THREE STREAMS OF SERVICE FOR CHILDREN:
• No and low technology
• Speech Generating Communication Devices (SGCD)
• Alternative access
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Augmentative Communication and
Educational Technology Service (ACETS)
403-955-7912
REFERRAL PROCESS
Clients can be referred to the service by Physicians, Occupational Therapists, Speech-Language Pathologist,
or by family/ client self-referral.
Community speech-language pathology and occupational therapy service involvement is strongly
encouraged.
RELEVANT INFORMATION TO BE INCLUDED WITH THE REFERRAL:
• Specific communication concern or goal
• Motor and developmental diagnoses (e.g. CP, autism, seizure disorders, neurogenerative conditions)
• Receptive and expressive language abilities
•Visual and motor abilities
• Educational, vocational, and/ or home setting descriptions
• Current or prior use of augmentative or alternative communication strategies including SGCD trials
• Planned seating appointments
• Other service providers/ programs/ supports involved in the client’s care
• Whether the client has access to telehealth facilities through local service providers
SERVICE TRANSITION
Clients are redirected to primary therapy team once referral question/ issue has been addressed. Re-referral
is welcomed when client needs change or new communication concern has been identified that cannot be
addressed by primary therapy team.
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Brachial Plexus Program
403-955-2576
T riage
C ategory
E xamples
P rocess
PRIORITY
(URGENT)
• New diagnosis of brachial
plexus injury
Therapist will see new babies in
NICU at other Calgary sites as
needed.
• Children requiring postsurgical rehabilitation
(e.g. nerve reconstruction,
tendon transfer, capsular
release)
ROUTINE
• Children experiencing
change in functional status
e.g. difficulty with ADLS,
change in equipment needs
including splinting.
Therapist to contact family upon
receipt of referral.
Approximate time
to be seen
APPOINTMENT
TO BE MADE
WITHIN ONE TO
TWO WEEKS
POST-SURGICAL
PROTOCOL
TIMELINES TO BE
FOLLOWED
Fax referral to Brachial Plexus
Program:
403-955-7045
• Children requiring
monitoring of
developmental status in
the absence of community
services.
FAMILY WILL BE
CONTACTED
WITHIN TWO
WEEKS UPON
RECEIPT OF
REFERRAL.
APPOINTMENT
TO BE
SCHEDULED
WITHIN SIX
WEEKS
DEPENDING
ON IDENTIFIED
ISSUES.
The Brachial Plexus Program offers diagnosis, assessment, treatment, care co-ordination and counseling
from birth to 18 years of age with a congenital/ obstetrical and/or traumatic injury to the brachial plexus.
Professional services available within the Brachial Plexus Program include: Neurology/ Pediatrics,
Neurophysiology, Orthopedic Surgery, Plastic Surgery, Physical Therapy, Occupational Therapy, and Social
Work.
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Brachial Plexus Program
403-955-2576
REFERRAL PROCESS
• A physician referral is required.
• Any health care provider or parent can refer a child through their physician to the Brachial Plexus Program
for follow-up of specific issues.
RELEVANT INFORMATION TO BE INCLUDED WITH THE REFERRAL:
• Specific identified issue(s) or problem(s)
•Birth History
• Results of any diagnostic testing
• Surgical history
• Other clinics and services involved in the child’s care
• Previous reports including therapy reports
• Languages spoken in the home including whether the parents speak English
SERVICE TRANSITION
• Therapists will facilitate transition of children and families into community- based rehabilitation services and/
or school-based services as appropriate.
• Clinic-based therapists liaise with community therapists (e.g. school board therapists, home care, rural
therapy agency, etc.) regarding relevant issues identified through assessments and clinic visits.
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Infant Cranial Remodeling Program/Head Shape Clinic
403-955-5437
T riage
C ategory
Approximate time
URGENT
E xamples
• Suspected
craniosynostosis
P rocess
Mail or fax referral to Head Shape
Clinic 403-955-7609
to be seen
WITHIN 2-4
WEEKS
The referral will be redirected to
Neurosurgical Clinic as appropriate.
SEMI
URGENT
• Infants eight to
twelve months of age
with plagiocephaly /
brachycephaly/
dolichocephaly
Mail or fax referral to Head Shape
Clinic 403-955-7609
WITHIN 4
WEEKS
ROUTINE
• Infants four to eight
months of age with
plagiocephaly /
brachycephaly/
dolichocephaly
Mail or fax referral to Head Shape
Clinic 403-955-7609
TRIAGE TO EIT
OR PA CLINIC
ACCORDING
TO AGE WITHIN
FOUR TO SIX
WEEKS OF
RECEIPT OF
REFERRAL
ROUTINE
• Infants < four months of
age with plagiocephaly
/brachycephaly/
dolichocephaly
Mail or fax referral to Head Shape
Clinic: 403-955-7609
LESS THAN 1
MONTH
DEPARTMENTOFMEDICINE.COM/MAS
or parents may call to register for an
Infant Repositioning Class
Pediatrics
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Pediatrics
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Infant Cranial Remodeling Program/Head Shape Clinic
403-955-5437
The Infant Cranial Remodeling Program/Head Shape Clinic offers assessment and treatment of
plagiocephaly, brachycephaly, dolichocephaly, and craniosynostosis for infants newborn to twelve months of
age. The clinic structure is as follows:
• Pediatrician Assessment (PA) Clinic: infants 6-12 months of age
• Early Identification and Treatment (EIT) Clinic: infants 4-6 months of age are seen by a Physical Therapist
or Occupational Therapist.
• Infant Repositioning Class: infants under 4 months of age. Referral to the clinic is not necessary; however
for all referrals received for this age group, it will be mandatory to attend class prior to being seen in the PA
or the EIT Clinics. Infants will be all be seen and assessed by an OT or PT.
SERVICE TRANSITION
• Children seen in Infant Repositioning classes may be followed up in EIT or discharged and redirected back
to their referral source
• Children seen in Infant Repositioning classes who are identified with torticollis are referred to Child Health
or Community Physical Therapy services for follow-up
• Children seen in Head Shape Clinic are referred for treatment with a cranial remodeling device, referred
back to Neurosurgery Clinic as appropriate or transitioned back to their referral source for ongoing followup
REFERRAL PROCESS
Relevant information to be included with the referral:
• The specific head shape concern for which the infant is being referred
• Any concurrent diagnoses (including, but not limited to, torticollis and/or developmental delay)
• Date of birth
• Whether or not the infant was born at term
• The results of any imaging that may have been completed
• Scaphocephaly (dolichocephaly)/plagiocephaly/brachycephaly severity assessment score (optional) developed by Cranial Technologies Inc. and downloadable off their website at www.cranialtech.com
CONTACT INFORMATION FOR THE HEAD SHAPE CLINIC/ INFANT REPOSITIONING
CLASSES
Head Shape Clinic, Neurosciences Program, Alberta Children’s Hospital
2666 Shaganappi Trail NW Calgary, AB T3B 6A8
Telephone: 403-955-5437
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Fax: 403-955-7609
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Movement Assessment Centre
403-955-2617
The Movement Assessment Centre provides video motion capture technology (video, force plates, surface
electromyography) for quantitative assessment of movement abnormalities in children and adults to assist in
clinical decision making or to assist in quantifying effects of interventions (e.g. surgery, drugs, Botox).
SERVICE TRANSITION
REFERRAL PROCESS
If assessment results in a surgical intervention, the client
will be reassessed at three, six, 12, 24, and 48 months
post-intervention. If the client begins a drug therapy,
reassessment will be done at six-month intervals. For all
other cases, reassessment will be completed only with a
new referral from the physician.
Referrals should be mailed or faxed to the
Movement Assessment Centre
Fax: 403-955-7501
or
Mail:
Movement Assessment Centre, Neuroscience
Department,
2888 Shaganappi Trail NW
Calgary, AB.
T3B 6A8
A physician referral is required.
Referrals can be made using the Internal Referral Form.
Referring physicians must include a question or statement describing their expectations of the assessment.
The question might refer to a clinical decision that will be made based on the assessment outcome. Relevant
information to be included with the referral:
Previous surgery or botox history
Assistive devices, including orthoses, currently being used
Time frame of proposed intervention (e.g. target surgery date)
Latex allergies
Impaired cognition that prevents the client from following instructions
History of falls
Community practitioners involved in the client’s care (e.g. school therapist, orthotist)
Client assessments generally occur within three weeks of referral; however, there may be a delay of up to
eight weeks in disseminating findings depending on the urgency of the referral and the availability of the
Centre Medical Director.
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Neurology Program
T riage
C ategory
URGENT
E xamples
• Acute neurological
deterioration
• New onset infantile spasms
or infantile epilepsy
• Suspected stroke or TIA
• New onset headache
with suspected increased
intracranial pressure
• Myasthenic crisis or unstable
neuromuscular disease
403-955-5437
P rocess
If you have a patient you believe
needs to be seen urgently, please
contact the pediatric neurologist
on-call through the ACH operator
Approximate time
to be seen
WITHIN 1 WEEK
403-955-7211
These referrals are NOT
ACCEPTED BY FAX
• Guillain Barre
SEMI
URGENT
• Deteriorating multiple
sclerosis
• New onset epilepsy
• New onset movement
disorder
• Severe intractable headache
• Progressive
neurodegenerative condition
• Stable myasthenic disease
• Acute neuropathy
ROUTINE
All other neurological concerns.
Referral received by fax or
telephone or by internal direct
department referral (DDR).
Reviewed daily MondayFriday by nurse and pediatric
neurologist.
WITHIN 1
MONTH
Physicians are encouraged to
send these referrals by fax.
Fax: 403-955-7609
Referral received by fax, by mail
or sent by DDR.
3 MONTHS
Fax: 403-955-7609
Reviewed within 72 hours
Monday-Friday by nurse and
pediatric neurologist.
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Neurology Program
403-955-5437
SERVICE DESCRIPTION
The Neurology Program provides assessment, diagnosis, treatment and transition planning for children from
birth to 18 years of age who have neurological disorders in collaboration with the community physicians.
These include seizures, epilepsy, debilitating headache disorders including migraines, neuromuscular
diseases, movement disorders, brain injury and stroke.
The Neurology Program operates as a consultative or shared-care model. We do not provide primary
care services. All referrals must have a family doctor/pediatrician or been referred to one. We encourage
physicians to call for advice and support for any child with a neurological disorder.
RELEVANT INFORMATION TO BE INCLUDED WITH THE REFERRAL:
• Name of responsible primary care physician/pediatrician.
• The specific question or concern for which you believe this child needs to be seen by a neurologist.
• Comprehensive history and physical examination details.
• Any abnormal neurological findings (including developmental screening information).
• Latest lab work & any that have been ordered.
• List of current medications.
• Whether the patient has had, or booked for, any of the following: CT, MR or EEG. If yes, please indicate
location and time.
• Whether this patient is followed through/or been referred to any other ACH specialty clinics. If yes, please
indicate which ones.
• Please note: headache referrals enter a screening process. Usually only atypical headache disorders,
worrisome headaches or debilitating headaches will be accepted. When referrals are not accepted, the
physician and patient will be notified and helpful information will be provided.
EXCLUSION CRITERIA
THE FOLLOWING REFERRALS WILL NOT BE ROUTINELY ACCEPTED TO THE NEUROLOGY CLINIC:
• Global developmental delay - unless referred by a pediatrician
• First seizures in children over 1 year of age
• Febrile convulsions
• Atypical febrile convulsion - unless seen & referred by a pediatrician
• Non-debilitating headaches
• Syncope or fainting spells
• Breath-holding spells
• Self-stimulatory behaviors
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Neuromotor Program
T riage
C ategory
URGENT
I ncluding ,
but not limited to :
403-955-5437
P rocess
• Child experiencing pain
Fax: 403-955-2996
• Child experiencing a
significant change in
function
or
• Children and families new
to the province without
required equipment or
connections to community
resources
ROUTINE
Mail:
Neuromotor Program,
Neuroscience Department,
2888 Shaganappi Trail NW,
Calgary, AB., T3B 6A8
Fax:
403-955-2996
or
Mail:
Approximate time to
be seen
FAMILY WILL BE
CONTACTED
WITHIN FOUR
TO SIX WEEKS
OF RECEIPT
OF COMPLETE
REFERRAL
FAMILY WILL BE
CONTACTED
WITHIN TWO
MONTHS OF
RECEIPT OF
COMPLETE
REFERRAL.
Neuromotor Program,
Neuroscience Department,
2888 Shaganappi Trail NW,
Calgary, AB., T3B 6A8
The Neuromotor Program is a consultative service that offers assessment, treatment, care co-ordination and
counseling for children from birth to 18 years of age with a diagnosis of cerebral palsy (CP).
Professional services available through the program include Pediatrics, Orthopedic Surgery, Physiatry,
Neurology, Nursing, Physical Therapy, Occupational Therapy, Speech and Language Pathology, Psychology,
Social Work and Clinical Nutrition.
SERVICE TRANSITION
Information will be exchanged between the clinic and the child’s community primary health providers. Transfer
of the young adult to adult services will be facilitated by the clinic as required.
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Neuromotor Program
403-955-5437
REFERRAL PROCESS
Referrals to the program can be made using the Internal Referral Form. A physician referral is required.
Relevant information to be included with the referral:
• Specific identified issue(s) or problem(s)
• Previous reports including therapy reports
• Date of birth
• Language spoken in the home, including
whether the parents speak English
• Birth record
• Diagnosis and concurrent diagnoses
• Equipment, splinting, bracing
• That a discussion of diagnosis of cerebral palsy or
of cerebral-palsy like condition has occurred with
the family
• Current address, phone number and names of
caregivers/guardians
• Medications
• Results of any developmental screening
• Healthcare coverage
• Results of any diagnostic imaging
• Surgical history
• History of botox injections
• Other clinics and services involved in the child’s
care
CONTACT INFORMATION NEUROMOTOR PROGRAM
Neuromotor Program, Neurosciences Program, Alberta Children’s Hospital
2666 Shaganappi Trail NW Calgary, AB T3B 6A8
DEPARTMENTOFMEDICINE.COM/MAS
Telephone: 403-955-5437
Pediatrics
Fax: 403-955-7609
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Neuromuscular Program
T riage
C ategory
URGENT
I ncluding ,
but not limited to :
P rocess
• Children experiencing acute
feeding issues
Mail or fax referral Neuromuscular
Program
• Children and families
requiring urgent
psychosocial support
403-955-7609
• New diagnosis presenting
with functional concerns and
no existing therapy support
in place
ROUTINE
403-955-7603
• Children experiencing
change in functional
status (e.g. increased
falls, difficulty with ADLS,
change in equipment needs,
including splinting)
Approximate time
to be seen
FAMILY WILL BE
CONTACTED
UPON RECEIPT
OF REFERRAL
A physician referral is required.
WAIT TIME
RANGES FROM
DAYS UP TO
FOUR WEEKS
DEPENDING
ON IDENTIFIED
ISSUES
Mail or fax referral Neuromuscular
Program
FAMILY WILL BE
CONTACTED
WITHIN TWO
WEEKS OF
RECEIPT OF
REFERRAL
403-955-7609
A physician referral is required.
• Children requiring
monitoring of developmental
status in the absence of
community services
APPOINTMENT
TO BE
SCHEDULED
WITHIN SIX
WEEKS
DEPENDING
ON IDENTIFIED
ISSUES
The Neuromuscular Program offers diagnosis, assessment, treatment, care co-ordination, and counseling for
children from birth to 18 years of age with a neuromuscular diagnosis such as muscular dystrophy, myotonic
dystrophy, spinal muscular atrophy, and Charcot-Marie-Tooth.
Professional services available within the program include Neurology/Pediatrics, Orthopedic Surgery,
Pulmonology, Nursing, Physical Therapy, Occupational Therapy, Psychology, and Social Work. Consultations
can be made to Cardiology, Sleep Lab, Speech-Language Pathology, and Clinical Nutrition as required.
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Neuromuscular Program
403-955-7603
SERVICE TRANSITION
Therapists will facilitate transition of children and families into community-based rehab services and/or schoolbased services as appropriate.
Clinic-based therapists liaise with community therapists (e.g. school board therapists, home care, rural
therapy agency, etc.) regarding relevant issues as identified through assessments and clinic visits.
REFERRAL PROCESS
A physician referral is required.
Referrals can be made using the Internal Referral Form Relevant information to be included with the referral:
• Specify languages spoken in the home, including whether the parents speak English
Mail or fax referral to Neuromotor Program Co-ordinator.
A referral is required from a physician who coordinates the child’s care.
Referrals can be made using the Internal Referral Form. Relevant information that must be included with the
referral:
Evidence for diagnosis of cerebral palsy, including diagnostic imaging and lab work
Clinical question to be addressed
Parental concerns related to cerebral palsy diagnosis
Birth history, including where child was born (hospital name and location)
Copy of most recent physician note/assessment
Developmental screen and/or therapy reports
Rehab Services requested or currently involved in child’s care
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Neurosciences Adolescent Transition Program (NATP)
T riage
C ategory
PRIORITY
(URGENT)
I ncluding ,
to :
P rocess
A pproximate
T ime to be seen
• Youth who are 17 –
19 and imminently
transferring to the adult
sector
Phone:
403-955-7645
WITHIN TWO
WEEKS
• Youth with complex
medical needs that
require a team approach
in planning successful
transition to the adult
sector
Fax:
403-955-7045
but not limited
• Youth with limited access
to community services in
their geographic location
ROUTINE
403-955-7045
• Youth who are motivated
to work towards transition
goals and are interested
in learning more about
transition resources.
or
or
E-mail: [email protected]
albertahealthservices.ca
Phone:
403-955-7645
WITHIN TWO
MONTHS
or
Fax:
403-955-7045
or
E-mail: [email protected]
albertahealthservices.ca
The goal of this program is to discuss the youth’s and family’s transition concerns and link them to appropriate
community based programs to address their ongoing needs
This program includes:
• Initial adolescent transition assessment with youth, parent(s) and a member of the NATP team
• Assistance with transition goal setting
• Referrals to community and health care agencies
• Information packages/resources on specific transition topics.
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Neurosciences Adolescent Transition Program (NATP)
403-955-7045
SERVICE TRANSITION
REFERRAL PROCESS
Youth are referred back to their clinic of origin, who
will initiate the referrals to adult care providers. The
transition team may refer to outside agencies for
ongoing follow-up of specific needs.
Referrals can be initiated by youth, family members or
health care professionals. Referrals that are initiated
by youth and/or their parents/guardians are preferred
The youth’s/family’s contact information should be
left on the transition voicemail or email. a member of
the NATP team will respond to the email or voicemail
within three working days
NATP is not able to meet with youth during their clinic
visits. exceptions will be made for youth from out of
town, if the team is notified prior to the clinic visit
REFERRAL ELIGIBILITY CRITERIA
Youth must be registered in one or more neurosciences programs
Any transition concerns must be directly related to the youth’s medical condition
Youth must be between the ages of 12 – 19 years of age
Youth must be self-referred and demonstrate willingness to work towards their transition goals
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403-955-2603
(for children registered in school)
Neuro Rehabilitation Program
403-955-7063
(for preschool-aged children)
T riage
C ategory
PRIORITY
ROUTINE
I ncluding ,
but not limited to :
P rocess
Child requires out-patient
therapy follow-up to support
discharge from an inpatient
setting
Mail or fax referral Neuro
Rehabilitation Program:
Child’s performance issues are
significantly impacting school or
home functioning
Mail or fax referral Neuro
Rehabilitation Program:
403-955-2620
403-955-2620
Approximate time
to be seen
WITHIN ONE
WEEK OF
DISCHARGE
CONTACTED
WITHIN TWO
WEEKS OF
RECEIPT OF
REFERRAL
The Neuro Rehabilitation Program provides assessment, treatment, care co-ordination, and counseling for
children from birth to 18 years of age who have experienced an acute change in functioning due to illness,
surgery, or injury (e.g. brain injury). Professional services available through the program include Neurology,
Physiatry, Nursing, Physical Therapy, Occupational Therapy, Speech and Language Pathology, Child Life/
Recreation Therapy, Psychology, Education Consultation and Social Work.
SERVICE TRANSITION
If required, children transition to receiving medical follow-up in other neuroscience clinics two years post
acute event. Children transition from this service to community/school based rehabilitation services when their
needs can be appropriately met there.
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403-955-2603
(for children registered in school)
Neuro Rehabilitation Program
403-955-7063
(for preschool-aged children)
REFERRAL PROCESS
• Children requiring therapy services can be referred to the program by any healthcare provider or team
• Children requiring medical follow-up in the Brain Injury Clinic require a physician’s referral
• Referrals can be made using the Internal Referral Form. relevant information to be included with the
referral:
• Description of presenting concern/specific issue or problem to be addressed
• Concurrent diagnoses
• Inpatient admission history
• Surgical history if applicable
• Results of any diagnostic imaging
• Other clinics and/or services involved in the child’s care
• Previous reports including therapy reports
• Language spoken in the home, including whether the parents speak English
CONTACT INFORMATION FOR THE NEURO REHABILITATION PROGRAM
Neuro Rehabilitation Program, Neurosciences Program, Alberta Children’s Hospital
2666 Shaganappi Trail NW Calgary, AB T3B 6A8
Neuro Rehabilitation Program Co-coordinator:
Brain Injury Clinic:
Telephone:
403-955-2603 (for children registered in school)
403-955-7063 (for children registered in pre-school)
Telephone: 403-955-7900
Fax:403-955-2620
Fax:403-955-2620
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Orthotics
403-955-7918
T riage
C ategory
I ncluding ,
EMERGENT
Inpatient
URGENT
Post-operative
Fax:
Scoliosis
403-955-7501
Skin breakdown
or
but not limited to :
P rocess
Approximate time
to be seen
SAME DAY
WITHIN ONE
WEEK OF
RECEIPT OF
REFERRAL
Mail:
Orthotics, Rehabilitation
and Education Clinics, 2888
Shaganappi Trail NW
Calgary, AB.,T3B 6A8
SEMIURGENT
Pain
Fax:
403-955-7501
or
WITHIN THREE
WEEKS OF
RECEIPT OF
REFERRAL
Mail:
Orthotics, Rehabilitation
and Education Clinics, 2888
Shaganappi Trail NW, Calgary,
AB., T3B 6A8
ROUTINE
New device due to growth
Fax:
403-955-7501
or
WITHIN ONE
MONTH OF
RECEIPT OF
REFERRAL
Mail:
Orthotics, Rehabilitation
and Education Clinics, 2888
Shaganappi Trail NW, Calgary,
AB., T3B 6A8
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Orthotics
403-955-7918
SERVICE TRANSITION
Families are transitioned from the program to private orthotic facilities when youth becomes 18 years old.
Clients/families are provided with a list of private orthotic facilities to contact to address their orthoses’
prescription. Families also have the option of accessing services through private orthotic facilities at any time.
REFERRAL PROCESS
Mail or fax prescription to Orthotics.
A written physician prescription with physician signature is required.
Relevant information to be included with the referral:
• Medical diagnosis
• Type of orthoses requested
• Parent contact information
• Guardianship information
• Language spoken in the home, including whether the parents speak English
• X-ray if necessary if bracing is for scoliosis
• Cast removal date if applicable
• Whether orthotics appointment needs to be coordinated with other clinic appointments
CONTACT INFORMATION FOR THE NEURO REHABILITATION PROGRAM
Neuro Rehabilitation Program, Neurosciences Program, Alberta Children’s Hospital
2666 Shaganappi Trail NW Calgary, AB T3B 6A8
Neuro Rehabilitation Program Co-coordinator:
Brain Injury Clinic:
Telephone:
403-955-2603 (for children registered in school)
403-955-7063 (for children registered in pre-school)
Telephone:
403-955-7900
Fax:
403-955-2620
DEPARTMENTOFMEDICINE.COM/MAS
Fax:
403-955-2620
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Pediatric Gastroenterology, Hepatology & Nutrition
403-955-7747
TRIAGE
CATEGORY
PROCESS
APPROXIMATE TIME
TO BE SEEN
Send to Emergency
SAME DAY
• Active IBD
Fax referral to:
IMMEDIATE TO
• Dysphagia or odynophagia
403-955-7639
1 MONTH
EMERGENT
EXAMPLES
• Caustic ingestion
• Acute pancreatitis
• Oesophageal foreign body
• Complete dysphagia
• Acute GI bleed
• Liver failure
• Diarrhea with dehydration
URGENT
• Hematemesis
• Obstructive jaundice
• Failure to thrive* - infants/severe
• Constipation (1 month of age)
• Acute hepatitis (ALT >10 x normal)
• Chronic liver disease/portal
hypertension
• Complicated GERD
• Rectal bleeding (without
constipation)*
• Celiac Screen (+) with symptoms
• Complicated vomiting‡
• Chronic diarrhea with weight loss
>5%
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Pediatric Gastroenterology, Hepatology & Nutrition
403-955-7747
TRIAGE
CATEGORY
PROCESS
APPROXIMATE TIME
TO BE SEEN
• Suspected IBD (normal labs)
Fax referral to:
1 TO 6 MONTHS
• Complex abdominal pain
403-955-7639
SEMIURGENT
EXAMPLES
• Abdominal pain (poorly coping)
• Failure to thrive*
• Iron deficiency anemia - recurrent
• Constipation referred by pediatrician
• Hepatitis B,C serology positive
• Abnormal GI imaging + symptoms
• Chronic nausea & vomiting
• Celiac Screen (+), no symptoms
• Polyposis Syndrome – asymptomatic
• Chronic/Recurrent pancreatitis
• Abnormal liver enzymes infant < 6
months
ROUTINE
• Simple GER
Fax referral to:
• Chronic constipation **
403-955-7639
• Fatty liver with elevated BMI‡
6-18 MONTHS
• Food allergies
• Abdominal pain – no alarm
symptoms
• Diarrhea no complications, (N)
investigations
• Abnormal GI Imaging in well child
• Abnormal liver enzymes (< 3 x (N) x
>4-6 m)
• * Uncomplicated FTT , probable allergic colitis may be triaged initially to the dietician
• ** Simple constipation will be triaged initially to Constipation Teaching sessions
• ‡ Suspected malrotation should be referred to Pediatric Surgery.
• Suspected eating disorders should be referred to Adolescent Medicine
• Fatty liver with elevated BMI should be referred to the ACH Pediatric Centre for Weight & Health
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Pediatric Gastroenterology, Hepatology & Nutrition
403-955-7747
SPECIFIC TESTS REQUIRED FOR TRIAGE
All referrals must include a growth chart
IBD – SUSPECTED OR ACTIVE
ABDOMINAL PAIN
CHRONIC DIARRHEA
• CBC
• CBC, ESR,CRP
• CBC, ESR, CRP
• ESR/CRP
• Albumin
• Total protein/albumin
• Albumin
• ALT,GGT,Bili
• Electrolytes,TCO2,Urea,Cr
• Ferritin/Iron studies
• Lipase
• Ferritin
• ALT, GGT, lipase
• Celiac screen
• Celiac Screen
• Stool C&S, O&P, C.difficile toxin
• U/S
• Stool O&P
• Urinalysis
• C. Diff toxin (Age> 1year)
• Pediatric consult
• Fecal elastase
CELIAC DISEASE
CONSTIPATION
GER/VOMITING
• CBC
• Electrolytes
• LFT’s, Lipase
• Abdominal U/S
• Barium swallow
• Urinalysis
FAILURE-TO-THRIVE
• CBC/ESR/CRP
• Electrolytes, BUN, Creatinine
• Calcium, Phosphate
• ALT, Alkaline phosphatase
• INR
• Fecal Elastase
• Total protein/Albumin
• Celiac screen
• Description of symptoms
• Description of stools
• TTG, EMA, IgA levels
• Treatment (Dose, duration, results)
• IgG-TTG if IGA<0.1
• CBC
• CBC, ferritin
• Electrolytes, TCO2
• TSH
• BUN, Cr., Ca, PO4, Alk.Phos.
• ALT/AST
• Celiac screen
• TSH
ELEVATED LIVER ENZYMES
• Urinalysis and culture
• CBC
• ALT,GGT, BIli T/D
• Albumin, INR
• IgG
• CK
• Abdominal US
• Medication exposure
• Viral hepatitis screen
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Seating Service
TRIAGE
CATEGORY
URGENT
403-955-2914
INCLUDING, BUT NOT LIMITED TO:
PROCESS
Pressure/skin integrity or safety
concerns
Phone:
403-955-2914
or
APPROXIMATE TIME
TO BE SEEN
WITHIN TWO
DAYS OF
RECEIPT OF
REFERRAL
Fax:
403-955-7501
Or mail to:
Seating Service, Rehabilitation
and Education Clinics, 2888
Shaganappi Trail NW, Calgary,
AB., T3B 6A8
ROUTINE
New referrals
Re-referrals for growth
Re-referrals for other changes in
physical/functional status
Phone:
403-955-2914
or
WITHIN THREE
WEEKS OF
RECEIPT OF
REFERRAL
Fax:
403-955-7501
Or mail to:
Seating Service, Rehabilitation
and Education Clinics, 2888
Shaganappi Trail NW, Calgary,
AB.
SERVICE TRANSITION
Children transition to adult seating services when they reach 18 years of age and require a new seating and
mobility system. Clients over the age of 18 who require modifications to an existing seating system continue
to be followed by the service. Children who require repairs or maintenance to mobility systems should contact
their medical equipment vendor.
REFERRAL PROCESS
Mail, phone, email or fax referral to ACH Seating Services.
Any health-care provider can refer to Seating Services. The clinic also accepts self-referrals from parents
whose children have previously received seating systems through the service.
Referrals must include a completed copy of the service referral form (contact service to obtain a copy).
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Surgical Services
TOC
Dr. Bathe 403-521-3179
Dr. Dixon 403-944-3045
Dr. Sutherland 403-944-1233
Hepatopancreaticobiliary (HPB)
T riage
C ategory
I ncludes
EMERGENT
•Complete
P rocess
obstruction
•Ascending
cholangitis or
bleeding from tumor of
pancreas, liver, or biliary system
URGENT
acute pancreatitis with
necrosis (AP)
Page Hepatopancreaticobiliary
(HPB)surgeon on call
Fax Hepatopancreaticobiliary
(HPB) referral to triage line:
•Newly
403-476-8798
•Complicated
pancreatitis
•Complicated
gallstone disease
time to be
seen
SAME DAY
(EMERGENCY)
403-944-1110
•Severe
diagnosed lesion, tumor
or masses (suspicious for
cancer) of the liver, pancreas,
bile ducts or gallbladder
A pprox .
WITHIN 2
WEEKS
•Any
cystic lesions of the liver,
pancreas, duodenum, bile ducts
•Any
biliary strictures
•Obstructive
jaundice
•Liver
metastases of any origin
that require assessment for
ablative treatments or resection
•Traumatic
or iatrogenic injuries
to the bile duct, liver, or
pancreas
DEPARTMENTOFMEDICINE.COM/MAS
Surgical Services
Updated 4 Nov 2014
201
Specialty Specific Guidelines
Surgical Services
TOC
Dr. Bathe 403-521-3179
Dr. Dixon 403-944-3045
Dr. Sutherland 403-944-1233
Hepatopancreaticobiliary (HPB)
T riage
C ategory
I ncludes
P rocess
ROUTINE
•Chronic
ax referral to
F
Hepatopancreaticobiliary (HPB)
triage line:
pancreatitis and benign
diseases of liver, pancreas, and
biliary system
A pprox .
time to be
seen
WITHIN 6
WEEKS
403-476-8798
**NOTE:Non-neoplastic conditions of the gallbladder (biliary colic, acute cholecystitis)
should NOT be sent to the Hepatopancreaticobiliary (HPB) triage line.
SPECIFIC CO-MORBIDITY INFORMATION
TO IDENTIFY IF RELEVANT:
SPECIFIC SYMPTOM INFORMATION TO
IDENTIFY IF RELEVANT:
•
•
Provide all considered relevant by the referring
source.
Provide all considered relevant by the referring
source.
PROVIDING THE FOLLOWING RELEVANT INFORMATION (IF AVAILABLE) WILL EXPEDITE
CARE OF YOUR PATIENT:
•Bloodwork
•Copy
of all biopsy results
•Tumor
Markers where appropriate- CEA, CA19-9, alpha fetoprotein
•Hepatitis
•Copy
(CBC, electrolytes, creatinine, PT, PTT, ALT, Alk Phos, T-Bili, GGT, Lipase)
serology where appropriate (hepatoma patients)
of all endoscopy and other interventional reports
•Copy
of all imaging results and for patients not imaged on Calgary PACS system (FMC, PLC, RGH,
Sheldon Chumir, South Calgary, High River, Canmore) a copy of MRI and/or CT scan on CD
DEPARTMENTOFMEDICINE.COM/MAS
Surgical Services
Updated 4 Nov 2014
202
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Calgary Breast Health Clinic
T riage
C ategory
URGENT
E xamples
403-944-2240
P rocess
• Confirmed or suspected breast
cancer
• Abnormal diagnostic imaging
suggestive of malignancy*
• Suspicious clinical exam
TOC
Fax referral to:
403-944-2250
Approximate time
to be seen
WITHIN 2
WEEKS
Call: 403-944-2240 for
guidance if required
• Inflammatory changes to the
breast
• Breast abscess
SEMIURGENT
• Solid persistent mass with
benign features on diagnostic
imaging
Fax referral to:
403-944-2250
WITHIN 3
WEEKS
• Abnormal imaging requiring
further investigations, likely
benign
• Complex cysts
• Nipple discharge: spontaneously
bloody, clear unilateral
• Atypical pathology on core
biopsy requiring surgical consult
• Papilioma confirmed
ROUTINE
• Mastalgia
Fax referral to:
• Fibrocystic breasts
403-944-2250
• Bilateral nipple discharge
WITHIN 8
WEEKS
• Family history
• Prophylactic mastectomy
• Worried patient with negative
workup seeking second opinion
from surgeon and teaching from
nurse
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
All mammogram, ultrasound or relevant pathology reports should be faxed with the referral.
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
203
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Colposcopy Program
TOC
403-944-2205
T riage
C ategory
E xamples
P rocess
URGENT
•
Fax referral to:
PAP smear Squamous Cell
Carcinoma
• PAP Adenocarcinoma
403-944-3125
Approximate time
to be seen
WITHIN 1-2
WEEKS
• PAP Other Malignant types
•PAP AGC
SEMI
URGENT
- favour neoplastic
• PAP ASC - H Atypical Squamous
Cell- cannot exclude HSIL
• PAP HSIL - High Grade
Squamous intraepithelial lesion
(CIN 2-3) including < age 21
Fax referral to:
403-944-3125
WITHIN 1
MONTH
• PAP AGC – NOS (not otherwise
specified)
• PAP AIS - Adenocarcinoma in Situ
• Abnormal appearing cervix
regardless of PAP smear findings
ROUTINE
• LSIL- ASCUS – 2 PAP smears at
least 6 months apart over 2 years
(LSIL/ASCUS; ASCUS/ASCUS;
LSIL/LSIL)
Fax referral to:
403-944-3125
WITHIN 2
MONTHS
•Lesions
• Genital warts
• Post-coital bleeding
• Under Age 21- 3 abnormal paps 2
year apart unless high grade;
• For women ≥ 30 years ASCUS
and high risk HPV positive
• For women ≥50 years LSIL and
high risk HPV positive
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
204
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Colposcopy Program
TOC
403-944-2205
PREGNANCY AND ABNORMAL PAP
• All pregnant patients with High Grade Pap results seen regardless of gestational age
• Low Grade not seen until 6 months post partum
SPECIFIC TESTS/INVESTIGATIONS REQUIRED TO ENABLE TRIAGE:
PLEASE IDENTIFY RELEVANT COMORBIDITIES:
PLEASE IDENTIFY RELEVANT
PHYSICAL AND HISTORY SUCH AS:
• Previous genital warts
• Abnormal looking cervix
• Infectious disease - sexually transmitted agents
• Abnormal vaginal bleeding
• Any other concurrent medical problems
• Other relevant information
• Therapeutic abortion, D&C or Ablation within the last 4
weeks
PLEASE PROVIDE SPECIFIC TESTS OR INVESTIGATIONS:
• Histopathology reports for any surgical procedures, biopsy, or cytology including PAP smear
• Any previous colposcopy results from another jurisdiction (out of province, out of country)
• History & Physical
• Any relevant DI reports
• All relevant Consultation reports
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
205
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Early Pregnancy Loss Clinic
T riage
C ategory
ROUTINE
403-944-3192
E xamples
P rocess
• Medical management of fetal demise/
missed abortion of 12 weeks or less
(gestational age as indicated by ultrasound).
Fax referral
to:
• Decision making around treatment options
for the retained products of conception
including:
TOC
Approximate time to
be seen
WITHIN 1–2
WEEKS
403-944-1111
ºº Dilatation and curettage (D&C)
ºº Medical management (misoprostol)
ºº Spontaneous or expectant management
Please include patient’s parity, LMP, age, date of birth, health care number, address, contact numbers, printed
name of referring doctor with PRACID #.
SPECIFIC TESTS/INVESTIGATIONS TO PROVIDE IF AVAILABLE:
PELVIC ULTRASOUND CONFIRMING FETAL DEMISE WITH ULTRASOUND CRITERIA OF:
• Embryo with no cardiac activity: trans vaginal >5mm; abdominal >9mm
• Gestational sac with no embryo and no yolk sac: trans vaginal > 8mm; abdominal >20mm.
• Gestational sac with yolk sac, no embryo: trans vaginal >16mm; abdominal >25 mm
LABORATORY RESULTS: PATIENT’S BLOOD TYPE AND RH, SERUM BETA HCG, IF
AVAILABLE.
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
206
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Gynecology Clinic(s)
TOC
403-944-1680
T riage
C ategory
E xamples
P rocess
ROUTINE
General gynecological assessment, diagnosis,
and treatment.
Fax referral
to:
403-944-5094
A pproximate
time
to be seen
VARIABLE
(1 TO 6
MONTHS)
Please include all diagnostic imaging and appropriate lab and pathology results.
Physician referral letter with PRACID # and reason for referral required.
Please indicate preference for first available physician or identify a preferred gynecologist (Philippa Brain,
Simrit Brar, Neville Galan, John Jarrell or Stephen Wood).
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
207
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
High Risk Breast Cancer Clinic
T riage
C ategory
ROUTINE
OFFERED NEXT
AVAILABLE
APPOINTMENT
WITH HRBCC
TEAM (MD, RN &
PSYCHOLOGIST
403-944-2547
E xamples
P rocess
All referrals are considered
routine, but wait time is dependent
upon the services required and
completion of the telephone
interview/history with the RN
Fax all referrals to
403-944-2250
Pre-cancerous conditions e.g.
Lobular Carcinoma in Situ (LCIS) or
Atypical Hyperplasia (ADH, ALH)
Include pathology
report
Mantle radiation < age 30
Include oncology
report, or provide
the name of the
treating cancer
centre
Medical genetics testing in the
family has:
Include genetics
letter or copy of
genetic test
• Confirmed a mutation
TOC
Approximate time to
be seen
And include the items below
2-4 WEEKS
•Been non-informative
•Been offered but appropriate
person to test is not alive or
available
5 year breast cancer risk of 1.7% or
greater (modified Gail) wishing to
discuss tamoxifen/raloxifene
DEPARTMENTOFMEDICINE.COM/MAS
(We use www.
cancer.gov/
bcrisktool)
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
208
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
High Risk Breast Cancer Clinic
T riage
C ategory
REFERRAL
TO TEAM
PSYCHOLOGIST
ONLY
Not requiring
assessment by
physician/nurse
consultant team
GENETIC RISK
FOR BREAST
+/- OVARIAN
CANCER
E xamples
403-944-2547
P rocess
• Client is aware of her own or a
family member’s high-risk status
and is having difficulty with
decision making, communicating
with family, or experiencing
anxiety or depression related to
risk
TOC
Approximate time to
be seen
Please indicate
“Psychosocial
referral only” on the
referral form
7-14 DAYS
Include medical
genetics letter
2 - 4 WEEKS
• Anxiety about breast cancer risk,
screening tests, or prevention
strategies and would like to meet
with psychologist only.
• Known BRCA gene mutation (or
other gene mutation associated
with increased breast cancer
risk) in self or first degree
relative and interested in further
discussion regarding screening
and prevention strategies.
• High risk for breast or ovarian
cancer as already assessed
by a Cancer Genetics Clinic
(i.e. strong family history but
BRCA negative family or genetic
testing not desired or no affected
family member alive to test) and
interested in further discussion
regarding screening and
prevention strategies. . If genetic
testing is desired referral should
be made to a Cancer Genetic
Clinic.
ELEVATED
BREAST
CANCER
RISK DUE TO
ANOTHER
REASON
DEPARTMENTOFMEDICINE.COM/MAS
Atypical hyperplasia or lobular
carcinoma in situ of the breast
and is interested in learning about
risk reduction hormonal therapies
(i.e. Tamoxifen, raloxifene,
exemestane.)
Women's Health Ambulatory Care (WHAC)
2 - 4 WEEKS
Updated 4 Nov 2014
209
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Obstetrical Clinic(s)
TOC
403-944-1680
T riage
C ategory
I ncluding ,
ROUTINE
OBSTETRICS:
but not limited to :
• General and high-risk obstetrical care consult
services (obstetrician)
• High risk obstetrical care consult service
provided by obstetrician with sub-speciality in
maternal fetal medicine.
MEDICAL DISORDERS IN PREGNANCY
(INTERNAL MEDICINE):
• Medical disorders management during
pregnancy
• Will be triaged by internal medicine and
appointment scheduled at one of the city
hospital clinics
P rocess
FAX
REFERRALS
TO:
A pproximate
time to be seen
1-4 WEEKS
403-944-5094
FAX
REFERRALS
TO:
1-4 WEEKS
403-283-6151
• Preconception assessment (internal
medicine)
1–3
MONTHS
INFORMATION REQUIRED TO ENABLE TRIAGE:
• Please include all pathology, diagnostic imaging and appropriate lab results (Alberta Health routine
prenatal initial screening for pregnant women).
• Physician or midwife referral letter with PRACID # and reason for referral required.
• Completed prenatal record to date.
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
210
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Pelvic Floor Clinic
TOC
403-944-4000
T riage
C ategory
E xamples
P rocess
URGENT
•
Fax Referral to:
Complete prolapse of vagina (procidentia),
causing obstruction of urethra and inability to
void
•
Sudden bleeding or infection of vaginal
tissues as a result of a “forgotten” or
impacted pessary
•
Acute urinary retention requiring selfcatheterization teaching
to be seen
1-3 WEEKS
403-944-2154
SEMIURGENT
• Severe prolapse of vagina extending 2 cm or
more beyond introitus
Fax Referral to:
ROUTINE
• Urinary incontinence of all types (stress,
urge, mixed, overflow)
Fax Referral to:
•Bowel evacuation dysfunction including anal
incontinence or constipation
Approximate time
1-3 MONTHS
403-944-2154
403-944-2154
EDUCATIONAL
SESSION:
2 – 3 MONTHS
AFTER TRIAGE
• Pelvic Organ Prolapse - (vaginal bulging or
heaviness)
CLINICAL
APPOINTMENT:
• Those having had previous surgical
interventions by Clinic physicians with
ongoing or new issues
9 – 12 MONTHS
AFTER
EDUCATIONAL
SESSION
• Referrals for only urodynamic testing
(accepted from gynecologists and urologists
only)
MANDATORY INFORMATION REQUIRED ON THE REFERRAL:
Reason for referral. Also, please indicate previous treatments including medications or surgical interventions
for these issues.
New patients will be triaged to an education workshop for initial appointment. Please indicate if your patient
has any limitation or disability which would not make them a suitable candidate for a 2 – 3 hour
education session. Patients who require the services of an interpreter should have this prominently
indicated on the referral.
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
211
Specialty Specific Guidelines
Women's Health Ambulatory Care (WHAC)
Pregnancy and Infant Loss Program
T riage
C ategory
E xamples
URGENT
403-944-2274
P rocess
• Patient seen in Early Pregnancy
loss clinic.
TOC
Approximate time
to be seen
Phone: 403-944-2274
WILL DEPEND
ON AVAILABILITY
• Patient calls secretary in distress.
SEMIURGENT
• Patient calls crying, not sleeping
or eating. Concerns heightened if
children in the house without any
support.
Phone: 403-944-2274
WILL DEPEND
ON AVAILABILITY
ROUTINE
• Patient calls the program
requesting an appointment with
the grief counselor.
Phone: 403-944-2274
WILL DEPEND
ON AVAILABILITY
NOTE: Pregnancy and Infant Loss Program offers counseling as needed for patients and their
families requiring further support for their loss.
Hours: Monday - Friday 0800-1600 hrs. Closed on Saturdays, Sundays and Statutory holidays.
The last available appointment is at 1500 hrs (3:00 pm)
DEPARTMENTOFMEDICINE.COM/MAS
Women's Health Ambulatory Care (WHAC)
Updated 4 Nov 2014
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