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Child Health Guideline Identifier

Rheumatology - inpatient referrals and admissions

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Background

The National Paediatric Rheumatology service is a consultative service based primarily at two sites - Starship and Hutt Hospitals - with Starship being the quaternary center for New Zealand. Current resource enables rheumatology day time cover as a consult only service Monday to Friday (0800-1700) in Starship.

Rheumatologists include: Jacqueline Yan (Starship), Genevieve Ostring (Starship and Waitakere), Anthony Concannon (Starship and Kidz First) and Priscilla Campbell-Stokes (Hutt Hospital).

New referral from any team in Starship

Most paediatric rheumatological diagnoses are "diagnosis of exclusion", thus it is unlikely that any new referrals will go directly from CED to the rheumatology team:

  • Children and young people who may have a rheumatological diagnosis will most often be admitted under the general paediatric, orthopaedic, infectious disease or renal team
  • Consultation requests will be accepted from any team in the hospital
  • Refer to 'Rheumatology Service appropriate referral criteria' for more detailed information
  • Any patient will be accepted for review, if the referring team can provide clear rationale as to the reasons for their request for review.

New referral urgency criteria

Contact the paediatric rheumatology registrar or on call paediatric rheumatologists early in the morning for any urgent review such as:

  • CNS disease such as seizures, confusion, psychotic episodes (CNS SLE, other vasculitides)
  • Respiratory compromise such as pleural effusions, pulmonary haemorrhage, interstitial lung disease , (SJIA, SLE, JDM, other vasculitis)
  • Cardiac complications such as pericardial effusions, arrhythmias, myocarditis (SJIA, SLE, other vasculitis)
  • Swallowing difficulties (JDM)
  • Suspected macrophage activation syndrome (MAS or secondary haemophagocytic lymphohistiocytosis, HLH) with e.g. fever, hyperferritinaemia, cytopenia and hepatic dysfunction
  • Suspected vasculitis

As many paediatric rheumatological diseases are diagnoses of exclusion, further time may be the most helpful diagnostic aid, and, as such, at times an outpatient review in clinic may be more useful. Conditions that are likely to need time and other investigations to exclude other diagnosis include:

  • Initial diagnosis of JIA (including Systemic JIA, provided life threatening complications as above are not present) as diagnosis requires 6 weeks of symptoms and other diagnosis (such as rheumatic fever) to have been ruled out
  • SLE (provided no life threatening complications as above)
  • JDM (provided no life threatening complications as above)
  • CRMO (Chronic Recurrent Multifocal Osteomyelitis) or NBO (Non Bacterial Osteomyelitis)
  • Auto-inflammatory conditions

In such cases the responsibility of ongoing care remains with the referring team. A plan should be clearly documented and should have been discussed with the rheumatologist of the day. It should be documented who it was discussed with.

Inpatients who are about to be discharged are not considered as requiring an urgent review and will be scheduled an outpatient appointment. Patients will not be able to be "brought back" the next day for a rheumatology review unless specifically discussed and agreed to, with the paediatric rheumatologist who will be reviewing the patient the following day.

Consultations Monday - Friday 0800-1700

A written or email referral is required with a specific question, with a summary of the course and investigations to date.

Referrals can be made through the Rheumatology registrar or Paediatric Rheumatologist of the day.

The Paediatric Rheumatologist of the day will discuss or review the patient as soon as is feasible, depending on the urgency, and formulate an opinion and suggested management plan.

If the patient is seen as an inpatient, an inpatient consultation letter will be generated by the Rheumatology registrar or Paediatric Rheumatologist to be determined at the time of review.

Consultations: weekends, public holidays, Mon-Friday 1700-0800

Non urgent referrals should be made during the first available working day (Monday to Friday 0800-1700) for discussion and review.

If inpatient review is required more urgently then all children should first be discussed with the General Paediatric registrar and/or the on call consultant for the most appropriate team. In the majority of cases this will be the General Paediatrician but occasionally another subspecialty service maybe more appropriate.

Timing of rheumatology review

Inpatients referrals will usually be seen within 1-3 days (depending on when referred) but please see above in regards to some instances where it is more useful to book into rheumatology outpatient clinic.

Outpatient clinic referrals will be seen within 12 weeks (depending on urgency at triage of referral).

New referrals with JIA will ideally be reviewed within 1 month of receiving the referral.

Patients known to the Rheumatology Service

  • There is currently no after hours on call rheumatology cover
  • Patients known to the National Rheumatology team requiring admission to Starship Hospital should be admitted after hours to the General Paediatric Team
  • At times it may be appropriate to admit under another involved sub-speciality team (e.g.child with SLE with renal lupus with a flare of their renal disease would be admitted under the Starship Renal team).
  • This usually involves discussion between the other sub-speciality and the General Paediatrician.
  • Rheumatology patients admitted for day procedures only (such as to Day Stay Unit) will be admitted under the paediatric rheumatologist on for the day
  • If patients initially admitted for the day only, need overnight admission, they will need to be discussed with and then admitted under the general pediatrician of the day.

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Document Control

  • Date last published: 09 February 2018
  • Document type: Other
  • Services responsible: Paediatric Rheumatology
  • Editor: Greg Williams
  • Review frequency: 2 years

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