Wounds of traumatic aetiology

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Wounds with complex foreign body involvement and significant damage to associated surrounding structures including blood vessels, nerves, muscles, joints and tendons.
• Wounds with associated compound fractures
• Persistent significant bleeding not controlled with usual measures
• Worsening pain and/or pain not in keeping with mechanism of injury
• Initial acute burns should be managed as per ANZBA guidelines
• Refer to Vascular High Risk Foot CPC or Diabetic High Risk Foot CPC

Arterial/ischaemic ulcer

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Sepsis or acutely unwell due to infection3
• Acute or critical limb ischaemia with necrosis
• Rapidly deteriorating ulceration or necrosis.3
• Ulcers or wounds in a limb with markedly compromised circulation

Wounds on the High-Risk Foot

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Progressive cellulitis despite initial treatment
• Acute or critical limb ischaemia with necrosis
• Acute Charcot arthropathy if access to podiatry is not accessible within 48 hours

Stoma related wounds

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Worsening pain and/or pain not in keeping with progression of the wound
• Progressive cellulitis despite initial treatment
• Suspected incarcerated hernia or underlying abscess
• Suspected bowel obstruction resulting in non-functioning stoma
• Persistent significant bleeding not controlled with usual measures
• Stomal change in colour from red / pink to blue or black
• Stomal prolapse causing circulatory compromise
• Bleeding peristomal varices
• Ongoing high output stoma and signs of dehydration

NB: If the problem is with the stomal appliance the patient can self-refer to stomal therapy nurse. Patients not in contact with regular stomal therapy nurse/service can be referred by GP.

Pressure injury

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Pressure injury if causing systemic infection
• Patients with spinal injuries should be referred to Spinal Outreach Team (SPOT)

Post-operative wound/dehiscence

• Systemic inflammatory response symptoms (SIRS) or clinically unwell
• Worsening pain and/or pain not in keeping with progression of the wound/ulcer
• Prosthesis / metal work is on view
• Purulent discharge with associated fevers

Reason for request

• To establish a diagnosis
• For treatment or intervention
• For advice and management
• For specialist to take over management
• Reassurance for GP/second opinion
• For a specified test/investigation the GP can't order, or the patient can't afford or access
• Reassurance for the patient/family
• For other reason (e.g. rapidly accelerating disease progression)
• Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

• Presenting symptoms (evolution and duration)
• Physical findings
• Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
• All conservative options that have been pursued unsuccessfully prior to referral
• Body mass index (BMI)
• Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
• Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use

Patient's Demographic Details

• Full name (including aliases)
• Date and country of birth
• Residential and postal address including whether patient resides at an aged care facility
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Name of delegate and contact details (Department of Corrective Services)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander
• Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature
• Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

• Willingness to have surgery (where surgery is a likely intervention)
• Choice to be treated as a public or private patient
• Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)