Specialist advice, referral and triage

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Overview

Best practice resources for specialist advice, referral and triage

Rheumatology professionals have a key role in the appropriate and timely referral of patients to the right clinical pathway. Better referral management aids rapid diagnosis and initiation of treatment, which ultimately improves patient outcomes.

Specialist advice pre- (supporting referrers) and post-referral (triage) are part of a referral optimisation strategy to ensure that people receive optimal care, by the right team, in a timely way and as close to home as possible.

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Referral criteria

This guidance, developed by clinicians from across the UK, serves to support adult rheumatology departments and primary care colleagues. It provides information on symptoms and signs that might suggest an underlying rheumatological diagnosis that can be helpful to include in referrals. It also provides information on when advice and guidance might be a more appropriate means to seek a rheumatology specialist opinion. The criteria can be adapted by teams to reflect local service provision.

Additional information:

Adult rheumatology referral guidance (BSR contributed to and endorsed this)

Enhanced triage and specialist advice

We have developed standard responses to referrals and requests for specialist advice with input from clinicians and specialists across the UK. These documents are intended to support adult rheumatology departments in responding to common advice requests from referrers. The advice within them is based on NICE and BSR guidelines, as well as prevailing best practice. These documents are to be adapted by departments to reflect local service provision and individual patient circumstances as needed.

ANCA, suspected vasculitis
Anti-osteoporosis treatment in patients receiving glucocorticoids
Dental advice for bisphosphonates and denosumab Osteoporosis

Duration of oral bisphosphonates Osteoporosis

Fibromyalgia

Fracture on treatment

Hypermobile Ehlers Danlos Syndrome (EDS) and Hypermobile Spectrum

Indication for DXA (bone density) scans Osteoporosis

Insufficient Information to triage

Management of Gout

Management of Raynaud’s

Non-specific back pain referral

Polymyalgia Rheumatica (PMR)

Positive ANA
Referral of patients at very high fracture risk Osteoporosis

Rheumatoid factor - anti-CCP antibodies

Suspected axial spondylarthritis referral

Suspected early inflammatory arthritis referral

Suspected Gout

Suspected Osteoarthritis

Suspected Raynaud’s phenomenon

Treatment options for patients with chronic kidney disease Osteoporosis

Additional documents for paediatric and adolescent rheumatology services are in development.

Quality improvement in early inflammatory arthritis

BSR NEIA Audit

NICE quality standards for rheumatoid arthritis require that people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than one joint, are referred to a rheumatology service within three working days of presentation.

A driver diagram developed by clinicians for the BSR National Early Inflammatory Arthritis Audit (NEIAA) details interventions aimed at increasing the proportion of patients referred within three days.

Head to the NEIA audit platform to access the driver diagram

Best practice case studies

BSR best practice award winners are selected on the basis of innovation, service improvement and transformation. We've included two relevant case studies from previous winners as useful resources:

Fast track pathway for GCA (Southend University Hospital)
Giant cell arteritis (GCA) is one of the most common types of vasculitis and can result in irreversible sight loss in up to 25% of cases. Barriers to fast and effective treatment of GCA in clinical practice due to delayed referrals can have a significant impact on patient outcomes. Southend University Hospital NHS Trust pioneered a Fast-Track Pathway (FTP) to ensure a rapid specialist review and initiation of treatment for suspected GCA cases, and to improve public and professional awareness of GCA. Having won a BSR Best Practice Award in 2016, this approach has been sustained by the Trust and adopted by others across the UK.

Best practice case study: Leeds Teaching Hospitals NHS Trust (improving the lives of people with GCA)
Improving time to assessment, diagnosis and treatment of GCA is vital for patients. Leeds Teaching Hospitals NHS Trust won a BSR Best Practice Award in 2022 for taking a collaborative approach to redesigning the care pathway for patients with suspected GCA. Co-designing a new model with the whole MDT team and patients, the trust has reduced the time from referral to a definitive decision on long-term treatment has declined from an average of 28 days to 7 days.
Best Practice Award winner: improving the lives of people with giant cell arteritis (rheumatology.org.uk)

Paediatric enhanced triage and specialist advice

We have developed standard responses to referrals and requests for specialist advice from paediatric and adolescent rheumatology services. These documents are intended to support departments in responding to common advice requests from referrers. The advice within them is based on available guidance and evidence, as well as prevailing best practice. These documents are to be adapted by departments to reflect local service provision and individual patient circumstances as needed.

- Hypermobile Ehlers Danlos Syndrome (EDS) and Hypermobile Spectrum Disorder in Children and Young People
- Management of Raynaud’s in Children and Young People
- Positive ANA in Children and Young People
- Raynaud’s phenomenon in Children and Young People
- Recurrent mouth ulcers
- Suspected juvenile inflammatory arthritis referral
- Suspected vasculitis in Children and Young People