• The following guidelines have been agreed by Chiefs of Service, Chief Medical Officer and Chief Executive Officer.

• This Guideline outlines the principles of emergency referral to the correct clinical team.

• In the event of dispute, clinical judgement may be exercised following discussion at Consultant level.

• Admission should not be delayed, and the ED Consultant will adjudicate if required.

• Subsequent referral after admission to the relevant ward or specialist team should be at Consultant level and/or accepted by a Consultant.

• Patients arriving to either ED with a GP letter, will be seen by the specialist team identified or most appropriate specialist team. If not needing emergency care, patients arriving from a GP should be seen in a speciality SDEC (where capacity allows)

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

• Patients with post-operative complications related to a recent procedure (e.g., pain/infection) should be assessed and, if needed, admitted by the Operating speciality.

• All upper and lower limb DVTs should be admitted to Medicine (Ambulatory Care pathway). Clot extending into the iliofemoral, axillary and subclavian veins should be discussed with Vascular Surgery: If clot thrombolysis or vascular intervention is required and accepted by the patient, these patients will be admitted under the Vascular team. Pregnant or breast-feeding women should be referred to Obstetrics as well: may place on Maternity if admission required.

• Post-operative PE/DVTs or chest infections are admitted to Medicine; the surgical team should be informed.

• Patients with abscesses should be admitted under the appropriate Surgical speciality. Truncal abscesses are referred to EST, perianal abscesses are referred to EST. Head and neck abscesses are referred to ENT. Limb abscesses are referred to orthopaedics.

• Patients with abdominal pain of unknown cause or bowel obstruction are admitted to Surgery whether or not they are fit for theatre or require an operation. The following exceptions apply:

  • Lower abdominal pain in women in the presence of gynaecological symptoms (e.g. PV bleeding), or in those with a previous gynaecological diagnosis (e.g. endometriosis) should be referred and admitted to gynaecology.

  • Abdominal pain in those with a previous diagnosis of inflammatory bowel disease should be referred to gastroenterology, unless there is immediate evidence of bowel obstruction or intestinal perforation.

  • Children under the age of 5 years should be referred to Paediatrics, although a surgical opinion can be sought for patients of any age.

• For surgical patients with a secondary diagnosis requiring medical input (e.g., fast AF), Medicine will see the patient and advise on the surgical or orthopaedic wards. Surgical teams remain responsible for care.

• Patients with sequelae of cancer who are currently under the care of a surgical team are admitted to Surgery. Patients undergoing oncological treatment (i.e., chemo/radiotherapy) will be admitted to Medicine, and any related surgical/gynaecological team should also be informed.

• Patients with urinary retention, gross haematuria and/or clot retention, or obstructive uropathy requiring admission are admitted to Urology (via general surgery on-call). Patients with acute renal failure (AKI) of other causes (or those needing ADU/ITU) and pyelonephritis without obstruction are admitted to Medicine.

• Gastrointestinal bleeding: patients who present with bright or dark red blood per rectum, clots per rectum or blood mixed in with the stool and who need admitting are admitted under the Surgeons at Wexham Park Hospital and under the Medicine team at Frimley Park Hospital. At both sites, if perianal conditions cannot be managed by ED clinicians, referral to SEU should be made (EST out-of-hours). Please refer to the: Lower Gastrointestinal Bleeding and Upper Gastrointestinal Bleeding guidelines for further details.

• 16- & 17-year-old patients known to paediatrics presenting with a medical condition not yet transitioned into adult care, refer to Paediatrics.

• 16- & 17-year-old patients not known to paediatrics with a new medical problem should be referred to adult Medicine except a new diagnosis of Diabetes or Cancer, who should be referred to Paediatrics.

• 16- & 17-year-old patients presenting with a surgical / orthopaedic / gynaecological problem should be referred to these teams. Paediatrics may also be informed if the patient is known to them.

• 16- & 17-year-olds requiring assessment by CAMHS requiring admission in exceptional circumstances prior to CAMHS assessment should be referred to adult Medical take.

Frimley Park

• Patients with fractures, musculoskeletal injuries or back pain unable to go home are admitted to Orthopaedics, even if operative treatment is inappropriate.

• Acute head injuries are admitted to Surgery.

• Upper limb cellulitis involving the forearm or hand should be admitted to Orthopaedics.

• Other upper and lower limb cellulitis should be referred to Medicine (Ambulatory Care pathway).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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