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Bay of Plenty

Find the referral acceptance for neurology in the Bay of Plenty.

Referral acceptance

Referral acceptance

Medical neurology

Category definition
Emergencies Immediate  In patient neurology 
Waiting times Urgent OPD grade 1
  Semi-urgent OPD grade 2
  Unable to be seen OPD grade 3
  Unable to be seen  OPD grade 4  
  Neurophysiology see below

 

Category

Signs or symptoms

Examples (not an exhaustive list)

Local notes

Emergencies

Immediate assessment via ED and medical teams
  • Sudden onset life threatening conditions
  • Persistent loss of consciousness
  • Signs of raised intracranial pressures
  • Rapidly evolving paralysis any distribution, any cause, with or without respiratory difficulty, loss or disturbance of sphincter functions
  • Sudden severe first ever headache
  • Stupor and coma or acute confusional states eg suspected encephalitis
  • Subarachnoid haemorrhage
  • Myasthenia gravis,
  • Guillain-Barré syndrome
  • Spinal cord compression or cauda equina syndrome
  • Meningitis
  • Stroke
  • Status epilepticus
  • Serial TIA's with high ABCD2 score

Neurological problems requiring urgent assessment or admission should be referred to the medical team of the day or the emergency department.

There is no acute specialist neurology service at TPH.

Please make use of the TIA guidelines.

 

Outpatient referrals

Urgent (OPD grade 1)
  • Any sub acute evolving or episodic neurological dysfunction with a potential for serious neurological impairment (usually over days to weeks)
  • Recurrent  seizures not needing admission
  • Focal  neurological disturbances
  • Acute cranial nerve palsy such as optic neuritis, diplopia.
  • Idiopathic intracranial hypertension or other headache with relevant neurological signs
  • New onset headache with neurological signs

In the absence of a neurologist due to leave, the physician on call should be contacted for advise

Semi-urgent (OPD grade 2 priority)
  • Progressive loss of neurological function (slower rate than 2)
  • Unsteadiness, poor balance without identified cause
  • Dysphagia
  • Cognitive impairments (especially less than 65 years)
  • Hyper and hypo kinetic movements
  • Symptoms suggestive of: multiple sclerosis; neuropathies; myopathy; motor neuron disease
  • Isolated seizures, transient amnesia
  • Trigeminal neuralgia
  • Parkinsonism
  • Functional disorders, with abnormal examination - suspected somatisation disorder

The better the referral history and examination findings the more likely the patient is to be seen appropriately. This especially means copies of prior specialist reviews.

Unable to be seen (OPD grade 3)
  • Chronic neurodegenerative disorders: acquired or inherited (slow rate of progression or long history)
  • Suspected Alzheimer's disease or other dementias
  • Intellectual handicap, cerebral palsy not  graded elsewhere

The key ingredients in your referral letters are the nature of the symptoms, their mode of onset and their time course.

ACC issues: The GP should ask the ACC to refer for a neurological opinion. The ACC case manager will usually chose a private provider.

Insurance, driving and other medico-legal type reports are not seen in public hospital clinics. 

Unable to be seen (OPD grade 4)
  • Primary headache including migraine and muscle tension headache
  • Episodic isolated vertigo
  • Simple Syncope
  • Dizziness not otherwise specified
  • Limb pain, neck, back pain or  other chronic pain without neurological signs
  • Fatigue NOS
  • Elderly neuropsychiatry
  • Second, third and subsequent neurological opinions
  • Screening for aneurysms

 

 

Referrals for neurophysiological investigations

 

Nerve conduction studies and EMG

Will be accepted from general practitioners, e.g. Possible CTS, as long as waiting time remain less than 6 months.

These will be graded, depending on the setting, by consultant staff as  a) Priority or b) routine

ACC cases not performed at TPH (private providers, Hamilton).

EEG

Usually performed in conjunction with an outpatient clinic or referral. 

Occasional EEG requests from General Practitioners will be performed without a clinic visit if this seems appropriate, based on the referral. 

See EEG request form for indications for EEG

Transient Ischemic Attack (TIA) - Clinical pathway guidance

Transient Ischemic Attack (TIA) - Clinical pathway guidance

Background

A TIA (Transient Ischemic Attack) is defined as stroke symptoms or signs that resolve within 24 hours (the majority resolve within 1 hour). A TIA is characterised by a sudden, focal neurological deficit that spontaneously resolves.

Assessment

  1. Typical symptoms of TIA:
    • unilateral weakness
    • unilateral altered sensation
    • dysphasia
    • monocular blindness
    • hemiamopia.
  2. Symptoms not typical of TIA:
    • confusion (exclude dysphasia)
    • impaired consciousness or syncope
    • dizziness or lightheadedness
    • generalised weakness or sensory symptoms
    • bilateral blurred vision or scintillating scotoma
    • incontinence: bladder or bowel
    • amnesia.
  3. Other symptoms:
    • ataxia
    • vertigo
    • dysphagia
    • dysarthria
    • sensory symptoms to part of one limb or the face may be consistent with TIA if they occur in conjunction with other typical symptoms.
    • NB: Transient loss of consciousness ('blackout') without focal neurological symptoms or signs is NOT a TIA.
  4. FAST Screening Test
    • FACE - ask the patient to smile. Is there a facial droop on one side?
    • ARM - ask the patient to raise both arms to 90 degrees. Is there a weakness on one side?
    • SPEECH - is there a new speech disturbance eg slurring, word-finding difficulties or difficulty naming objects?
    • TIME - if the patient has any of these signs at the time of assessment, get to hospital FAST. They may be eligible for thrombolysis. Early intervention in stroke makes a difference.
  5. The FAST screening test looks for signs of stroke in the carotid (anterior) circulation. Remember that posterior circulation strokes also need to be admitted to hospital.
  6. Clinical features of TIA/stroke with arterial territory:
    1. Anterior (carotid) circulation:
      • cortical dysfunction (ie dysphasia, sensory or visual inattention, hemianopia)
      • monocular blindness
      • unilateral weakness
      • unilateral sensory disturbance Dysarthria*
      • neuromuscular dysphagia*
    2. Posterior (vertebrobasilar) circulation:
      • cranial nerve palsy Ataxia/inco-ordination
      • diplopia Isolated homonymous hemianopia
      • bilateral visual loss
      • unilateral/bilateral weakness
      • unilateral/bilateral sensory disturbance
      • dysarthria*
      • neuromuscular dysphagia*

Management

  1. If the patient still has symptoms or signs of stroke at the time of assessment, they need to be admitted to hospital immediately. The patient may need urgent thrombolysis or other intervention. Phone stroke physician or medical team on duty.
  2. This pathway recognises that some patients present late. If a patient has probably had a stroke and presents after 2 weeks or more, they can be referred to the TIA Clinic instead (in the absence of any other reason for admission).
  3. Assess risk:
    • Is the ABCD2 score 4 or more? Please see scoring guideline below.
    • Is the patient in AF?
    • Has the patient had more than one TIA in the last week?
    • Is the patient anti-coagulated?
  4. If yes to any one of these questions treat as high risk and admit to hospital:
    • In WBOP phone the stroke registrar, or on-call medical registrar after hours at Tauranga Hospital: 
      • Phone: 027 268 8658. They are available Monday to Friday, 8am to 4pm. 
    • In EBOP phone on-call physician at Whakatane Hospital.
  5. If no to all four risk questions, treat as low risk:
    • In WBOP, refer to TIA service at Tauranga Hospital. Complete e-referral on BPAC, and inform patient that they may receive a phone call from the hospital stroke specialist.
    • In EBOP, discuss with on-call physician at Whakatane Hospital.
  6. For all low risk patients:
    • Optimise BP control (<140/80, in diabetes <130/80)
    • Lipid control (40-80mg OD atorvastatin)
    • Lifestyle advice (weight, diet etc)
    • Antiplatelets:
      1. 1st line treatment: clopidogrel 75mg OD
      2. 2nd line treatment: if unable to tolerate clopidogrel give low dose aspirin with dipyridamole modified release 150mg BD
      3. 3rd line treatment if unable to tolerate dipyridamole then aspirin low dose monotherapy

ABCD2 score for TIA

Score

    

Age

> 60

1

Blood pressure

>140/90

1

Clinical features

Unilateral weakness

Speech disturbance alone

Other

2

1

0

Duration of symptoms

> 60 minutes

10-59 minutes

< 10 minutes

2

1

0

Diabetes

Present

1