How to Refer a Patient

TIA Service

The flagship, Daily, Weekday, ‘One-Stop’ RASP service for patients in our catchment area with suspected TIAs operates under the co-direction of Prof. Dominick McCabe and Dr. Dan Ryan, in collaboration with our RASP service colleagues.

Please ensure that you include your patient’s name and DOB in the ‘subject information box’ of the email referral and attach the latest compulsory ‘RASP Service e-mail referral proforma’ The form must include your own contact details, and the patient’s details and contact number(s). The proforma has been slightly modified to make the ‘urgent admission criteria’ even clearer, to allow you to type in the information on the proforma which can be saved and sent as an attachment, or to print the proforma as before, handwrite in relevant information, scan and attach the completed scanned document to your email.

The referral will be urgently prioritised by the attending Consultant Neurologist or Stroke Physician who is covering the service. An urgent appointment will be offered, if deemed appropriate for the RASP service based on the information on the RASP referral proforma and any attached documentation which you may decide to send. We aim to allocate an appointment within 24 hours to urgently assess these patients. You will be contacted by our team if an alternative referral pathway is advisable for your patient. Prof Dominick McCabe / Dr Allan McCarthy (Vascular Neurology) will run the clinic service one week, and Dr Dan Ryan / Prof Rónán Collins / Prof Tara Coughlan / Prof Des O’Neill / Dr James Mahon (ARHC/Stroke Service) will run the service the following week.

All TIA patients with ‘high risk’ clinical features should be referred to ED for urgent assessment with a view to admission with the revised TUH RASP referral proforma regardless of their ABCD² Score, as should all suspected TIA patients with an ABCD² Score of ≥ 4. ‘Lower risk TIA patients’ who do not fulfil any of the high risk admission criteria, and who have an ABCD² Score of 0-3, should be referred by e-mailing the web-based email-RASP referral proforma to RASP@tuh.ie each day from Monday at 9am to Friday at 12pm.

This email account will not be checked after 12pm on Fridays or at weekends. Therefore, because TIAs are medical emergencies, all suspected TIA patients in the catchment area seen by their GP / Emergency Department (ED) staff at the weekend from 12pm on Friday to 9am on Monday, regardless of their ABCD² Score, also need to be referred to the ED that day for assessment and possible admission under the medical team on call if a TIA is confirmed (a low threshold for referral to the medical team is recommended). The ED / medical team will initially investigate, treat and subsequently refer patients to the RASP / Stroke Service, as appropriate, on Monday am. Specific arrangements for Bank Holidays will be posted on the website in advance. Following assessment by RASP service staff, urgent decisions re management and secondary prevention, including anti-thrombotic therapy, will be made and communicated to the referring doctor. 

Central Referrals Office

The TUH Outpatients’ Department runs over 100 clinics across 30 Adult specialties, this excludes nurse, technician and Allied Health Professional clinics. The Department holds consultations with approx 132,000 patients every year. Clinics are scheduled to run from 8:30am to 5pm, Monday to Friday weekly, with morning & afternoon sessions. The Hospital only accepts GP referrals through the HSE National eReferral system called Healthlink. 

PLEASE NOTE From Monday, January 13th 2025 the Central Referrals Office (CRO) in the Hospital will only accept out-patient referrals from GPs via Healthlink. If a GP sends a referral to the CRO in TUH via post or email, the referral will be returned to the GP and they will be advised to create the OPD referral via Healthlink.

Accessing our outpatient clinics

To obtain an appointment within the TUH Outpatient Service, a patient must first have a referral from one of the following sources of referral.

• General Practitioner (GP)
• Emergency Department
• Consultant to consultant
• Inpatient referrals originating from an admission
• Other Hospitals or Health Centres
• National and regional specialist clinics including National Cancer Control Programme

How are referrals submitted?
GP Referrals can be submitted to the department electronically via www.Healthlink.ie

 What happens after we receive the referral?
The referral is assessed by the consultant team and issued with a priority. The priority is based on clinical need. An appointment date is issued based on the clinical priority. Note that waiting times vary depending on the specialty.

If referral is routine priority, the patient is added to a routine waiting list and will be notified of the routine priority. Confirmed appointment dates are issued six to eight weeks before the confirmed date. Please be aware that different specialties have different waiting times for their waiting lists.

If referral is urgent priority: The Patient is added to an urgent Outpatient waiting list and an appointment will be offered in chronological order. Please be aware that different specialties have different waiting times for their waiting lists.

The following services will accept direct referrals from GP’s:

Atrial Fibrillation

Don’t Wait! Stroke prevention in newly diagnosed Atrial Fibrillation (AF)

A seven step practical guide
Evidence:  Newly diagnosed Atrial fibrillation is normally confirmed by a 12 lead ECG, rhythm strip, cardiac monitor (e.g. holter) or Interrogation of implanted Device (loop recorder, PPM). Please attach a copy of confirmatory recording when referring to AF Clinic at TUH

Stroke Prevention: Almost all cases of AF pose some risk of stroke and it is important to start anti-coagulation as soon as possible. Before starting anti-coagulation we recommend the following seven step process

1. Assess Stroke risk The recommended stroke risk tool is CHA₂DS_2-VASc score - available online at https://chadsvasc.org/ 

2. Who should I anti-coagulate? Based on the CHA₂DS_2-VASc score the following is the current ESC guidance. 

* Men with a score of 0 and women with score of 1 still have some risk of stroke and need a specialist opinion.

3. What is the risk of bleeding? Recommended bleeding risk tool is the HASBLED score. https://chadsvasc.org/ 

In general, caution is advised when using anti-coagulation where the HASBLED score > 3. However the risk of bleeding may not be equivalent in seriousness to a stroke. Discuss with the patient, weigh up risk and advise. (e.g. a previous GI bleed in a patient with remote history of peptic ulcer disease may not be as serious as a stroke)

4. How do I prepare to start Anti-coagulation? Take a detailed medical history and bleeding history. Address factors that increase risk of bleeding before starting anti-coagulation such as:

- Discuss any proposed elective surgery or planned dental work
- Check bloods (renal & liver profile, FBC, coagulation, thyroid function)
- Determine renal function: Patient age, weight and creatinine level is required (Cockcroft-Gault equation - available online at https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation

5. What options do you have regarding anti-coagulants?

ESC recommends a NOAC as first line rather than warfarin. NOACS are renally excreted and below is how to dose them in relation to renal profile https://academic.oup.com/view-large/figure/115896945/ehy136f4.tif

6. Before writing the prescription? Provide patient education and check the patients pre-existing medications for potential interaction or contra-indication. Start anti-coagulation if safe to do so. Make the PCRS application online before the patient's discharge / attendance at clinic. 

7. REFER! Let us know after starting a patient on anti-coagulation
Please refer the patient to the AF clinic as required. The referral form is available through this link. The clinic will see a patient within a four to six week period upon receipt of a referral. 

_{*Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC Endorsed by the European Stroke Organisation (ESO). European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery. 2016.}

Refer for Respiratory Pathways

Respiratory Referral Pathways for Winter for Dublin South West via this link.