How urgent referrals are handled
Incoming referrals are logged on arrival and reviewed by a dermatologist, who assigns each one a priority based on the clinical information provided. An urgency flag from the referring office is taken seriously, but the priority is set by the dermatologist on the basis of the whole referral. This is why the reason for urgency needs to be written down: a referral marked urgent with no supporting detail cannot be distinguished from a routine one.
Urgent referrals are booked to the earliest appropriate appointment and the patient is contacted directly by telephone. If we cannot reach the patient, we notify the referring office by fax so that the patient can be prompted to call us.
Target times from receipt to appointment for urgent and routine referrals are being confirmed and will be published here.
What is treated as urgent
The standard examples of an urgent dermatology referral are:
- Suspected melanoma. A pigmented lesion with asymmetry, irregular border, more than one colour, a diameter above six millimetres, or a history of change. A lesion that stands out from the patient's other moles.
- A rapidly changing pigmented lesion. Any mole or dark spot that has grown, changed shape or colour, started to bleed, itch or crust over weeks to a few months, regardless of size.
Other presentations that are commonly triaged ahead of routine cases include a suspected invasive non melanoma skin cancer on the face or in an immunosuppressed patient, a widespread or rapidly progressing eruption in a patient who is otherwise well enough for outpatient care, and severe disease causing significant functional impairment. The full list of urgent categories, and the criteria for each, is pending sign off by Dr. Ejaz and will be published once approved. Until then, please describe the clinical picture and we will triage on the description.
What to write on an urgent referral
The dermatologist triaging the referral has only what is on the page. For an urgent referral please include:
- The word URGENT at the top of the referral, and the reason in one line
- Site and size of the lesion, and how long the patient has been aware of it
- What has changed, and over what period
- Symptoms: bleeding, itch, pain, crusting, ulceration
- Personal or family history of melanoma or other skin cancer
- Immunosuppression, including transplant medication and biologic therapy
- An image, with a ruler or coin for scale, and a dermoscopic image if you have one
- Two working telephone numbers for the patient, since urgent bookings are made by phone within days
Call as well as fax
For a lesion you consider highly suspicious for melanoma, fax the referral and then call 905 625 5600 to tell the referral desk it is on its way. This ensures it is pulled for review the same day rather than waiting in the queue with the day's routine referrals.
When to send the patient to emergency instead
An outpatient dermatology clinic is not the right setting for a patient who is acutely unwell. The following presentations need same day assessment in an emergency department, where systemic treatment, fluid management, wound care and inpatient dermatology consultation are available. Please do not fax a referral to us in place of that.
| Presentation | Why it needs emergency care |
|---|---|
| Rapidly spreading rash with fever | May represent a severe infection, a systemic drug reaction or an acute inflammatory emergency. Requires blood work and observation. |
| Widespread blistering or skin peeling | Loss of the skin barrier over a large area carries risks of fluid loss, temperature dysregulation and infection comparable to a burn. |
| Mucosal involvement | Blistering, erosions or pain affecting the mouth, eyes or genitals alongside a rash raises concern for Stevens Johnson syndrome or toxic epidermal necrolysis. |
| Suspected severe drug reaction | A new rash within weeks of a new medication, particularly with fever, facial swelling, lymph node enlargement or abnormal blood work, may indicate a severe cutaneous adverse reaction. Stop the suspected drug and refer to emergency. |
| Rapidly spreading painful red skin with systemic symptoms | Concern for necrotising soft tissue infection, which is a surgical emergency. |
| Purpura with fever or an unwell patient | Concern for meningococcal disease, vasculitis or a bleeding disorder. |
| Rash with airway swelling or difficulty breathing | Anaphylaxis or angioedema. Call 911. |
Where a patient has been seen in emergency and discharged, and dermatology follow up is needed, a referral to us is appropriate and should include the discharge summary. Mark it urgent if the diagnosis remains open.
Upgrading a referral already sent
If a patient's condition changes after a routine referral has been faxed, call the referral desk on 905 625 5600 with the patient's name and date of birth and describe the change. The referral will be re-triaged on the new information. A second fax is not needed unless there are new images or results to add.