For Referring Practitioners

  1. Purpose and scope
  2. Who This Clinic Sees
  3. Who We Do Not See
  4. How Triage Works
  5. Triage Categories and Targets
  6. Minimum Referral Information: Inflammatory Arthritis
  7. Minimum Referral Information: Ankylosing Spondylitis
  8. Minimum Referral Information: Connective tissue disease (e.g., Lupus)
  9. Common Reasons for Redirection
  10. When to Re-Refer
  11. Phone Advice Line

Purpose and scope

Our goal is to accurately triage and book the right patient into the right slot, with minimal back-and-forth. This guidance applies to adult patients. Pediatric cases should be referred to pediatric rheumatology.

Who This Clinic Sees

  • Rheumatoid arthritis
  • Seronegative spondyloarthritis
    • Psoriatic arthritis
    • Ankylosing spondylitis
    • Inflammatory bowel disease related arthritis
    • Reactive arthritis
  • Polymyalgia rheumatica
  • Crystal arthritis (gout, pseudogout)
  • Connective tissue disease
    • Lupus
    • Sjogren’s disease
    • Scleroderma
    • Dermatomyositis
    • Mixed connective tissue disease
    • Undifferentiated connective tissue disease
  • Vasculitis
    • ANCA vasculitis
    • Giant cell arteritis
    • Behcet’s disease
    • Other vasculitidies (e.g., polyarteritis nodosa, Takaysu arteritis, etc.)
  • Sarcoidosis
  • IgG4 related disease
  • Autoinflammatory disease (e.g. Adult Onset Still’s disease, Familial Mediterranean Fever)

If unsure, you are welcome to refer — triage decisions are based on the information available at the time.

Who We Do Not See

  • Osteoarthritis
  • Fibromyalgia
  • Mechanical or soft-tissue pain syndromes
  • Chronic pain
  • Chronic fatigue
  • Osteoporosis
  • Heritable connective tissue disease (e.g., Ehler’s Danlos, Marfan)
  • Idiopathic uveitis
  • Idiopathic pericarditis
  • Unexplained elevated CRP
  • Positive blood tests without specific symptoms of a rheumatic disease
    • e.g. Low titer positive ANA without specific symptoms of lupus

How Triage Works

Referrals may result in:

  • Acceptance and booking
  • Request for additional information
  • Redirection to another pathway, with clear re-referral criteria if symptoms evolve

All three outcomes are expected parts of the triage process.

Triage Categories and Targets

Urgent (less than 1 month)

  • Giant cell arteritis
  • Organ-threatening connective tissue disease or vasculitis
  • Severe inflammatory arthritis
    • Joint swelling on exam
    • Rapid functional decline
    • Markedly elevated CRP
    • +/- positive RF, CCP

If your patient has a medical emergency, call the office at (250) 824-0266 or have the patient go directly to the emergency room. Our faxes are not monitored during office closures, which can result in delays in care.

Semi-urgent (3-4 months)

  • New onset inflammatory arthritis
    • Joint swelling on exam
    • Morning stiffness over 1 hour
    • Elevated CRP
    • +/- positive RF, CCP
  • Ankylosing spondylitis
  • Non-organ threatening connective tissue disease
  • Polymyalgia rheumatica
  • Sarcoidosis
  • IgG4 related disease

Routine (6-12 months)

  • Transfer of care from another in-province rheumatologist
  • Sjogren’s disease
  • Crystal arthritis (gout, pseudogout)

Minimum Referral Information: Inflammatory Arthritis

We require a minimum amount of information to accurately triage referrals. For inflammatory arthritis, please ensure your referral includes the following information.

Incomplete referrals will be returned to the referring provider.

  1. Reason & urgency (1 line)
  2. Symptom summary
    • Onset
    • Joints involved
    • Morning stiffness (minutes)
  3. Physical exam noting any joint swelling
  4. CRP
  5. RF
  6. +/- anti-CCP (if covered by MSP)
  7. X-rays of affected joints

Minimum Referral Information: Ankylosing Spondylitis

We require a minimum amount of information to accurately triage referrals. For ankylosing spondylitis, please ensure your referral includes the following information.

Incomplete referrals will be returned to the referring provider.

  1. Inflammatory back pain (see below) and
  2. Onset before age 45
  3. Relevant associated diseases
    • Uveitis
    • Crohn’s disease or ulcerative colitis
    • Psoriasis
    • Family history of ankylosing spondylitis
  4. HLA B27
  5. CRP
  6. X-ray of the sacroiliac joints
  7. +/- MRI of the sacroiliac joints

Features of inflammatory back pain:

  • Morning stiffness over 1 hour
  • Nocturnal awakening due to stiffness (not pain)
  • Alternating buttock pain
  • Improves with NSAIDs
  • Improves with activity

Minimum Referral Information: Connective tissue disease (e.g., Lupus)

A positive ANA can be seen in healthy people who do not have connective tissue disease. It is a non-specific test and should only be ordered if there is a high clinical suspicion of connective tissue disease.

IReferrals are accepted if there are specific signs or symptoms of connective tissue disease (see below) and the appropriate lab work has been completed.

Incomplete referrals will be returned to the referring provider.

  • Specific signs/symptoms
    • Photosensitive rash (differentiate from rosacea)
    • Joint swelling on exam
    • Pleuritis or pericarditis
    • Oral ulcers
    • Significant dry eyes and/or dry mouth
    • Alopecia
    • Raynaud’s phenomenon +/- digital pits or ulcers
    • Skin thickening
    • Proximal muscle weakness on exam
    • Recurrent miscarriages, venous thromboembolism or stroke
  • Labs
    • CBC + diff, Cr, eGFR, ALT, AST
    • ANA, ENA, dsDNA, C3, C4
    • CRP, CK
    • Urinalysis, urine ACR

Common Reasons for Redirection

Referrals may be redirected when:

  • There is no joint swelling
  • Clinical pattern is non-inflammatory
  • Symptoms fit non-rheumatic disease, e.g., osteoarthritis or fibromyalgia
  • Morning stiffness is not prolonged (less than 60 minutes)
  • The symptoms are not specific for rheumatic disease
    • e.g., “fatigue”, joint pain/”polyarthralgia”, “rash”
  • Inflammatory markers are normal
  • Serology is normal

Redirection is intended to:

  • Keep the patient moving
  • Avoid unnecessary waits
  • Support reassessment if symptoms evolve

When to Re-Refer

Please re-refer using the inflammatory arthritis minimum set if new or evolving features develop:

  • Persistent and objective joint swelling
  • Morning stiffness over 60 minutes
  • Rising CRP or ESR
  • Positive RF or CCP

Evolving inflammatory patterns are prioritized.

Phone Advice Line

If you are not sure whether your patient requires a consultation or you are looking for phone advice, a rheumatologist can be reached via Rapid Access Consultative Expertise (RACE)

Number: (604) 696-2131 or use the RACEapp+

Hours: Monday to Friday, 9:00 AM to 5:00 PM

https://www.raceconnect.ca/