Montréal West Island CIUSSS | Comprehensive approach

1. Validate the general inclusion and exclusion criteria

General inclusion and exclusion critera for Access Clinic

The Clinical Access Service is an ambulatory service. To ensure its proper operation, it is important to consult the information below.

General inclusion criteria

General exclusion criteria

18 years of age and over.
Ambulatory clientele:
- Ability to mobilize alone or with the help of one person.
- Does not require hospitalization or observation time on a stretcher.
Stable clinical condition (and / or symptoms) of a sub-acute nature as per the conditions listed in the Access Clinic's preprinted individual orders registry.
Referral form completed and signed by the referring doctor or nurse practitioner.
Commitment of the referring physician (or nurse practitioner) to follow-up with the patient throughout the period of care (himself or a colleague he/she has identified).

Known pregnancy (exception if inherent condition ex 1^st trimester bleed).
Unstable medical condition.
Requiring urgent support (<24 hours).
Unstable mental health condition or cognitive impairment.
Requiring the help of 2 people or a medical ergo-lift to mobilize.
Absence of an identified physician or nurse practitioner to monitor and follow the patient’s care.
One or more exclusion criteria specific to the clinical condition listed in the Access Clinic's preprinted individual orders registry.

2. Validate the specific inclusion and exclusion criteria

All diagnostic tests, examinations and consultations with specialists stated in the algorithms will be managed by the Clinical Access Service team according to established clinical timelines.

It is not necessary to send requests for these examinations with the referral request.

Biliary colic

Consult the algorithm

Specific inclusion criterias:

Present signs of biliary colic

Specific exclusion criterias:

Infection signs: Intense sweats, shivers, fever
Intense pain for more than 12 h, not alleviated by analgesics
Active and known liver disease
Severe hematologic disorder
Patient taking immunosupressants
Ascites

To be filled out / given to the patient

Please print, fill out and fax the referral form.
The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Renal colic

Consult the algorithm

Specific inclusion criterias:

Present signs of nephritic colic

Specific exclusion criterias:

Signs or urosepsis: shivers, fever, nausea, vomiting, tachycardia
Intense pain for <12 h, not alleviated by analgesics
Patient taking immunosuppressants
Kidney disease or single kidney

To be filled out / given to the patient

Please print, fill out and fax the referral form.
The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Hematuria

Consult the algorithm

Specific inclusion criterias:

MD/NP sends report of urinalysis which confirms hematuria

Specific exclusion criterias:

Signs or urosepsis: shivers, fever, nausea, vomiting, tachycardia
Anuria (macroscopic obstructive hematuria)
Intense pain for > 12h, not alleviated by PO analgesics
Patient taking anticoagulants or immunosupressants
Kidney disease or single kidney

To be filled out / given to the patient

Please print, fill out and fax the referral form.

The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Restrosternal chest pain

Consult the algorithm

Specific inclusion criterias (min of 1 out of 3):

Substernal chest discomfort of characteristic quality & duration
Discomfort provoked by exertion or emotional stress
Discomfort relieved by rest or nitroglycerin within minutes

Specific exclusion criterias:

According to the Canadian Cardiovascular Society classification: Grade III or IV angina
Chest discomfort within the last 12 hours
Hemodynamically unstable
Crescendo pattern
Known aortic stenosis

Exclusion criterias for stress test:

Pt on B-blocker, Cardizem or Verapamil
Arthritis to knee, hip or back
Lumbar stenosis
Patient not able to walk independently
LBBB

To be filled out / given to the patient

Please print, fill out and fax the referral form.

The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Rectorrhagia

Consult the algorithm

Specific inclusion criterias:

Significant blood loss (toilet water completely red)
Referring MD/NP must do a rectal exam and write findings on reference form

Specific exclusion criterias:

Hemodynamic instability: tachycardia, hypotension
Severe abdominal pain not relieved by PO analgesics
Patient at risk of cardiac instability (ex: with implantable cardioverter-defibrillator, mechanical heart valve, CHA2DS2-VASc ≥ 3, LVEF ≤ 35%, etc.)
Repeated vomiting
Hematemesis
Fever > 38.5 °C
Melena, maroon stool
≥ 2 episodes of significant rectal bleeding in last 12 h

To be filled out / given to the patient

Please print, fill out and fax the referral form.

The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

First trimester vaginal bleeding

Consult the algorithm

Specific inclusion criterias:

< 13 weeks pregnancy

Specific exclusion criterias:

>1 sanitary napkin/Hour
Hemodynamically unstable
Abdominal pain not relieved with PO analgesia
Fever > 38,5 °C oral

To be filled out / given to the patient

Please print, fill out and fax the referral form.

The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Suspected transient ischemic attack (TIA) > 48 H

Consult the algorithm

Specific inclusion criterias:

Transient unilateral motor weakness
Transient unilateral sensory deficit
Transient speech difficulty, expressive or receptive
Transient monocular vision loss

Specific exclusion criterias:

Brief symptoms (<1 min)
Extremity numbness accompanied by pain
Isolated vertigo that is positional
Stereotypical and frequently recurring symptoms over he past weeks
Migraine with aura
Progressive gait difficulty
Generalized weakness
Isolated memory/cognitive decline

To be filled out / given to the patient

Please print, fill out and fax the referral form.
The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Suspicion of diverticulitis

Consult the algorithm

Specific inclusion criterias:

Patient is experiencing NEW LLQ (left lower quadrant) pain >24h
The following symptoms are common: Nausea / vomiting, fever > 37.5°C , constipation or change in bowel habits

Specific exclusion criterias:

Signs of shock: hypotension, tachycardia, desaturation
Intense pain not relieved by PO analgesia
Signs of peritonitis: Abdominal rigidity, rebound tenderness upon abdominal palpation, absence of peristalsis

To be filled out / given to the patient

Please print, fill out and fax the referral form.
The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Suspected artial fibrillation (AFIB) > 48 H

Consult the algorithm

Specific inclusion criterias:

Presents signs and symptoms of AF (palpitations, tachycardia, fatigue, weakness, lightheadedness, mild dyspnea)

Specific exclusion criterias:

Signs of hypoperfusion
HR > 120 beats/min
AF < 48 h
Syncope
Signs of ischemia: angina, ↑ chest pain
Signs of severe heart failure: panting, palpitations, lipothymia
Patient with mechanical heart valve
Symptoms of TIA/stroke or previous event: partial paralysis, paralysis, numbness, aphasia, visual/cognitive impairment
Significant arrhythmia
- Ventricular tachycardia
- Ventricular fibrillation
- Polymorphic ventricular tachycardia
- Ventricular flutter
- Idioventricular rhythm
- Paroxysmal supra-ventricular tachycardia
- AV block 2^nd degree Mobitz 2 or 3^rd degree
- Wolf-Parkinson-White syndrome

To be filled out / given to the patient

Please print, fill out and fax the referral form.
The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

Suspected deep vein thrombosis (DVT)

Consult the algorithm

Specific inclusion criterias:

Referring MD/ NP must specify Wells Score for the patient on the referral sheet.

Specific exclusion criterias:

Febrile > 38,5 °C
Hemorrhage/peptic ulcer within the last 3 months
Kidney failure (eGFR <30)
Severe liver failure (AST > 37 IU/L, ALT >41 IU/L)
Patient anticoagulated
Active bleeding
Thrombocytopenia < 50 X 10⁹/L
Signs of pulmonary emboli: Sudden chest pain (CP) or CP ↑ on deep breath, HR ≥100bpm, RR ≥22/min, O2 Sat<92% (unless chronic)
Recent CVA
Concomitant use of drugs that are strong CYP3A4 inhibitors and P-GP inhibitors (ex : antiepileptic, Amiodarone, Diltiazem, Omeprazole)

To be filled out / given to the patient

Please print, fill out and fax the referral form.
The patient handout and the appointment trajectory should be printed and given to the patient.

Print the document

3. Fill out the referral request form and the prescription

Please print and fill out the referral request form if the user’s condition meets all the criteria.

Pay particular attention to the clinical score, if necessary, to ensure that the Clinical Access Service team carries out an investigation that is appropriate and relevant.

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4. Submit the documents and get the results

Send the documents intended for the Clinical Access Service by fax to the number on the referral request form.

During the course of the next business day, a nurse from the Clinical Access Service should contact the user to start the care episode.
The nurse will contact the referring physician if there are significant abnormalities unrelated to the clinical condition or discrepancies.
You will also get updates on the progress of the patient’s care episode.

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