OPD Referral & Case Escalation
This page outlines the shared referral and escalation protocols for cases that exceed primary care management capacity or require specialist, emergency, or medico-legal intervention. It consolidates common mechanics (referral letter, Room 8 preparation, ambulance coordination, escort, handover) with summary escalation criteria from all linked units.
Referral Pathways
- (1) Internal Referrals
- (2) Specialist Referral
- (3) ED Referral
- NCD Unit — new case registration, complication screening, uncontrolled chronic disease review
- TB Clinic — case detection, HRG screening, transfer-in verification
- Wound Care Clinic — complex wound review, dressing programme, post-debridement follow-up
- MCH (KKIA) — antenatal booking, postnatal care, family planning, child health
- Fever Clinic — febrile illness assessment, notifiable disease workup
- Physiotherapy — neuropathy, limited mobility, rehabilitation
- Dietitian / Nutritionist — obesity, poor glycemic control, diet-related issues
- Quit Smoking Programme — motivated current or recent smokers
- Methadone Programme — opioid substitution therapy
- Virtual Consultation Services — telehealth follow-up where appropriate
- Social Services — safeguarding, financial support, carer assessment
- All internal referrals are managed through the Register Special Services Hub in SystmOne.
- Send a TASK to the receiving team to alert them of the referral.
- Print the referral form and provide the patient with clear instructions on date, location, and preparation.
- Use the standard referral template in SystmOne to prepare the referral letter.
- Certain clinics have dedicated templates: Eye Clinic, ECHO referral.
Print and direct the patient to Hospital Pakar Sultanah Fatimah (HPSF) Muar.
For urgent cases, contact the receiving Medical Officer or Specialist directly by phone before sending the patient.
Referral letter validity: 2 weeks from the date of issue.
General specialist clinics: medical, surgical, orthopaedic, ENT, ophthalmology, cardiology, etc.
TB treatment failure, MDR-TB, severe extrapulmonary TB, complicated HIV-TB, paediatric TB.
Deep partial-thickness or full-thickness burns, inhalational injury, electrical/chemical burns, %TBSA thresholds.
Complex wounds with exposed structures, facial lacerations, diabetic foot with vascular compromise, necrotising infections.
Life-threatening conditions, severe sepsis, ACS, stroke, severe asthma/COPD exacerbation, major trauma, anaphylaxis, status epilepticus, severe dehydration, ectopic pregnancy, antepartum haemorrhage, NSTI / gas gangrene.
Follow the accompanied transfer protocol. Escort depends on referring unit (see Escort Rules below).
Arrange ambulance transport if clinically indicated. If clinic ambulance is unavailable, MA calls 999 or requests ED HPSF Muar ambulance dispatch.
- Ensure the SystmOne referral letter accompanies the patient.
- Doctor must auto-allocate patient to Emergency Rota for proper case transfer.
- MA / Nurse must document ED Referral in the procedure template for workload tracking.
- Phone ED to alert the receiving team of the incoming patient.
- In emergency or infectious disease cases, MO must inform ED MO on-call of patient condition.
ED Referral Preparation Protocol
Doctor completes assessment
- Patient is assessed as requiring ED referral or urgent specialist transfer.
- Document clinical findings, working diagnosis, procedure summary (if relevant), and referral reason in SystmOne.
- For high-risk cases, initiate disease-specific protocol where appropriate (sepsis pathway, ACS protocol, stroke protocol).
Coordinate high-risk or special conditions
- Psychiatric case: Inform MO PSY on-call for coordination.
- O&G case: Inform O&G Specialist on-call regarding case status and referral indication.
- OSCC case: Inform MO OSCC ED in-charge for coordination.
- Severe infectious disease: Inform MO ED in-charge regarding isolation and infection control needs.
- All high-risk cases: Direct phone communication with receiving team is mandatory before transfer.
Prepare referral documentation
- Print the referral letter generated via SystmOne.
- Auto-allocate patient to Emergency / Room 8 and state the indication for referral.
- Update patient checklist.
- Notify Room 8 staff when possible so preparation can start before patient arrival.
Room 8 prepares patient for transfer
- Verify patient identity and review the doctor's referral instruction.
- Prepare IV line, stat medication, wheelchair, stretcher, oxygen, or other transfer support if ordered.
- MA coordinates ambulance dispatch with ED HPSF Muar when clinic ambulance is unavailable.
Escort and handover
- Escort rules depend on referring unit (see Escort Rules below).
- Submit the printed referral letter and provide verbal handover to the receiving ED team.
- Ensure all documentation is complete in SystmOne before leaving the clinic.
All ED referrals must have a clear SystmOne note, printed referral letter when feasible, documented referral reason, and verbal communication for severe, high-risk, infectious, psychiatric, abuse, rape, O&G, or OSCC cases.
ED Escort Rules by Referring Unit
Escorted by Medical Assistant (MA). Standard protocol: stabilise in Room 8, accompany to ED, hand over referral letter.
Escorted by Staff Nurse or Public Health Nurse (PHN). High-risk obstetric cases: referring doctor coordinates with O&G Specialist before transfer.
Escorted by MA from Room 8 following standard protocol. Complete procedure, stabilise patient, initiate referral as instructed.
MCH ED & Labor Room Routing
| Condition | Destination | Coordination |
|---|---|---|
Pregnant >32 weeks | Labor Room, HPSF Muar | Discuss with O&G Specialist prior to referral |
Pregnant <32 weeks | ED, HPSF Muar | Discuss with O&G Specialist prior to referral |
| Reduced fetal movement (RFM) | Labor Room, HPSF Muar | Discuss with O&G Specialist prior to referral |
| Acute / high-risk antenatal | ED or Labor Room per clinical assessment | Discuss with O&G Specialist prior to referral |
Unit-Specific Escalation Criteria
NCD Unit — FMS & Specialist Referral
| Indication | Action | Receiving Service |
|---|---|---|
| Young hypertension | FMS review | FMS / NCD team |
| Type 1 DM | FMS review | FMS / NCD team |
| HbA1c >10% | FMS review + DM-MTAC | FMS + Pharmacist |
| Resistant hypertension | FMS review | FMS / NCD team |
| CKD Stage IIIB and above | FMS & MOPC Referral | FMS / MOPC |
| Pregnancy with NCD comorbidity | FMS review + hospital co-management | FMS + Hospital O&G |
| Diagnostic uncertainty | Specialist opinion | Relevant specialist clinic |
| DM-MTAC indication | Pharmacist-led review | Pharmacist (HbA1c >10%, polypharmacy, adherence issues) |
| Diet-related glycemic issue | Nutrition review | Dietitian |
| Neuropathy / limited mobility | Rehabilitation input | Physiotherapist |
Wound Care Clinic — Hospital Referral
| Condition | Referral Destination |
|---|---|
| Burns — deep partial thickness or higher | Burn surgeon / tertiary burn centre |
| Traumatic wounds — vascular/nerve/tendon injury, open fracture | Orthopaedic / vascular / plastic surgery |
| Diabetic foot ulcer — poor healing, vascular compromise | Vascular services |
| NSTI / gas gangrene / life-threatening infection | Emergency surgery |
| Malignant wound | Oncology / treating team |
| Complex wound — exposed tendon/bone/vessels/nerves, facial laceration | Plastic surgery |
| Pressure injuries requiring OT / dietitian | Allied health referral |
TB Clinic — Chest Clinic Referral
| Indication | Referral Reason |
|---|---|
| Smear-positive after 5 months | Suspected treatment failure or drug resistance |
| MDR-TB suspected or confirmed | Requires specialist care, often with hospitalization |
| Severe extrapulmonary TB (CNS, bones) | Requires advanced imaging, biopsy, or surgical input |
| TB in HIV-positive patients (complicated) | Multidisciplinary management needed |
| Pediatric / congenital TB cases | Requires pediatric ID or chest specialist input |
Sensitive Cases
Ensure all sensitive case documentation is flagged appropriately in SystmOne for follow-up and continuity of care. Access to these records must be role-based and confidential.