For Veterinary Surgeons

How To Refer

If you are referring a patient to Dick White Referrals, we can assure you that you will receive a professional and efficient service from each of our clinicians, whose aims is to be approachable and friendly. We like to distinguish ourselves by the standard of our specialist expertise and the level of rapid communication we can provide. Specialist referral centres differ slightly in their approach to referrals and we hope that the following information will help to make the referral process as smooth and easy as possible for your and your clients.

Considering referral

We are always happy to discuss cases with colleagues prior to referral, to confirm whether or not referral is likely to be of benefit, which particular type of specialist would be best placed to investigate the case wish and to provide an idea of cost.

We are available for emergency referrals on a 24 hour/day basis. However, we are a referral centre rather than an out-of-hours service, and referral of cases for routine care (eg post operative management) should be managed within normal working hours.

The referral process

Prior to a consultation, we need information from the referring vet which outlines the nature of the problem, reason for referral and the previous medical and medication history. We will then see the client for a consultation of about 45 minutes during which we will take a detailed background, previous and current medical history, discuss the presenting concerns with them and then systematically discuss any changes in all body systems, even if these may not appear at face-value to be related. We will examine the patient, discuss our initial differential diagnoses and what investigation we propose. If appropriate, we will offer an idea of prognosis at this stage (although often this is not possible) and we will give an estimate of cost and likely time-course for procedures.

In most circumstances, patients are admitted to the hospital for investigation and management. It is usually not realistic for a diagnosis to be made on an outpatient basis and it is very helpful if you can prepare your clients for this likelihood. Referral is not suitable for clients that are not prepared for their pets to be hospitalised

We keep all clients informed daily of their pets' progress and, provided they pick their pet up in normal working hours, we will discharge cases personally unless we are dealing with an emergency. Wherever possible, we will give them written discharge instructions. These are also faxed to referring vets at the time of discharge. This provides an interim report prior to our formal referral letter being sent.

Follow-up care

Follow-up care may be provided by Dick White Referrals or the referring vet, depending on the circumstances. For example, in the case of a rare condition with which we are more familiar because of the selective nature of our caseload and our level of qualification, our advice may be for follow-up appointments within our clinic until we are satisfied that the patient is no longer in need of a specialist's ongoing In other situations it may be more desirable or practical for re-evaluations to be made at the referring practice, in which case we are happy to provide advice if and when required. Our aim is to ensure that referring vets and their clients receive the full benefit value of our expertise, when it is required.

On discharge, we will usually supply sufficient medication for immediate use but presume that the referring vet will dispense ongoing medication.

What information to provide

Please always supply a written referral letter - without this your client's appointment may be delayed

In essence, the more information you can provide, the better placed we are to help you, your client and your patient. It is essential that we receive a referral letter outlining the reason for referral, a précis of the history and details of the referring vet (please print a name and not just initials /signature). Although computer print-outs of patient history allow us to see what the course of events has been (and can save a lot of writing on your part of items such as previously prescribed drugs), a brief covering letter is also vital. Please also supply ALL diagnostic images and laboratory results, even if they are normal. It is very helpful for us to know which results have been normal previously so that we can monitor changes. It is equally essential that a referral letter accompanies any emergency referral.

Please ensure that we have all of this information by the time of the client's consultation. It can be brought by the client or sent directly. Without this information we can't start taking a history from the client and discussing investigation with them and it is frustrating for clients if they are kept waiting whilst we are seeking information.

Medication

Some medications may need to be withdrawn prior to referral and some, frustratingly, make diagnosis very difficult. Corticosteroids must generally be withdrawn prior to investigation of conditions that may have an inflammatory / immune-mediated component. Investigations such as bronchoalveolar lavage cytology, joint fluid and CSF analysis, gastrointestinal biopsies etc may be rendered non-diagnostic or, and even more dangerously, falsely normal, by recent corticosteroid administration. The time for which such agents may have clinical effect can be surprisingly long, even with apparently short-acting products, and may be up to 4-6 weeks. It is safest not to administer corticosteroids until a definitive diagnosis has been made. Similarly antibiotics administered recently may reduce the chances of diagnosing bacterial infections as they may render cultures falsely negative. If you have any questions regarding the withdrawal of drug therapy prior to referral please contact us. The most important consideration is to make clients aware that medications can interfere with diagnostic test results and that it may be necessary to repeat tests subsequently.

How to prepare your client

We advise all referring vets to discuss with their clients the possibility of their pet having to be hospitalised. It is also important to make them aware of the likely costs relating to referral, even if they are insured, as it is important that consideration is given to how the costs of referral work undertaken will be met. In many circumstances, insurance policies do not cover the costs of all investigations and clients should read their policy information carefully for excluded conditions.

It is important that the client understands the need, on occasions, for repetition of diagnostic tests. This can often be perceived as needless and therefore generating unnecessary expense.However serial assessment of dynamic changes often provides invaluable information. Similarly where radiographs of diagnostic quality and views are provided, and the underlying disease is not likely to have altered, these will not be repeated. However, if radiographic quality is not sufficient for diagnosis, or where a disease state may have altered, repetition of radiographs may be needed.

Communication

A referral letter is sent to referring vets by fax and post after the patient is discharged. They will also be sent the patient's discharge letter at the time of discharge. If patients are hospitalised for a significant period, we will try to discuss progress with the referring vet.

Emergencies / out-of-hours

Genuine medical emergency referrals are accepted on a 24 hour/day basis. All emergency referrals should be arranged between the specialist on emergency duty and the referring veterinary surgeon (rather than an appointment being made by nurses or lay-staff). This is essential to assess the urgency of the situation. Therefore, emergency referrals should only be made when the case has been assessed recently by a vet. If subsequently the emergency appointment is not needed (for instance if the client decides upon euthanasia), it is vital that we are aware of this as early as possible.