Neurological on-call transfers

Clinical presentation appropriate for direct admissions under Neurology service

The Neurology service accepts patients with unequivocal primary non-vascular neurological presentations including the following:

• relapses of Multiple Sclerosis without evidence of sepsis/active infection
• status epilepticus
• functional neurological disorders
• relapse of Myasthenia Gravis without evidence of sepsis/active infection
• new clinical presentations in keeping with demyelination
• seizures in patients with pre-existing epilepsy
• 1st unprovoked seizures with persistent post-ictal deficits i.e. without full recovery
• clinical presentations in keeping with Guillian-Barre syndrome
• clinical presentations in keeping with acute or subacute spinal cord disease where cord compression requiring emergency neuro-surgical intervention has been excluded
• neuro-ophthalmological presentations with exception of clear vascular presentations e.g. central or branch retinal artery occlusion (which should be admitted under the Stroke service)

Acute Stroke service

Any patient initially assigned a 'FAST' call or otherwise presenting with a stroke-like presentation should be referred directly to the stroke service, irrespective of age. For guidance on individual cases the Neurologist on-call is available for advice.

Inappropriate admissions

1. Acute cerebral presentations that are likely to be vascular in origin including TIA and minor strokes
2. Patients where primary reason for admission is clearly not neurological in origin, irrespective of prior or concurrent chronic neurological illness e.g. patient with MS presenting with a GI bleed or signs of sepsis
3. Non-specific presentations such as delirium, indeterminate collapses, probable or evolving sepsis in patients with pre-existing chronic neurological disease
4. Patients presenting with Traumatic Brain Injury including concussion
5. Subarachnoid Haemorrhage [need to exclude aneurysmal/vascular cause]
6. Cauda equina syndrome [need to exclude neurosurgical cause]
7. Low back pain with sciatica [need to exclude neurosurgical cause]
8. Neck pain with brachalgia [need to exclude neurosurgical cause]

Specific scenarios

• Sepsis or other internal medical presentations in patients with chronic neurological disease. These patients should not be admitted under the Neurology service. These patients should be seen by Neurology consult service
• Acute severe headaches where SAH is a possibility. These patients should be managed by ED and Neurosurgical services with Neurology consultation where needed
• Unprovoked 1^st seizures with full recovery with no evidence of underlying acute brain disorder. These patients can be referred to the 'Rapid Access Seizure Clinic (RASC)' using designated referral form (can be found in CDU)
• Acute symptomatic seizures in the setting of alcohol, drug misuse, infections. Provoked seizures secondary to alcohol or drug misuse or other clear external trigger should not be admitted under the Neurology service. If needed, these patients can be seen by Neurology consult service
• Transfers from other hospitals. The on-call Neurology or Medical registrar needs to discuss the case with the on-call Consultant Neurologist before accepting an acute transfer from another hospital
• Neurological presentations in pregnant women. These patients typically are admitted into the CUMH and are seen by the CUMH Neurology consult service
• Suspected Meningitis: Patients with confirmed meningitis and/or encephalitis (i.e. abnormal CSF analysis) can be admitted under Neurology service (or ID service if preferred). Patients with headache or meningismus with normal CSF should not be admitted under the neurology service. These patients can be seen by Neurology consult service
• Anoxic brain injury after cardiac arrest: Survivors of out-of-hospital cardiac and/or respiratory arrests should be admitted under the on-call Medicine service or ITU service with early Neurological consultation

Of note

1. The Neurology service provides an in-patient consult service where we try to see patients on the day of referral. This service is appropriate for patients where the primary reason for admission is either non-neurological or unclear in nature. Please contact the registrar assigned to consults before 1pm
2. The Neurology consult service at weekends (Saturday and Sunday 9am- 1pm) is for emergency referrals only. There is no in-house Neurology registrar after 1pm at the weekend
3. This policy serves as a guideline. The Neurologist on-call is always available by phone to discuss particular cases

Links

• Print version (July 2022) neurology admissions policy