Chronic Fatigue/ME Service - RD&E NHS Foundation Trust

Scope

  • This guidance covers the referral criteria to the Chronic Fatigue/ME Service
  • This service covers Exeter, East, Mid and North Devon
  • Our service is commissioned to provide the treatment strategies outlined in the NICE guideline for this condition. The treatment pathway is delivered as follows:
    • Via a group programme over 11 sessions
    • Alternatively it may be more appropriate to offer patients a set number of sessions, providing guided self-help strategies on an individual basis
    • For a patient who is bedbound or completely housebound, a home assessment can be arranged after liaison with yourself as their G.P..

Out of scope

  • Patients under the age of 18 years of age

Assessment

Signs and Symptoms

CFS/ME is a syndrome characterised by abnormal FATIGUE which is:

  • The principal complaint
  • Medically unexplained (i.e. not caused by conditions such as inflammation or chronic disease)
  • Of definite onset (i.e. not lifelong) but chronic (4 months presentation).
  • Not the result of ongoing exertion (i.e. shift work or over activity)
  • Not substantially relieved by rest
  • Causing a substantial reduction in effectiveness of occupational, educational, social or personal activities.

Diagnosis

In many cases the diagnosis of CFS/ME can be made confidently in Primary Care. Please refer to NICE guideline CG53 for referral criteria. When making the referral please EXCLUDE FIBROMYALGIA, where Fibromyalgia is the primary diagnosis, or where pain dominates fatigue. The Fukuda diagnostic criteria is summarised below:

Summary of Fukuda Criteria for Diagnosis of CFS/ME

Debilitating, persistent or relapsing fatigue for at least 4 months but not lifelong

Not the result of ongoing exertion, not substantially alleviated by rest.

Severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities

At least four of the following symptoms, which have persisted or recurred during 4 or more consecutive months of illness and did not predate the fatigue;

  • impaired memory or concentration
  • sore throat
  • tender lymph nodes
  • muscle pain
  • pain in several joints without swelling or redness
  • headache
  • unrefreshing sleep
  • post-exertional malaise with at least a 24 hour delay and slow recovery

No clinical evidence of other causes of fatigue:

  1. organ failure
  2. chronic infections
  3. rheumatic and chronic inflammatory disease
  4. major neurological diseases
  5. systemic treatment for neoplasms
  6. untreated endocrine disease
  7. primary sleep disorders
  8. obesity (BMI greater than 40)
  9. alcohol/substance abuse
  10. reversible causes of fatigue
  11. psychiatric conditions with a presentation of psychoses, bipolar disorder or dementia
  12. eating disorders.

Routine investigations do not suggest a cause for fatigue:

  • Full blood count, ESR, CRP, LFT, U&E, Calcium Phosphate, random glucose, thyroid function, coeliac serology (endomysial abs or tTG], urinalysis)

Differential Diagnoses

The following conditions would EXCLUDE a diagnosis of CFS/ME and should be screened prior to referral:

  • Established medical disorders known to cause chronic fatigue. This is especially important in the elderly in whom cardiac, respiratory and neurological causes of fatigue can be frequently missed
  • Psychosis e.g. schizophrenia, bipolar disorder
  • Alcohol or substance abuse
  • Eating disorders, anorexia, bulimia or severe obesity with a BMI greater than 40 or less than 18 Adults with behaviour or conditions which prevent engagement with the service
  • Adults with Fibromyalgia as a primary diagnosis or where pain dominates fatigue
  • Severe depressive illness with psychotic or melancholic features (but not anxiety states or mild to moderate depression)
  • Somatisation disorder
  • Possible dementia

Investigations

As part of the referral process the following investigations should have been performed and are within normal limits:

  • Full blood count
  • Acute phase protein changes (i.e. ESR and CRP)
  • Liver function tests
  • Urea, electrolytes and routine biochemistry
  • TSH and free thyroxine
  • Creatine phosphokinase
  • Urine test for protein and glucose
  • Coeliac screen

Please consider whether the following tests are required:

  • Hepatitis screen
  • Ferritin
  • B12
  • Folate

Referral

Referrals are only accepted from GP's/Medical Consultants

Referral Criteria

  • Referrals may be returned to the referrer if not on the correct Referral form
  • Referrals from GPs following criteria and suggested investigations
  • Symptoms have persisted for:
    • At least 4 months but not lifelong
    • Patients should be 18 or over to access the service
    • Debilitating, persistent or relapsing fatigue for at least 4 months but not lifelong, that is new or of definite onset, is not the result of ongoing exertion and is not substantially alleviated by rest. Severe enough to cause substantial reduction of previous levels of social, occupational, educational or personal activities.
  • In addition, at least four of the following symptoms which have persisted or recurred during 4 or more consecutive months of illness and did not predate the fatigue:
    • Impaired memory or concentration
    • Tender lymph nodes/recurrent sore throat
    • Muscle pain
    • Multi-joint pain without swelling or redness
    • Headaches of a new type, pattern or severity
    • Un-refreshing sleep
    • Post-exertional malaise (lasting more than 24 hours)
    • Sleep disturbance
    • Other symptoms include digestive disturbances, intolerance to alcohol/light/noise, sensitivity to medication and other substances, temperature disturbance.
  • Second opinions are not included in standard referral criteria but should be dealt with through normal GP second opinion referral processes
Service Notes
  • CFS/ME for people 18 and over, is a service based at the Exeter Community Hospital delivering assessment and treatment and then interventions on an outpatient basis primarily. For a patient who is bedbound or completely housebound a home assessment can be arranged providing the GP confirms that this is the case.
  • To provide a specialist service for patients with Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME) and support local clinicians in the continued management of the condition, where this proves appropriate.
  • Primary care, social care/ employment/ housing or benefits services should continue to be involved whilst the patient is seen within the specialist service to ensure continuity of care and a seamless service upon discharge
Contact Details for the service
  • Telephone Number: 01392 405479
  • CFS/ME service, Exeter Community Hospital, Hospital Lane, Exeter EX1 3RB
  • This service is commissioned by the Healthcare Commissioning organisations covering NEW Devon CCG and provided by the RD&E NHS Foundation Trust.

Referral Instructions

Refer using the e-Referral Service

  • Speciality: General Medicine
  • Clinic Type: General Medicine
  • Service: DRSS-Eastern-Chronic Fatigue Syndrome\ME-NEW Devon CCG- 99P

Referral Form

Chronic Fatigue/ME referral form - No merge fields

Chronic Fatigue/ME referral form - EMIS WEB

Chronic Fatigue/ME referral form - Systmone

Supporting Information

Patient Information

ME Association

GP Information

NICE Guideline CG53

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: January 2018

 

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