May 05 CLINICAL REFERENCE PEDIATRIC GASTROENTEROLOGY
INTRODUCTION Introduction Alberta Referral Pathways for Pediatric GI Services has been a collaborative project. The referral guidelines have considered the roles of family physicians, general pediatricians, pediatric GI subspecialists and nutrition services to provide the most appropriate pathway for referral to the pediatric GI services of children and adolescents with gastrointestinal and liver symptoms and/or disease indications. Representatives from primary care, pediatrics, nutrition services, feeding and swallowing services, pediatric weight management services, together with Alberta s two pediatric GI and hepatology services in Calgary and Edmonton, have participated in developing this provincial referral pathway. The purpose of this document is to provide referring providers with a guide that clearly outlines referral processes and key information necessary for appropriate triage and acuity assessment. It also aims to provide the referring physicians approximate wait time for their patients to be seen by the GI services. To allow for the best use GI services resource, some of the referred indication may best be seen first by pediatricians and other services such as nutrition services and pediatric weight management services. Wait times were determined by each of the services based on the available man power resources in February 05. They do not define a standard of care, nor should they be interpreted as regulatory or legal advice. Variations in practice may be necessary and appropriate based on the needs of the individual patient, resources and limitations unique to the institution or type of practice. Hopefully these guidelines will enable timely access of children to appropriate levels of services and help improve communications between service providers. Similar pathway development in BC has been quite successful and meshes with progressive IT communication and EMR system developments. The use of general pediatrician expertise is essential in helping our more complex patients in receiving timely access to tertiary care services. Hien Q. Huynh, MBBS, FRACP, FRCPC(Hon) Associate Professor and Head Division of Pediatric GI Nutrition Department of Pediatrics, Stollery Children s Hospital, University of Alberta Steven R. Martin MD, FRCP(C) Professor and Head, Section of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, University of Calgary, Alberta Children s Hospital Robert R. Moriartey, BSc, MD, FRCP(C) Clinical Professor and Head, Division of Community Pediatrics Department of Pediatrics, University of Alberta Introduction 3
Contents INTRODUCTION GENERAL WHAT IS ALBERTA REFERRAL PATHWAYS? HOW TO USE THESE GUIDELINES REFERRAL ELEMENTS REFERRAL REQUIREMENTS EMERGENCY REFERRAL REQUIREMENTS FOR ALL NON-EMERGENCY REFERRALS S Abdominal imaging: abnormal finding 0 Abdominal pain 0 Celiac screen: Positive finding Chronic Diarrhea Constipation Diet / texture progression difficulty 3 Dysphagia or odynophagia 3 Enlarged liver 4 Failure to thrive 5 Fatty liver with elevated BMI 6 Fatty liver without elevated BMI 6 Feeding difficulty with suspected aspiration 7 Feeding difficulty without failure to thrive 8 Food allergy or food intolerance 9 Gastroesophageal reflux 9 CONTACT APPENDIX A: APPROXIMATE WAIT TIMES APPENDIX B: PRIORITY LEVELS Hematemesis (normal hemoglobin) 9 Hepatitis: Acute 0 Hepatitis B, C serology positive 0 Hyperbilirubinemia (conjugated) 0 Hyperbilirubinemia (unconjugated) Inflammatory bowel disease Iron deficiency anaemia Liver disease (chronic) / portal hypertension Liver enzymes 3 Nutrition / nutrient deficiency 3 Pancreatitis 3 Persistent vomiting / nausea 4 Polyposis, family history 4 Rectal bleeding age < months 4 Rectal bleeding age year 4 4 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 5
General Information WHAT IS ALBERTA REFERRAL PATHWAYS? A patient s journey often seems like a confusing maze of uncertain choices and endless waiting. Patients and health care providers want seamless and efficient transitions between primary and specialty care. The AHS Provincial Access Team is collaborating with the Strategic Clinical Networks, primary care, Primary Care Networks, the Alberta Medical Association and Alberta Health to lead referral transformation. Alberta Referral Pathways is a provincial program that builds connections between primary and specialty care to support clinicians and administrators to define standards and introduce processes to improve Alberta s referral experience. Each referral pathway is led by medical co-champions and representatives of both primary and specialty care. The working group is populated by representatives from every point in a patient s care pathway. Determined and reviewed over a ninemonth process, the resulting provincial referral guidelines include clinical content, referral processes, triage priority levels and approximate wait times. They are then widely distributed for physician review, feedback and adoption. HOW TO USE THESE GUIDELINES THIS DOCUMENT IS DIVIDED INTO THE FOLLOWING SECTIONS: INTRODUCTION A letter of introduction from the clinical champions leading the pediatric gastroenterology referral pathway GENERAL Information about Alberta Referral Pathways, how to use these guidelines, elements of a referral (see below), and emergency referral information REFERRAL REQUIREMENTS Mandatory requirements for all non-emergency referrals, and alphabetically listed reasons for referral with accompanying referral recommendations, contact inforamtion and required investigations CONTACT Additional contact information for services listed within the reference APPENDICES Supplementary information outlining the approximate wait times for each service, and the priority level for referrals to pediatric gastroenterology listed by reason for referral. REFERRAL ELEMENTS 3 4 These guidelines are organized by reason for referral. Use the table of contents to find the reason for referral, and click the reason to take you directly to the referral information This information recommends whom or where to send the referral, and provides contact information for each suggestion. The mandatory information is patient specific and required for the referral to be appropriately triaged. This information is required in addition to the comorbidities and demographics previously outlined. The recommended assessments and essential investigations are required to be completed within the suggested time frame. 3 4 6 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 7
REFERRAL REQUIREMENTS Referral Requirements EMERGENCY REFERRAL REQUIREMENTS FOR ALL NON-EMERGENCY REFERRALS For all emergencies, refer directly to the Emergency Department PATIENT DEMOGRAPHICS Patient last name, first name, given names REFERRING PROVIDER Name or PHN/ULI Address, including city and postal code Contact RAAPID North: -800-8-9 or 780-735-08 South: -800-66-700 or 403-944-4486 & INVESTIGATIONS APPROXIMATE TIME TO BE SEEN Gender Home address including city and postal code Home phone, other phone (multiple contact numbers preferred) Emergency contact name and phone Guardian name & phone, and relation to patient Phone & fax FAMILY PHYSICIAN Name Indicate if same as referrer or if patient has no primary care provider Address including city and postal code Phone & fax ACUTE DIARRHEA WITH DEHYDRATION < 4 HOURS RELEVANT Summary of medical and treatment history Physical limitations ACUTE LIVER FAILURE (INR >.5) Within 4 hours: ALT INR < 4 HOURS Current medications Languages - indicate if an interpreter is required and for which language Economic and social / psychological factors Special considerations Description of symptoms (e.g. altered level of consciousness) ACUTE PANCREATITIS ACUTE SIGNIFICANT GASTROINTESTINAL BLEEDING / MELENA < 4 HOURS < 4 HOURS GROWTH CHART (OR AT LEAST CURRENT WEIGHT AND HEIGHT) It is recommended to have at but preferably a record of multiple measures over time. All measures should be plotted on recommended growth charts. BMI should be calculated and plotted for children ages -7 years More information can be found at www.albertahealthservices.ca/cgm.asp CAUSTIC INGESTION < 4 HOURS ESOPHAGEAL FOREIGN BODY / FOOD IMPACTION < 4 HOURS 8 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 9
Referral Requirements ABDOMINAL IMAGING: ABNORMAL FINDING ABDOMINAL PAIN (chronic or recurrent) Consider contacting pediatric gastroenterology service directly to determine the optimal approach Description of symptoms if relevant Red flags: OPTIONAL: Image finding CELIAC SCREEN: POSITIVE FINDING CHRONIC DIARRHEA (duration >4 weeks) Consider referral to pediatrician Description of symptoms (e.g. weight loss, diarrhea) < 6 MONTHS Celiac screen on gluten Ferritin weight loss diarrhea ± blood vomiting nocturnal waking fever fatigue (if required by pediatrician) age <3 years old Red flag: >5% weight loss < MONTH, ESR/CRP Total protein/albumin Electrolytes,TCO Iron studies Celiac screen on gluten Stool O&P, culture Description of symptoms if relevant Red flags: weight loss diarrhea ± blood < 6 MONTHS Pediatric consult Celiac screen on gluten, ESR/CRP Albumin ALT, GGT, Bili C. Diff toxin (age > year) vomiting nocturnal waking fever fatigue age <3 years old 0 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05
Referral Requirements CONSTIPATION DIET / TEXTURE PROGRESSION DIFFICULTY (if required by pediatrician) Consider referral to Nutrition Services if food groups are missing from the diet or very low food variety with suspected nutrient deficiency In Calgary, simple constipation is triaged initially to constipation teaching sessions. Four sessions are currently offered in a year. < 6 MONTHS Pediatric consult Description of stool Treatment (dose, duration, results) Electrolytes, TCO Ca TSH Celiac screen on gluten Nutrition Counselling (Dietitian) Pediatric www.informalberta.ca KEYWORD SEARCH: Nutrition Counselling Pediatric Call specific clinic to request a referral form 3 For feeding issue, refer to Feeding and Swallowing Services Calgary Feeding Coordinator PH 403-955-7464 FX 403-955-36 Edmonton: children with typical development Stollery Children s Hospital PH 780-407-8859 FX 780-407-6586 Edmonton: children with developmental/neurological issues Glenrose Rehabilitation Hospital PH 780-735-6066 FX 780-735-7930 DYSPHAGIA OR ODYNOPHAGIA Description of symptoms www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 3
Referral Requirements FAILURE TO THRIVE Consider referral to both pediatrician and Nutrition Services Nutrition Counselling (Dietitian) Pediatric www.informalberta.ca KEYWORD SEARCH: Nutrition Counselling Pediatric Call specific clinic to request a referral form Refer to Feeding and Swallowing Services when there is difficulty eating due to an anatomical or developmental concern or when there is a swallowing difficulty. Calgary Feeding Coordinator PH 403-955-7464 FX 403-955-36 Edmonton: children with typical development Stollery Children s Hospital PH 780-407-8859 FX 780-407-6586 Pediatric and/or Nutrition Services consult Edmonton: children with developmental/neurological issues Glenrose Rehabilitation Hospital PH 780-735-6066 FX 780-735-7930 For case with suspected GI causes, refer to pediatric gastroenterology < 3 MONTHS Pediatric and/or Nutrition Services consult /ESR/CRP Electrolytes, BUN, Creat. Ca., Phos., ALT Total protein/albumin Celiac screen on gluten 4 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 5
Referral Requirements FATTY LIVER WITH ELEVATED BMI (BMI-for-age 85th percentile) FEEDING DIFFICULTY WITH SUSPECTED ASPIRATION Refer to Feeding and Swallowing Services Calgary Feeding Coordinator PH 403-955-7464 FX 403-955-36 Edmonton: children with typical development Refer to Provincial Pediatric Weight Management Services Stollery Children s Hospital PH 780-407-8859 FX 780-407-6586 Alberta Health Services Central Access PH (toll free) -877-44-665 / 780-40-665 FX (toll free) -866-979-3553 / 780-735-3553 Age: -7 years old Options for referral: BMI Edmonton: children with developmental/neurological issues Glenrose Rehabilitation Hospital PH 780-735-6066 FX 780-735-7930 outpatient dietitian counselling May require a prior referral to pediatrician and/or Nutrition Services for a clinical assessment multidisciplinary specialty care Referral form www.albertahealthservices.ca/807.asp 3 (if required by pediatrician) < 6 MONTHS Abdominal U/S AST, ALT,GGT, ALP BIL, ALB Lipid profile Nutrition Counselling (Dietitian) Pediatric www.informalberta.ca KEYWORD SEARCH: Nutrition Counselling Pediatric Call specific clinic to request a referral form FATTY LIVER WITHOUT ELEVATED BMI (BMI 85th percentile) < 6 MONTHS Abdominal U/S AST, ALT,GGT, ALP BIL, ALB Lipid profile 6 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 7
Referral Requirements FEEDING DIFFICULTY WITHOUT FAILURE TO THRIVE Consider referral to Nutrition Services if food groups are missing from the diet or very low food variety with suspected nutrient deficiency FOOD ALLERGY OR FOOD INTOLERANCE Pediatrician may consider referral to Nutrition Services for overall assessment and/or to pediatric allergist for allergy confirmation History and type of allergy Nutrition Counselling (Dietitian) Pediatric www.informalberta.ca KEYWORD SEARCH: Nutrition Counselling Pediatric Call specific clinic to request a referral form 3 If child is not able to eat anatomically/developmentally, refer to Feeding and Swallowing Services Calgary Feeding Coordinator PH 403-955-7464 FX 403-955-36 Edmonton: children with typical development Stollery Children s Hospital PH 780-407-8859 FX 780-407-6586 Edmonton: children with developmental/neurological issues Glenrose Rehabilitation Hospital PH 780-735-6066 FX 780-735-7930 4 Pediatric and/or Nutrition Services consult For suspected eating disorder, consider refer to adolescent medicine (in Calgary) or psychiatry (in Edmonton) Calgary: Eating Disorder Program PH 403-955-7700 FX 403-955-3066 least current weight and height GASTROESOPHAGEAL REFLUX HEMATEMESIS (NORMAL HEMOGLOBIN) Persistent, complicated* or medication-dependent GE reflux may be referred to pediatric gastroenterology for long term management *Complicated: failure to thrive, hematemesis, respiratory symptoms < MONTH Pediatric consult < MONTH Edmonton : Child and Adolescent Psychiatry, Acute Care, Royal Alexandra Hospital PH 780-735-4635 FX 780-735-535 Calgary Referral Form: www. albertahealthservices. ca/408.asp 8 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 9
Referral Requirements HEPATITIS: ACUTE (ALT >0x normal, normal INR) < WEEK ALT, AST, GGT Bili T/D INR HYPERBILIRUBINEMIA (UNCONJUGATED) Pediatrician may consider a referral to hematology HEPATITIS B, C SEROLOGY POSITIVE (if required by pediatrician) < MONTH Pediatric consult Bili T/D HYPERBILIRUBINEMIA (CONJUGATED) < WEEK Stool colour ALT, AST, GGT Bili T/D INR Abdominal U/S INFLAMMATORY BOWEL DISEASE (active/ suspected/ inactive) Description of symptoms (active: abnormal labs; suspected: normal labs) < MONTH ESR/CRP Albumin Ferritin/Iron studies ALT, GGT, lipase Stool C&S, O&P C. difficile toxin 0 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05
Referral Requirements IRON DEFICIENCY ANAEMIA For anemia with suspected GI cause, refer to pediatric gastroenterology LIVER ENZYMES (abnormal on occasions over 3 to 6 months) < MONTH ALT,GGT, Bili T/D Albumin INR 3 < MONTH Iron studies ESR/CRP Celiac screen on gluten Potential reason for deficiency Refer to Nutrition Services if food groups are missing from the diet or very low food variety with suspected nutrient deficiency NUTRITION / NUTRIENT DEFICIENCY Consider referral to both pediatrician and Nutrition Services IgG CK Abdominal U/S Viral hepatitis screen (B & C) Nutrition Counselling (Dietitian) Pediatric Nutrition Counselling (Dietitian) Pediatric www.informalberta.ca KEYWORD SEARCH: Nutrition Counselling Pediatric www.informalberta.ca KEYWORD SEARCH: Nutrition Counselling Pediatric Call specific clinic to request a referral form Call specific clinic to request a referral form PANCREATITIS LIVER DISEASE (CHRONIC) / PORTAL HYPERTENSION (chronic/ recurrent) < MONTH Abdominal U/S Lipase www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 3
CONTACT Contact Information SPECIALTY CLINICS/DIRECTORIES PHONE FAX PERSISTENT VOMITING / NAUSEA Red flag: bilious vomiting (emergency) Pediatric gastroenterologists may refer to surgery for confirmed malrotation < 6 MONTHS Electrolytes Abdominal U/S Barium swallow PedLink Telephone Consultation Services Service will provide 8 AM to 8 PM (including weekends) access to the pediatrician telephone consultation service in Calgary. Family physicians leave a message and the on-call pediatrician will return the call within an hour. (403) 955-098 Community Pediatrics Find your local pediatrician POLYPOSIS, FAMILY HISTORY **May require referral to medical genetics Family history (mutation and/or names of polyps if available) OPTIONAL: Previous screening / colonoscopy if available Nutrition Services Nutrition Counselling (Dietitian) Pediatric Call specific clinic to request a referral form www.informalberta.ca Provincial Pediatric Weight Management Services Alberta Health Services Central Access Referral form: KEYWORD SEARCH: Nutrition Counselling Pediatric -877-44-665 (TOLL FREE) -866-979-3553 (TOLL FREE) RECTAL BLEEDING AGE < MONTHS www.albertahealthservices.ca/807.asp (780) 40-665 (780) 735-3553 (without constipation) Feeding and Swallowing Services In Calgary, please contact Feeding Coordinator 403) 955-7464 MAIN: (403) 955-36 (if required by pediatrician) < MONTH Pediatric consult Albumin ESR/CRP For questions about videofluorscopic swallow studies (VFSS), call Feeding Coordinator. For referral to VFSS, fax to (403) 955-535. Children with typical development: Stollery Children s Hospital Unit G., Speech and Audiology 8440 Street, Edmonton, Alberta T6G B7 VFSS: (403) 955-535 (780) 407-8859 (780) 407-6586 RECTAL BLEEDING AGE YEAR (without constipation) < MONTH Albumin ESR/CRP Children with developmental/neurological issues: Glenrose Rehabilitation Hospital Pediatrics - Glen East 030 Avenue NW, Edmonton, Alberta T5G 0B7 (780) 735-6066 (780) 735-7930 4 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 5
APPENDIX A: APPROXIMATE WAIT TIMES Appendix A: approximate wait times SPECIALTY CLINICS/DIRECTORIES PHONE FAX SPECIALTY APPROXIMATE WAIT TIMES Pediatric Gastroenterology, Hepatology and Nutrition* Pediatric Gastroenterology and Nutrition* Alberta Children s Hospital Level 3, GI/Metabolic/Endocrine Clinics 888 Shaganappi Trail NW, Calgary, Alberta T3B 6A8 Stollery Children s Hospital Edmonton Clinic Health Academy (ECHA) 4th floor, Room 4-594 405-87th Avenue, Edmonton, Alberta T6G C9 (403) 955-7747 (403) 955-7639 (780) 48-540 -888-353-57 (TOLL FREE) *Note: Patients aged 7-8 years in Calgary and 6-7 years in Edmonton should be triaged by pediatric gastroenterology services but referrals may be redirected to adult gastroenterology. COMMUNITY PEDIATRICS NUTRITION SERVICES PROVINCIAL PEDIATRIC WEIGHT MANAGEMENT SERVICES Preferable WITHIN MONTH but not longer than 6 WEEKS WEEKS TO 4 MONTHS (Wait times may vary depending on the zone and reason for referral) TYPE OF REFERRAL Outpatient Dietitian Counselling Multi-Disciplinary Specialty Care (Pediatric Centre for Weight and Health) APPROXIMATE WAIT TIMES WEEKS TO 3 MONTHS (Wait times may vary depending on zone capacity) < 3 MONTHS (Wait times may vary depending on clinic capacity and family readiness/schedule) FEEDING AND SWALLOWING SERVICES ALBERTA CHILDREN S HOSPITAL STOLLERY CHILDREN S HOSPITAL GLENROSE REHABILITATION HOSPITAL** PRIORITY LEVEL APPROXIMATE WAIT TIMES PRIORITY LEVEL APPROXIMATE WAIT TIMES PRIORITY LEVEL APPROXIMATE WAIT TIMES Urgent IMMEDIATELY - WEEKS Urgent IMMEDIATELY - WEEKS High (urgent) 6-7 WEEKS - 6 WEEKS High - MONTHS Medium 4 MONTHS 6 - WEEKS Medium 3 MONTHS Low (routine) 6 MONTHS Low 4-6 MONTHS PEDIATRIC GASTROENTEROLOGY PRIORITY LEVEL APPROXIMATE WAIT TIMES IN CALGARY* APPROXIMATE WAIT TIMES IN EDMONTON* Urgent IMMEDIATELY - WEEKS IMMEDIATELY - WEEKS WEEKS - 5 MONTHS WEEKS - MONTHS 5 MONTHS - 0 MONTHS 3 MONTHS - 7 MONTHS 3 0 MONTHS - 8 MONTHS 8 MONTHS - 4 MONTHS *Note: The listed wait times are as of 05-0-4 **Note: The listed wait times are as of January 05 in Glenrose Rehabilitation Hospital 6 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 7
Appendix B: Priority Levels PRIORITY LEVEL PRIORITY LEVEL ABDOMINAL IMAGING: ABNORMAL FINDING -3 DEPENDING ON THE LESION HYPERBILIRUBINEMIA (CONJUGATED OR UNCONJUGATED) EMERGENCY - ABDOMINAL PAIN (CHRONIC OR RECURRENT) RED FLAGS = NO RED FLAGS = 3 INFLAMMATORY BOWEL DISEASE (ACTIVE/ SUSPECTED/ INACTIVE) ACTIVE = EMERGENCY SUSPECTED = - CELIAC SCREEN: POSITIVE FINDING SYMPTOMS = NO SYMPTOMS = IRON DEFICIENCY ANAEMIA (WITH SUSPECTED GI CAUSES) LIVER DISEASE (CHRONIC)/ PORTAL HYPERTENSION CHRONIC DIARRHEA (DURATION >4 WEEKS) >5% WEIGHT LOSS = EMERGENCY - UNCOMPLICATED = -3 LIVER ENZYMES (ABNORMAL ON OCCASIONS OVER 3 TO 6 MONTHS) EMERGENCY - CONSTIPATION AGE < MONTH = AGE > MONTH = 3 DYSPHAGIA OR ODYNOPHAGIA - ENLARGED LIVER PANCREATITIS (CHRONIC / RECURRENT) EMERGENCY - PERSISTENT VOMITING/NAUSEA COMPLICATED = UNCOMPLICATED = -3 RECTAL BLEEDING FAILURE TO THRIVE (WITH SUSPECTED GI CAUSES) INFANTS/SEVERE = EMERGENCY - UNCOMPLICATED = FAMILY HISTORY OF POLYPS FATTY LIVER WITHOUT ELEVATED BMI (BMI 85TH PERCENTILE) FATTY LIVER WITH ELEVATED BMI (BMI 85TH PERCENTILE) GASTROESOPHAGEAL REFLUX - DEPENDING ON AGE/SYNDROME - -3 COMPLICATED: FAILURE TO THRIVE, HEMATEMESIS, RESPIRATORY SYMPTOMS HEMATEMESIS (NORMAL HEMOGLOBIN) HEPATITIS (ACUTE: ALT >0X NORMAL, NORMAL INR) HEPATITIS B, C SEROLOGY POSITIVE - Copyright (05) Alberta Health Services. This material is protected by Canadian and other international copyright laws. All rights reserved. This material is intended for general information only and is provided on an as is, where is basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. 8 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 www.albertahealthservices.ca/pathways LAST UPDATED 30 Apr 05 9