Primary care and hematology department: referral and management guidelines

Abstract

Introduction: In 2015, we started working on the Improvement Plan of the Outpatient Clinic at the Hematology Department of our Hospital. We noticed that many of the cases referred from Primary Care to the Hematology Department were inappropriate referrals as they had no hematological pathology. An analytical alteration was the main reason for referring patients from primary care. 60% of the referred patients presented one or more of the following 6 alterations according to their blood test: monoclonal gammopathy, leukocytosis, lymphocytosis, neutropenia, monocytosis and/or thrombocytosis. Method: We set up a workgroup composed of primary care, hematologists and nurses. Together, we elaborated guidelines for the referral of patients presenting any of these 6 analytical alterations. In this document, we suggested a series of studies to be carried out in Primary Care prior to referral, and we indicated whether the follow-up should be carried out in the Primary Care Center or in the Hematology Department. We presented this initial document in Primary Care Centers of Donostialdea public health area and their feedback was added into the final version of the document. Results: In the document, there are indications for each 6 of the analytical alterations mentioned above. As an example, neutropenia is summarized: NEUTROPENIA 1x109/L -Analyze: autoimmune disorders (ANA, RF, PCR), vitamin B12 and folic, Igs, HIV. Dismiss:Viral infections, sepsis, drugs (metamizole, antipsychotics, omeprazole, and assess to withdraw it), autoimmune disorders, B12 and folate severe deficiency, aplastic anemia, or bone marrow infiltration. Neu1x109/L (Caucasian) or Neu>0.5x 109/L in BEN. Procedure:Annual analytical control. Referral (NPC: Non presential consultation): Clinical Criteria(If any of the following): -Recurrent infections -Adenopathy, splenomegaly -B symptoms -Febrile neutropenia* Analytical Criteria (if any): -Neu <1x109/L (Caucasian) or Neu <0.5x109/L (if African, Caribbean or Middle East origin) -Associated cytopenias: anemia, thrombocytopenia. -Blood smear suggests a hemopathy: patient will be given an appointment from the laboratory filter. *If fever and Neu <1x109/L: must be referred to Emergency. Conclusions: The aim of this guideline is to avoid the unnecessary referral of patients who are unlikely to benefit from a specialist opinion. The collaboration between Primary Care and Hematology department allowed us to elaborate an agreed document. We would like this document to be dynamic and we will modify and update it with every suggestion that emerges in response to its use. It is an ongoing co-operation work between Primary Care and Hematology, putting patient´s wellness first.

Keywords

• monoclonal gammopathy
• leukocytosis
• lymphocytosis
• neutropenia
• monocytosis
• thrombocytosis