Hematology

Seton Infusion Center
A department of DSMC-UT
Hematology Criteria

Scope

• To provide specialty expertise in the evaluation and management of blood disorders beyond the scope of primary care physicians.
• To prioritize limited availability to patients with malignancies or complex hematologic disorders

Appropriate patients for referral include:

• Persistent, severe anemia after complete evaluation and treatment
• Severe and/or clinically significant
  • thrombocytopenia
  • thrombocytosis
  • leukopenia
  • leukocytosis
• Monoclonal gammopathy
• Sickle Cell disease
• Hypercoagulable state
• Bleeding disorder

Documentation required for scheduling an appointment:

• Current medication list and co-morbidities or problem list
• Two most recent provider notes describing condition for which patient is being referred
• Recent pertinent labs (See worksheet by diagnosis, drawn within the past 6 months, substantiating the disorder.
• If previously treated by a Hematologist, send all hematology notes and previous treatment records.

Additional information needed from previous 6 months (IF APPLICABLE):

• Notes from all consultants (inpatient and outpatient)
• Discharge summaries from relevant hospitalizations
• All operative reports
• Diagnostic procedure reports (endoscopy, bronchoscopy, biopsies)
• All radiology reports

See Worksheet below for more information

 Hematology Referral Worksheet

• Persistent, severe anemia after complete evaluation and treatment
  • Three consecutive CBC’s within the last year at least 1 month apart, most recent within 1 month of referral, with hemoglobin less than 10.0
  • TIBC, Ferritin, Serum Iron, B12 level, Folate level, TSH
  • Iron deficiency is not appropriate for referral unless a complete GI evaluation has been performed (colonoscopy and upper endoscopy)
  • Anemia of renal insufficiency should be treated by nephrologist and is not appropriate for referral
• Thrombocytosis
  • Three consecutive CBC’s within the last year at least 1 month apart, most recent within 1 month of referral
  • Persistent platelet count > 600
  • Peripheral Smear
  • Iron deficiency has been ruled out

• Thrombocytopenia
  • Three consecutive CBC’s within the last year at least 1 month apart, most recent within 1 month of referral
  • Persistent platelet count < 100, or two platelet counts < 50
  • 1 CBC in citrated (blue top) tube to evaluate for clumping

• Leukopenia:
  • Three consecutive CBC’s within the last year at least 1 month apart, most recent within 1 month of referral
  • Persistent absolute neutrophil count less than 1500
  • Lymphopenia is not appropriate for referral
• Leukocytosis:
  • Three consecutive CBC’s within the last year at least 1 month apart, most recent within 1 month of referral
  • Physician documentation excluding infection
  • Persistent absolute neutrophil count > 20,000
  • Persistent absolute lymphocyte count > 10,000

• Monoclonal gammopathy:
  • Serum protein electrophoresis (SPEP)
  • Serum immunofixation
  • Urine protein electrophoresis
  • CBC, CMP

• Sickle Cell disease
  • Hemoglobin electrophoresis documenting diagnosis

• Hypercoagulable state (high risk thrombo-embolic event: DVT, PE, or atypical arterial event)
  • All radiology reports documenting thrombosis
  • Coumadin flowsheets if applicable
  • Specific question from referring physician, written on referral form, which is to be addressed by consultant

• Bleeding disorder
  • Documentation of clinically significant bleeding
  • All related labs

REVISED 11/2018

Have questions or comments about the specialty referral guidelines? Submit them here.