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Hematology

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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.